Psychiatric Nursing Certification Review Guide for the Generalist and Advanced Practice Psychiatric and Mental Health Nurse Third Edition

Victoria Mosack, PhD, RN, APNP, BC Assistant Professor School of Nursing Wichita State University Wichita, Kansas World Headquarters Jones and Bartlett Publishers Jones and Bartlett Publishers Jones and Bartlett Publishers 40 Tall Pine Drive Canada International Sudbury, MA 01776 6339 Ormindale Way Barb House, Barb Mews 978-443-5000 Mississauga, Ontario L5V 1J2 London W6 7PA [email protected] Canada United Kingdom www.jbpub.com

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Library of Congress Cataloging-in-Publication Data Mosack, Victoria. Psychiatric nursing certification review guide for the generalist and advanced practice psychiatric and mental health nurse / Victoria Mosack.—3rd ed. p. ; cm. Rev. ed. of: Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing / editor, Clare Houseman . 2nd ed. c1998. Includes bibliographical references and index. ISBN-13: 978-0-7637-7599-5 (alk. paper) ISBN-10: 0-7637-7599-1 (alk. paper) 1. Psychiatric nursing. 2. Psychiatric nursing—Examinations, questions, etc. I. Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing. II. Title. [DNLM: 1. Psychiatric Nursing—Examination Questions. 2. Mental Disorders—nursing—Examination Questions. WY 18.2 M893p 2011] RC440.P72985 2011 616.8990231—dc22 2009033393

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Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 Contents

Preface vii Interdisciplinary Treatment & the Healthcare Team 16 Acknowledgments ix Client Advocacy 17 Chapter 1 Case Management 17 Psychiatric Liaison Nursing 18 Test Taking Strategies and Techniques 1 Milieu 18 Strategy #1 Know Yourself 1 Principles of Prescriptive Authority 19 Strategy #2 Develop Your Thinking Skills 1 Mental Health Education 21 Strategy #3 Know the Content 3 Family Therapy 21 Strategy #4 Become Test-Wise 6 Group Dynamics & Group Process Strategy #5 Apply Basic Rules of Test Theory 22 Taking 7 Ethical Considerations 23 Strategy #6 Psych Yourself Up: Taking a Test Questions 25 is Stressful 8 Answers 32 Summary 9 Bibliography 33 Bibliography 9 Chapter 3 Chapter 2 Major Theoretical Frameworks for Essentials of Psychiatric Nursing Care 11 Psychiatric Nursing 35 Mental Health 11 Theory 35 Change 11 Evidence-Based Practice (EBP) 35 The Nursing Process 12 Research 36 Nurse–Client Relationship 12 Nursing Theoretical Models 37 Communication 13 Nursing Theories 37 Cultural & Ethnic Factors 15 Personality Theories 39

iii iv Contents

Theories of Growth and Development 42 Chapter 7 Social/Interpersonal Theories 43 Mood Disorders 137 Existential/Humanistic Theories 43 Mood Disorders—Overview 137 Behavioral Theories 45 Depressive Disorders 139 Cognitive Theories 45 Bipolar Disorders 140 Theories of Communication 46 Mood Disorder Due to . . . (Indicate General Theories of Group Behavior and Medical Condition) 141 Therapy 47 Substance-Induced Mood Disorder 141 Family Theories 48 Suicide 141 Neurobiological Theories 49 Etiology of Mood Disorders 142 Miscellaneous Theories 51 Diagnostic Studies/Tests 143 Questions 52 Screening Instruments 143 Answers 60 Interventions 144 Bibliography 61 Questions 156 Chapter 4 Answers 164 Bibliography 164 Substance-Related Mental Disorders 63 Substance-Related Disorders 63 Chapter 8 Questions 76 Behavioral Syndromes and Disorders of Answers 80 Adult Personality 165 Bibliography 80 Eating Disorders 165 Chapter 5 Sexual and Gender Identity Disorders 168 Sexual Dysfunctions 170 Anxiety and Stress-Related Disorders 83 Sleep Disorders 171 Anxiety Disorders 83 Impulse Control Disorders 173 Somatoform Disorders 95 Personality Disorders—Coded on Axis II of Factitious Disorders 98 the DSM-IV-TR Multiaxial Classification Dissociative Disorders 99 System 174 Adjustment Disorder 104 Questions 179 Questions 105 Answers 184 Answers 111 Bibliography 184 Bibliography 111 Chapter 9 Chapter 6 Cognitive Mental Disorders and Schizophrenia and Other Psychotic Geropsychiatric Nursing 187 Disorders 115 Cognitive Disorders 187 Overview of Disorders 115 Geropsychiatric Nursing 196 Information Common to Schizophrenia Questions 197 and Other Psychotic Disorders 118 Answers 202 Questions 129 Bibliography 202 Answers 134 Bibliography 134 Contents v

Chapter 10 Chapter 11 Behavioral and Emotional Disorders of The Larger Mental Health Environment Childhood and Adolescence 205 Mental Healthcare Delivery System 253 Child and Adolescent Psychiatric and Managed Care—An Internal Force of Mental Health Nursing 205 Change within the Mental Health Mental Disorders Diagnosed in Children & Delivery System 257 Adolescents 208 Reimbursement for Mental Health Other Disorders of Infancy, Childhood, or Services 257 Adolescence 227 Types of Healthcare Insurance Plans 257 Treatment Modalities for Mental Disorders External Forces Interacting with the Mental in Childhood and Adolescence 231 Health System 258 Questions 240 Leadership and Management 261 Answers 249 Questions 270 Bibliography 249 Answers 276 Bibliography 276

Index 279

Preface

This is the third edition of a book developed especially The book has been organized to provide the reviewer for nurses preparing to take certification examinations with test taking strategies and techniques. This is offered by the American Nurses Credentialing Center followed by chapters on the Essentials of Psychiatric (ANCC). Major revisions were needed in a number of Nursing Care, Major Theoretical Frameworks for Psychi- areas to accommodate changes in the field of psychiatric Nursing, Substance-Related Mental Disorders, atric and mental health nursing and to incorporate Anxiety and Stress-Related Disorders, Schizophrenia more recent references as well as evidence-based prac- and Other Psychotic Disorders, Mood Disorders, tice guidelines that may have become available since Behavioral Syndromes and Disorders of Adult Person- the previous revision was published. ality, Cognitive Mental Disorders and Geropsychiatric The book is inclusive in that it contains both basic Nursing, Behavioral and Emotional Disorders of Child- and advanced content, and may be used by nurses hood and Adolescence, and The Larger Mental Health seeking certification as generalists as well as nurses Environment. seeking certification in advanced practice psychiatric Following each chapter are test questions, which and mental health nursing. It is assumed that the reader are intended to serve as an introduction to the testing of this review guide has completed a course of study in arena. In addition, a bibliography is included for those psychiatric and mental health nursing. The Psychiatric who desire a more in-depth discussion of the subject Nursing Certification Review Guide for the Generalist matter in each chapter. These references can serve as and Advanced Practice Psychiatric and Mental Health additional instructional material for the reader. (PMH) Nurse is not intended to be a basic learning tool. Certification is a process that is gaining recognition The purpose of the book is twofold. It will assist indi- both within and outside the profession. For the profes- viduals engaged in self-study preparation for certifi- sional, it is a means of gaining special recognition as cation examinations, and may be used as a reference a certified psychiatric nurse, which not only demon- guide in the practice setting. Many nurses preparing strates a level of competency, but may also enhance for certification examinations find that reviewing an professional opportunities and advancement. For extensive body of scientific knowledge requires a very the consumer, it means that a certified nurse has met difficult search of many sources that must be synthe- certain predetermined standards set by the profession. sized to provide a review base for the examination. The purpose of this publication is to provide a succinct, yet comprehensive review of the core material.

vii

Front/EndAcknowledgments Matter Title

The author of the third edition would like to express Chapter 6. Schizophrenia and Other Psychotic Disor- appreciation to the authors of the first and second ders: Mary Ann Camaan, MN, RN, CS and Mary Fultz editions of this review guide. The contributions of these Spencer, MN, RN, CS authors provided a sound foundation upon which the Chapter 7. Mood Disorders: Mary D. Moller, DNP, ARNP, present revision was built. APRN, PMHCNS-BC, CPRP, FAAN Chapter 1. Test Taking Strategies: Clare Houseman, Chapter 8. Behavioral Syndromes and Disorders of PhD, RN, CS and Nancy A. Dickenson Hazard, MSN, Adult Personality: Richardean Benjamin-Coleman, RN, CPNP, FAAN PhD, MPH, RN, CS Chapter 2. The Essentials of Psychiatric Nursing Care: Chapter 9. Cognitive Mental Disorders and Clare Houseman, PhD, RN, CS Geropsychiatric Nursing: Jane Bryant Neese, PhD, Chapter 3. Major Theoretical Frameworks for Psychi- RN, CS, Anita Thompson-Heisterman, MSN, RN, CS, atric Nursing: Clare Houseman, PhD, RN, CS and and Ivo L. Abraham, PhD, RN, CS, FAAN Joan Donovan, PhD, RN, CS Chapter 10. Behavioral and Emotional Disorders of Chapter 4. Substance-Related Mental Disorders: Therese Childhood and Adolescence: Michele L. Zimmerman, K. Killeen, PhD, RN, CS MA, RN, CS Chapter 5. Anxiety and Stress-Related Disorders: Karma Chapter 11. The Larger Mental Health Environment: Castleberry, PhD, RN, CS Janice V. R. Belcher, PhD, RN, CS

1 Test Taking Strategies and Techniques

We all respond to testing situations in different ways. of thinking as well as the techniques to enhance the What separates the successful test taker from the un- thought process. successful one is knowing how to prepare for and take a Everyone has a personal learning style, but we all test. Preparing yourself to be a successful test taker is as must proceed through the same process to think. important as studying for the test. Each person needs Thinking occurs on two levels––the lower level of to assess and develop their own test taking strategies memory and comprehension and the higher level of ap- and skills. The primary goal of this chapter is to assist plication and analysis (ABP, 1989). Memory is the abil- potential examinees in knowing how to study for and ity to recall facts. Without adequate retrieval of facts, take a test. progression through the higher levels of thinking cannot occur easily. Comprehension is the ability to understand memorized facts. To be effective, comprehension STRATEGY #1 Know Yourself skills must allow the person to translate recalled information from one context to another. Application, or the When faced with an examination, do you feel threat- process of using information to know why it occurs, is ened, experience butterflies or sweaty palms, have a higher form of learning. Effective application relies trouble keeping your mind focused on studying or on on the use of understood memorized facts to verify in- the test questions? These common symptoms of test tended action. Analysis is the ability to use abstract or anxiety plague many of us, but can be used advanta- logical forms of thought to show relationships and to geously if understood and handled correctly (Divine & distinguish the cause and effect between the variables Kylen, 1979). Over the years of test taking, each of us in a situation. has developed certain testing behaviors, some of which As applied to testing situations, the thought pro- are beneficial, while others present obstacles to success from memory to analysis occurs quite quickly. cessful test taking. You can take control of the test tak- Some examination items are designed to test memory ing situation by identifying the undesirable behaviors, and comprehension, while others test application maintaining the desirable ones, and developing skills and analysis. An example of a memory question is as to improve test performance. follows:

STRATEGY #2 Develop Your Clients’ initial response to learning that they have a Thinking Skills terminal illness is generally: Understanding Thought Processes A. Depression B. Bargaining In order to improve your thinking skills and subsequent C. Denial test performance, it is best to understand the types D. Anger

1 2 Chapter 1 Test Taking Strategies and Techniques

To answer this question correctly, the individual has Building Your Thinking Skills to retrieve a memorized fact. Understanding the fact, knowing why it is important, or analyzing what should Effective memorization is the cornerstone to learning be done in this situation is not needed. An example of a and building thinking skills (Olney, 1989). We have all question that tests comprehension is as follows: experienced “memory power outages” at some time, due in part to trying to memorize too much, too fast, Shortly after having been informed that she is in the too ineffectively. Developing skills to improve memo- terminal stages of breast cancer, Mrs. Jones begins to rization is important to increasing the effectiveness of talk about her plans to travel with her husband when your thinking and subsequent test performance. he retires in two years. The nurse should know that: a. The diagnosis could be wrong and Mrs. Jones may Technique #1 not be dying. Quantity is NOT quality, so concentrate on learning im- b. Mrs. Jones is probably responding to the news by portant content. For example, it is important to know using the defense mechanism of denial. the various pharmacologic agents appropriate for the c. Mrs. Jones is clearly delusional. management of chronic obstructive pulmonary disease d. Mrs. Jones is not responding in the way most cli- (COPD), not the specific dosages for each medication. ents would. Technique #2 In order to answer this question correctly, an individual must retrieve the fact that denial is often the first Memory from repetition, or saying something over and response to learning about a terminal illness and that over again to remember it usually fades. Developing Mrs. Jones’ behavior is indicative of denial. memory skills that trigger retrieval of needed facts is In a higher level of thinking examination question, more useful. Such skills are as follows: individuals must be able to recall a fact, understand Acronyms that fact in the context of the question and apply this These are mental crutches that facilitate recall. Some understanding to explaining why one answer is correct are already established such as PERRL (pupils equal, after analyzing the answer choices as they relate to the round, reactive to light), or PAT (paroxysmal atrial situation (Sides & Cailles, 1989). An example of an ap- tachycardia). Developing your own acronyms can be plication analysis question is as follows: particularly useful since they are your own word associ- Mr. Smith has just learned that he has an inoperable ation arrangements in a singular word. Nonsense words brain tumor. His comment when the nurse speaks to or funny, unusual ones are often more useful since they him later is “This can’t possibly be true. Mistakes are attract your attention. made in hospitals all the time. They might have mixed Acrostics up my test results.” The nurse’s most appropriate re- This mental tool arranges words into catchy phrases. sponse would be to: The first letter of each word stands for something that a. Refer Mr. Smith for a psychiatric consultation. is recalled as the phrase is said. Your own acrostics are b. Neither agree nor disagree with Mr. Smith’s most valuable in triggering recall of learned informa- comment. tion since they are your individual situation associa- c. Confront Mr. Smith with his denial. tions. An example of an acrostic is as follows: D. Agree with Mr. Smith that mistakes can happen Kissing Patty Produces Affection stands for the and tell him you will see about getting repeat four types of nonverbal messages: Kinesics, Para- tests. language, Proxemics and Appearance. To answer this question correctly, the individual must ABCs recall the fact that denial is often the initial response to This technique facilitates information retrieval by using learning about a terminal illness; understand that Mr. the alphabet as a crutch. Each letter stands for a symp- Smith’s response in this case is evidence of the normal tom, which when put together creates a picture of the use of denial; apply this knowledge to each option, un- clinical presentation of the disease. For example, the derstanding why it may or may not be correct; and ana- characteristics of the disease and symptoms of osteoar- lyze each option for what action is most appropriate for thritis using the ABC technique are as follows: this situation. Application/analysis questions require the examinee to use logical rationale, which demon- a) Aching or pain strates the ability to analyze a relationship, based on b) Being stiff on awakening a well-defined principle or fact. Problem-solving abil- c) Crepitus ity becomes important as the examinee must think d) Deterioration of articular cartilage through each question option, deciding its relevance e) Enlargements of distal interphalangeal joints and importance to the situation of the question. f) Formation of new bone at joint surface Strategy #3 Know the Content 3

g) Granulation inflammatory tissue Words that rhyme can also be used to jog the mem- h) Heberden’s nodes ory about important characteristics of phenomena. For example, the stages of group therapy can be remem- One letter bered and characterized by the following, according to Recall is enhanced by emphasizing a single letter. The Tuckman (1965): major symptoms of schizophrenia are often remembered as follows: • Forming • Storming • Affect (flat) • Norming • Autism • Performing • Auditory hallucinations Setting content to music is sometimes useful for re- Imaging membering. Melodies that are repetitious jog the mem- This technique can be used in two ways. The first is ory by the ups and downs of the notes and the rhythm to develop a nickname for a clinical problem that of the music. when said produces a mental picture. For example, Links connect key words from the content by us- “a wan, wheezy pursed lip” might be used to visual- ing them in a story. An example given by Olney (1989) ize a patient with pulmonary emphysema who is thin, for remembering the parts of an eye is: IRIS watched a emaciated, experiencing dyspnea, with a hyperin- PUPIL through the LENS of a RED TIN telescope while flated chest, who has an elongated expiratory breath- eating CORN-EA on the cob. ing phase. A second form of imaging is to visualize a Additional memory aids may also include the use specific patient while you are trying to understand or of color or drawing for improving recall. Use different solve a clinical problem when studying or answering colored pens or paper to accentuate the material being a question. For example, imagine an elderly man who learned. For example, highlight or make notes in blue is experiencing an acute asthma attack. You are trying for content about respiratory problems and in red for to analyze the situation and place him in a position cardiovascular content. Drawing assists with visualiz- that maximizes respiratory effort. In your mind you vi- ing content as well. This is particularly helpful for re- sualize him in various positions of side lying, angular membering the pathophysiology of the specific health and forward, imaging what will happen to the man in problem. each position. A second form of imaging is to visual- The important thing to remember about remem- ize a specific situation while you are trying to answer bering is to use good recall techniques. a question. For example, if you are trying to remember how to describe active listening or physical attend- Technique #3 ing skills, see yourself in a comfortable environment, Improving higher level thinking skills involves exercis- facing the other person, with open posture and eye ing the application and analysis of memorized fact. contact. Small group review is particularly useful for enhancing Rhymes, music & links these high level skills. It allows verbalization of thought The absurd is easier to remember than the most com- processes and receipt of input about content and mon. Rhymes, music or links can add absurdity and thought process from others (Sides & Cailles, 1989). humor to learning and remembering (Olney, 1989). Individuals not only hear how they think, but how oth- These retrieval tools are developed by the individual ers think as well. This interaction allows individuals for specific content. For example, making up a rhyme to identify flaws in their thought process as well as to about diabetes may be helpful in remembering the pre- strengthen their positive points. dominant female incidence, origin of disease, primary Taking practice tests is also helpful in developing ap- symptoms and management, as illustrated by: plication/analysis thinking skills. These tests permit the individual to analyze thinking patterns as well as There once was a woman the cause-and-effect relationships between the ques- whose beta cells failed, tion and its options. The problem-solving skills needed She grew quite thirsty to answer application/analysis questions are tested, and her glucose levels sailed, giving the individual more experience through practice Her lack of insulin caused her to (Dickenson-Hazard, 1990). increase her intake And her increased urinary output STRATEGY #3 Know the Content was certainly not fake, So she learned to watch her diet Your ability to study is directly influenced by organiza- and administer injections tion and concentration (Dickenson-Hazard, 1990). If That kept her healthy, happy effort is spent on both of these aspects of exam prepa- and free of complications. ration, examination success can be increased. 4 Chapter 1 Test Taking Strategies and Techniques

Preparation for Studying: Table 1-1 Sample Content Assessment Getting Organized Exam Content: Theories & Skills Study habits are developed early in our educational Rating: experiences. Some of our habits enhance learning, al- Category: Provided Provided by though others do not. To increase study effectiveness, by Test Giver Examinee organization of study materials and time is essential. Group dynamics 2 Organization decreases frustration, allows for easy re- Group process 2 sumption of study, and increases concentrated study time. Behavior modification 3 Crisis intervention 1 Technique #1 Reality therapy 4 Create your own study space. Select a study area that Communication process 3 is yours alone, free from distractions, comfortable, and Interviewing skills 3 well lighted. The ventilation and room temperature Self-care 4 should be comfortable since a cold room makes it difficult to concentrate and a warm room may make you Decision making 1 sleepy (Burkle & Marshak, 1989). All your study materi- Legal/ethical issues 2 als should be left in your study space. The basic premise Cognitive techniques 2 of a study space is that it facilitates a mind-set that you Mental status evaluation 3 are there to study. When you interrupt study, it is best to leave your materials just as they are. Do not close books Problem solving 3 or put away notes as you will just have to relocate them, Community resources evaluation 3 wasting your study time, when you do resume study. Nursing process 3 Nursing theory 2 Technique #2 Role theory 3 Define and organize the content. From the test giver, se- Change theory 2 cure an outline or the content parameters that are to be examined. If the test giver’s outline is sketchy, develop a Communication theories 2 more detailed one for yourself using the recommended Organizational theory 2 text as a guideline. Next, identify your available study Research design 2 resources: class notes, old exams, handouts, textbooks, Research evaluation 2 review courses, or study groups. For national standardized exams, such as initial licensing or certification, it Research application 2 is best to identify one or two study resources that cover Team building 3 the content being tested and stick to them. Attempt- Conflict management 2 ing to review all available resources is not only mind Teaching/learning skills 3 boggling, but increases anxiety and frustration as well. Supervisory skills 3 Make your selections and stay with them. Observation skills 3 Technique #3 Evaluation skills 2 Conduct a content assessment. Use a simple rating Nursing diagnosis 3 scale such as the following: DSM IV 3 1 = requires no review Grief and loss theory 3 2 = requires minimal review Death and dying 2 3 = requires intensive review Stress management theory 2 4 = start from the beginning Stress management skills 4 Read through the content outline and rate each con- Family dynamics 2 tent area (Dickenson-Hazard, 1990). Table 1-1 provides Assertiveness training skills 3 a sample exam content assessment. Be honest with Motivation skills 4 your assessment. It is far better to recognize your content weaknesses when you can study and remedy them, Houseman, C. (Ed.). (1998). Psychiatric certification review rather than thinking during the exam how you wished guide for the generalist and clinical specialist in adult, child, you had studied more. Likewise with content strengths: and adolescent psychiatric and mental health nursing (2nd ed.). if you know the material, do not waste time studying it. Sudbury, MA: Jones and Bartlett. Strategy #3 Know the Content 5

Table 1-2 Sample Study Plan

Goal: Achieve a passing grade on the certification exam. Time available: 2 Months Objective Activity Date Accomplished Understand elements of milieu Read section in Chapter 2 Feb. 5 & 6, 1 hour each day therapy Read notes from review class and combine Feb. 7, 1 hour with notes taken from text Review combined notes and sample test Feb. 8, 1 hour questions Master social/cultural/ethnic Read section in Chapter 2—Take notes on Feb. 9 & 10, 1 hour each day factors chapter content Read notes from review class and combine Feb. 11, 1 hour with notes taken from text Review combined notes and sample test Feb. 12, 1 hour questions

Know material contained in Read ANA Publication—Take notes on Feb. 13 & 14, 1 hour each day Code for Nurses with Interpretive content Statements

Houseman, C. (Ed.). (1998). Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.). Sudbury, MA: Jones and Bartlett.

Technique #4 your peak study times and using techniques to maxi- Develop a study plan. Coordinate the content that mize them. needs to be studied with the time available (Sides & Technique #1 Cailles, 1989). Prioritize your study needs, starting with weak areas first. Allow for a general review at the end Study in short bursts. Each of us have our own biologic of the study plan. Lastly, establish an overall goal for clock that dictates when we are at our peak during yourself––something that will motivate you when it is the day. If you are a morning person, you are gener- brought to mind. ally active and alert early in the day, slowing down and Table 1-2 illustrates a study plan developed on the ba- becoming drowsy by evening. If you are an evening per- sis of the exam content assessment in Table 1-1. Con- son, you do not completely wake up until late morning ducting an assessment and developing a study plan and hit your peak in the afternoon and evening. Each should require no more than 50 minutes. It is a wise person generally has several peaks during the day. It is investment of time with potential payoffs of reduced best to study during those times when your alertness is study stress and enhanced exam success. at its peak (Dickenson-Hazard, 1990). During our concentration peaks, there are mini- Technique #5 peaks, or bursts of alertness (Olney, 1989). These alertness peaks of a concentration peak occur because Begin now and use your time wisely. The smart test levels of concentration are at their highest during the taker begins the study process early (Olney, 1989). Sit first part and last part of a study period. These bursts down, conduct the content assessment, and develop can vary from 10 minutes to 1 hour depending on the a study plan as soon as you know about the exam. DO extent of concentration. If studying is sustained for 1 NOT PROCRASTINATE! hour there are only two mini-peaks; one at the beginning and one at the end. There are 8 mini-peaks if that Getting Down to Business: same hour is divided into 4, 10-minute intervals. Hence The Actual Studying it is more helpful to study in short bursts (Olney, 1989). More can be learned in less time. There is no better way to prepare for an examination than individual study (Dickenson-Hazard, 1989). The Technique #2 responsibility to achieve the goal you set for this exam Cramming can be useful. Since concentration ability lies with you alone. The means you employ to achieve is highly variable, some individuals can sustain their this goal do vary and should begin with identifying mini-peaks for 15, 20, or even 30 minutes at a time. 6 Chapter 1 Test Taking Strategies and Techniques

Pushing your concentration beyond its peak is fruitless helpful. Ways to be active include: taking notes on the and verges on cramming, which in general is a poor content as you study; constructing questions and an- study technique. There are, however, times when cram- swering them; taking practice tests; or discussing the ming, a short-term memory tool, is useful. Short-term content with yourself. Also, using your individual study memory generally is at its best in the morning. A quick quirks is encouraged. Some people stand, others walk review or cram of content in the morning can be useful around, and some play background music. Whatever the day of the exam (Olney, 1989). Most studying, how- helps you to concentrate and study better, you should ever, is best accomplished in the afternoon or evening use. when long-term memory functions at its peak. Technique #8 Technique #3 Use study aids. Although there is no substitute for in- Give your brain breaks. Regular times during study to dividual studying, several resources, if available, are rest and absorb the content are needed by the brain. useful in facilitating learning. Review courses are an The best approach to breaks is to plan them and give excellent means for organizing or summarizing your yourself a conscious break (Dickenson-Hazard, 1990). individual study. They generally provide the content This approach eliminates the “day dreaming” or “wan- parameters and the major concepts of the content that dering thought” approach to breaks that many of us you need to know. Review courses also provide an op- use. It is better to get up, leave the study area and do portunity to clarify not-well-understood content, as something nonstudy related for longer breaks. For well as to review known material (Dickenson-Hazard, shorter breaks of 5 minutes or so, leave your desk, gaze 1990). Study guides are useful for organizing study. out the window or do some stretching exercises. When They provide detail on the content that is important your brain says to give it a rest, accommodate it! You to the exam. Study groups are an excellent resource for will learn more with less stress. summarizing and refining content. They provide an op- Technique #4 portunity for thinking through your knowledge base, with the advantage of hearing another person’s point of Study the correct content. It is easy for all of us to be- view. Each of these study aids increases understanding come bogged down in the detail of the content we are of content and when used correctly, increases effective- studying. However, it is best to focus on the major con- ness of knowledge application. cepts or the “state of the art” content. Leave the details, the suppositions, and the experience at the door Technique #9 of your study area. Concentrate on the major textbook Know when to quit. It is best to stop studying when facts and concepts that revolve around the subject mat- your concentration ebbs. It is unproductive and frus- ter being tested. trating to force yourself to study. It is far better to rest or Technique #5 unwind, then resume at a later point in the day. Avoid studying outside your morning or afternoon concen- Fit your studying to the test type. The best way to pre- tration peaks and focus your study energy on your right pare for an objective test is to study facts, particularly time of day or evening. anything printed in italics or bold. Memory enhancing techniques are particularly useful when preparing for an objective test. If preparing for an essay test, study STRATEGY #4 Become Test-Wise generalities, examples, and concepts. Application techniques are helpful when studying for this type of an Most nursing examinations are composed of multiple- exam (Burkle & Marshak, 1989). choice questions (MCQs). This type of question requires the examinee to select the best response(s) for a Technique #6 specific circumstance or condition. Successful test tak- Use your study plan wisely. Your study plan is meant ing is dependent not only on content knowledge but on to be a guide, not a rigid schedule. You should take test taking skill as well. If you are unable to impart your your time with studying. Do not rush through the con- knowledge through the vehicle used for its conveyance, tent just to remain on schedule. Occasionally study i.e., the MCQ, your test taking success is in jeopardy. plans need revision. If you take more or less time than planned, readjust the plan for the time gained or lost. Technique #1 The plan can guide you, but you must go at your own pace. Recognize the purpose of a test question. Most test questions are developed to examine knowledge at two Technique #7 separate levels: memory and application. A memory Actively study. Being an active participant in study question requires the examinee to recall and com- rather than trying to absorb the printed word is also prehend facts from their knowledge base, while an Strategy #5 Apply Basic Rules of Test Taking 7 application question requires the examinee to use and Technique #4 apply the knowledge (ABP, 1989). Memory questions test recall, but application questions test synthesis and Practice, practice, practice. Taking practice tests can problem-solving skills. When taking a test you need to improve performance. Although they can assist in eval- be aware of whether you are being asked a fact or to use uation of your knowledge, their primary benefit is to that fact. assist you with test taking skills. You should use them to evaluate your thinking process, your ability to read, understand and interpret questions, and your skills in Technique #2 completing the mechanics of the test. Exam resources, including sample questions for the Recognize the components of a test question. Multiple- American Nurses Credentialing Center (ANCC) cer- choice questions may include the basic components of tification exams, are available online at: http://www. a background statement, a stem, and a list of options. nursecredentialing.org/Certification/ExamResources.aspx The background statement presents information that facilitates the examinee in answering the question. The stem asks or states the intent of the question. The op- STRATEGY #5 Apply Basic Rules tions are four to five possible responses to the question. of Test Taking The correct option is called the keyed response and all other options are called distractors (ABP, 1989). Know- Technique #1 ing the components of a test question helps you sift through the information presented and focus on the Follow your regular routine the night before a test. Eat question’s intent (see Table 1-3). familiar foods. Avoid the temptation to cram all night. Go to bed at your regular time (Nugent and Vitale, 1997). Technique #3 Recognize the item types. Basically two styles of MCQs Technique #2 are used for examinations. One requires the examinee to select the one best answer; the other requires selec- Be prepared for exam day. It is important to familiarize tion of multiple correct answers. Among the one-best- yourself with the test site, the building, the parking, and answer styles there are three types. The A type requires travel route prior to the exam day. If you must travel, the selection of the best response among those offered. arrive early to allow time for this familiarization. It is The B type requires the examinee to match the options helpful to make a list of things you need on the exam with the appropriate statement. The X type asks the ex- day: pencils, admission card, watch, and a few pieces aminee to respond either true or false to each option of hard candy as a quick energy source. On exam day (ABP, 1989). Most standardized tests, such as those allow yourself plenty of time to arrive at the site. Wear used for nursing licensure and certification, are com- comfortable clothes and have a good breakfast that posed of four or five option-A type questions. morning.

Table 1-3 Anatomy of a Test Question

Background statement A woman brings her 65-year old mother in to see a clinical nurse specialist because she is concerned that it is now a month since her mother was widowed, and she continues to be tearful when talking about the loss and wants to visit the grave regularly. Stem Which of the following initial approaches would most likely result in compliance with your nursing recommendations? Options a. Three or four short questions followed by a request to a psychiatrist to prescribe an antidepressant b. Immediate reassurance only c. Careful listening and open-ended questions d. Refering the mother to a support group

Technique #3 Considerations for Computerized Examinations Understand all the directions for the test. Know if the test has a penalty for guessing or if you should attempt All ANCC certification examinations are computer- every question (Nugent and Vitale, 1997). based exams. • Be sure that you have completed all information Technique #4 needed to register for the exam. • Bring a photo ID—if a letter of authorization is Read the directions carefully. An exam may have sev- needed, have it with you. eral types of questions. Be on the lookout for changing • If you are easily distracted by sound, consider us- item types and be sure you understand the directions ing earplugs (these may be available at the testing on how you are to answer before you begin reading the center; check before using your own). question. • Personal items such as books, laptop computers, iPods, cellular telephones, food, or drink are not al- Technique #5 lowed during testing; secure these items elsewhere. • Arrive 30 minutes before the appointed testing Use time wisely and effectively. Allow no more than 1 time. minute per question. Skip difficult questions and re- • If you are not comfortable taking exams using a turn to them later or make an educated guess. computer, consider taking a practice exam usually available at the examination site. Technique #6 • Use computer-based practice exams, particularly if you are unfamiliar with this testing format. Sample Read and consider all options. Be systematic and use online questions for each ANCC certification exam problem-solving techniques. Relate options to the are available at: http://www.nursecredentialing. question and balance them against each other. org/Certification/ExamResources.aspx • Know what to do if you experience any electronic Technique #7 or other difficulties during the examination. In addition to addressing the issue at the test site, you Check your answers. Reconsider your answers, espe- should also notify the certifying board (inform cially those in which you made an educated guess. You ANCC about problems during exam using the post- may have gained information from subsequent ques- test survey). tions that is helpful in answering previous questions or may be less anxious and more objective by the end of STRATEGY #6 Psych Yourself Up: the test. Taking a Test is Stressful Some Dos & Don’ts to Remember Although a little stress can be productive, too much can incapacitate you in your studying and test taking • Do identify key words in the stem before looking at (Divine & Kylen, 1979). For persons with severe test options. anxiety, interventions such as Cognitive Therapy, Sys- • Do confine your thinking to the information tematic Desensitization, Study Skills Counseling and provided. Biofeedback have all been used with some success • Do eliminate wrong answers and focus on the one (Spielberger, 1995). Techniques derived from these ap- or two most likely correct responses. proaches can influence the results achieved by chang- • Do guess; generally there is no penalty (loss of extra ing attitudes and approaches to test taking and thereby points) for having done so—true for ANCC exams. reducing anxiety. Psyching yourself up can have a posi- • Don’t spend too much time on any one question— tive effect and make examinations a nonanxiety-laden it is a timed examination. experience (Dickenson-Hazard, 1990). The following • Don’t second-guess—your first response is likely techniques are based on the principles of successful the best response. test taking as presented by Sides & Cailles (1989). Incor- • If you tend to second-guess your responses, only poration of these techniques can improve response and review questions that you could not answer on performance in examination situations. the first pass through the exam—computer- based exams allow you to mark questions that Technique #1 you may want to address later in the exam. • Don’t change an answer without a good reason, Adopt an “I can” attitude. Believing you can succeed such as having misread the question. is the key to success. Self-belief inspires and gives you Bibliography 9 the power to achieve your goals. Without a success atti- is not the end of the world unless you allow it to be. It is tude, the road to your goal is much harder. We all stand best to deal with the failure and move on, otherwise it an equal chance of success in this world. It is those interferes with your success. who believe they can who achieve it. This “I can” attitude must permeate all your efforts in test taking, from Technique #8 studying, to improving your skills, to actually writing the test. Persevere, persevere, persevere! Endurance must underlie all your efforts. Call forth those reserve energies Technique #2 when you have had all you think you can take. Rely upon yourself and your support systems to help you Take control. By identifying your goal, deciding how to maintain a sense of direction and keep your goal in the accomplish it, and developing a plan for achieving it, forefront. you take control. Do not leave your success to chance; control it through action and attitude. Technique #9 Technique #3 Motivation is muscle. Most individuals are motivated by fear or desire. The fear in an exam situation may be Think positively. Examinations are generally based on one of failure, the unknown, or discovery of imperfec- a standard that is the same for all individuals. Every- tion. Put your fear into perspective; realize you are not one can potentially pass. Performance is influenced the only one with fear, and that all have an equal op- not only by knowledge and skill but by attitude as well. portunity for success. Develop strategies to reduce fear Those individuals who regard an exam as an opportu- and use fear to your advantage by improving the imper- nity or challenge will be more successful. fections. Desire is a powerful motivator, and you should keep the rewards of your desire foremost in your mind. Technique #4 Whatever motivates you, use it to make you successful. Reward yourself during your exam preparation and Project a positive self-fulfilling prophecy. While prepar- once the exam has been completed. You alone hold the ing for an examination, project thoughts of the posi- key to success; use what you have wisely. tive outcomes you will experience when you succeed. Self-talk is self-fulfilling. Expect success, not failure, for SUMMARY yourself. This chapter has provided concepts, strategies, and Technique #5 techniques for improving study and test taking skills. Your first task in improvement is to know yourself: how Feel good about yourself. Without feeling a sense of you study and how you take a test. You should use your positive self-worth, passing an examination is difficult. strengths and remedy the weaknesses. Next you need Recognize your professional contributions and give to develop your thinking skills. Work on techniques yourself credit for your accomplishments. Think “I will to improve memory and reasoning. Now you need to pass,” not “I suppose I can.” organize your study and concentrate on using your strengths and these new and improved skills to be suc- Technique #6 cessful. Create a study space, develop a plan of action, then implement that plan during your periods of peak Know yourself. Focus exam preparation and test taking concentration. Before taking the exam, be sure you un- on your strengths. Try to alter your weaknesses instead derstand the components of a test question, can iden- of becoming hung up on them. If you tend to overana- tify key words and phrases, and have practiced. Apply lyze, study and read test questions at face value. If you the test taking rules during the exam process. Finally, are a speed demon when taking a test, slow down and believe in yourself, your knowledge, and your talent. read more carefully. Believing you can accomplish your goal facilitates the fact that you will. Technique #7 Bibliography Failure is a possibility. We all have failed at something at some point in our lives. Rather than dwelling on the American Board of Pediatrics. (1989). Developing ques- failure, making excuses and believing you will fail again, tions and critiques. Unpublished material. recognize your mistakes and remedy them. Failure is a Burke, M. M., & Walsh, M. B. (1992). Gerontologic nurs- time to begin again; use it as a motivator to do better. It ing. St. Louis, MO: Mosby Year Book. 10 Chapter 1 Test Taking Strategies and Techniques

Burkle, C. A., & Marshak, D. (1989). Study program: Millonig, V. L. (Ed.). (1994). The adult nurse practitio- Level 1. Reston, Va: National Association of Second- ner certification review guide (rev. ed). Potomac, MD: ary School Principals. Health Leadership Associates. Conaway, D. C., Miller, M. D., & West, G. R. (1988). Geri- Nugent, P. M., & Vitale, B. A. (1997). Test success: Test- atrics. St. Louis, MO: Mosby Year Book. taking techniques for beginning nursing students. Dickenson-Hazard, N. (1989). Making the grade as a Philadelphia, PA: F.A. Davis Co. test taker. Pediatric Nursing, 15, 302–304. Olney, C. W. (1989). Where there’s a will, there’s an A. Dickenson-Hazard, N. (1989). Anatomy of a test ques- New Jersey: Chesterbrook Educational Publishers. tion. Pediatric Nursing, 15, 395–399. Sides, M., & Cailles, N. B. (1989). Nurse’s guide to suc- Dickenson-Hazard, N. (1990). The psychology of successful test taking. Philadelphia, PA: J. B. Lippincott cessful test taking. Pediatric Nursing, 16, 66–67. Co. Dickenson-Hazard, N. (1990). Study smart. Pediatric Sides, M., & Korchek, N. (1998). Nurse’s guide to success- Nursing, 16, 314–316. ful test taking: Learning strategies for nurses (3rd ed.). Dickenson-Hazard, N. (1990). Study effectiveness: Are Philadelphia, PA: Lippincott-Raven. you 10 a.m. or p.m. scholar? Pediatric Nursing, 16, Sides, M., & Korchek, N. (1994). Nurse’s guide to suc- 419–420. cessful test taking (2nd ed.). Philadelphia, PA: J. B. Dickenson-Hazard, N. (1990). Develop your thinking Lippincott. skills for improved test taking. Pediatric Nursing, 16, Spielberger, C. D., & Vagg, P. R. (1995). Test anxiety: The- 480–481. ory, assessment, and treatment. Washington, DC: Tay- Divine, J. H., & Kylen, D. W. (1979). How to beat test anx- lor and Francis. iety. New York, NY: Barrons Educational Series, Inc. Millman, J., & Pauk, W. (1969). How to take tests. New York: McGraw-Hill Book Co. 2 Essentials of Psychiatric Nursing Care

Mental Health 3. Challenge—viewing change as normal and obstacles as opportunities (Johnson, 1997) • Definition—Mental health is a state of psychological and emotional well-being. The mentally • Absence of mental health may be perceived as healthy individual: a) strives to achieve balance in uncomfortable to the individual and/or significant physical, emotional, social, and spiritual spheres; others and result in the perception of a need for and b) is able to cope effectively with normal change. stresses in life and function productively to meet individual, family, and community needs (World Change Health Organization [WHO], 2005). • Definition—process resulting in transformation • Factors influencing mental health according to Videbeck (2006) include: • Planned change—deliberate, goal-directed effort 1. Individual/Personal factors—including one’s to solve problems; applicable to any system (indi- biological and genetic makeup, emotional re- vidual, family, organization) silience or hardiness, self-esteem, autonomy and independence, reality orientation, and • Process involves the following responses (Huelsko- ability to cope with stressors etter and Romano, 1991): 2. Interpersonal/Relationship factors—including 1. Feelings of tension, anxiety, and fear effective communication skills and strategies, 2. A sense of need ability to socially/emotionally engage with and 3. Feelings of hope help/be helped by another, intimacy, and a 4. A search balance of connectedness and separateness 5. Decision and goal setting 3. Social-cultural/Environmental factors—includ- 6. Commitment to goals and change ing positive and realistic social awareness, a 7. Creative behavior sense of community, access to resources, sup- 8. Changes in behavior port of diversity, and intolerance of violence • Success of change is dependent on the change • Hardiness is viewed as a characteristic of mentally agent’s ability to facilitate a helping relationship healthy people and involves the following: and collaborate with the individual, group, family, 1. Control—feeling in charge of and able to influ- or organization. ence own life 2. Commitment—feeling deeply involved in life • Change involves risk and resistance. It cannot be and work rushed.

11 12 Chapter 2 Essentials of Psychiatric Nursing Care

• Change is effected by nurses within the nursing • Intervention—treatment according to diagnoses process. and care plan should be based on scientific theory and includes: The Nursing Process 1. Psychotherapeutic interventions—may be talking, poetry writing, social skills training, • Assessment—Data are collected in a continuous, cooking, modeling assertiveness, or expression comprehensive, accurate, and systematic manner. of feelings Interviews are usually conducted with clients and 2. Health teaching—about medication, nutrition, others to complete the nursing history. Relevant sleep hygiene data for adult patients include: 3. Self-care activities—e.g., relaxation, exercise, 1. Appearance spirituality 2. Presenting problem 4. Somatic therapies—e.g., nursing care of clients 3. Personal and family history receiving ECT 4. Medical and psychiatric history 5. Therapeutic environment—milieu 5. Physical status 6. Psychotherapy (advanced practice role for 6. Mental status Psychiatric-Mental Health Clinical Nurse a. Reaction to interview Specialist [PMHCNS] or Nurse Practitioner b. Behavior (speech, ADL, etc) [PMHNP]) c. Level of consciousness 7. Prescriptive authority & treatment (advanced d. Orientation practice role for PMHNP and in some states e. Intellect PMH-CNS) f. Thought content and process Interventions can be interdependent (other team g. Judgment members must collaborate) or independent (dis- h. Affect cussed and determined with client). i. Mood j. Insight • Evaluation of client responses to nursing action is k. Memory based on client changes in the following: l. Comprehension 1. Cognition 7. Sociocultural status a. Giving up irrational beliefs a. Socioeconomic status b. Making positive self-statements b. Life values and goals c. Improving ability to problem solve c. Social habits—including drinking and 2. Affect drug use a. Decreased anxiety d. Sexual behavior b. Decreased depression e. Social support network c. Decreased loneliness 8. Spiritual status 3. Behavior a. Philosophy and meaning of life a. Adaptive responses b. Sense of oneness or spiritual integrity b. Improved coping skills c. Relatedness to God or higher power c. Improved social skills d. Relatedness to people and nature See Chapter 10 for information regarding assess- • Revisions to plan of care are made as needed and ment of children. the process continues.

• Diagnoses are made according to: • The nursing process and all nursing interven- 1. North American Nursing Diagnosis Asso- tions occur within the context of the nurse–client ciation (NANDA) (See Examples in Clinical relationship. Chapters) 2. Standard classification of mental disorders, Nurse–Client Relationship i.e., The American Psychiatric Association’s Diagnosis and Statistical Manual (DSM IV-TR) • Definition—A dynamic, collaborative, therapeu- or International Classification of Disease tic, interactive process between the nurse and the (ICD-10-CM) client

• Planning provides goals and actions that are: • Purpose—to create a safe climate wherein clients 1. Specific feel free to reveal themselves and their concerns 2. Individualized and feel comfortable to try out new ideas and 3. Collaborative behaviors Communication 13

• Phases of nurse–client relationship (Peplau, 1952) 4. Resistance—client attempts to keep anxiety- 1. Orientation—begin as strangers provoking thoughts and feelings out of aware- a. Client—seeks or is brought in for help; ness by disrupting the interactional process communicates needs and expectations with avoidance, acting out, forgetting, silence, b. Nurse—responds to client; explains pa- lateness, etc. Nursing response is to make ob- rameters of relationship; gathers data; servations and support client in dealing with listens and clarifies areas of concern; anxiety. establishes rapport; negotiates contract 5. Testing behaviors (McMahon, 1992) that establishes frequency and duration of a. Attempting a social relationship sessions, specifies type of work to be done, b. Casting nurse into parental role clarifies fees if any, and lays groundwork c. Assessing whether nurse trusts them for termination d. Attempting to take care of nurse 2. Identification e. Avoiding discussion of problems a. Client—responds to help offered by nurse; f. Asking for personal data explores deeper feelings; identifies with g. Violating personal space nurse and may be dependent, active, and h. Seeking attention from nurse compliant i. Assessing nurse’s commitment b. Nurse—structures relationship to focus on j. Revealing information to shock nurse client and facilitates expression of prob- k. Touching nurse inappropriately lems and feelings; avoids fostering unnec- Nurse must set limits and encourage client to dis- essary dependency; encourages self-care cuss meaning of behavior. 3. Exploitation—working a. Client—more independent in accessing • Psychotherapy—use of relationship and communi- services and working in partnership to cation to change feelings, attitudes, and behaviors interpret behaviors; begins to try out new 1. Supportive—expressing feelings, exploring behaviors choices b. Nurse—supports client and explores feel- 2. Re-educative—learning new ways of belief and ings and problems at client’s pace; deals behavior with resistances, encourages risk taking, 3. Reconstructive—deep emotional and cogni- and facilitates achievement of goals tive restructuring 4. Resolution—termination a. Client—engages in new problem-solving • Clinical supervision—use of more experienced skills and coping behaviors; views self practitioner or peers to “obtain feedback on in- positively and plans for future; may de- terventions and analyze the emotions particular compensate when anticipating separation clients generated; this process allows nurses to b. Nurse—reviews goals and accomplish- be objective about their reactions and to decen- ments; shares own feelings and assists cli- ter emotions” (Delaney & Lettieri-Marks, 1997, ent to express feelings about relationship p. 134) that may interfere with the nurse–client and separation relationship.

• Phenomena that occur in nurse–client Communication relationships 1. Therapeutic use of self-application of nurse’s • Definition—Continuous process by which infor- own personality characteristics within the in- mation is transmitted between people and their teraction to facilitate healing. environment 2. Transference–client experiences emotional reaction towards nurse based on unconscious • Goal—understanding feelings that originated in past relationships. Nursing response is to confront distortions of • Process of communication (See Figure 2-1) reality gently in order to facilitate client self- awareness. • All behavior communicates some message. 3. Countertransference—nurse responds to client with feelings from own earlier conflicts. • Verbal messages include the written and spoken Nurse must increase self-awareness and ac- word. cess supervision to assist in dealing with client more effectively. • Nonverbal messages are observed by the receiver in four ways: Figure 2-1 – Process of Communication 14 Chapter 2 Essentials of Psychiatric Nursing Care

Message sent verbal/nonverbal

Receiver decodes Sender encodes message, interprets message & encodes response

Feedback message sent verbal/nonverbal

Figure 2.1 Process of Communication

Houseman, C. (ed.) (1998). Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.). Sudbury, MA: Jones and Bartlett.

1. Kinesics—body motion, i.e., facial expression, Therapeutic Communication includes: posture, position of arms and legs, eye contact, touch • Active listening or physical attending skills 2. Paralanguage—tone of voice, inflection, em- 1. Comfortable environment—privacy, low noise, phasis, pauses, sighs, laughter soft light 3. Proxemics—use of personal space, territorial- 2. Facing the other person and leaning towards ity, i.e., backing away or moving closer, selec- him/her tion of a particular seating arrangement 3. Open, relaxed posture 4. Appearance—personal image, i.e., clothing, 4. Eye contact makeup, hair, beard • Attitudes and behaviors that build trust and • Nonverbal messages may be congruent with verbal rapport messages or they may conflict with them. 1. Nonjudgmental, positive regard 2. Punctuality • Culture and social class influence perceptions and 3. Honesty values that influence how communication is trans- 4. Respect, acceptance, and confirmation mitted and received. 5. Genuineness, empathy 6. Congruence between verbal and nonverbal • Type of relationship also influences type of behaviors (Johnson, 1997) communication: 7. Stated purpose of interaction 1. Therapeutic communication takes place be- 8. Being unhurried; giving undivided attention tween the nurse and client and focuses on the 9. Being sensitive and responsive to nonverbal client’s thoughts, feelings, behavior, and roles communication with the expectation that the active listening 10. Listening of the nurse will help the client explore, under- 11. Being professional but warm, accepting, sup- stand, and change. portive, and objective 2. Social communication is less goal oriented, 12. Recognizing and accepting culture-specific more superficial, and does not necessarily in- attitudes and behaviors Jones & Bartlettvolve the expectation of help. 13. Using understandableChapter and acceptable No.: 02 75995 - Mosack language Filename: 75995_CH02_F0001.eps • Although nurse–client relationships may involve 14. Being aware of own feelings and how they af- some social communication, the main component fect one’s behavior is therapeutic communication. 15. Being clear that responsibility for action rests with client Cultural & Ethnic Factors 15

16. Helping to develop awareness of conse- feelings, support their goals, and validate quences and alternatives (McMahon, 1997) their reality (McMahon, 1997) c. Termination—expression of feelings about • Communication techniques end of relationship to model appropriate 1. Using broad openings and open-ended behaviors for client questions 2. Clarifying content and feelings Cultural & Ethnic Factors 3. Reflecting content and feelings 4. Confronting content and feelings • Definitions 5. Verifying perceptions 1. Culture—patterns of knowledge, belief, behav- 6. Giving information ior, and custom that are learned by members 7. Providing feedback of a particular society 8. Stating observations 2. Ethnicity—membership in diverse groups ac- 9. Silence cording to race, birthplace, language, culture, 10. Directing or religion 11. Focusing 3. Ethnocentricism—judging others’ behavior by 12. Questioning the values of our own culture 13. Connecting information 4. Cultural relativism—attempting to understand 14. Summarizing the behavior of others within the context of their own culture • Barriers to therapeutic communication 5. Stereotyping—overgeneralizations based on 1. Advice culture or ethnicity; may occur unconsciously 2. Reassurance 3. Being judgmental • Impact of culture on mental health nursing 4. Changing the subject 1. Influences client coping behaviors 5. Excessive questioning/closed-ended questions 2. Defines what symptoms are labeled as illness 6. Challenging 3. Determines explanations for illnesses, e.g., 7. Stereotypical comments may be personalistic or caused by purposeful 8. Self-focusing behavior intervention of others 9. Using emotionally charged words 4. Prescribes taboo topics and behaviors 5. Determines how mentally ill are perceived • Communication with children 6. Prescribes health-seeking behaviors and atti- 1. Introducing to play materials tudes to healthcare providers 2. Encouraging verbalization at own pace 7. Determines types of acceptable treatment 3. Asking questions that are relevant to develop- approaches mental age 8. Influences behavioral expression of mental illnesses resulting in culture-bound illnesses • Result of therapeutic communication is enhanced such as susto, mal ojo (Hispanic), falling out client self-disclosure. (African American), and voodoo 9. Determines distribution of illness, e.g., so- • Nurse self-disclosure can enhance or inhibit thera- matic vs depressive symptoms, male vs female peutic communication depending on its use. Like all interventions, it requires timing and judgment. • Cultural differences according to Tripp-Reimer and Its use, according to Auvil and Silver (1984) de- Lively (1993) pends on: 1. Time—emphasis on present (predominant in 1. Nurse’s theoretical framework—i.e., more African American, Native American, and His- likely to occur if working from a humanist per- panic culture) vs future (predominant in US spective than from a psychoanalytic or behav- and other highly industrialized nations that iorist approach also value schedules) 2. Stage of the relationship 2. Success—doing: people valued for accom- a. Orientation—nurse self-disclosure that plishments (predominant in US) vs being: occurs early in the relationship more likely people valued for being themselves (Chinese to meet nurses’ needs culture) b. Working phase—appropriate if used 3. Relational–collectivist: individual goals are by nurse to hasten therapeutic alliance subordinate to group goals (African American, to help clients learn about themselves Native American, and Hispanic) vs individual- and others, encourage their catharsis of 16 Chapter 2 Essentials of Psychiatric Nursing Care

istic: individual goals are more important than 7. Flexibility—negotiate a treatment plan that group goals (predominant in US) reflects, respects, and incorporates both 4. Nature—people dominant to nature (middle traditional treatment and folk remedies. class US) vs living in harmony with nature (Na- (Campinha-Bacote, 1997) tive American), vs subjugated to nature (Mos- 8. Design culturally responsive programs that are lem cultures) available, accessible, appropriate, acceptable, 5. Verbal communication—volume (Asians speak and adoptable to decrease underutilization of softly), speed and directness (Asians value in- mental health services by ethnic groups. directness); silence interpreted differently by 9. Show respect and acceptance to clients in various cultures ways they understand. 6. Privacy—personal space (Arabic: closer vs US: 10. In completing cultural assessments, nurses further); eye contact (Native Americans prefer should examine the cultural influences of less than predominant US) basic elements of care including (Keltner, Schwecke, & Bostrom, 2007): • Impact of ethnicity on mental health nursing a. Communication (fluency/preferred lan- 1. Metabolism rates, clinical drug responses guage other than English, nonverbal or and side effects found in research to be sig- culturally-related preferences related to nificantly different among racial and ethnic touch, etc.) populations b. Orientation (identification with a specific 2. Field of ethnic pharmacology developed group, following traditions, beliefs, etc.) (Campinha-Bacote, 1997) c. Nutrition (preferred & “feel good” foods, and avoided foods) • Culturally competent nursing care—“care that is d. Views of health—including culturally sensitive to issues related to culture, race, gender based beliefs about mental health/illness, and sexual orientation; this care is provided by how one develops illness, beliefs about nurses who use cultural nursing theory, models what is needed for treatment, and how and research principles in identifying and evaluat- wellness is achieved and “cure” is defined ing the care provided within the cultural context of e. Learning style (preferred method for ob- the clients.” (AAN, 1992) taining information) 1. Be aware of one’s own cultural beliefs and behaviors. Interdisciplinary Treatment & 2. Be culturally aware—have knowledge of cul- the HealthCare Team tural differences. 3. Assess the degree to which the client has as- • Components similated the predominant culture; do not 1. Interdisciplinary treatment utilizes members assume. of different professions who come together to 4. Perform a Cultural Assessment to determine plan and evaluate the treatment of individual from the client and the client’s reference clients. group their emic (native) view of what is con- 2. Each member is considered to have vital input sidered normal and abnormal in both prob- to the treatment plan based on his/her par- lem definition and expectations for treatment ticular area of expertise. and care. 3. The client is also considered to be a member 5. Intercultural communication of the team. a. Adapt activity level, tone of voice, and remarks to the cultural background of the • Goal—targeted interventions, consistently imple- client. mented and evaluated by everyone involved with b. Develop listening skills, observe nonver- the client bal behavior and eliminate barriers to communication. • Attributes of mental health team c. Show respect and acceptance to clients in 1. Strong team commitment ways they understand. 2. Shared responsibility, control, and decision 6. Facilitation skills—negotiate interactions that making may tend to be inconsistent with the value and 3. Common goals and philosophy of intervention belief system of an individual or family from 4. Flattened hierarchy of authority another culture; conflict resolution. 5. Decision making by consensus 6. Open communication 7. Examination of roles and relationships Case Management 17

8. Setting limits on own and others’ behavior in a Client Advocacy nonpunitive way 9. Flexibility, versatility, creativity, and optimism • Definition—interceding on behalf of clients who are unable to speak or act for themselves or are un- • Professions involved with mental health team aware of available options 1. Diet therapy—provides culturally relevant, attractive, nourishing foods with awareness of • Examples psychological importance of food, conflicts 1. Informing clients about treatment alternatives about eating (eating disorders), and drug in- 2. Presenting information to the treatment team teractions with certain foods (MAO inhibitors) 3. Helping clients enter and navigate the health- 2. Expressive therapies care system a. Art—uses artwork of clients to express un- 4. Testifying on behalf of clients in court derlying feelings and conflicts. 5. Promoting respect for mentally ill in policy b. Music—vicarious listening stimulates the and law expression of ideas and emotions verbally; active production of music allows for non- • Guidelines for advocacy according to Boyd and verbal expression. Luetje (1991) c. Psychodrama—explores psychological 1. Make sure client has need for advocacy. conflicts through enactment rather than 2. Check plans with clients and others regarding verbalization. support system. 3. Nursing—establishes and maintains milieu; 3. Get support and information from others with responsible for 24-hour care, activities of daily similar goals. living, and safety; advanced practice psychiat- 4. Present data clearly. ric & mental health nurses may perform indi- 5. Include all pertinent information. vidual, family, or group psychotherapy. 6. Do not use more power than is necessary. 4. Ministry—assists with spiritual care of client 7. Be patient and persistent. and family; may provide marital therapy or pastoral counseling. Case Management 5. Psychiatry—diagnoses and treats conditions amenable to medical treatment; responsible • Definition—assessment for, and coordination of, for admission and discharge; may provide in- individualized, culturally appropriate mental- dividual, group, or family therapy. health, and other health and social services, for 6. Occupational therapy—involves clients in clients and their families or residential care groups meaningful activities and provides vocational rehabilitation if needed. • Goal—improved functioning and empowerment 7. Recreational therapy—assists clients to iden- for clients and cost containment and provider ac- tify appropriate leisure activities. countability for third party payers 8. Psychology—performs diagnostic testing, and provides plans for treatment based on • Types causative factors; may implement individual, 1. Rehabilitative—refers to time-limited services group, or family therapy. provided as part of a private benefit plan with 9. Social work—evaluates family, social, and emphasis on returning client to productivity environmental contributions to problem; 2. Supportive—refers to services provided to may provide family, group, or individual chronically mentally ill clients for as long as psychotherapy. necessary 10. Voluntary agencies—recognized organizations that offer information and support (often • Outcomes provided by peers) to individuals with mental 1. Enhanced communication, education, and health problems and their families: Recovery participation of clients and families Incorporated, Alcoholics Anonymous, Na- 2. Discharge planning that begins at start of tional Alliance for the Mentally Ill, National treatment Depressive and Manic Depressive Association; 3. Early identification of client problems, pos- these agencies may vary depending on locality. sible delays in treatment and barriers to care at both individual and group levels • Nurses may be case managers for clients or cli- 4. Increased communication among providers ent advocates at all levels within the healthcare and reduction of duplication or overlapping system. services (Farnsworth & Biglow, 1997) 18 Chapter 2 Essentials of Psychiatric Nursing Care

• Tools 2. Milieu therapy—scientific planning of the 1. Interdisciplinary Treatment Plans (ITPs)—inte- social and physical environment so that every grate the care of all health care team members; interaction and activity is therapeutic directed by case manager. 3. Therapeutic community—a structured envi- 2. Critical Pathways—identify essential treatment ronment with an established philosophy of interventions that must be performed each care day to meet the expected time-specific cli- 4. Token community—therapeutic community ent outcomes; usually reflects a specific DRG drawn from behavior modification theory; (Farnsworth & Biglow, 1997). uses tokens to reinforce adaptive behavioral 3. Nursing Care Plans—more detailed than ITPs responses; clients can then exchange tokens and more individualized than critical path- for privileges. ways; use NANDA nursing diagnoses and interventions derived from individual assess- • Structured aspects of milieu ment of client. 1. Community meetings 4. Research Based Practice Protocols 2. Daily schedule a. Agency for Health Care Policy and Re- 3. Physical environment search (ACHPR) guidelines for depression 4. Rules and regulations b. Nursing Intervention Classification (NIC) 5. Classes, activities, and groups (Farnsworth & Big-low, 1997) • Unstructured aspects of milieu Psychiatric Liaison Nursing 1. Daily interactions among clients 2. Interactions between clients and staff • An advanced practice psychiatric and mental health nurse (Clinical Nurse Specialist), as mem- • Characteristics of successful milieu ber of the healthcare team, provides direct care, 1. Effective interaction between and among staff including psychotherapy, to individuals, groups, and clients and families as well as consultation to nursing and 2. Norms that provide predictability and security other hospital staff, around client, unit, or institu- 3. Patient government using democratic process tional issues. 4. Patient’s active responsibility for own treatment and for treatment of others • Liaison nurses use knowledge about “systems, 5. Fostering growth in direction of increased change, organizations, problem solving, stress, recognition of strengths and personal crisis, interpersonal relationships, communica- empowerment tion, and sociocultural concepts” (Walker & Price- 6. Encouragement of self-awareness, risk taking, Hoskins, 1992, p. 267). See Chapter 11 for more and change information. 7. Confrontation of misperceptions, destructive behavior, and poor judgment Milieu 8. Links with client’s family and significant others 9. Links with community NOTE: Although the primary focus of psychiatric hospitalization has evolved to that of crisis sta- • Nurses’ role in milieu bilization, the nursing role in creating and main- 1. Creation and maintenance of milieu taining a therapeutic environment is important. 2. Physical care and assurance of safety Because all treatment environments affect patient a. Assessing, reinforcing and promoting cli- care and outcomes, information about milieu ther- ent’s ability to perform activities of daily apy is presented here and within the mental disor- living (ADLs)—eating, bathing, dressing, ders chapters, as a cue to all psychiatric nurses to etc. value the elements of a therapeutic environment b. Assessment of physical illness or reactions regardless of setting, whether inpatient, residen- to medications tial, outpatient, or community. c. Assessment of detoxification reactions in chemically dependent • Definitions d. Assessment of self- or other-directed de- 1. Therapeutic environment—physical and psy- structive behavior chosocial surroundings as an integrated, inter- (1) Providing for surveillance—observa- related whole acting as the treatment agent in tions every 15 minutes a variety of settings (Watson, 1992) (2) Ensuring safety in physical environment (Greene, 1997) Principles of Prescriptive Authority 19

3. Medication administration and education measure of safety/toxicity of a drug (e.g., 4. Attitude therapy—active friendliness, passive with small differences between toxic and friendliness, kind firmness, no demand effective doses, lithium has a low thera- 5. Modeling healthy behavior as participant in peutic index). community b. Examples of receptor mechanisms 6. Intervening to influence attitudes, behaviors, include: and relationships in therapeutic way as de- (1) Agonists—drugs that activate recep- scribed by Greene (1993): tors; can be full, partial or inverse a. Clarifying and correcting perceptions of (2) Antagonists—drugs that block recep- current stressors tors sites, generally retuning the re- b. Identifying thoughts and feelings evoked ceptor conformation back to the same by stressors state that exists without an agonist c. Examining how thoughts and feelings in- present—can be competitive (with ag- fluence behavior onist for receptor) or noncompetitive d. Evaluating the extent to which coping be- 5. Pharmacogenetic research goals include haviors are adaptive or effective identification of variant alleles that alter e. Identifying alternative adaptive coping pharmacokinetics and pharmacodynamics; strategies and why patients differ in the way drugs are f. Testing of identified alternative coping metabolized. strategies in milieu • Principles of prescribing Principles of Prescriptive 1. General guidelines (Buppert, 2008) Authority (for advanced practice a. Prescribe the right drug at the right time psychiatric & mental health (PMH) for the right indication for the right nursing) person. b. Follow the practice protocols/guidelines • Prescriptive authority and treatment is a function for prescribing at the site of advanced of advanced practice PMH nurses as granted by nursing practice. federal and state law (nurse practice act) in the c. Before prescribing, obtain the following jurisdiction of nursing practice (ANA, APNA, ISPN, information: 2007). Most state laws involve advanced practice (1) Known allergies nurses writing prescriptions through a collabora- (2) Other prescribed, over-the-counter, tive relationship with a physician or under del- and herbal preparations the patient is egated authority from a physician (Buppert, 2008). currently using (3) For female patient, ascertaining the • Principles of pharmacotherapy (Sadock & Sadock, possibility of pregnancy (see Table 2007; Stahl, 2008) 2-1) and/or breastfeeding—obtain 1. Pharmacology—the study of what drugs do appropriate laboratory testing as and how they do it indicated 2. Psychotropic medications—drugs used to (4) Any liver or kidney dysfunction, other treat psychiatric conditions (also called health condition that can affect ab- psychotropics) sorption, distribution, metabolism, or 3. Pharmacokinetics—“what the body does to excretion of drug the drug”—includes absorption, distribution, (5) Any cardiac condition, suicide/ metabolism, and elimination homicide ideation, symptoms of 4. Pharmacodynamics—“what the drug does psychosis, mania/hypomania to the body” (desired effect and adverse side (6) Personal or familial experiences with effects)—site of action (target organs/systems) the medication (what worked/did not including receptors, ion channels, enzymes, work, side effects experienced, and and carrier proteins tolerability of adverse side effects) a. Pharmacodynamic considerations include d. Address any contraindications, cross- receptor mechanisms, dose-response sensitivities, and drug interactions. curve, development of tolerance, de- e. Inform patient of potential adverse ef- pendence and withdrawal; includes fects and ask whether patient wants to mechanism of action and therapeutic accept risk of side effects (documentation index (TI)—TI is the ratio of median toxic advised). dose to median effective dose—a relative 20 Chapter 2 Essentials of Psychiatric Nursing Care

Table 2-1 Food & Drug Administration (FDA) Pregnancy Categories

Category Definition A Controlled studies in humans have demonstrated no risk. B Animal trials show no risk; no evidence of risk in 2nd or 3rd trimester. C Human risk unknown and cannot be ruled out. D Positive risk to fetus; must weigh benefit to pregnant women vs fetal risk. X The drug is contraindicated in women who are or may become pregnant.

NOTE: FDA has proposed revision of current pregnancy labeling (eliminating A through X labeling). The proposed labeling would include: a summary of fetal risk, clinical considerations (dosing, risks of not treating, & complications), as well as data upon which the recommendations are made. A summary of the proposed rule is available at: http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/ Labeling/ucm093310.htm

f. Inform patient when to call/return if ad- • Controlled substances (see Table 2-2) verse change in condition occurs. 1. The federal government, through the Drug g. Other considerations include: Enforcement Administration (DEA) oversees (1) Affordability of medication(s) prescribing of controlled substances and the prescribed granting of license to providers for the purpose (2) Inclusion of drug on formulary for of prescribing. the agency or health maintenance 2. Certain conditions must exist before the ad- organization vanced practice PMH prescribes controlled (3) Potential for abuse of the medi- substances. cation (e.g., methylphenidate, a. State law in the jurisdiction of practice benzodiazepines) must allow prescription of controlled substance by the advanced practice nurse.

Table 2-2 US Drug Enforcement Administration—Schedule of Controlled Substances

Schedule Description Examples I Substance has a high potential for abuse, has no heroin, LSD, marijuana medical use in the US, and has a lack of accepted safety for use under medical supervision. II Substance has a high potential for abuse, has a amphetamine, codeine, currently accepted medical use in the US with dextroamphetamine, hydrocodone, severe restrictions, and abuse may lead to severe methadone, oxycodone (OxyContin) psychological or physical dependence. III Substance has a potential for abuse less than codeine with aspirin, II, has currently accepted medical use in the acetaminophen/hydrocodone US, and may lead to moderate or low physical (Vicodin) dependence or high psychological dependence. IV Substance has a low potential for abuse as benzodiazepines (e.g., alprazolam, compared to Schedule III, has currently accepted lorazepam, oxazepam), medical use in the US, and abuse may lead to phenobarbital, zolpidem (Ambien) limited physical and psychological dependence. V Substance has a low potential for abuse atropine, buprenorphine as compared to Schedule IV, has currently (Buprenex), Lomotil, codeine/ accepted medical use in the US, and abuse has guaifenesin (Robitussin A-C) a narrow scope for physical and psychological dependence. Family Therapy 21

b. The advanced practice nurse must be Theories and Practice of registered with the DEA, have applied Individual Psychotherapy— for, and been granted license to prescribe See Chapter 3 controlled substances as evidenced by provision of a DEA number, which must be used on all prescriptions for scheduled Family Therapy drugs. • Background Mental Health Education 1. Treatment modality that theorizes that the presenting problem displayed by the client • Definition—imparting of knowledge to clients and with psychiatric symptoms (identified patient) families is the result of pathology throughout the entire family system. • Goals according to Walker and Price-Hoskins 2. This family dysfunction is due to imbalances (1992) in the system, generally caused by conflict 1. Offering information about the illness and between the marital partners. This conflict interventions is expressed unconsciously by the following 2. Helping people recognize symptoms behaviors: 3. Teaching people when and how to intervene a. Triangling—another family member is for themselves brought in, in order to stabilize the emo- 4. Offering relief from blame and guilt tional process. 5. Clarifying family expectations b. Scapegoating—another family member is 6. Instilling confidence that change can occur blamed. 7. Developing an objective perspective and 3. Result of these behaviors is psychiatric balance symptoms.

• Methods of Learning • Therapeutic goals 1. Lecture 1. Assisting family members to identify and ex- 2. Discussion press their thoughts and feelings 3. Modeling 2. Resolving conflict between marital partners to 4. Observation decrease need for triangling and scapegoating 5. Experiential methods 3. Assisting parents in working together and a. Role playing strengthening their parental authority b. Behavioral rehearsal 4. Clarifying family expectations and roles 6. Coaching 5. Practicing different, more constructive meth- 7. Audio or video recorded presentation ods of interacting 8. Computer-aided instruction 9. Self-instruction • Techniques used in family therapy according to a. Keeping a diary Hogarth (1993) b. Monitoring thoughts, feelings, and 1. Joining—finding similarities and matching behaviors family’s behaviors; respecting their values and hierarchies • Guidelines for teaching adult learners 2. The family history 1. Assess knowledge base. a. Data are gathered beginning with the par- 2. Increase awareness of need for learning. ents’ initial relationship and include each 3. Encourage self-direction. family member in chronological order. 4. Encourage learners to apply material to what b. Information may be recorded in a geno- they already know. gram that maps out significant events and 5. Use mode of learning most useful to the relationships over three generations of the learner, i.e., auditory, visual, or kinesthetic. family. 6. Repeat as often as necessary, changing and c. History taking takes focus off identified combining methods and modes as required. patient and emphasizes the family as a 7. Accommodate teaching to the client’s capacity whole. for learning and attention span, both of which 3. Encouraging interactions and relationships may be affected by illness. a. The family, or specific family members, are instructed to discuss a pertinent issue. 22 Chapter 2 Essentials of Psychiatric Nursing Care

b. Therapist clarifies and interprets the fam- • Therapeutic factors of groups (Yalom, 2005) ily’s communication. 1. Instillation of hope c. Individuals are required to speak for them- 2. Universality selves in expressing feelings and concerns 3. Imparting information rather than allowing others to speak for 4. Altruism them. 5. Corrective recapitulation of primary family d. Family members are asked to share re- group sponsibility for resolution of problems 6. Development of socializing techniques instead of laying blame. 7. Imitative behaviors 4. Experiential activities 8. Interpersonal learning a. Homework—tasks assigned by the thera- 9. Group cohesiveness pist, which when enacted by the family 10. Catharsis members further the therapeutic process; 11. Existential factors completion or failure to complete the task is discussed at the next session. • Descriptors of groups b. Paradoxical prescription—instructions are 1. Homogeneous—members chosen from prese- given to perform the opposite of what is lected criteria, e.g., sexually abused women intended in order to produce change. 2. Heterogeneous—mix of individuals regarding c. Sculpting—enactment of an experience diagnosis, sex, age, etc. with words omitted that when “frozen’’ is 3. Mixed—sharing an essential feature, i.e., same a symbolic representation of the family diagnosis but varying sex, age, etc. members’ relationships; by asking a fam- 4. Closed—after group begins, no new members ily member to rearrange the “sculpture,” are added change is modeled. 5. Open—members and leaders change 5. Results in family therapy are measured by the degree to which families are moved from • Types of groups dysfunctional to functional patterns. Opti- 1. Task—emphasis on accomplishing what needs mal family functioning according to Hogarth to be done (1993) includes: 2. Teaching—imparting information, i.e., orien- a. Open systems orientation tation to unit b. Clear boundaries 3. Supportive/therapeutic—helping others who c. Positive links to society share same experience cope with stress and d. Contextual clarity overcome dysfunction, e.g., bereavement, e. Clear and congruent communication weight loss f. Strong parental coalition 4. Psychotherapy—emphasis on person reducing g. Appropriate power distribution intrapsychic stress, changing behavior, ideas, h. Autonomous persons etc.; may follow a variety of theoretical frame- i. Warm, caring affective tone works, e.g., Psychoanalytic, Transactional j. High self-esteem of members Analysis, Rational Emotive, Rogerian, Gestalt, k. Efficient negotiation and task Interpersonal, Bion; advanced practice role performance 5. Psychoeducational—structured group in- l. Transcendent values of hope and altruism volving teaching, with member disclosure of related thinking and behavioral problems, Group Dynamics & Group and homework to put learned information Process Theory and skills into practice, e.g., groups for family members of the chronically mentally ill and • Background assertiveness training groups 1. Groups are complex human systems whose 6. Peer support group—sharing stresses related whole is greater than the sum of their parts. to common situation, e.g., hospice nurses 2. Individuals can learn, grow, and change more 7. Multiple family—teaching about disease pro- in groups due to opportunities for feedback cess and utilizing group process to understand and consensual validation. mental health issues; may also refer to a group 3. Nurses who participate in groups or advanced modality in which the therapist works with practice psychiatric and mental health nurses one family while other families watch and who serve as group therapists are aware of the learn vicariously powerful forces harnessed by group work. Ethical Considerations 23

• Basic roles of therapist (Yalom, 2005) for structure and approval. Leader describes 1. Technical expert group contract (i.e., goals, confidentiality, and 2. Model setting participant communication rules), encourages interaction among group, and maintains working level of • Group dynamic issues according to Long and anxiety. Members develop initial roles. McMahon (1992) 2. Storming—Conflict develops regarding con- 1. Rank—position member holds in relation to trol, power, and authority. Anxiety increases other members of the group; members who and resistance may occur as evidenced by participate frequently and actively usually client absence, shared silence, excessive de- rank high in the group and thus have greater pendency on leader, scapegoating, excessive influence on group behavior hostility toward leader, formation of sub- 2. Status—prestige given to certain positions or groups and acting out. Leader encourages individuals in a group; members vie for status healthy expression of anger. in group; may be due to member characteris- 3. Norming (cohesiveness stage)—Members ex- tics or behavior press positive feelings toward one another and 3. Group content—what is said in a group, i.e., feel strongly attracted to group. Self-disclosure information discussed occurs and new roles are adopted. 4. Group process—activities in a group, i.e., how 4. Performing (working phase)—Leader’s activity interactions occur among members, timing decreases and usually consists of keeping the of interactions, roles of members, seating ar- group on course or dealing with resistance of rangements, tone of voice of members, and group and individuals within. Responsibility nonverbal behaviors for group is more equally shared. Anxiety of 5. Sociogram—method of recording group process group is decreased, and energy is channeled to completing tasks. • Group process issues 5. Mourning (termination)—Begins during first 1. Style of leader phase but is most acutely felt in closed group a. Autocratic—leader is in charge and when it approaches end and in open group controls. when members or leaders leave. Leaders en- b. Democratic—leader shares responsibility courage discussion of ending and expression of with members. pain and loss experienced in grieving process. c. Laissez Faire—leader is nondirective. Members may try to avoid, experience anxi- 2. Roles of members ety, anger, or regression; they should also be a. Building or maintenance roles—contrib- encouraged to reminisce, evaluate, and experi- ute to group process and functioning, e.g., ence sense of accomplishment and give feed- encourager, gatekeeper, harmonizer. back to one another (Lasalle & Lasalle, 1991). b. Task roles—emphasize completing the task, e.g., initiator, opinion giver, evalua- • Transference and countertransference also occur tor, energizer, information seeker. in groups and may be dealt with by group mem- c. Individual roles—not related to group bers as well as leaders. tasks or maintenance and may inhibit group, e.g., aggressor, dominator, help- E thical Considerations seeker, playboy, special-interest pleader, blocker. • Ethics—branch of philosophy that deals with morality • Therapeutic group norms (Yalom, 2005) 1. Self-monitoring—assuming responsibility for • Ethical theories or perspectives according to Sellin own functioning (1991) 2. Self-disclosure 1. Egoism—the right act is the one best for 3. Procedural norms—spontaneous, interactive oneself. 4. Group importance to members 2. Utilitarianism—the right act promotes the 5. Members as agents of help greatest good for the greatest number. 6. Support 3. Deontology or formalism—the right act is 7. Working in the here and now established by use of ethical principles as follows: • Group development stages (Tuckman, 1965) a. Autonomy—individuals are respected for 1. Forming (orientation)—Group leader is more themselves and should have control over directive and active, members look to leader their own choices whether or not these 24 Chapter 2 Essentials of Psychiatric Nursing Care

are in their best interest or agree with c. Clients can wear their own clothes and our opinions. If someone decides what is keep their own personal effects excluding best for another it is termed paternalism. dangerous objects and valuables that can- Children, the mentally retarded, and the not be protected. mentally ill are often thought not to be d. Clients, who with support can live in the competent enough to be autonomous. community, should be discharged to out- b. Beneficence—promoting the good of oth- patient care. ers and preventing them from harm e. Seclusion and restraint can only be uti- c. Nonmaleficence—responsibility to do no lized when therapeutically necessary, harm; many suggest that it is more im- and where all other methods have failed portant to avoid harm than to do good. to control violent behavior toward self or Some interpret it as a person’s duty to pre- others. vent someone else from harming a third 4. Right to informed consent person. a. Voluntary permission can be given by a d. Justice—distribution of resources, benefits competent client after procedures to be and burdens fairly among members of a performed have been explained and are society understood. Ethical principles may conflict with one another so b. Clients often sign forms on admission that that it is difficult to determine which act produces cover psychiatric treatment. the most good. c. Commitment procedure gives hospital the From ethical principles client rights have been right to treat involuntary patients. specified. d. Written consent must be obtained for ECT and experimental drugs. • Right—a just claim that is due an individual or 5. Right to refuse treatment group: rights may be established by policies and/ a. Clients, including committed patients or protected by laws. Important patient rights in in nonemergencies, may not be forcibly psychiatric nursing include: medicated. 1. Right to privacy b. Guardians can give permission or a court a. Confidentiality—no information can be order can be sought for incompetent shared about client, including fact of hos- clients. pitalization or whether in therapy. c. If patient is violent toward self or others b. Privileged communication—in five states and all less restrictive methods have failed, court may not legally mandate nurses to patients (including those who have been give information obtained in a profes- voluntarily admitted) may be forcibly sional capacity (Stuart & Sundeen, 1991); medicated. does not apply to patient records. d. Nurses must know the laws in their c. Exceptions: state and assure adequate written (1) Tarasoff—if therapist is reasonably documentation. certain that a client is going to harm 6. Right to habeas corpus—committed clients someone, must breach confidentiality may at any time petition the court for release and inform potential victim. on the grounds that they are sane. (2) Possible child abuse—many states 7. Right to independent psychiatric examina- mandate that cases be reported to tion—clients may demand evaluation by phy- authorities. sician of own choice and must be released if (3) Guardianship or involuntary commit- determined to be not mentally ill. ment hearings—clinical information 8. Right to outside communication must be shared. a. Clients may have visitors, write and re- 2. Right to treatment—patients cannot be held ceive letters, make and receive phone against their will without an individualized calls, including those to judges and treatment plan and certain other standards of lawyers. care specified by law. b. The hospital can limit times for phone 3. Right to treatment in least restrictive setting calls and visitors and deny access when a. Clients who are not dangerous cannot be visitors could cause harm to clients or hospitalized against their will. staff. b. Clients capable of functioning on an open 9. Right to be employed if possible—clients can- ward should not be held in a locked ward. not be forced to work, and if they choose to as part of therapy, must be paid minimum wage. Questions 25

Questions street. Which of the following items on the mental status exam would the nurse NOT mark Select the best answer “impaired”?

1. According to traditional definitions of mental a. Behavior health, which of the following would the nurse b. Judgment be most likely to describe as mentally healthy? c. Memory d. Affect a. Jerry Jones, a Viet Nam veteran with no family ties, who has been unemployed for 10 6. Which of the following is NOT necessary for the years nurse to make a spiritual assessment? b. Tom Sarris, a CEO, who spends 14 hours at a. Assure that the client has a religious work each day and is too tired to do any- affiliation. thing with his family on weekends b. Determine if client believes in a higher c. George Connors, a shoe salesman who power. delights in playing affectionately with his c. Evaluate the client’s relationship to others. children but has been unable to hold a d. Determine the client’s philosophy of life. steady job since they were born d. Sam Thomas, a restaurateur who loves his 7. Which of the following interventions would be work, but sets limits on the hours he spends labeled as an independent nursing intervention there in order to enjoy his family and friends on a psychiatric unit? 2. Which of the following would be described as a. Giving medications a component of mental health according to b. Making discharge plans Johnson? c. Deciding privileges d. Assuring safety a. Refusing to be involved in any relationship that limits independence 8. The staff of a day treatment program have b. Absence of anxiety under any circumstances determined that all clients must participate in a c. Dependence on friends and family to assist group outing to a local museum because all of with crises the staff want to see the exhibit. Two women d. Ignoring cues from the environment when clients in the group voice their opposition to deciding what to do visiting the museum because they do not wish to risk being identified as psychiatric clients by 3. In helping a client change, the nurse should: others in the community. The staff refuse to a. Encourage the client to move rapidly to listen to their concerns and insist that they go avoid delay on the trip, but do not describe any particular b. Realize that the problems the client is facing reason. Which adjective describes the type of will make him or her eager to change goal planning evident in this situation? c. Encourage feelings of hope a. Specific d. Understand that change is a natural process b. Individualized that never involves anxiety and fear c. Collaborative 4. In facilitating change the nurse should: d. Authoritarian a. Avoid deliberate goal-directed activity since 9. Which of the following behaviors would indicate this will inhibit the process a good client response to a nursing action? b. Restrict clients to few choices to avoid over- a. The client’s body is noticeably less tense and whelming them he or she has stopped pacing. c. Give up if resistance is encountered b. The client stops interacting with others on d. Form a helping relationship and collaborate the unit. with clients c. The client states “If I don’t do what people 5. John Korman is a 36-year-old male recently want they won’t like me.” admitted to a psychiatric unit. The nurse taking d. The client refuses to listen to feedback from his history observes that his speech is slurred, other members of the community. and he states that he cannot remember where 10. A nurse brings a client the Clozapine medica- he has been for the past 12 hours, but the tion that she has been taking. The client does police who brought him in stated that he was not look well and complains of a sore throat. arrested driving the wrong way on a one-way The nurse notes that her temperature is elevated 26 Chapter 2 Essentials of Psychiatric Nursing Care

and concludes that the client has an upper d. Comment on her observations and assist respiratory infection. After giving the client Sarah to understand her behavior. the medication, she states that she will ask the 15. Jim, a 14-year-old client, is discussing his drug doctor for a PRN aspirin order. The doctor orders abuse problem with his nurse. When she asks a CBC and determines that the client has agranu- him to clarify the types of substances he rou- locytosis. At which step of the nursing process tinely uses, he responds by saying “How about did this nurse’s problem begin? you, have you ever used marijuana?” How a. Diagnosis should the nurse respond? b. Planning a. “That’s none of your business, Jim, now let’s c. Intervention get back to your problem.” d. Revision of plan b. “Why, yes I have, but I was older and more 11. Which of the following is NOT true of the Reso- responsible.” lution or Termination phase of the nurse–client c. “As you recall, Jim, we agreed to work on relationship? your problems with drugs in our sessions. I wonder what concerns you about whether I a. Preliminaries for this phase are introduced in have used drugs.” the Orientation phase. d. “That’s an inappropriate question. I don’t b. Talk about the impending separation should have to answer that and wonder why you’d be avoided so that the client does not even ask it.” decompensate. c. The client should be encouraged to review 16. According to the Communication Process, at the his progress and goals. end of the feedback loop, the sender becomes d. The nurse should model appropriate expres- the receiver. sion of feelings. a. True 12. Which of the following statements would the a. False nurse NOT make in negotiating a contract with 17. Which of the following statements is true con- the client within the nurse–client relationship? cerning communication? a. “I would like to meet with you on a once a a. Some behavior is random and does not com- week basis while we are trying to resolve this municate a message. crisis.” b. The message sent by the sender is obvious b. “We need about 10 sessions to work on this and does not have to be interpreted by the problem.” receiver. c. “I have malpractice insurance in case there is c. The main goal of communication is any problem.” understanding. d. “We will not be exploring your past, but only d. The only real form of communication is the looking at things that are going on now.” verbal message, either written or spoken. 13. In a session with the nurse, the client begins 18. Sobbing and grunting would be forms of what to whine about his inability to complete his kind of nonverbal messages? assigned task from the previous session. The nurse responds by scolding him for his failure. a. Kinesics This is an example of: b. Paralanguage c. Proxemics a. Transference d. Appearance b. Countertransference c. Transference and Countertransference 19. Terry Barr is describing to the nurse that he sees d. Goal setting himself as extremely patient and laid back. As he speaks, he drums his fingers on the arm of 14. Sarah has been at least 10 minutes late for each the chair. What can the nurse infer from this of her previous sessions. Today she arrives 20 communication? minutes late. The nurse should: a. Terry is obviously lying and trying to fool the a. Express anger towards Sarah. nurse. b. Confront Sarah firmly and set limits on her b. Terry’s verbal and nonverbal communications behavior. are not congruent. c. Discuss terminating their sessions if she con- c. Terry is in touch with his feelings and tinues this pattern. expressing them openly and honestly. Questions 27

d. Terry’s culture is interfering with his ability to c. The nurse–client relationship was in the communicate. working phase. d. The nurse–client relationship was in the ori- 20. As they are walking down the hall, the nurse and entation phase. client are discussing their favorite movies. This is an example of: 25. Susan, a new graduate, has recently joined the staff of an inner-city mental health clinic. She is a. Social communication shocked at some of the parenting behaviors of b. Therapeutic communication her initial client and tells other clinicians that she c. Inappropriate communication thinks her client should know better. How could d. Lack of communication her attitude be labeled? 21. Which of the following would be the best a. Stereotyping example of an open-ended question? b. Culturally relativistic a. How did you come to be in the hospital? c. Ethnocentric b. Did your husband bring you over to the d. Culturally deprived hospital? 26. Susan finds herself frustrated when her client c. Who brought you to the hospital? uses some money she receives to buy winter d. When did you come into the hospital? coats for her nephews instead of saving it to 22. Adrienne has just finished describing how buy a car so she could commute to a better job. devastated she was at the recent loss of her Susan’s client is demonstrating which cultural mother. Which of the following responses by values? the nurse would NOT be a barrier to therapeutic a. Present oriented, individualistic communication? b. Future oriented, individualistic a. “I know how you feel. I lost my mother c. Present oriented, collectivist recently, too.” d. Future oriented, collectivist b. “Well, it’s better to have loved and lost, if 27. A Middle Eastern client comes to the nurses’ you know what I mean.” station and stands face to face less than a foot c. “When did she die? Of what? Does anyone away from the nurse. The nurse should be aware else in your family have that problem?” that: d. “It sounds like it’s been a really tough period for you.” a. The client is becoming aggressive and trying to intimidate the nurse. 23. Timmy, a 6-year-old, is accompanying his parents b. The client has a different sense of personal to a family therapy session to deal with his space than the predominant American school phobia. Which of the following behaviors culture. by the nurse would NOT constitute therapeutic c. The client is testing the nurse and needs to communication skills with a child? be confronted. a. “Let’s pick out some toys from the closet d. The client is being seductive with the nurse. to play with while I talk to your Mom and 28. An Asian American client arrives for her first Dad.” session with the nurse. She speaks softly and b. “What do you like best about school, Timmy? avoids discussion of her problem directly. The What do you like least?” nurse should: c. “Tell me about the picture you drew of your family.” a. Understand that she has low self-esteem and d. “Is there something that makes you anxious suggest that they work on this problem. about going to school, Timmy?’’ b. Realize that this behavior is due to extreme guilt and shame and indicates a secret that 24. In a peer supervision group a nurse is discussing needs disclosing. a recent self-disclosure to a client. The group is c. Be aware that this is defensive behavior most likely to question the appropriateness of and probably foreshadows a great deal of the behavior if: resistance. a. The nurse has been using a humanistic theo- d. Understand that this is culturally appro- retical approach. priate behavior and should be respected and b. The nurse–client relationship was in the ter- mirrored. mination phase. 28 Chapter 2 Essentials of Psychiatric Nursing Care

29. In a well-functioning mental health team who is 35. Jerry Coleman is a 46-year-old client with Bipolar the most important member? Disorder who has recently had an exacerbation of his manic symptoms. He has been referred for a. The doctor appropriate services to a psychiatric and mental b. The nurse health advanced practice nurse by his disability c The psychologist insurance company. What kind of services might d. The client he expect to receive from his case manager? 30. Which of the following characteristics is most a. A thorough evaluation of his case and coor- indicative of success in a mental health team? dination of all services a. A team leader with a decisive authoritarian b. Referral for medication evaluation and approach maintenance b. A set of firm rules and regulations to cover c. Referral for vocational rehabilitation if most situations that could arise necessary c. Many diverse philosophies of treatment d. Weekly reports to his boss concerning the d. Open communication details of his disability 31. The goal of Art therapy and Music therapy is: 36. Sharon Getty has been admitted to a neurological unit with a complaint of chronic pain. She a. To assist clients in passing time in the hos- has been referred to the psychiatric and mental pital productively. health advanced practice nurse who functions as b. To teach clients a new skill or hobby. the Psychiatric Liaison Nurse for that unit. Which c. To evaluate clients for possible job training. might be a response of the liaison nurse? d. To stimulate the expression of feelings. a. Discussion with R.N.s on the unit about the 32. Which of the following is not a responsibility of need for them not to talk with the client the generalist nurse? about the emotional components of her pain a. Psychotherapy b. Avoiding talking with the client’s family b. 24-hour care because they will probably be upset to learn c. Milieu management that they might be contributing to the cli- d. Safety ent’s problems with pain c. Realizing that individual psychotherapy with 33. Which of the following is most true about a the client is the role of the psychiatrist psychiatric and mental health advanced practice d. Referring the client to occupational therapy nurse who testifies in court on behalf of a child if appropriate who has been sexually abused? 37. Which of the following is NOT true? a. The nurse is functioning as an advocate for the child. a. Milieu therapy implies that all activity is b. The nurse is functioning as a case manager therapeutic. for the child. b. A therapeutic environment cannot exist c. The nurse is exceeding her capabilities as a without community meetings. psychiatric and mental health advanced prac- c. Token communities use privileges to reward tice nurse. appropriate behavior. d. The nurse is functioning as a Psychiatric d. The physical environment is an important Liaison Nurse. part of the milieu. 34. Of the following advocacy guidelines, which is 38. To which of the following values would the true? nurse working within the therapeutic milieu probably NOT subscribe? a. All clients are in need of advocacy as provided by the nurse. a. The need for accessible team members and b. Joining forces with other groups with similar cooperative working relationships goals should be avoided since this leads to a b. Empowerment of clients and staff to make large group that is difficult to handle. decisions that affect the group c. The maximum power possible should be c. Emphasis on the individual at the expense of brought to the task to ensure the maximum the group benefit. d. Encouragement of risk taking and growth d. Patience and persistence are important char- 39. Carmine d’Angelo is a 29-year-old client with a acteristics of successful client advocates. diagnosis of Schizophrenia, Paranoid Type. When Questions 29

he is denied off-unit privileges at a community its residents. The psychiatric and mental health meeting, he becomes hostile and accuses certain advanced practice nurse decides to begin an community members of “having it in for me.” ongoing Resocialization Group since many of What would be the most appropriate response the clients have been pretty much isolated from of the nurse? others in their previous living situations. How would such a group be classified? a. Ignore the behavior because it is inappropriate. a. Homogeneous, closed ended b. Confront Mr. D’Angelo with his inappro- b. Heterogeneous, open ended priate behavior and put him in seclusion. c. Open ended, task c. Meet with him at their usual time and clarify d. Closed ended, psychotherapy his misperceptions. 44. Ann and John lose their first child to Sudden d. Ask the community members that he accused Infant Death Syndrome. They decide to attend a to have nothing more to do with him. hospital-sponsored group for people who have 40. What types of things would the nurse NOT work had this experience. What type of group will on with Mr. D’Angelo over the next few sessions? they be attending? a. How his thoughts and feelings influence his a. Teaching group behavior b. Psychotherapy group b. Whether or not his behavior at the previous c. Task group community meeting achieved his purpose d. Supportive/Therapeutic group c. What other coping strategies might be more 45. A psychiatric and mental health advanced prac- effective tice nurse working as a group psychotherapist d. Who seems to be “most out to get” him makes observations about the effective way 41. In a therapy group, a client makes inappropriate members handled a participant who was acting demands of the psychiatric and mental health out in the group. What type of leadership style advanced practice nurse who is the group thera- does this nurse exhibit? pist. The psychiatric and mental health advanced a. Autocratic practice nurse responds assertively and effec- b. Democratic tively resolves the problem to the satisfaction of c. Laissez faire all concerned. What curative factor, according to d. Materialistic Yalom does this situation exemplify? 46. After a particularly difficult community meeting, a. Altruism the staff of a unit sit down and begin to talk b. Catharsis about which clients were seated in close prox- c. Interpersonal Learning imity and who agreed with whom on the issues d. Universality that came up. What is the staff discussing? 42. Mrs. C. S. is an extremely shy individual who was a. Gossip admitted to the hospital with a depressive dis- b. Rank and Status order. What characteristics of therapy groups will c. Group Content best serve her needs? d. Group Process a. The realization that no one else in the group 47. A nursing group has convened to make deci- has anything like the problem she has sions about renovation plans for a psychiatric b. The fact that two members of the group unit. One of the members is discussing how little are talking constantly without interruption the hospital ever pays attention to input from will protect her from feeling like she must nursing staff. Which member role is this partici- participate. pant exhibiting? c. The experience of being left alone by other group members will protect her autonomy a. Maintenance role and decrease her performance anxiety. b. Task role d. The fact that others support one another c. Individual role in learning to change will encourage her to d. Gatekeeper role take the risks needed to grow. 48. A psychiatric and mental health advanced 43. A psychiatric and mental health advanced practice nurse has had several meetings with a practice nurse is called in as a consultant to a therapy group. On this particular occasion it is nursing home seeking to enhance the morale of noted that members seem angry with the nurse 30 Chapter 2 Essentials of Psychiatric Nursing Care

and each other. They seem to be competing with 53. A psychiatric and mental health advanced prac- each other to see who can refrain from breaking tice nurse is the family therapist for a family the silence longest. Which stage of group devel- whose youngest child is the identified patient. opment do these behaviors signify? The child has been brought in for therapy because he has been doing poorly and acting out a. Storming at school. How will the nurse begin the initial b. Norming session with the family? c. Performing d. Mourning a. By asking the child why he is doing poorly in school 49. A psychiatric and mental health advanced prac- b. By asking the parents why they think he is tice nurse notes that members of her therapy doing poorly at school group have become most supportive of one c. By asking each family member how they did another and very attached to the group. Which in school stage of group development do these behaviors d. By asking questions about the family in signify? general a. Forming 54. In working with the family, the nurse finds that b. Storming the child is waking many times during the night c. Norming and climbing into the parents’ bed. Which of the d. Performing following would the nurse probably NOT use as 50. Whose responsibility is it to deal with transfer- an intervention in this situation? ence issues in group therapy? a. Suggesting that one of the parents sleep in a. The nurse the child’s room so everyone can get a good b. The group members night’s sleep c. The nurse and the group members b. Encouraging the parents to work together to d. The group member who is involved in the set limits on the child’s sleeping in their bed transference c. Asking the parents to talk together about how they will handle the situation when the 51. How should a member terminating be handled child wakes up in the night in groups? d. Encouraging each member of the family to a. Little attention should be paid to it since talk about his/her feelings in the matter this person is now ready to leave and other 55. The nurse suggests that if the child cannot sleep, members are more in need of assistance. that he play a cassette tape on his recorder b. Members may discuss it if they wish, but and try to listen to as many cassettes as he can, should be allowed to avoid it if it causes making sure that he gets out of bed, so that he anxiety. does not fall asleep in the process. This interven- c. Members should be encouraged to focus tion is known as: only on the positive aspects of the leaving so that negative feelings do not arise. a. Homework d. Members should be encouraged to express b. Paradoxical prescription whatever feelings arise in the process of c. Sculpting leaving. d. Triangling 52. Which of the following best summarizes the 56. The nurse also asks the parents to keep a record family therapist’s position on how mental illness of the number of nights the child stays in his occurs? own room and to reward him with a treat if he can do it three nights in a row. This intervention a. The symptomatic person is the innocent is known as: victim of other members of the family. b. If other family members are given education a. Homework and support, they can help the symptomatic b. Paradoxical prescription person. c. Sculpting c. The symptomatic person is the result of d. Triangling pathology throughout the entire family 57. A family with extremely rigid boundaries will system. probably NOT have: d. If other family members set limits and confront the symptomatic person with reality, a. Positive links to society they can help him or her. b. Clear boundaries Questions 31

c. Strong parental coalition 62. A mother brings her adolescent son in to be seen d. Efficient negotiation and task performance by a psychiatric and mental health advanced practice nurse. The mother wishes to hospitalize 58. Members of a therapeutic community decide the boy. She indicates that she can no longer at a community meeting that it is not right for control his behavior and that he is dating girls of two extremely demanding clients to determine whom she does not approve and staying out past the activities for the entire group. This deci- his curfew. Based on the boy’s right to treatment sion can best be classified under which ethical in the least restrictive setting, what is the psychi- perspective? atric and mental health advanced practice nurse’s a. Egoism best response? b. Utilitarianism a. Determine the most secure facility to hospi- c. Deontology talize the child because he is probably a “run d. Formalism risk.” 59. When the nurse asks potentially suicidal clients b. Seek a Day Treatment Program since the to relinquish any sharp objects they have in child’s behavior is not dangerous. their possession, which ethical principle is being c. Offer to work with the mother and son in utilized? regard to appropriate expectations and discipline. a. Autonomy d. Tell the mother that all adolescents act that b. Beneficence way and that she is wrong to be upset about c. Nonmaleficence this normal behavior. d. Justice 63. Leroy Jones was committed to an inpatient 60. A government agency doing a security check psychiatric unit because of hallucinations that on an individual calls a psychiatric and mental have not been controlled by oral medications health advanced practice nurse seeking informa- prescribed on an outpatient basis. In the hos- tion about any mental health problems that the pital, Mr. Jones has been prescribed I.M. Prolixin. individual might have. What initial response is When the nurse brings the first injection, Mr. the best for the psychiatric and mental health Jones refuses the medication. What is the nurse’s advanced practice nurse? best immediate response in this situation? a. Turn all written records over to the a. Talk with Mr. Jones about his objections to investigators. the medication. b. Submit a treatment summary describing the b. Tell Mr. Jones that he cannot refuse the med- client’s problems. ication since it is necessary for his treatment. c. Write a report that describes the cli- c. Call his doctor and tell him/her that Mr. ent’s problems in the least damaging way Jones has refused the medication. possible. d. Call an emergency team to restrain Mr. Jones d. Refuse to acknowledge that the client is in while the medication is being given. therapy until a release of information form is signed by the client. 64. Which of the following is NOT an accurate statement regarding client rights? 61. A psychiatric and mental health advanced practice nurse has been treating a client for several a. Committed clients may petition the courts months. Recently the client has become increas- for release. ingly agitated and expressed a great deal of b. Committed clients may demand an evalua- hostility towards his ex-wife. At their last session, tion by any physician. the client described a detailed plan to kill her c. Committed clients may not have letters and kidnap his children. What is the psychiatric restricted. and mental health advanced practice nurse’s d. Committed clients may not be hospitalized response? involuntarily. a. Call the client’s ex-wife and inform her that 65. A nurse who is unaware of standards of care she may be in danger. and fails to provide care that results in harm to b. Call the police and discuss the case with the client is not subject to being charged with them. malpractice. c. Consult a lawyer about the case. a. True d. Preserve the client’s right to confidentiality. b. False 32 Chapter 2 Essentials of Psychiatric Nursing Care

66. The parents of an autistic child consult a psy- c. A standard of practice granted to advanced chiatric and mental health advanced practice practice nurses by federal and state law nurse about their failure to relate to their child. d. The singular function of advanced practice The nurse decides that some education would psychiatric nurse practitioners be helpful to this family in dealing with the 70. In the mental health setting, the best prescribing problem. What could the family NOT expect practice includes: to receive as a result of the nurse’s teaching intervention? a. Assessing thoughts of harm to self or other b. Writing patient’s height and weight on all a. An objective perspective prescriptions b. Decreased blame and guilt c. Selecting the appropriate medication for the c. Clarification of expectations identified patient d. A solution to their problems d. Both a and c are correct 67. In an assertiveness group, a nurse encourages a client to role play a distressing interaction she Answers has had repeatedly with her mother-in-law. The nurse has the client play herself while the nurse 1. d 36. d plays the mother-in-law. Which methods of 2. c 37. b learning are exemplified in this situation? 3. c 38. c a. Lecture 4. d 39. c b. Experiential 5. d 40. d c. Self-instruction 6. a 41. c d. Audio presentation 7. d 42. d 68. Alice Walsh is a 46-year-old admitted to a psy- 8. d 43. b chiatric unit with Major Depression. Her doctor 9. a 44. d prescribes an MAO inhibitor that she will be 10. b 45. b taking when she leaves the hospital in four 11. b 46. d days. Her nurse wants to teach her about the 12. c 47. c side effects of her medication, particularly the 13. c 48. a dietary restrictions. She prepares a 45-minute presentation that covers everything about the 14. d 49. c medication. Afterwards Mrs. Walsh seems con- 15. c 50. c fused and still cannot relate several essential 16. a 51. d facts about the medication. What is the best 17. c 52. c nursing response to the situation? 18. b 53. d a. Phone the doctor and suggest that Mrs. 19. b 54. a Walsh be placed on another medication with 20. a 55. b fewer restrictions. 21. a 56. a b. Realize that Mrs. Walsh will probably not be 22. d 57. a able to understand the essentials regarding 23. d 58. b her medication and teach a relative instead. 24. d 59. b c. Realize that Mrs. Walsh’s depression is prob- 25. c 60. d ably inhibiting her ability to learn and repeat 26. c 61. a the presentation in a few days when she is a little better. 27. b 62. c d. Break down the essential facts into a few 28. d 63. a brief sessions that can be repeated over the 29. d 64. d next several days and assess Mrs. Walsh’s 30. d 65. b knowledge of the previous session before 31. d 66. d proceeding. 32. a 67. b 69. Prescription writing is: 33. a 68. d 34. d 69. c a. A standard of practice granted to nurses by the American Medical Association 35. d 70. d b. A standard of practice granted to all nurses by the American Nurses Association Bibliography 33

Bibliography Lasalle, P. C. & Lasalle, A. J. (1991). Small groups and their therapeutic forces. In G. W. Stuart & S. J. Sun- American Academy of Nursing Expert Panel Report. deen (Eds.), Principles and practice of psychiatric (1992). Culturally competent nursing care. Nursing nursing (pp. 809–826). St. Louis, MO: Mosby Year Outlook, 40(6), 277–283. Book. American Nurses Association (ANA), American Psy- Long, P., & McMahon, A. L. (1992). Working with groups. chiatric Nurses Association (APNA), & International In J. Haber, A. McMahon, P. Price-Hoskins & B. Siede- Society of Psychiatric-Mental Health Nurses (ISPN). leau (Eds.), Comprehensive psychiatric nursing (pp. (2007). Psychiatric-mental health nursing: Scope and 324–346). New York, NY: Mosby-Year Book. standards of practice. Silver Springs, MD: Author. McMahon, A. L. (1997). The nurse-client relationship. Auvil, C. A., & Silver, B. W. (1984). Therapist self-disclo- In J. Haber, B. Krainovich-Miller, A. L. McMahon, & sure: When is it appropriate? Perspectives in Psychiat- P. Price-Hopkins (Eds.), Comprehensive psychiatric ric Care, 22(2), 57–64. nursing (pp. 143–159). St. Louis, MO: Mosby. Boyd, M. A., & Luetje, V. M. (1991). Nursing advocacy in Peplau, H. (1952). Interpersonal relations in nursing. mental health settings. In R. B. Murray & M. M Huel- New York, NY: G. P. Putnam. skoetter (Eds.), Psychiatric mental health nursing: Sellin, S. R. (1991). Ethical issues in psychiatric mental Giving emotional care (pp. 731–748). Norwalk, CT: health nursing. In G. K. McFarland & M. D. Thomas Appleton and Lange. (Eds.), Psychiatric mental health nursing (pp. 943– Buppert, C. (2008). Nurse practitioner’s business practice 949). Philadelphia, PA: J. B. Lippincott. & legal guide (3rd ed.). Sudbury, MA: Jones & Bartlett. Shanks, S. R. (1991). Legal issues in psychiatric mental Campinha-Bacote, J. (1997). Understanding the influ- health nursing. In G. K. McFarland & M. D. Thomas ence of culture. 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Price Hoskins (Eds.), Comprehen- tal health-psychiatric nursing: A holistic life-cycle sive psychiatric nursing (pp. 318–331). St. Louis, MO: approach (pp. 166–179). New York, NY: Mosby-Year Mosby. Book. Greene, J. A. (1997). Milieu therapy. In B. S. Johnson Tuckman, B. W. (1965). Developmental sequences in (Ed.), Psychiatric and mental health nursing: Adapta- small groups. Psychology Bulletin, 63, 384–389. tion and growth (pp. 221–231). Philadelphia, PA: J. B. Walker, M., & Price-Hoskins, P. (1992). Role of the nurse Lippincott. in psychiatric settings. In J. Haber, A. McMahon, Greene, J. (1993). Milieu therapy. In B. S. Johnson P. Price-Hoskins and B. Siedeleau (Eds.), Comprehen- (Ed.), Psychiatric-mental health nursing: Adapta- sive Psychiatric Nursing (pp. 267–287). New York, NY: tion and growth (pp. 183–193). Philadelphia, PA: J. B. Mosby Year Book. Lippincott. Watson, J. (1992). Maintenance of therapeutic com- Hogarth, C. R. (1993). Families and family therapy. 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3 Major Theoretical Frameworks for Psychiatric Nursing

Theory practice. An example is Rogers’ Theory of Nursing. • Definition—a set of concepts, definitions, and b. Inductive theory construction proceeds propositions, used to describe, explain, predict, or from the specific to the general. The theo- control a phenomenon rist or investigator immerses himself/ herself in the data and attempts to gener- • Characteristics ate theoretical statements. An example is 1. Can interrelate concepts in such a way as Orem’s Theory of Self-Care (Riehl & Roy, to create a different way of looking at a 1980). phenomenon 2. Theory serves to: 2. Must be logical in nature a. Guide research—the theory sets limits on 3. Should be relatively simple, yet generalizable questions to ask and methods to pursue in 4. Can be the basis for hypotheses that can be research. tested b. Guide practice—after validation from 5. Contributes to and assists in increasing the research, theory can give direction to general body of knowledge within the disci- practice. pline through the research implemented to c. Provide a common language between validate it practitioners and researchers. 6. Can be utilized by the practitioners to guide d. Enhance professional autonomy and and improve their practice accountability—theory, supported by 7. Must be consistent with other validated theo- research, allows the nurse to predict con- ries, laws, and principles, but will leave open sequences of care, contributing to autono- unanswered questions that need to be investi- mous nursing practice (Meleis, 1985). gated (George, 1990) Evidence-based Practice (EBP) • Theory and research 1. Theory is constructed through deductive or EBP involves clinical decision making based on the inductive approaches best practice evidence, emphasizing disciplined a. Deductive theory construction proceeds research. A nurse engaged in EBP is adept at ac- from the general to the specific. The theo- cessing, evaluating, synthesizing, and using new rist or investigator borrows concepts from research evidence (Polit & Beck, 2010). Evidence other bodies of knowledge and tests the hierarchies are used to rank the strength of evi- concepts and relationships in nursing dence from the lower level (expert opinion) to the

35 36 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

highest level (systematic reviews of randomized variable, and uses control and experimental control trials that include meta-analyses). groups. 2. Quasi-experimental—variable may be ma- • Systematic reviews can be accessed through the nipulated but subjects not assigned randomly following: to control and treatment groups. 1. Cochrane Database of Systematic Reviews 3. Nonexperimental—researcher measures vari- (CDSR) – www.cochrane.org/reviews/ ables as they occur naturally; uses correlations 2. Agency for Healthcare Research and Quality to determine nature and extent of relationship (AHRQ) – www.ahrq.gov between and among variables; includes prospective and retrospective. • Other pre-appraised evidence 4. Qualitative—researcher makes observa- 1. Clinical Practice Guidelines – available at: tions or interviews participants. Data used www.guideline.gov to describe process or phenomenon—most common forms are phenomenological and • Models of EBP include the following: ethnographic. 1. Iowa Model 5. Case study—researcher describes and analyzes 2. Ottawa Model one or a small number of cases. 3. Stetler Model • Research instruments—may measure physical or Research psychological characteristics. Often questionnaires are used that must be evaluated for the following: • Definition—Systematic method of gathering data 1. Reliability—ability to measure the same trait that provides means of developing and testing repeatedly theories as well as measuring outcomes of nurs- 2. Validity—ability to measure what it is sup- ing interventions in the clinical area. Participation posed to be measuring in research is a Psychiatric Mental Health Nursing Standard of Practice recognized by the American • Statistical data analysis (McCrum-Gardner, 2007; Nurses Association (ANA), American Psychiatric Polit & Beck, 2008, 2010; Polit & Hungler, 1991) Nurses Association (APNA), and International So- 1. Descriptive—means, medians, modes, stan- ciety of Psychiatric-Mental Health Nurses (ISPN) dard deviation (ANA, APNA, ISPN, 2007). 2. Inferential statistics—to test hypotheses and decide if relationship between variables is • Researcher roles for nurses supported 1. Principal investigator a. Testing differences between two group 2. Coinvestigator means 3. Member of research team (1) t-Tests for independent samples 4. Data collector (2) Paired t-Tests 5. Client advocate b. Testing differences between three or more 6. Evaluator of research findings groups 7. User of research outcomes in evidence-based (1) ANOVA practice (2) Kruskal-Wallace test 8. Problem-area identifier (3) Mann Whitney U (4) Friedman test • Research process c. Comparing differences between cases that 1. Determine problem. fall into categories—Chi Square (x2) test 2. Review relevant literature. d. Testing the relationship between two 3. Identify a theoretical framework. variables 4. Determine the research variables. (1) Pearson product moment correla- 5. Formulate hypothesi(e)s. tion (r) 6. Select research instruments. (2) Spearman’s rho 7. Collect data. (3) Kendall’s tau 8. Analyze data. e. Multivariate statistics 9. Determine results and conclusions. (1) Multiple regression analysis—to understand the effects of two or more • Types of research independent variables on a depen- 1. Experimental—experimenter uses random dent measure sampling, manipulates the independent Nursing Theories 37

(2) Stepwise multiple regression—all 2. Self-care deficit—the inability to provide com- potential predictors considered simul- plete self-care; the need for nursing care. Nurs- taneously to determine the combina- ing care includes the following: tion of variables providing the most a. Entering into and maintaining nurse– predictive power patient relationships (3) Analysis of covariance—used statisti- b. Assessing how patients can be helped cally to control one or more extrane- c. Responding to patients’ requests and ous variables; useful to adjust for needs initial differences in situations where d. Prescribing, providing, and regulating di- random assignment is impossible rect help (4) Factor analysis—reducing a large set e. Coordinating and integrating nursing with of variables into a smaller set of re- other services lated variables 3. Nursing systems refer to the amount of nurs- 3. Level of significance—the probability of a paring care a patient requires. Categories are as ticular result occurring by chance follows: a. Wholly compensatory—the nurse pro- • Protection of human subjects vides all care. 1. Right to informed consent—may be more b. Partly compensatory—the nurse and pa- complicated with psychiatric clients due to tient provide care. nature of illness c. Supportive-educative—the patient pro- 2. Right to confidentiality (privacy of data) and vides care. The nurse promotes the patient anonymity (privacy of source of information) as a self-care agent (Foster & Janssens, 3. Right to refuse to participate or withdraw at 1990). anytime • Theory of Goal Attainment (Imogene King) Nursing Theoretical Models King describes her theory of goal attainment within an open systems framework. Developed around four core concepts 1. The three systems in the framework are as (metaparadigm): follows: a. Personal systems—each individual is a • Individual—the person or client in need of nursing personal system. care b. Interpersonal systems—the interaction among human beings • Environment—the combination of all forces that c. Social systems—an organized boundary affect an individual system of roles, behaviors, and practices 2. The theory of goal attainment states that • Health—a state of well-being people come together to help and be helped to maintain health. Concepts of the theory are as • Nursing—the discipline and practice of assisting follows: others to maintain or recover health (George, 1990; a. Interaction—goal-directed Fawcett, 1984) communication b. Perception—organizing, processing, stor- Nursing Theories ing, and exporting information c. Communication—information given from • Theory of Self-Care (Dorothea Orem) one person to another 1. Self-care—an individual’s activities to main- d. Transaction—observable behaviors of tain life, health, and well-being. Self-care people interacting with their environment requisites are actions directed toward the pro- e. Role—set of behaviors expected of a per- vision of self-care. The three categories of self- son occupying a certain position care requisites are: f. Stress—an energy response to a stressor a. Universal—activities of daily living g. Growth and development—continuous b. Developmental—specialized activities re- changes that take place in life lated to a developmental task or an event h. Time—a sequence of events moving to the c. Health deviation—activities required by future illness, injury, or disease i. Space—physical area; territory (George, 1990) 38 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

• Theory of Nursing (Martha Rogers) (1) Physiological function mode—identi- 1. The phenomenon central to nursing is the life fies patterns of physical functioning. process of human beings. (2) Self-concept mode—identifies pat- 2. Assumptions of Rogers’ theory: terns of values, beliefs, and emotions. a. The human being is a unified whole pos- (3) Role function mode—identifies pat- sessing his/her own integrity and mani- terns of social interactions. festing characteristics that are more than (4) Interdependence mode—identifies and different from the sum of his/her patterns of human value, affection, parts. love, and affirmation. b. The person and environment are continu- d. Output: ally exchanging matter and energy with (1) Adaptive response, or each other. (2) Ineffective response c. The life process revolves irreversibly and 2. The goal of nursing—the promotion of adap- unidirectionally along the space–time tive responses in relation to the adaptive continuum. modes d. Pattern and organization identify indi- 3. Health—a process of being and becoming an viduals and reflect their wholeness. integrated person e. The human being is characterized by the 4. Environment—conditions, circumstances, and capacity for abstraction and imagery, influences affecting the growth and behavior language and thought, sensation, and of a person emotion. 5. The Nursing Process: 3. Building blocks of Rogers’ theory: a. First-level assessment—behavioral assess- a. Energy field—an electrical field in a con- ment; assessment of four adaptive modes tinuous state of flux b. Second-level assessment b. Openness—energy fields are open to ex- (1) Identification of focal, contextual, and change with other energy fields. residual stimuli c. Pattern—energy fields have patterns that (2) Identification of ineffective responses change as required. c. Identification of nursing diagnosis d. Four dimensionality—energy fields are d. Goal setting with the client embedded in a four-dimensional space– e. Implementation—manipulating focal, time matrix. contextual, or residual stimuli 4. Principles of homeodynamics are built upon f. Evaluation—assessment of goal behaviors the five assumptions and four building blocks: and possible readjustment of goals and a. Integrality—the continuous, mutual, si- interventions (Galbreath, 1990) multaneous interaction between human and environmental fields • Theory of Culture Care Diversity and Universality b. Resonancy—the identification of human (Madeleine Leininger) and environmental fields by changing 1. The main tenet of the theory is that “care is the wave patterns essence of nursing and the central, dominant, c. Helicy—the evolving innovative repattern- and unifying focus” (Leininger, 1991, p. 35). ing growing out of the mutual interaction 2. Other concepts include: of man and environment (Rogers, 1983; a. Culture—the learned, shared, and trans- Falco & Lobo, 1990) mitted values, beliefs, norms, and lifeways of a group that guide their actions and • The Adaptation Model (Sister Callista Roy) decisions There are five essential elements of the model: b. Cultural care diversity—differences in 1. Each person is an adaptive system with in- meanings, patterns, values, or symbols of put, internal processes, adaptive modes, and care, within or between collectivities re- output. lated to human care expressions a. Input—internal or external stimuli c. Cultural care universality—uniform mean- b. Internal processes—coping mechanisms ings, patterns, or symbols that are mani- (1) Regulator subsystem—chemical, neu- fest in many cultures and reflect ways to ral, and endocrine transmitters help people (2) Cognator subsystem—perception, d. Cultural and social structure dimen- information processing, judgment, sions—patterns of structural and orga- emotion nizational factors of a particular culture, c. Adaptive modes or system effectors including: Personality Theories 39

(1) Religious factors (3) Perceived self-efficacy—the personal (2) Social and kinship factors evaluation of capacity/ability to orga- (3) Political and legal factors nize and execute healthy behavior (4) Economic factors (4) Activity-related affect—a subjective (5) Educational factors assessment of the positive or nega- (6) Technological factors tive emotional consequence of the (7) Cultural values behavior (8) Ethnohistorical factors (5) Interpersonal influences—health be- e. Ethnohistory—past facts, events, and ex- havior cognitions related to the beliefs periences of individuals, groups, cultures, and attitudes of others—including or institutions that are people-centered norms (expectations of others), social and that describe, explain, and interpret support (encouragement), and vicari- human lifeways within a certain culture ous models (watch what others do) f. Cultural care preservation or mainte- (6) Situational influences—circumstances nance—actions and decisions that help that can facilitate or impede health people retain relevant cultural care values behavior to maintain well-being, recover from ill- (7) Commitment to a plan of action—in- ness, and face handicaps or death tention to implement health behavior g. Cultural care accommodation or negotia- (8) Immediate competing demands and tion—actions and decisions to help people preferences that can affect health of a designated culture negotiate for a behavior beneficial outcome with health caregivers (a) Competing demands—alternative h. Cultural care repatterning or restructur- behaviors over which the person ing—actions and decisions to help clients has little control, such as work modify their lifeways for beneficial health and child-care responsibilities care, while respecting their cultural values (b) Competing preferences—alter- and beliefs native behaviors over which the i. Cultural congruent nursing care—actions person has high control, such as and decisions tailored to fit cultural values having a chocolate bar rather than and beliefs (Leininger, 1991) a carrot for a snack. c. Behavioral outcomes that involve: • Health Promotion Model (Nola Pender) (1) Health promoting behavior—outcome 1. The Health Promotion Model (HPM) builds measure of behavior; directed toward on theories of social learning (Bandura) and attaining positive health outcome of reasoned action and planned behavior such as optimal well-being, personal (Fishbein; Ajzen). The HPM describes the mul- fulfillment, and productive living. tidimensional interactions between the environment and persons in the pursuit of health. • Interpersonal Relations/Psychodynamic Nurs- A main focus of the model is promotion of ing (Peplau)—See Chapter 2 - Nurse–Client preventative health behaviors—to optimize Relationship health and prevent/limit the infirmities of disease (Pender, Murdaugh, & Parsons, 2005). Personality Theories 2. The HPM focuses on the following three areas: a. Individual characteristics and experiences (Corsini & Wedding, 2008; Seligman, 2006) that involve: (1) Previous health-related behavior • Psychoanalytic/Psychodynamic (Sigmund Freud) (2) Personal factors (biological, psycho- concepts in the theory of Freud include the logical, and sociocultural) following: b. Behavior-specific cognitions and affect 1. Levels of awareness that involve: a. Conscious—thoughts, feelings, and de- (1) Perceived benefits of action—positive sires a person is aware of and able to outcomes that will occur with health- control related behavior b. Preconscious—thoughts, feelings, and de- (2) Perceived barriers to action—antici- sires that are not in immediate awareness pated, imagined, or actual blocks that but can be recalled to consciousness inhibit execution of behavior 40 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

c. Unconscious—thoughts, feelings, and 5. Treatment—psychoanalysis: desires that are not available to the con- a. Daily therapy sessions are conducted for scious mind several years. 2. Stages of development—according to Freud, b. The patient reveals thoughts, feelings, each person passes through the following dreams, etc. stages of psychosexual development. A person c. The therapist reveals no personal informa- can get stuck in any stage: tion, functioning primarily as a shadow a. Oral—the focus is on sucking and swal- figure. The therapist interprets the pa- lowing, gratification of oral needs tient’s behavior for him or her. b. Anal—focus on spontaneous bowel movements, control over impulses • Psychoanalysis (Carl Jung) c. Phallic—focus on genital region, identifi- The major concepts of Jung’s theory are as follows: cation with parent of the same gender 1. Archetype—unconscious, intangible collective d. Latency—focus on coping with the envi- idea, image, or concept; Scroggs (1985) de- ronment; sexual impulses dormant fines the main archetypes identified by Jung as e. Genital—focus on erotic and genital be- follows: havior, developing mature sexual and a. The Way—the image of a journey or voy- emotional relationships age through life 3. Personality structure—the personality has b. The Self—the aspect of mind that unifies three main components: and orders experience a. Id—the pleasure principle; unconscious; c. Animus and Anima—the image of gender desire for immediate and complete satis- d. Rebirth—the concept of being reborn, res- faction; disregard for others urrected, or reincarnated b. Ego—the reality principle; rational and e. Persona—the role or mask one shows to conscious; weighing of actions and others consequences f. Shadow—the dark side of one’s personality c. Superego—the censoring force of the per- g. Stock characters—dramatic roles that ap- sonality; conscious and unconscious; evalu- pear over and over in folktales ating and judging behavior (Scroggs, 1985) (1) Hero—the character who vanquishes 4. Several terms common to psychiatric nursing evil and rescues the downtrodden originated with Freud, including: (2) Trickster—the character who plays a. Oedipus complex or Electra conflict—at pranks or works magic spells the age of 4 or 5, the child falls in love with (3) Sage—the wise old person the parent of the opposite sex and feels h. Power—symbol, such as the eagle or the hostility toward the parent of the same sword sex. i. Number—certain numbers that reappear b. Defense mechanisms—conscious or un- throughout history and across cultures conscious actions or thoughts to protect 2. Psychological types—Jung described two the ego from anxiety (See Table 3-1). attitudinal and four functional types of c. Freudian slips—also known as para- personalities: praxes—overt actions with unconscious a. Attitudinal types meanings (1) Introvert—oriented toward the inner, d. Free association—a method for discover- subjective world ing the contents of the unconscious by (2) Extrovert—oriented toward the outer, associating words with other words or external world emotions b. Functional types e. Transference—feelings, attitudes, and (1) Thinking—intellectual process involv- wishes linked with a significant figure in ing ideas one’s early life projected onto others in (2) Feeling—evaluative function involv- one’s current life ing value or worth f. Countertransference—feelings and at- (3) Sensing—function involving recogni- titudes of the therapist projected onto the tion that something exists, without patient inappropriately categorizing or evaluating it g. Resistance—anything that prohibits a (4) Intuiting—function involving creative person from producing material from the inspiration, knowing without having unconscious the facts (Scroggs, 1985) h. Fixation—getting stuck in one stage of de- 3. Collective unconscious velopment (Scroggs, 1985; Drapela, 1987) Personality Theories 41

Table 3-1 Defense Mechanisms

Type Defense Mechanism Definition Denial Avoiding the reality of a painful/anxiety-producing situation by refusing to acknowledge it Primitive Projection False attribution of the person’s own undesirable feelings, thoughts, and impulses onto others (splitting is a form of projection) Fantasy Symbolic fulfillment of wish or impulse with irrational thought Identification Conscious/unconscious modeling of characteristics of an idealized/ respected person Introjection Unconsciously taking on another person’s values/traits and becoming like that person Immature Regression Unconsciously returning to an earlier, more comfortable level of development to avoid emotional discomfort Somatization Transferring emotional distress to bodily symptoms (pains and other ailments) Undoing Conscious behavior to cancel out an unacceptable action that has already been done (heightened superstitiousness) Displacement Shifting of feelings from an emotionally charged person or object to a substitute, less threatening, person or object Dissociation Unconscious separation from emotional pain through temporary but drastic modification of character or sense of personal identity Intellectualization Reasoning or logic used in attempt to avoid intimacy and confrontation with objectionable impulse or affect Neurotic Isolation Splitting or separating of affect from the rest of a person’s thinking Rationalization Using logical or acceptable, but incorrect, reasons or excuses for behavior that is unacceptable to one’s self-image—can be conscious or unconscious Reaction formation Substitution of behavior, thoughts, and feelings diametrically opposed to unacceptable ones Repression Considered to be the basis for all defense mechanisms—unconscious exclusion of ideas, feelings, and situations that are unacceptable to the self Compensation An individual consciously making up for a perceived lack in one area by emphasizing strengths in another Sublimation Conscious/unconscious channeling of unacceptable impulses to a primary goal that is socially acceptable Suppression Conscious exclusion of thoughts, feelings, and situations that produce Mature discomfort and some anxiety (active forgetting) Altruism Conscious use of service to others; doing good for others to reduce or avoid negative feelings about self Humor Using comedy to assuage emotions without producing discomfort for self or others—wit is a form of displacement that deflects emotion onto others

(Fitch & O’Brien-Pallas, 1991; Keltner, Schwecke, & Bostrom, 2007; Sadock & Sadock, 2007; Wheeler, 2008)

• Theory of Individual Psychology (Alfred Adler) 3. Complexes: Adler saw individuals in a social context; he is con- a. Inferiority complex—an inability to solve sidered a social–interpersonal theorist by some. life’s problems Key ideas include: b. Superiority complex—an exaggerated 1. Inferiority feelings as the source of all human opinion of one’s abilities and accomplish- strivings ments, a result of the attempt to overcom- 2. Personal growth as resulting from the attempts pensate for an inferiority complex to compensate for inferiority 4. The goal of life—to strive for superiority 42 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

5. Lifestyle—the unique set of behaviors created c. Preschooler (3–6 years) by each individual to compensate for inferior- Initiative—focus on genital needs, pur- ity and achieve superiority pose, task-orientation vs 6. The influence of birth order Guilt—denial, inhibition, showing off, self- a. First-born—happy and secure, the center righteous psychosomatic disease of attention, until dethroned by the sec- d. School-age (6–12 years) ond child; develops interest in authority Industry—focus on socialization, compe- and organization tence, perseverance vs b. Second-born—born into a more relaxed Inferiority—inadequacy, self-restriction, atmosphere; has the first-born as a model, conformity or a threat to compete with; develops in- e. Adolescent (13+ years) terest in competition Identity—focus on search for self, ideal- c. Youngest child—pet of the family; may ism, confidence vs retain dependency (Schultz, 1987; Adler, Identity diffusion—delinquency, psycho- 1983) sis, overidentification with heroes, cliques f. Young Adult • Theory of Basic Anxiety (Karen Horney) Intimacy—focus on human closeness, Because of her focus on family, some consider sexual fulfillment, love vs Horney a social–interpersonal theorist. Concepts Isolation—distancing behaviors, self- include: absorption, character problems 1. A child has two basic needs—safety and g. Middle Aged Adult satisfaction. Generativity—focus on productivity, cre- 2. When those needs are not met, the child feels ativity, guiding next generation vs hostility. Stagnation—lack of faith, obsessive need 3. The child represses the hostility, and this leads for pseudointimacy, early invalidism to basic anxiety. h. Older Adult 4. Basic anxiety is a pervasive feeling of being Integrity—emotional and spiritual integra- lonely or helpless in a hostile world tion, fellowship with others, leadership vs 5. Protective mechanisms against basic anxiety Despair—disgust, fear of death (Erikson, in relationships include: 1963; Whiting, 1997) a. Moving toward people b. Moving against people • Theory of Cognitive Development (Jean Piaget) c. Moving away from people Piaget’s stages of development are: 6. Neurosis—compulsive and unconscious 1. Sensory-Motor Period—0 to 2 years extension of maladaptive childhood mecha- a. Stage I—0 to 1 month—no distinction nisms (Scroggs, 1985; Wilson & Kneisl, 1992) between self and outer reality; characterized by reflexive, uncoordinated body Theories of Growth and movements. Development b. Stage II—1 to 4 months—response patterns begin to be formed; the baby’s fist • Theory of Psychosocial Development (Erik Hom- finds its way into his or her mouth. burger Erikson) c. Stage III—4 to 8 months—response pat- 1. The term used in naming each stage identifies terns are coordinated and repeated the conflict to be resolved during that stage. intentionally. 2. In each stage, the individual has a particular d. Stage IV—8 to 12 months—more coor- focus and a task, which results in adaptive or dinated responses ensue; child pushes maladaptive characteristics: obstacles aside, searches for vanished a. Infant (0–2 years) objects. Trust—focus on oral needs, acquisition of e. Stage V—12 to 18 months—behavior pat- hope vs terns are deliberately varied, as if to ob- Mistrust—withdrawal (schizoid or serve different results; groping toward a depressive) goal emerges. b. Toddler (1.5–3 years) f. Stage VI—18 months to 2 years—behavior Autonomy—focus on anal needs, acquisi- patterns are internalized; symbolic repre- tion of skill vs sentation emerges. Shame and doubt—low self-esteem, secretiveness, persecution Existential/Humanistic Theories 43

2. Pre-operational Period—2 to 7 years—char- 1982). Gilligan has not yet described stages of de- acterized by egocentric thinking expressed in velopment in females. artificialism, realism, and magic omnipotence a. Pre-conceptual Stage—2 to 4 years—con- Social/Interpersonal theory ceptualization begins to emerge, represented in language, drawings, dreams, and • Theory of Interpersonal Development (Harry Stack play. Sullivan—the basis of H. Peplau’s work) b. Perceptual or Intuitive Stage—4 to 7 Sullivan focuses on behavior as interpersonal. Ma- years—prelogical reasoning appears, jor concepts include: based on appearances; trial and error may 1. Self-system—a construct built from the child’s lead to discovery of correct relationships. experience, made up of reflected appraisals 3. Concrete Operations Period—7 to 11 years— from the approval or disapproval of significant characterized by thought that is logical and others reversible; the child understands classes, rela- 2. Two basic drives that underlie behavior: tionships, and part-whole relationships deal- a. The drive for satisfaction—basic physi- ing with concrete things. ological drives, e.g., hunger 4. Formal Operations Period—11 years to b. The drive for security—a sense of well- adulthood—characterized by the develop- being and belonging ment of logic and reasoning and second-order 3. Anxiety—any painful feeling or emotion that thoughts, that is, thinking about thoughts arises from social insecurity or blocks to satis- (Pulaski, 1971). faction; characteristics of anxiety are: a. Interpersonal • Theory of Moral Development (Lawrence b. Can be described; can be observed in Kohlberg) behavior The stages of moral development are: c. Attempts to reduce anxiety 1. Level I—external standards 4. Security operations—measures are taken by a. Stage 1—avoidance of punishment; the individuals to reduce anxiety, e.g., selective punishment or power of others deter- inattention. mines what is right and wrong. 5. Mental illness—self-system interferes with b. Stage 2—desire for reward or benefit; ac- ability to attend to basic drives. tion is based on getting something in re- 6. Therapy is based upon the belief that by ex- turn, in satisfying gratification. There is a periencing a healthy relationship with the sense of fairness and reciprocity, but not a therapist, the patient can learn to build better sense of loyalty, gratitude, or justice. relationships. Therapy is an active partnership 2. Level II—conventional order based on trust (Sullivan, 1953). a. Stage 3—anticipation of disapproval of others, or “good boy–nice girl” orientation; Existential/Humanistic there is conformity to expectations of ap- theories propriate behavior, seeking approval. b. Stage 4—anticipation of dishonor; behav- The theorists focus on experience in the here and ior is oriented toward respecting authority, now, with little attention to the past. maintaining social order, and obeying social rules for their own goodness. • Client Centered Therapy (Carl Rogers) 3. Level III—principled morality The key concept is that people can become fully a. Stage 5—social contract, legalistic orienta- functioning persons when they are uncondi- tion; behavior is oriented toward the belief tionally valued. that justice flows from a social contract 1. The attributes of the therapist: that assures equality for all. Behavior is a. Congruence—inner feelings match outer geared toward rules and legalities. actions. b. Stage 6—universal ethical principles b. Unconditional positive regard—the thera- orientation; behavior is oriented toward pist sees the client as a person of intrinsic universal, ethical abstract principles worth, likes the client, and treats the client (Kohlberg, 1984). nonjudgmentally. c. Empathic understanding—the therapist is • Theory of Moral Development (Carol Gilligan) an empathetic, sensitive listener. Moral development of women is based more upon an ethic of caring and attachment (Gilligan, 44 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

2. The goal of therapy is to help the client be- 2. Best known for his description of a heirarchy come a fully functioning person. The client of basic needs: reaches this goal by: a. Physiological needs a. Relinquishing facades. b. Safety needs b. Banishing “oughts.” c. Love and belongingness needs c. Moving away from cultural expectations d. Self-esteem needs and becoming nonconformist. e. Self-actualization needs (Drapela, 1987; d. Pleasing oneself, as opposed to pleasing Scroggs, 1985) others; being self-directed. e. Opening up and dropping defenses. • Rational Emotive Behavior Therapy (Albert Ellis) f. Trusting his or her inner self, his or her Some consider this an existential theory while intuition. others refer to it as a “cognitive” theory, because g. Becoming willing to be a complex process. the focus is on changing thinking, rather than on h. Accepting others (Rogers, 1961; Scroggs, feeling or experiencing. Assumptions and key con- 1985). cepts include: 1. People largely control their own destinies. • Gestalt (Frederick (Fritz) Perls) 2. People act on their basic values and beliefs. 1. Here-and-now therapy of immediate expe- 3. People interpret events according to their ba- riencing, attained by removing masks and sic values or beliefs and the interpretation can facades change. 2. Involves a creative interaction between thera- 4. A-B-C-D-E-F of therapy (Seligman, 2006): pist and client to gain ongoing awareness of a. Activating event what is being felt, sensed, and thought b. Belief 3. Describes boundary disturbance—lack of c. Consequences—emotional and/or awareness of the immediate environment, behavioral which takes the following forms: d. Dispute (debate) a. Projection—fantasy about what another e. Effective rational beliefs (interventions are person is experiencing used to promote change) b. Introjection—accepting the beliefs and f. Feelings and behavior change as a result of opinions of others without question effective rational beliefs. c. Retroflection—turning back on oneself 5. Irrational beliefs have four basic forms: that which is meant for someone else a. Something should, ought, or must be d. Confluence—merging with the different. environment b. Something is awful, terrible, or horrible. e. Deflection—a method of interfering with c. One cannot bear, stand, or tolerate contact, used by receivers and senders of something. messages d. Something or someone is damned, as a 4. Goal of therapy—integration of self and world louse, rotten person, etc. awareness 6. “Musturbatory” ideologies have three forms: 5. Techniques of therapy include: a. I must do well and win approval or I am a a. Playing the projection—taking and experi- rotten person. encing the role of another b. You must act kindly and justly toward me b. Making the rounds—speaking or doing or you are a rotten person. something to other group members to ex- c. My life must remain comfortable and easy periment with new behavior or the world is damnable and life hardly c. Sentence completion—e.g., “I take respon- seems worth living. sibility for. . . .” 7. Therapy consists of detecting and eradicating d. Exaggeration of a feeling or action irrational beliefs and musturbatory ideologies e. Empty chair dialogue—having an interac- by: tion with an imaginary provocateur a. Disputing—detecting irrationalities, de- f. Dream work—describing and playing bating against them, discriminating be- parts of a dream (Hardy, 1991) tween logical and illogical thinking, and defining what helps to create new beliefs • Humanistic/Holistic (Abraham Maslow) b. Debating—questioning and disputing the 1. When basic needs are met, health and growth irrational beliefs will naturally follow. Cognitive Theories 45

c. Discriminating—distinguishing between her imagination. They are repeated wants and needs, desires and demands, until the anxiety is eliminated. and rational and irrational ideas (2) In vivo desensitization—in addition d. Defining—defining words and redefining to fantasy desensitization, the client beliefs actually faces the feared object or situation. Behavioral THEORIES 2. Avoidance (aversive) conditioning is the application of the reciprocal inhibition principle to The behavioral theories are generally not con- overcome undesirable responses. An example cerned with thoughts, feelings, or unconscious of avoidance conditioning is the use of the phenomena, except to view them as “behaviors.” drug antabuse to overcome an alcoholic’s un- The focus of behavioral therapy is on replac- desirable response of drinking (Wolpe, 1968). ing maladaptive behaviors with more effective behaviors. • Reality Therapy (William Glasser) Focuses on changing present behavior—the basic • Behavior Therapy (Burrhas Frederic Skinner) premise is that everyone who seeks psychiatric All behavior is determined by contingencies of re- treatment is unable to fulfill his or her basic needs inforcement (Scroggs, 1985). Important concepts and is denying the reality of the world around him include: or her. Major concepts include: 1. Operant conditioning (also called instru- 1. Each person has two basic needs: mental learning)—the individual performs a a. The need to love and be loved—each per- behavior that leads to a positive or negative son needs to be involved with at least one reinforcement, making it either more or less other person who is in touch with reality likely that the behavior will be repeated. and able to fulfill his/her own basic needs. 2. Schedules of reinforcement—Skinner found b. The need to feel worthwhile to himself and that different schedules of reinforcement had others—to be worthwhile, one must main- different effects on supporting or extinguish- tain a satisfactory standard of behavior. ing particular behaviors: 2. Responsibility—the ability to fulfill one’s needs a. Fixed ratio schedule—behaviors are rein a way that does not deprive others of the warded or reinforced every time they are ability to fulfill their needs; the cause of all repeated. psychiatric problems is irresponsibility. b. Variable ratio schedule—behaviors are 3. Role of the therapist: rewarded randomly. a. Become so involved with the patient that c. Fixed interval schedule—behaviors are the patient can face reality. rewarded at specific time intervals. b. Reject the behavior that is unrealistic e. Random interval schedule—behaviors are while accepting the patient and maintain- rewarded at random time intervals (Skin- ing involvement. ner, 1974; Scroggs, 1985). c. Teach the patient better ways to fulfill his/ her needs. • Reciprocal Inhibition (Joseph Wolpe) d. Emphasize behavior, not attitude or A “process of relearning whereby in the presence emotions. of a stimulus a non anxiety producing response is e. Emphasize responsibility and planning to continually repeated until it extinguishes the old, change inappropriate behavior. undesirable response” (Wolpe, 1969, p. 91). Types of reciprocal inhibition include: Cognitive Theories 1. Systematic desensitization—used primarily in the treatment of phobias—the following steps • Cognitive Therapy (Aaron Beck) comprise the most common mode of system- While practicing psychoanalysis, Beck discovered atic desensitization: that, in addition to the thoughts verbalized during a. Training in deep muscle relaxation “free association,” his patients had a concurrent, b. Listing examples of phobic reactions; second set of thoughts. He called these “automatic arranging them in descending order of thoughts.” Automatic thoughts were those that intensity labeled, interpreted, and evaluated, according to a c. Desensitization: personal set of rules. Beck called dysfunctional au- (1) Fantasy desensitization—while the tomatic thoughts “cognitive distortions.” Concepts client relaxes as deeply as possible, in cognitive therapy include: the examples are presented to his or 46 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

1. Elements of the relationship between therapist is modeling, also called imitating or learning by and client: observation. Other concepts include: a. The relationship is a collaborative 1. Retention process—verbally encoding an ob- partnership. served behavior b. Therapist and client determine the goal of 2. Motor reproduction process—practicing the therapy together. motor skills of the observed behavior c. The therapist encourages the client to 3. Reinforcement and motivational process— verbalize disagreement with the therapist receiving reward or reinforcement for the be- when appropriate. havior (Scroggs, 1985) 2. The process of therapy: a. The therapist explains to the client that: • Dialectic Behavior Therapy (Linehan) (1) Perception of reality is not reality. Dialectic Behavior Therapy (DBT) is a form of CBT (2) Interpretation of sensory input de- that also incorporates insight-oriented therapy and pends on cognitive processes. is used primarily to treat persons with borderline b. Recognition of maladaptive ideation—the personality disorder. DBT sessions include weekly client is trained to observe his/her cogni- 1-hour individual and 2-hour group sessions last- tive and emotional reactions to events, ing 1 year. Emphasis in therapy sessions is on skill identifying: building and problem solving (Linehan, Schmidt, (1) The observable behavior Dimeff, Craft, Kanter, & Comtois, 1999; Sadock & (2) The underlying motivation Sadock, 2007; Seligman, 2006). Basic assumptions (3) His/her thoughts and beliefs of DBT: c. Distancing and decentering—the cli- 1. There is a desire for improvement and with ent practices distancing the maladaptive support, improvement can be achieved. thoughts. 2. Any effort is progress, thus failure is not d. Authentication of conclusions—the cli- possible. ent explores his/her conclusions and tests 3. While clients may not have caused all of their them against reality. problems, they are responsible for the solu- e. Changing the rules tions; they must try harder or be more moti- (1) The client makes the rules less abso- vated to change. lute and extreme. (2) The client drops false rules from the repertoire and substitutes adaptive Theories of Communication rules. Theories of communication focus on the process • Cognitive Behavior Modification (Meichenbaum) of verbal and nonverbal communication between Meichenbaum’s theory combines the goals of and among people. cognitive and behavior therapies to focus on improving thoughts and behaviors. A broad range of • Neurolinguistic Programming (NLP) (Richard change strategies are used by CBT therapists in- Bandler & John Grinder) cluding (Seligman, 2006): The assumption behind NLP is that we all create 1. Strategies to improve thinking (e.g., positive personal models or maps of the world and use lan- self-talk, reframing, problem solving, Ellis’s guage to represent our models. People “get stuck,” ABCDEF model) not by their situation, but by the choices they per- 2. Strategies to improve coping (e.g., visual and ceive are available to them because of their maps. guided imagery, bibliotherapy, role playing, Concepts include: cognitive modeling, homework) 1. Representational systems—sensory modalities 3. Strategies to stop rumination and self-defeat- through which people access information, to ing behaviors (e.g., flooding, thought stopping, include: letter writing) a. Auditory 4. Strategies to reinforce positive change (e.g., b. Visual affirmations, focusing on the positive) c. Kinesthetic 2. Cues to representational systems—patterns • Social Learning Theory (Albert Bandura) that are associated with representational sys- Bandura’s theory combines cognitive and be- tems and can be heard or observed havioral theories—the key concept of the theory Theories of Group Behavior and Therapy 47

a. Preferred predicates—e.g., the word (1) A message sent from the ego state of “view” suggests a visual system. Person A is responded to in that ego b. Eye-accessing cues—e.g., looking upward state. suggests a visual system. (2) A message sent to an ego state in Per- c. Gross hand movements—e.g., pointing to- son B is responded to from that ego ward the ear suggests an auditory system. state. d. Breathing patterns—e.g., deep abdominal b. Crossed transactions breathing suggests a kinesthetic system. (1) A message sent from the ego state of e. Speech pattern and voice tone—e.g., quick Person A is responded to in another bursts of high pitched words suggest a vi- ego. sual system. (2) A message sent to an ego state in Per- 3. Language structure son B is responded to from another a. Surface structure—the sentences that ego state. native speakers of a language speak and c. Ulterior transactions—messages that oc- write cur on two levels b. Deep structure—the full linguistic repre- (1) The social or overt level sentation from which the surface struc- (2) The hidden or psychological level tures of a language are derived 3. Games—recurring sets of ulterior transactions c. Ambiguity—the idea that a surface struc- with a concealed motive, e.g., “Why don’t you ture may represent more than one deep . . . Yes, but.” structure 4. Script—an unconscious life plan 4. Human modeling—the process of represent- 5. Therapy using TA may be done in conjunction ing something, e.g., the world of experience with other modes of therapy, e.g., psychoanal- as represented in language. Modeling involves ysis. Therapy process consists of: the following processes: a. Explanation of TA to the client a. Generalization—a specific experience b. Structural analysis of the client’s ego states comes to represent the entire category of c. Transactional analysis of the client’s which it is a member. interactions b. Deletion—selected portions of the world d. Game analysis are excluded from the representation cre- e. Script analysis (Berne, 1961, 1964; Wilson ated by an individual. & Kneisl, 1992) c. Distortion—the relationships among the parts of the model differ from the rela- Theories of Group Behavior tionships they are supposed to represent and Therapy (Bandler & Grinder, 1975, 1976; Wilson & Kneisl, 1992). Many theories already described in this chapter have been applied to group behavior and group • Transactional Analysis (TA) (Eric Berne) therapy, including theories of psychoanalysis, per- The focus is on the interaction between persons. sonality, and communication. The theory consid- Concepts include: ered basic to all groups is systems theory. 1. Ego state—frame of mind a. Parent—exhibits feelings and behaviors • Systems Theory (Von Bertalanffy) learned from parents and authorities; the According to Von Bertalanffy (1934) the world con- parent may be nurturing or critical. sists of entities called “systems.” The theory has b. Adult—exhibits feelings and behaviors of frequently been used to explain group behavior. a mature adult, e.g., analysis, perception, Selected concepts include: and sociability. 1. All systems are hierarchically arrayed and fall c. Child—exhibits feelings and behaviors into the following categories: natural to children under 7 years old; a. Suprasystem the child may be natural or adapted. The b. System adapted child is acting under parental c. Subsystem influence. 2. A system has three functions: 2. Transaction—verbal and nonverbal communi- a. Meeting its purpose cation between two people b. Self maintenance a. Complementary transactions c. Adaptation 48 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

3. The whole is more than the sum of the parts. 4. Multigenerational transmission process—re- 4. A change in one part affects other parts and/or lationship patterns and anxiety about specific the whole system. issues that have been transmitted through the 5. There is feedback or input and output: generations a. Within the system. 5. Family projection process—assignment of b. Between the system and the environment characteristics to certain family members (Von Bertalanffy, 1934; Van Servellen, 6. Sibling position—birth order and gender 1984). 7. Emotional cutoff—distancing to deal with intense unresolved emotional issues • Group Theories—See Chapter 2 - Group Dynamics 8. Therapy—consists of role modeling and guid- & Group Process Theory: Curative factors of groups ing family members to: (Yalom, 2005) a. Increase differentiation of self from a “pseudoself” consisting of beliefs. and • Psychodrama (J. L. Moreno) values acquired in the family to a highly Psychodrama is a here-and-now action psycho- differentiated self. therapy, a therapeutic drama, used primarily in b. Detriangle—observe one’s own effect and group settings. The therapist functions as the “Di- control one’s participation in the triangle, rector” of the drama chosen by the client. Psycho- while maintaining emotional contact (Bo- drama consists of a three-part process: wen, 1978; Stuart & Sundeen, 1991; Kerr & 1. Warm up—the protagonist chooses the time, Bowen, 1988). place, scene, and auxiliary egos for his/her production. • Structural Family Therapy (Salvador Minuchin) 2. Action—the issue or conflict is acted out or In this theory, the therapist joins the family and relived. works to modify the family structure. Concepts in 3. Post-action sharing—group members discuss Structural Family Therapy include: their identification with the subject (Moreno, 1. The family in transition—the family is con- 1964). sidered a social system in transformation that must maintain its continuity and adapt to in- Family Theories ternal and external stressors. 2. Stages of family development—each stage re- Family therapies focus on the family as a whole. quires restructuring. The stages include: The family member who has a problem to be a. Courtship period—when the young per- dealt with in therapy is known as the “identified son reaches adulthood and seeks a mate patient.” b. Marriage—when one member moves from the family of origin to create a new family • Family Systems Theory (Murray Bowen) c. Middle years of marriage—when parents Bowen applied systems theory to the treatment of must wean themselves from their children dysfunctional families, developing a “transgenera- d. Retirement and old age—when one tional” therapy. The main concepts of the theory spouse may die; adult children may as- are: sume care provider role. 1. Differentiation of self—in the lower the level 3. Family structure, which consists of: of self-differentiation, the less adaptive one is a. Power and influence—the hierarchy of under stress. There are two types of differentia- power and authority; parental authority is tion of self: advocated. a. Differentiating thought from emotion b. Subsystems—sets of relationships or dy- b. Differentiating oneself from one’s “family ads formed by generation, gender, inter- ego mass” est, or function 2. Triangles—when a two-member alliance, c. Boundaries—rules of who partici- or dyad, becomes emotionally stressed, the pates with whom. Boundary problems members pull in a third member to reduce include: anxiety. Bowen considers a triangle the basic (1) Enmeshment—weak or absent building block of any emotional system. boundaries between individuals and/ 3. Nuclear family emotional system—patterns or subsystems; perceptions of self and of emotional interaction among family others are poorly differentiated. members Neurobiological Theories 49

(2) Disengagement—rigid boundaries (1) Straightforward—e.g., the mother is between individuals and/or subsys- directed to assume a parental role. tems; communication and contact is (2) Paradoxical, e.g.—a spouse is directed minimal. to encourage the other spouse to have 4. Tasks of the therapist include: the “symptom” more frequently. a. Joining and accommodation d. Changes are planned in stages so that (1) Maintenance—e.g., joining the family changes in one situation or relationship and maintaining family strengths by will lead to changes in another. The thera- pointing them out pist may even create another problem and (2) Assessment—e.g., assessing the family shift to another abnormal hierarchy before structure and transaction patterns shifting to a normal hierarchy. b. Restructuring e. If the strategy does not work within a few (1) Actualizing family transactional pat- weeks, the therapist plans and imple- terns—e.g., re-creating communica- ments another strategy (Madanes, 1981; tion channels Haley, 1987). (2) Marking boundaries—delineating individual and subsystem boundaries Neurobiological Theories (3) Escalating stress—e.g., blocking transactional patterns The 1990s were termed “The Decade of the Brain” (4) Assigning tasks within and between by the National Institutes of Mental Health in order sessions to promote the development of theoretical and (5) Utilizing symptoms—e.g., exaggerat- practical interventions. Neurobiological theories ing, de-emphasizing or relabeling are based on the following general statements: symptoms; moving to new symptoms 1. Cognitive and emotional dysfunctions result (6) Supporting, educating, and guiding from multiple causes, such as genetic influ- (Minuchin and Nichols, 1993; Helm, ences, nutrition, infectious processes, and 1991) other pathological conditions that contribute to neurotransmitter imbalances in the brain • Strategic Family Therapy (Madanes and Haley) (Sanford, 1995). Strategic Family Therapy, also known as Problem 2. Neurotransmitters are chemical substances, Solving Therapy, is brief therapy that focuses on found at the synapses between neurons in the solving the presenting problem(s) (Haley, 1987; central nervous system that influence cogni- Madanes, 1981). Concepts include: tive, emotional, and behavioral functioning by 1. Symptom—a behavior that analogically or carrying messages from the axon of one neu- metaphorically expresses a family problem ron to the receptor sites on the postsynaptic 2. Problem—part of a sequence of acts between neuron (See Table 3-2). people; the way one person communicates 3. At the end of the process, neurotransmitters with another are either inactivated by enzymatic degrada- 3. Focus of therapy—changing analogies and tion or taken back into the presynaptic neuron metaphors (reuptake). 4. Goal—preventing repetition of problem se- 4. There are thought to be more than a 100 dif- quences; introducing more complexity and ferent transmitters and many neurons that alternatives release more than 1 neurotransmitter (Harris 5. Hierarchy—parents are considered respon- & McMahon, 1997, p. 224). sible for and in charge of children. 5. “Psychotherapeutic drugs are prescribed to 6. Interventions: manipulate the processes of neurotransmitter a. Decide which family members are production and absorption to reestablish ‘nor- involved. mal’ neurochemical balance.” (Sanford, 1995, b. Design and implement a strategy to shift p. 31) the family organization so the present 6. Neuroendocrinology—brain biochemicals, by problems are not necessary. way of the hypothalamus, stimulate the pitu- c. Directives—the therapist tells the family itary gland, which affects the endocrine glands members to do something. Directives may along three brain endocrine axes (cascades) be: (Harris & McMahon, 1997) (See Table 3-3). 50 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

Table 3-2 Selected Neurotransmitters & Effects on Mental Health

Neurotransmitter Related State Effect of Psychotropic Acetylcholine—Involved in Decreased activity implicated in Cholinesterase inhibitors increase attention, memory, thirst, mood Alzheimer’s disease levels of acetylcholine regulation, REM sleep, muscle tone, Antipsychotic action can create & sexual behavior imbalance between acetylcholine & dopamine leading to EPS Dopamine—Involved in fine motor Increased activity implicated in Antipsychotic medications block actions, thinking, decision making schizophrenia and mania dopamine receptors & reduce and integrated cognition, & dopamine activity pleasure/reward seeking behavior Norepinephrine (NE)—Involved Decreased activity implicated in Some antidepressants block in alertness, focused attention, depression reuptake of NE and others inhibit orientation, learning, memory— Depleted in dementia of the MAO from metabolizing NE derivative (epinephrine) controls Alzheimer’s type (DAT) and “fight or flight” response Korsakoff’s syndrome Transmission & uptake impaired in anxiety/addiction Serotonin (5-HT)—involved in Decreased activity implicated SSRIs & some TCAs increase mood states; libido; regulation of in depression and obsessive- functional activity by blocking temperature, aggression and sleep; compulsive disorder (OCD) serotonin reuptake perception of pain Dysregulation implicated in anxiety, violence and schizoaffective disorder and personality disorders Gamma-aminobutyric acid Decreased levels implicated in Anxiolytics (benzodiazepines) aim to (GABA)—involved in modulation anxiety disorders increase GABA function of aggression, anxiety, arousal, and excitation Glutamate (amino acids)—involved Excitotoxicity—neurotoxic at high PCP & ketamine (NMDA in cognition/memory; sustained levels antagonists) trigger psychosis autonomic functions Decreased levels can lead to psychosis

(Hams & McMahon, 1997; Harris & McMahon, 1997; Sadock & Sadock, 2007; Sanford, 1995; Videbeck, 2006)

Table 3-3 Neuroendocrinology—Endocrine Cascades

Axis Response Hypothalamic-pituitary thyroid axis (HPTA) Blunted TSH response to thyrotropin releasing hormone (TRH) in depression Hypothalamic-pituitary adrenal axis (HPA) Hyperactive in depression and some anxiety Nonsuppression of cortisol by dexamethasone suppression test in depression Elevated cortisol levels in depression Elevated corticotropin-releasing hormone (CRH) levels in depression Hypothalamic-pituitary gonadal axis (HPGA) Blunted prolactin response in exogenous obesity Reduces testosterone levels in depression

(Harris & McMahon, 1997) Miscellaneous Theories 51

Miscellaneous Theories 10. Average number of sessions is usually five or six, with clients choosing time between ses- • Solution Focused Therapy (de Shazer & O’Hanlon, sions to allow for a comfortable rate of change 1985) as determined by the client. 1. Theory assumes that complaints are maintained by client belief that their response to • Crisis Intervention (Donna Aguilera) the original difficulty was the only right thing 1. Types of crises: to do (de Shazer, 1985). a. Situational—external events that cause 2. Therapist reframes the beliefs and puts them unusual stresses, e.g., hospitalization or in a different perspective that allows symp- divorce toms to be transformed into part of a mutually b. Maturational—normal processes of developed solution. growth and development in which there 3. Focus is on the present and future rather than is difficulty with maturation, e.g., adoles- the past. cence and adulthood a. Only information about past success is c. Adventitious—accidental, uncommon, sought. and unexpected events, e.g., fire, earth- b. Emphasizes strengths of client; “Tell me quake, or flood (Aguilera, 1990) how you dealt with a similar situation in 2. Phases of crisis intervention: the past” (Cline & Davidson, 1997). a. Assessment—assessing the precipitating 4. Emphasis is on outcomes with expectations of event and the client’s perceptions of the rapid change: event a. “When you are not feeling depressed what b. Planning of the intervention—evaluating will you be feeling instead?” (Cline & strengths, coping skills, support systems, Davidson, 1997) and alternative methods of coping b. “How will you know when the problem is c. Intervention—treatment lasting 1 to 6 solved?” weeks, with the goal of returning the in- 5. Therapist helps clients reformulate goals to a dividual to his/her previous level of func- reachable level, i.e. “having a more calm ap- tioning by: proach” instead of “stop yelling” (de Shazer, (1) Helping the person gain an intellec- 1985). tual understanding of the crisis. 6. Therapist compliments clients on what they (2) Helping the person express feelings. are doing right. (3) Exploring coping mechanisms. 7. Therapist uses exceptions: “What do you do (4) Reopening the social world. when you overcome the urge to yell?” (de d. Resolution and anticipatory planning— Shazer, 1985). reinforcing adaptive mechanisms, sum- 8. Solution is formulated around reframed belief marizing the process of intervention, and and way clients describe life after “problem” planning for future coping (Aguilera, 1990) no longer occurs: a. Have client leave with beginning step to- • Theory of Self-Concept (John Hattie) ward solution. The attributes of self-concept include: b. Goals or tasks may be assigned: “Between 1. A cognitive appraisal consisting of beliefs now and the next time we meet I would about self like you to notice what happens in your re- 2. Three aspects: lationship that you would like to continue a. Expectations from self and others—high to have happen.” (de Shazer, 1997). expectations in a dimension or a task can 9. Evaluation occurs at next session. lead to low self-concept and vice-versa. a. If “problem” is better, therapist warns of For example, if an average high school relapse: “These things rarely resolve with- athlete expects to become a professional out some recurrences. You will probably basketball star, his or her high expectation have a big fight in the next few weeks.” may lead to low self-concept. b. If problem is the same: “You must be do- b. Descriptions of oneself that are: ing something right or it would be worse.” (1) Hierarchical—from a description of c. If worse: “May have to go from bad to a simple, isolated characteristic to a worse before it gets better.” “Is this the general, all-inclusive description of bottom or do things need to go from worse self to worst before getting better?” (de Shazer, (2) Multi-faceted—having numerous 1985). dimensions 52 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

c. Prescriptions—standards of correctness 1. Problem-Focused Coping 3. Integration across various dimensions by a. Defining the problem means of: b. Generating alternative solutions a. Self-verification—soliciting feedback to c. Weighing alternatives re cost and benefits confirm the view of self d. Choosing alternatives b. Self-consistency—internal harmony e. Implementation among opinions, attitudes, and values 2. Emotion-Focused Coping c. Self-complexity—viewing self as complex a. Cognitive reappraisal to alter the meaning and multi-faceted of situation without changing objective d. Self-enhancement—viewing self’s posi- facts tive qualities as more important than self’s b. Behavioral strategies such as physical ex- negative qualities ercise, meditation, or talking to friends 4. Subjecting self-concept to confirmation from 3. Defense mechanisms (See Chapter 2) can be self and others viewed as unconscious coping methods. 5. That self-concept is implicit and culturally bound (Hattie, 1991). • Role Theory (Hardy & Conway) Role Theory “represents a collection of concepts • Theory of Self-Disclosure (Richard L. Archer) and a variety of hypothetical formulations that Summarizing the research on and definitions of predict how actors will perform in a given role, or self-disclosure, Archer (1987) focused on its orien- under what circumstances certain types of behav- tations and functions as follows: ior can be expected” (Hardy & Conway, 1988, 1. Self-orientation—disclosures are concerned p. 63). Concepts include: with exploring the nature and contents of one- 1. Approach to studying roles: self, for oneself. a. Structural approach—roles are fixed posi- 2. Self-to-other orientation—disclosures are con- tions with certain expectations and de- cerned with locating oneself in relation to oth- mands, enforced by societal sanctions. ers by getting feedback. b. Symbolic Interactionist approach—be- 3. Other-to-self orientation—disclosures are havior is a response to the symbolic acts used as a means of social control or of obtain- (primarily gestures and speech) of others. ing benefits from others. 2. Role making—a process of modifying a role; 4. Other orientation—disclosure is geared toward phases of role making include: obtaining reciprocal disclosure. a. Initiator behavior 5. Self-and-other orientation—disclosure is con- b. Other response cerned with interdependence of participants c. Interpretation in a relationship (Archer, 1987). d. Altered response e. Role validation • Stress Theory (Hans Selye) 3. Role taking—the process of imagining oneself Selye developed a theory of the physical response in the place of another to stress called the General Adaptation Syndrome 4. Socialization—the process of learning the so- (GAS). The stages of the GAS are as follows: cial roles, skills, and knowledge that prepare 1. Alarm stage—a threat is perceived, and the one for role performance endocrine system and the immune system re- 5. Role stress—a condition in which role obliga- spond, creating physical and mental alertness. tions are unclear, conflicting or impossible to 2. Resistance stage—the threat continues, and meet attempts are made to adapt. 6. Role strain—a subjective state of frustration or 3. Exhaustion stage—if the threat continues be- distress in meeting role expectations yond a certain point, the adaptive hormones 7. Stratification—a hierarchical ranking of people are depleted and the body succumbs to illness according to wealth, status, power, or occupa- (Selye, 1976; Wilson & Kneisl, 1992). tion (Hardy & Conway, 1988)

• Coping (Monat & Lazarus, 1991) Questions According to Monat and Lazarus (1991) Coping ”refers to a person’s efforts to master demands Select the best answer (conditions of harm, threat, or challenge) that are appraised (or perceived) as exceeding or taxing a 1. The purpose of a theory is to: person’s resources.” a. Describe, explain, predict or control a phenomenon Questions 53

b. Encourage the development of more a. A health deviation research b. Illness c. Prove that there can be one way to describe c. A self-care deficit a phenomenon d. A diagnostic indication d. Prove that a phenomenon exists 9. Imogene King’s theory of nursing is: 2. Characteristics of theories include: a. A theory of personal systems a. They provide laws by which to govern b. A theory of goal attainment practice. c. A theory of adaptation b. They have little in common with practice. d. A behavioral systems theory c. They can guide and improve practice. 10. In King’s theory, a set of behaviors expected d. They need not be logical. of a person occupying a certain position is 3. Inductive theory construction: called a: a. Consists largely of concepts borrowed from a. Role other disciplines b. Perception b. Validates deductive theory construction c. Transaction c. Proceeds from the general to the specific d. Developmental position d. Proceeds from the specific to the general 11. One of the basic assumptions in the theory of 4. Which of the following do theories NOT do? Martha Rogers is that: a. Guide practice a. People come together to help and be b. Guide research helped to maintain health. c. Provide a common language for practitio- b. The universe is a continuously expanding, ners and researchers evolving, growing field of energy. d. Limit autonomy of practice c. The person and environment are continually exchanging matter and energy with 5. The concepts central to nursing theoretical each other. models are: d. Energy fields are four dimensional, unidi- a. Self-care, self-care deficit, and nursing rectional, expanding sources of knowledge. systems 12. According to Rogers, which of the following b. Caring and curing does NOT describe the human being? c. Assessment, diagnosis, intervention, and evaluation a. Characterized by the capacity for abstrac- d. Person, environment, health, and nursing tion and imagery b. Characterized by the capacity for revers- 6. Dorothea Orem’s theory of nursing is also called ibility and multidirectionality the theory of: c. Characterized by the capacity for language a. Behavioral Systems and thought b. Self-care d. Characterized by the capacity for sensation c. The environment and emotion d. Adaptation 13. The building blocks of Rogers’ theory are: 7. In Orem’s theory, Nursing Systems are de- a. Energy, openness, pattern and four- scribed as: dimensionality a. Descriptions of a variety of ideal hospital b. Person, life process, pattern and organiza- staffing models tion, energy b. The theories that she drew from c. Person, environment, health, nursing c. Simple, complex, and combined d. Openness, environment, pattern and d. Wholly compensatory, partly compensatory, energy and supportive–educative 14. Sister Callista Roy’s theory of nursing is: 8. Nurse A, who utilizes Orem’s theory, is caring a. The Interpersonal Relations Model for Patient B. Patient B requires a complete b. The Problem Solving Model bed bath. When charting, Nurse A will describe c. The Communication Model Patient B’s inability to provide complete self- d. The Adaptation Model care as: 54 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

15. Roy’s adaptive modes are: 21. The two most famous psychoanalytic theorists are: a. Physiological function, self-concept, role function, and interdependence a. Homey and Adler b. Regulator, cognator, external, and b. Freud and Jung informational c. Kohlberg and Gilligan c. Value, belief, thought, and emotion d. Adler and Sullivan d. Adaptive response, ineffective response, 22. According to Freudian theory, unconscious output actions or thoughts to protect the ego from 16. The nurse who utilizes Roy’s model in providing anxiety are called: nursing care would first: a. Freudian slips a. Identify focal stimuli b. Unconscious motivation b. Manipulate focal stimuli c. Defense mechanisms c. Identify input and internal processes d. Transference d. Conduct a first-level assessment 23. According to Freudian theory, thoughts, feel- 17. The nurse who utilizes Roy’s model in providing ings, and desires that are not in immediate nursing care will include in the second-level awareness, but can be recalled to conscious- assessment: ness, are considered: a. Identification of ineffective responses a. Conscious b. Identification of nursing diagnosis b. Preconscious c. Identification of goals c. Subconscious d. Patterns of physical functioning d. Unconscious 18. The main concept in Leininger’s Theory of 24. According to Freudian theory, the personality Culture Care Diversity and Universality is that: has three main components. The component characterized by the desire for immediate and a. Culture is the learned, shared, and trans- complete satisfaction is the: mitted values, beliefs, norms, and lifeways of a group. a. Reality principle b. Care is the essence of nursing. b. Id c. There is diversity and universality in every c. Ego culture. d. Superego d. Nurses should seek to know the universality 25. Freud suggests that children of 4 or 5 fall in of Transcultural nursing. love with the parent of the opposite sex. This is 19. According to Leininger, the important factors to known as: study in cultural care include: a. Projection a. Religious factors b. Transference b. Nutritional factors c. The pleasure principle c. Rest patterns d. The Oedipus complex d. Prenatal care 26. According to Freud, whatever inhibits a person 20. Cultural care accommodation refers to: from producing material from the unconscious is considered: a. Actions and decisions to help people of a given culture negotiate for a beneficial a. Resistance outcome with health caregivers b. Transference b. Actions and decisions to help a client c. Countertransference modify their lifeways for beneficial health d. Fixation care, while respecting their cultural values 27. In Jungian theory, the unconscious collective and beliefs intangible idea, image, or concept is the: c. Actions and decisions that help people retain relevant cultural care values a. Persona d. Actions and decisions that are based on b. Shadow universal cultural care c. Archetype d. Rebirth Questions 55

28. Jung’s archetypes do NOT include: 35. If a child’s activities are primarily social interaction, doing homework and practicing a. The animus basketball, then according to Erikson, he is in b. The shadow the following stage of development: c. Stock characters d. The id a. Trust vs mistrust b. Autonomy vs shame 29. The functional types described by Jung include: c. Initiative vs guilt a. Extrovert and introvert d. Industry vs inferiority b. The hero, the trickster, and the sage 36. According to Erikson, the stage of development c. Thinking, feeling, sensing, intuiting characterized by the acquisition of wisdom is: d. Animus and anima a. Identity vs identity diffusion 30. Adler developed the Theory of Individual Psy- b. Intimacy vs isolation chology. The main concern of Adler’s theory is: c. Generativity vs stagnation a. The individual going through the stages of d. Integrity vs despair development 37. Jean Piaget developed a theory of: b. Personal growth through compensating for inferiority a. Psychosexual development c. Providing client-centered therapy b. Cognitive development d. The effect of relationships on unconscious c. Moral development behaviors d. Social development 31. Adler identified effects of the birth order of 38. In the developmental theory of Piaget, the siblings. According to his theory, the child most period characterized by egocentric thinking, likely to be interested in authority and organi- expressed in artificialism, realism, and magical zation is: thinking is the: a. The first-born a. Sensory motor period b. The second-born b. Pre-operational period c. The middle child in a large family c. Concrete operations period d. The youngest child d. Formal operations period 32. The key concept in the personality theory of 39. In the developmental theory of Piaget, the Horney is: period characterized by the development of logic and reasoning, and second-order a. Neurosis thoughts, that is, “thinking about thoughts,” is b. Hostility the: c. Basic anxiety d. Satisfaction of needs a. Sensory motor period b. Preoperational period 33. According to Horney, which of the fol- c. Concrete operations period lowing is NOT a way by which people protect d. Formal operations period themselves? 40. The nurse is working with Mrs. L., who has a. Moving toward other people been sexually promiscuous and manipulative b. Moving against other people with her family. While developing a treatment c. Moving away from other people plan for Mrs. L., the nurse recognizes that her d. Moving in accord with other people behavior is consistent with the behavior in 34. Erikson identified eight stages of growth and Stage 2 of Kohlberg’s theory of moral develop- development. The stage characterized by a ment. Mrs. L. will be motivated by: focus on genital needs and the acquisition of a a. Avoidance of punishment purpose is: b. Desire for reward or benefit a. Trust vs mistrust c. Anticipation of disapproval of others b. Autonomy vs shame d. Anticipation of dishonor c. Initiative vs guilt 41. If Mrs. L.’s behavior was consistent with the d. Industry vs inferiority behavior of Stage 4 of Kohlberg’s theory of moral development, she would be motivated by: 56 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

a. Anticipation of disapproval of others c. One’s philosophy of life b. Anticipation of dishonor d. Conforming to societal demands c. A legalistic orientation 48. According to Carl Rogers, the important attri- d. Belief in universal ethical principles butes of the therapist are: 42. In Kohlberg’s theory of moral development, a. Congruence, unconditional positive regard, behavior in Stage 6 is motivated by: and empathetic understanding a. Anticipation of disapproval of others b. Knowledge of Rogers’ theory, patience, and b. Anticipation of dishonor ability to interpret dreams c. A legalistic orientation c. Knowledge of Rogers’ theory, congruence, d. Belief in universal ethical principles and interest in human development d. Willingness to drop facades, openness to 43. According to the work of Gilligan on moral individual meanings, and compassion development: 49. According to Monat and Lazarus which of the a. In applying Kohlberg’s theory, women are following would be considered as part of generally more moral than men. emotion-focused coping? b. Most women achieve the moral reasoning in Stage 6 of Kohlberg’s theory. a. Defining the problem c. Women and men have the same moral b. Physical exercise reasoning. c. Generating alternative solutions d. The moral development of women is based d. Weighing alternatives re cost and benefits on different motivations than that of men. 50. The therapist utilizing Gestalt therapy recog- 44. The main focus of social–interpersonal theories nizes that introjection is: of personality is: a. A fantasy about what another person is a. Neurosis experiencing b. Anxiety about relationships b. Accepting the beliefs and opinions of c. The effects of interactions with others others without question d. Inferiority and superiority feelings c. Turning back on oneself that which is meant for someone else 45. In the interpersonal theory of Harry Stack Sul- d. Merging with the environment livan, the “self-system” is: 51. The main goal of Gestalt therapy is: a. The part of the personality that satisfies the drive for security a. Dropping facades b. A construct to describe the narcissism b. Differentiating between self and others inherent in all interpersonal relationships c. Integration of self and world awareness c. A construct built from the child’s experi- d. Resolving conflicts from the past ence, made up of reflected appraisals by 52. Techniques in Gestalt therapy do NOT include: significant others d. The part of the personality that satisfies the a. Playing the projection drive for satisfaction b. Making the rounds c. Exaggeration of a feeling or action 46. According to Sullivan, the basic drives that d. Paradoxical prescription underlie human behavior are: 53. Maslow’s hierarchy of basic needs includes: a. The drive to reduce anxiety and the drive to avoid fear a. Safety and satisfaction, health and growth b. The drive for satisfaction and the drive for b. Physiological needs, safety, love and security belongingness, self-esteem, and self- c. The drive to fulfill basic physical needs and actualization the drive to fulfill sexual needs c. Physical, biological, psychological, socio- d. The drive for love and work logical, and spiritual needs d. Food, fluid, activity, meaning and purpose, 47. The existential theories of personality focus on: and self-actualization a. The meaning of life for the individual 54. The A-B-Cs of Ellis’s Rational Emotive Therapy b. Present experience, with little attention to are: the past Questions 57

a. Action, behavior, congruence 61. The two types of systematic desensitization are: b. Anticipation, belief, consequence a. Automatic desensitization and standard c. Acceptance, behavior, caring desensitization d. Activating behavior, belief, consequence b. Fantasy desensitization and in vivo 55. According to Ellis’s Rational Emotive Therapy, a desensitization basic form of irrational beliefs is that: c. Desensitization with medication and desensitization without medication a. One cannot meet one’s goals. d. Reciprocal inhibition and aversive b. Life is difficult. conditioning c. Something is awful, terrible, or horrible. d. Behavior has meaning. 62. According to the Reality Therapy of William Glasser, each person has the following two 56. For the nurse who uses Rational Emotive basic needs: Therapy in practice, the focus of treatment is on: a. Psychological needs and spiritual needs b. Physiological needs and psychological a. Behavior rather than beliefs needs b. Accepting the beliefs of others c. The need to love and be loved, and the c. Disputing, debating, discriminating, and need to be productive defining d. The need to love and be loved, and the d. Anticipating, acting, and accepting need to feel worthwhile 57. Behavioral theories of personality are con- 63. According to Glasser, the cause of all psychiatric cerned with: problems is: a. Unconscious phenomena a. Neurosis b. Cognition b. Irresponsibility c. Emotions c. Childhood training d. Reinforcement d. Irrational beliefs 58. One concept of Skinner’s theory is that an 64. The therapist who is utilizing Glasser’s therapy individual performs a behavior that leads to a will emphasize: positive or negative reinforcement, making it either more or less likely that the behavior will a. Unconscious motivation be repeated. This is called: b. Dream interpretation c. Changing behavior a. A schedule of reinforcement d. Re-experiencing traumatic childhood events b. A fixed ratio c. A variable interval 65. Aaron Beck developed a theory of cognitive d. Operant conditioning therapy after he discovered that his clients had “automatic thoughts.” The automatic thoughts: 59. In a variable ratio schedule of reinforcement, behaviors are rewarded: a. Came from too much free association b. Labeled, interpreted, and evaluated situa- a. Each time they are performed tions according to a personal set of rules b. Every time they are repeated c. Indicated to the client that he should not c. At specific times of performance trust the therapist d. At random times of performance d. Warned clients of any physiological needs 60. Mrs. J. seeks treatment for her fear of auto- 66. The therapist who utilizes Beck’s therapy will mobiles. After the initial assessment, the nurse warn the client: decides to use systematic desensitization. The first step in systematic desensitization is to: a. To try to ignore or suppress his automatic thoughts a. Help Mrs. J. get a prescription for valium b. That emotionally healthy individuals do not and take her for an automobile ride have automatic thoughts b. Explore other means of transportation c. That automatic thoughts are deeply c. Train Mrs. J. in deep muscle relaxation imbedded and cannot be changed d. Show Mrs. J. a picture of an automobile d. That a perception of reality is not neces- and ask how she feels sarily reality 58 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

67. The therapist utilizing Beck’s therapy will help a. Crossed transaction the client to: b. Ulterior transaction c. Complementary transaction a. Recognize and change his/her automatic d. Confused transaction thoughts b. See reality as the therapist sees it 75. In TA, a message that occurs on two levels is: c. Change his/her reality by changing his/her a. A crossed transaction environment b. An ulterior transaction d. Recognize and accept that automatic c. A complementary transaction thoughts suggest delusional thinking d. A game 68. In the Social Learning Theory of Alfred 76. Concepts in Systems Theory include: Bandura, the key concept is: a. Systems are designed to serve people. a. Modeling b. Systems are by nature complex. b. Encoding a behavior c. All systems are hierarchically arrayed. c. Rewarding behavior appropriately d. All systems have five functions. d. Rewarding behavior on a ratio interval scale 77. According to Systems Theory, the functions of a system include: 69. In the Neurolinguistic Programming (NLP) of Bandler and Grinder, the “representational a. Cooperation systems” are: b. Conflict c. Adaptation a. Auditory, visual, and kinesthetic d. Accommodation b. Methods of analyzing communication c. Right brain and left brain 78. The originator of Psychodrama was: d. Parent, adult, and child a. Moreno 70. An assumption behind NLP is that: b. Minuchin c. Beck a. We all have irrational beliefs. d. Adler b. We all create models of the world, and use language to represent them. 79. In Psychodrama, the therapist functions as a: c. We are all philosophers. a. Protagonist d. Verbal and nonverbal communication is b. Auxiliary ego important in nursing. c. Director 71. In NLP, the sentences that native speakers of a d. Partner language speak and write are called: 80. The nurse utilizing Bowen’s theory in family a. Deep structure therapy will observe the patterns of emotional b. Surface structure interaction within a family. Bowen calls these c. Multimodel sentences patterns: d. Cues to beliefs a. Triangles 72. In NLP, human modeling does NOT involve: b. The family projection process c. The nuclear family emotional system a. Generalization d. The family differentiation process b. Deletion c. Distortion 81. In Bowen’s Family Systems Therapy, the multi- d. Disintegration generational family transmission process refers to: 73. In Transactional Analysis (TA), the theory by Eric Berne, ego states include: a. Genetic traits b. Relationship patterns and anxiety about a. Sane, neurotic, and psychotic specific issues that have been transmitted b. Rational and irrational through the generations c. Parent, adult, and child c. Relationships between grandparents and d. Manic, depressive, and schizophrenic grandchildren 74. In TA, when a message is sent from an ego state d. Hereditary disorders of Person A and is responded to in that ego state, there is a: Questions 59

82. The nurse practicing Bowen’s Family Systems c. Help the family to be more democratic Therapy will guide family members to: d. Identify and solve all family problems a. Use their sibling position to their advantage 89. After identifying the symptom and the b. Periodically cut off other family members problem, the nurse who is practicing Strategic emotionally Family Therapy will: c. Create specific triangles a. Identify the family structure d. Increase differentiation of self b. Work to detriangle all family members 83. When the nurse using Minuchin’s Structural c. Design a strategy to shift the family Family Therapy observes that a mother holds a organization 7-year-old child in her lap, answers questions d. Mark subsystem boundaries for the child, and describes protecting the child 90. In a depressed client, which of the following from siblings and neighbors, the nurse will neurobiological explanations can the nurse suspect: expect? a. Accommodation a. Overactivity of serotonin (5-HT) b. Enmeshment b. Underactivity of norepinephrine/ c. Disengagement epinephrine d. An unusual transaction c. Overactivity of dopamine 84. In Minuchin’s Structural Family Therapy, the d. Underactivity of acetylcholine main tasks of the therapist are: 91. A client seeks treatment from a Solution- a. Joining and restructuring Focused therapist for somatic complaints. What b. Clarifying the family structure and would the therapist’s question to her most explaining it likely be? c. Identifying family communication patterns a. Can you tell me what happened in your and maintaining family strengths childhood? d. Enacting the family structure and delin- b. Tell me about the surgeries you have had? eating boundaries c. When you aren’t in terrible pain, or vis- 85. A therapist who utilizes Minuchin’s Structural iting your doctor, what will you be doing Family Therapy will probably: instead? d. What was going on in your life when the a. Point out family strengths pain started? b. Identify multigenerational transactions c. Maintain his/her position of authority 92. According to the Crisis Intervention Theory of d. Decrease stress Aquilera, types of crises are: 86. In the Structural Family Therapy of Minuchin, a. Familial, academic, and social when the therapist blocks the usual transac- b. Major disasters and daily events tional patterns or emphasizes differences among c. Situational, maturational, and adventitious family members, he is probably trying to: d. Growth inducing and growth hindering a. Accommodate the family 93. Crisis Intervention Therapy usually lasts: b. Identify the true patient a. From 1 to 6 weeks c. Escalate stress b. From 1 to 6 months d. Identify the executive subsystem c. From 3 months to 1 year 87. A therapist who utilizes the Structural Family d. More than 1 year Therapy of Minuchin would NOT utilize symp- 94. The main goal of Crisis Intervention is to: toms by: a. Assist the client in identifying his strengths a. Moving to new symptoms b. Assist the client to gain insight as to why he b. De-emphasizing symptoms reacted as he did c. Exaggerating symptoms c. Help the client to return to his previous d. Rewarding symptoms level of functioning 88. The focus of Strategic Family Therapy is to: d. Help the client to prevent another crisis a. Emphasize symptoms 95. According to the Self-Concept Theory of Hattie, b. Change analogies and metaphors in the the first attribute of self-concept is: family 60 Chapter 3 Major Theoretical Frameworks for Psychiatric Nursing

a. A cognitive appraisal of oneself Answers b. A feeling of wholeness c. Determined completely by one’s 1. a 52. d environment 2. c 53. b d. Undefined 3. d 54. d 96. In the Self-Concept Theory of Hattie, internal 4. d 55. c harmony among opinions, values, and attitudes 5. d 56. c is called: 6. b 57. d a. Self-complexity 7. d 58. d b. Self-verification 8. c 59. d c. Self-consistency 9. b 60. c d. Self-regulation 10. a 61. b 11. c 62. d 97. Self-concept is: 12. b 63. b a. Subject to confirmation from others 13. a 64. c b. Culturally bound 14. d 65. b c. Multifaceted 15. a 66. d d. Fixed at birth 16. d 67. a 98. Purposes of self-disclosure include: 17. a 68. a 18. b 69. a a. Exploring oneself 19. a 70. b b. Locating oneself in relation to others c. Social control 20. a 71. b d. Cutting off feedback 21. b 72. d 22. c 73. c 99. The General Adaptation Syndrome, as identi- 23. b 74. c fied by Hans Selye, has the following stages: 24. b 75. b a. Surprise, alertness, reaction 25. d 76. c b. Inflexibility, adaptation, engulfment 26. a 77. c c. Alarm, resistance, exhaustion 27. c 78. a d. Openness, closedness, paranoia 28. d 79. c 100. In the structural approach to Role Theory, roles 29. c 80. c are considered: 30. b 81. b 31. a 82. d a. Subject to change depending on immediate circumstances 32. c 83. b b. Fixed positions with certain expectations 33. d 84. a and demands 34. c 85. a c. Responses to a number of things in the 35. d 86. c environment 36. d 87. d d. Synonymous with job descriptions 37. b 88. b 101. Role taking refers to: 38. b 89. c 39. d 90. b a. Socialization into a role 40. b 91. c b. The process of moving into a role that was 41. b 92. c previously held by another person 42. d 93. a c. The process of imagining oneself in the 43. d 94. c place of another d. Being taken by surprise by the expectations 44. c 95. a of a certain role 45. c 96. c 46. b 97. d 102. The defense mechanism considered to be the 47. b 98. d basis for all defense mechanisms is: 48. a 99. c a. Suppression 49. b 100. b b. Repression 50. b 101. c c. Denial 51. c 102. b d. Projection Bibliography 61

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Substance-Related Disorders 1. Males, rather than females, responding to the 2007 National Survey on Drug Use and Health • Definition—a cluster of mental disorders associ- reported higher rates for current use of alcohol ated with exposure to or excessive use of psychoac- (56.6% vs 46.0%), tobacco (35.2% vs 22.4%), tive substances, medications, or toxins. and illicit drugs (10.4% vs 5.8%). In the Diagnostic and Statistical Manual of Mental 2. Young adults aged 18 to 25 and youth aged 12 Disorders (DSM-IV-TR, APA, 2000), substance- to 17 years were more likely than older persons related disorders are divided into two groups: (1) to engage in binge drinking and illicit drug substance use disorders (abuse and dependence) use, and to consume alcohol concurrently with and (2) substance-induced disorders (intoxication, an illicit drug (Substance Abuse and Mental withdrawal, and specific substance-induced (S-I) Health Services Administration, 2008, 2009). conditions including S-I delirium, S-I mood disor- 3. Co-occurring substance-related and other psy- der, S-I psychotic disorder, etc.). chiatric disorders (also known as dual diagnosis) are common. • Epidemiology a. Persons diagnosed with anxiety or mood Results from the 2006–2007 National Surveys on disorders are twice as likely to also abuse Drug Use and Health (Hughes, Sathe & Spagnola, one or more substances. This is also true 2009) found that 8.1% of the population 12 years for individuals diagnosed with conduct or older reported past month illicit drug use. disorder or antisocial personality disorder. About 23.2% of the population 12 years and older b. Higher rates of alcohol, tobacco, and other engaged in past month binge drinking (5 or more drug abuse have been reported in persons drinks on one occasion), and 3.4% of the popu- with schizophrenia than in the general lation were estimated to be alcohol dependent. population. Following alcohol, tobacco is the second most c. Cigarette smoking is higher among per- commonly used substance in the United States sons with comorbid schizophrenia (up to with 24.6% of the population 12 years and older 90%), bipolar disorder (70%), and other smoking cigarettes in the past month. Marijuana psychiatric diagnoses than among those is the most commonly used illicit drug with 10.2% without a comorbid condition (National of persons age 12 and older reporting use in the Institute on Drug Abuse, 2008). past year. Illicit drug use other than marijuana (cocaine, heroin, hallucinogens, inhalants, and the • Signs and symptoms nonmedical use of prescription-type pain relievers, 1. Dependence—Criteria established by the Di- tranquilizers, stimulants, and sedatives) was 3.8% agnostic and Statistical Manual for Mental Dis- for persons 12 years and older. orders (DSM-IV-TR) for substance dependence

63 64 Chapter 4 Substance-Related Mental Disorders

include the occurrence of at least three of the 2. Evidence that symptoms are better accounted following within the same 12-month period for by a disorder that is not substance induced (American Psychiatric Association [APA], 2000): include: a. Use of amounts greater than intended a. Symptoms precede onset of the substance b. Attempts at control abuse/dependence. c. Excessive time spent in obtaining, using, b. Symptoms persist for a substantial period recovering of time after the cessation of acute with- d. Use despite social obligations or hazards drawal or severe intoxication. e. Use despite recurrent problems c. Symptoms are substantially in excess of f. Presence of tolerance—needing increas- what would be expected given the character, ing amounts of substance to produce de- duration, or amount of the substance used. sired effect or markedly diminished effect d. Other evidence is presented suggesting with continued use of same amount of the existence of an independent nonsub- substance stance induced disorder (history of recur- g. Presence of withdrawal or use to avoid rent nonsubstance-related episodes). or relieve withdrawal symptoms—a substance-specific syndrome producing • Diagnostic studies/tests (APA, 2006) a state of disequilibrium with clinically 1. Common laboratory values associated with significant distress or impairment of func- Substance Use Disorders (SUD): tioning produced by an abrupt discon- a. Liver function tests (LFTs)—liver enzymes tinuation, or rapid decrease in dosage, of a increased in alcohol dependence—gamma- substance glutamyltransferase (GGT), aspartate ami- h. Specifiers including notation of the pres- notransferase (AST), and alanine amino- ence of physiological dependence (evi- transferase (ALT). Other increased values dence of tolerance or withdrawal), or lack include mean corpuscular volume (MCV), thereof high density lipoprotein cholesterol and 2. Abuse—Criteria for substance abuse include: carbohydrate deficient transferrin (CDT). a. Recurrent use resulting in a failure to fulfill b. Urine drug screening (UDS) detects pres- major role obligations ence of drug in the urine—diagnostic limi- b. Continued use despite having persistent tations include: or recurrent social or interpersonal prob- (1) Short “window” of detection of lems caused or exacerbated by the effects metabolites of the substance (2) Intermittent use patterns of abusers c. Recurrent use in hazardous situations (3) Issues of civil liberties (driving while under the influence of a c. Blood alcohol level (BAL)—greater than substance of abuse) 150 mg/dl = evidence of intoxication; and d. Recurrent substance-related legal problems greater than 300 mg/dl at any time sug- e. Criteria for substance dependence (for the gests potential for alcohol dependence. specific substance) have never been met. d. Breathalyzer—represents blood alcohol 3. Substances with abuse potential include: al- concentration (BAC) cohol, sedatives/hypnotics, amphetamines, (1) Legal intoxication level in most states cocaine, cannabis, hallucinogens, opioids, is 0.08%. phencyclidine, inhalants, caffeine, nicotine, (2) Levels above 0.1% without associated and anabolic steroids. behavioral symptoms indicate possible tolerance. • Differential diagnosis 2. Screening instruments (partial list) 1. DSM-IV-TR (APA, 2000) Disorders with similar a. CAGE questionnaire symptoms/presentations b. Self Administered Alcohol Screening Test a. Mood/Depressive Disorders (SAAST) b. Anxiety c. Drug Abuse Screening Test, short version c. Psychotic Disorders (DAST-10) d. Personality Disorders d. Addiction Severity Index (ASI) e. Impulse Control Disorders e. National Institute of Drug & Alcohol f. Adjustment Disorders (NIDA) Modified Alcohol, Smoking, and g. Sleep Disorders Substance Involvement Screening Test h. Sexual Dysfunction Disorders (NMASSIST)—online and print versions i. Amnesia, Dementia, and Delirium available at: http://www.drugabuse.gov/ Disorders nidamed/screening Substance-Related Disorders 65

• Assessment—involves careful interview skills that and stage of physical withdrawal as well as are goal-directed and focused on the presenting medical complications symptoms and problems in major areas of func- a. Vital signs tioning. The interview is adapted to the client’s age, b. Urine/blood drug screens, breathalyzer culture, and current cognitive ability. c. Assessment for trauma—broken bones, 1. Interview elements bruises, lacerations, edema a. Drug and/or drink of choice—include d. Assessment for dehydration and malnutri- amount, frequency of use, duration of use, tion, weight loss route of administration, time and amount e. Assessment for masses and lesions of last use f. Evaluation of respiratory, cardiac, and gas- b. Other substances used trointestinal status c. Past history of and response to withdrawal g. Evaluation of neurologic status d. History of delirium tremens, seizures, falls, (1) Orientation to time, place, person, blackouts or alcoholic amnesia, injury to date, day of the week self or others (2) Assessment of cognitive functioning e. Changes in mood and behavior (anger, for confusion or delirium, concentra- apathy, anxiety, depression, labile mood, tion and attention, recent and remote irritability, low or high energy, impulsivity, memory, abstract reasoning, problem- isolation, change in peer group, secretive- solving ability, thought disturbances ness, guardedness, or paranoia) and sensory perceptual distortions f. Sleep pattern and eating habits (3) Pupil size g. Problems with interpersonal and social re- (4) Checking reflexes for hyperreflexia lationships, finances, occupation, school, (5) Assessment for numbness and tin- family, legal system, medical disorders, gling in extremities psychiatric disorders h. Family history of alcohol, drug, and/or • Medical complications associated with SUD (sub- psychiatric illness stance abuse or dependence) i. Access and availability of substances 1. Hepatic complications—alcoholic fatty liver, j. Context of substance use (solitary vs social alcoholic hepatitis, alcoholic cirrhosis consumption) 2. Gastrointestinal complications—esophagitis, k. Previous treatments and longest periods gastritis, pancreatitis associated with alcohol of sobriety 3. Cardiovascular complications—cardiomyopa- l. Presence of defense mechanisms, such as thy, hypertension, arrhythmias associated with denial, minimization, and rationalization, alcohol and cocaine warrant a collateral interview with family 4. Neurologic complications members or significant others a. Stroke, seizures associated with alcohol m. Assess motivation and stage of/readiness and cocaine for change (Prochaska, DiClemente & Nor- b. Polyneuropathy, alcoholic dementia, cross, 1992): Wernicke-Korsakoff Syndrome (thiamine (1) Precontemplation—personal realiza- deficiency) associated with alcohol tion and decreased defensiveness and 5. Nutritional complications—vitamin and rationalization through social pres- iron deficiency, malnutrition associated with sure, dramatic experience, media, alcohol consequences, and social norms 6. Pulmonary damage associated with smoking (2) Contemplation—shifting decisional crack, cannabis, and nicotine balance, making a commitment to 7. Infectious disease—increased chance of hepa- a change attempt, and resolving titis, HIV, sexually transmitted diseases, cel- ambivalence lulitis, endocarditis associated with high risk (3) Preparation—commitment, plan, and addiction behaviors concrete strategies a. Unprotected sexual promiscuity and (4) Action—daily implementation of prostitution plan, coping with withdrawal and de- b. Intravenous route of administration sire to use, behavioral coping activities 8. Obstetrical complications (5) Maintenance—lifestyle changes, shifts a. Noncompliance with prenatal care (asso- in social network, behavioral coping ciated with SUD in pregnancy) activities b. Premature labor and delivery, spontane- 2. Physical and mental status examination— ous abortion, abruptio placenta associ- system-by-system assessment for presence ated with cocaine and crack addiction 66 Chapter 4 Substance-Related Mental Disorders

c. Hypertension, spontaneous abortion, (2) Disturbed feeding problems, gastroin- abruptio placenta, premature delivery, testinal disturbances such as vomiting and postpartum hemorrhage associated and diarrhea, respiratory depression, with heroin addiction and hypoxia d. Miscarriage and spontaneous abortion (3) Frequent yawning, nasal flaring, and associated with alcohol sneezing e. Earlier menopause, osteoporosis, reduced (4) Jitteriness, increased muscle tone, fertility, and increased risk of strokes when tremors, depressed normal neuro- taking oral contraceptives associated with logic reflexes, temperature instability, tobacco addiction; spontaneous abortion, seizures unexplained vaginal bleeding, abruptio c. Fetal alcohol syndrome (FAS) character- placenta and placenta previa associated ized by: with tobacco addiction (1) Growth retardation 9. Teratogenic complications (2) Central nervous system involve- a. Low birth weight, prematurity, small head ment—developmental delay, neuro- circumference, anomalies associated with logic or intellectual impairment cocaine, cannabis, nicotine (3) Facial dysmorphology b. Neonatal abstinence syndrome related to withdrawal from narcotics occurs anytime • Mental status variations and clinical manifesta- between birth to the sixth day of life tions—See Table 4-1 (APA 2006, 2007; Sadock & (1) Irritability, shrill or persistent cry, in- Sadock, 2007) ability to self-regulate state, more sensitive to external stimuli, sleep-wake pattern disturbance

Table 4-1 Mental Status Variation & Clinical Manifestations of Substances-Induced Disorders

Substance Intoxication Effects Withdrawal (WD) Features Pharmacologic Treatment Alcohol Disinhibition & increased Onset usually 6 hours after Withdrawal & confidence a substantial fall in blood Detox—benzodiazepines Slurred speech alcohol concentration, peaks • Chlodiazepoxide (Librium) at about 24–36 hours and • Diazepam (Valium) Impaired insight, judgment, subsides after 48 hours • Lorazepam (Ativan) & memory • Tremulousness Haloperidol—for DTs Decreased concentration • Malaise Dependence treatment— Altered motor skills & • Anorexia, nausea, vomiting (reduce craving &/or sensory perception • Hyperreflexia promote abstinence) • Tachycardia, increased blood Mood swings • Disulfiram (Antabuse) pressure • Naltexone (ReVia, Vivitrol) • Irritability • Acamprosate (Campral) • Insomnia • SSRIs • Diaphoresis • Perceptual distortions Severe WD—delirium tremens (DT) (5% incidence)—Onset 72–96 hours after cessation of drinking • Gross tremors and agitation • Disorientation • Confusion • Hallucinations • Increased psychomotor and autonomic nervous system activity • Seizures Substance-Related Disorders 67

Table 4-1 Mental Status Variation & Clinical Manifestations of Substances-Induced Disorders (continued)

Substance Intoxication Effects Withdrawal (WD) Features Pharmacologic Treatment Amphetamines Euphoria Onset variable due to typical Supportive rather than (stimulants Grandiosity binge pattern of abuse but biochemical intervention e.g., cocaine, symptoms can occur 9–96 Psychomotor agitation or methamphetamine) hours after last use retardation • Insomnia/Hypersomnia Hypervigilance • Increased appetite Impaired judgment • Psychomotor agitation or Alteration in blood pressure retardation • Fatigue Tachycardia/Bradycardia, • Depression chest pain, cardiac • Vivid/Unpleasant dreams arrhythmias • Irritability Visual/tactile hallucinations • Anxiety Caffeine Restlessness/ Nervousness/ Onset 12–24 hours after last Analgesics (aspirin) for relief Excitability dose, peak in 24–48 hours of head & muscle aches; Insomnia • Marked anxiety/depression Rarely—benzodiazepines in • Marked fatigue/drowsiness Muscle twitching small doses for up to 10 days • Nausea/Vomiting Diuresis • Headache Rambling thoughts & • Muscle aches speech Tachycardia/Cardiac arrhythmia GI disturbance Excessive energy Psychomotor agitation Cannabis Excitement & dissociation None specific—may experience Supportive therapies (e.g., marijuana, of ideas craving, irritability (individual, family, group) hashish) Distortions of time & space rather than biochemical intervention Diminished attention span & memory Deterioration of motor skills Increased appetite Dry mouth Tachycardia Hallucinogens Anxiety & feeling loss of None specific—psychological During intoxication— (e.g., LSD, MDMA/ control rather than physiological psychological support/ Ecstasy) Paranoid ideation/ withdrawal “talking down” suspiciousness Delusions & hallucinations Confusion & delirium Distortion of time, place, distance Impaired judgment Physical symptoms include: dilated pupils, sweating, tachycardia, palpitations, blurred vision and tremors (continues) 68 Chapter 4 Substance-Related Mental Disorders

Table 4-1 Mental Status Variation & Clinical Manifestations of Substances-Induced Disorders (continued)

Substance Intoxication Effects Withdrawal (WD) Features Pharmacologic Treatment Inhalants Euphoria None specific—May Supportive rather than • Hydrocarbon Dizziness experience GI problems, biochemical intervention solvents (gasoline anorexia, confusion, and Blurred vision & glues) headache • Aerosol Loss of inhibition propellants Headache • Anesthetics & General muscle weakness gases (chloroform, Depressed reflexes nitrous oxide) Slurred speech Loss of motor coordination Narcotic analgesics Euphoria & sense of well Onset depends on drug’s half Overdose treatment— (opioids) being life and chronicity of use, peak Naloxone (Narcan) Analgesia, sedation & in 36–72 hours Withdrawal & Detox— somnolence • Muscle aches • Methodone • Lacrimation or rhinorrhea Lethargy & apathy • Buprenophine • Dilated pupils • Clonidine (Catapres)—off Pupillary constriction • Yawning label Decreased respirations & • Nausea/Vomiting/Diarrhea Abstinence—Naltrexone hypotension • Dysphoric mood (ReVia, Vivitrol) • Fever • Insomnia Nicotine At toxicity levels Onset within 2 hours after last Nicotine replacement • Nausea/Vomiting use peak in 24–48 hours therapies • Salivation • Anxiety/Restlessness Nicotine gum, lozenges, • Poor concentration • Dysphoria or depressed patches, and nasal spray • Weakness mood • Varenicline (Chantix) • Tachycardia • Irritability/Frustration/Anger • Bupropion (Zyban) • Tremor • Insomnia • Meecamylamine • “Cold sweats” • Poor concentration (Inversine) • Increased appetite/Weight • Clonidine (Catapres)—off gain label • Bradycardia Sedative Hypnotics Disinhibition & increased Onset with short-acting drugs Overdose—gastric lavage, (e.g., confidence 12– 24 hours, long-acting activated charcoal, monitor benzodiazepines, Slurred speech drugs 5–8 days VS & CNS functions—can be barbiturates) • Seizures lethal for barbiturates Impaired insight, • Insomnia and nightmares judgement & memory Withdrawal—long-acting • Slurred speech benzodiazepines or Decreased concentration • Nausea or vomiting phenobarbital tapering Altered motor skills & • Confusion, delirium, doses down sensory perception memory problems, Mood swings hallucinations (tactile, visual, auditory) • Restlessness, anxiety, tremors, diaphoresis, hyperpyrexia, muscle spasms • Tachycardia, palpitations

(APA 2006, 2007; Sadock & Sadock, 2007) Substance-Related Disorders 69

• Dual diagnosis (comorbidity)—concomitant exis- mg every 6 hours initially, with dosage tence of a substance use and psychiatric disorder; tapered on subsequent days (15% to many co-occurring psychiatric symptoms remit 25% per day); adverse effects include with 2 to 4 weeks of abstinence from substances; memory disruption, lethargy, motor the most common co-occurring psychiatric disor- impairment, disinhibition and high ders include antisocial personality, affective and abuse potential. anxiety disorders, and schizophrenia (2) Carbamazepine (Tegretol)—200 mg 4 times daily, then tapered off • Nursing diagnosis—several of the 2009-2011 in reduced doses over 5 to 7 days; NANDA International (2009) nursing diagnoses useful for mild/moderate with- can be applied to substance-related disorders, drawal symptoms; less sedating than including: benzodiazepines. 1. Behavior, risk-prone health (3) Adjunct medications—clonidine (see 2. Coping, defensive under Opiates/Narcotics); haloperidol 3. Coping, ineffective for agitation, or psychotic symptoms 4. Denial, ineffective associated with DTs.

5. Powerlessness (4) Supplements—thiamine (Vitamin B1) 6. Self-Esteem, chronic low 100 mg daily to avoid Wernicke en-

7. Self-Esteem, situational low cephalopathy; folic acid (Vitamin B9) 8. Self-Esteem, risk for situational low 1 mg daily. 9. Neglect, self b. Opiates/Narcotics 10. Violence, risk for self-directed (1) Methodone (Dolophine) in tapered 11. Family Processes, dysfunctional doses to slowly withdraw from opioid 12. Health Behavior, risk-prone agent—must be part of FDA approved 13. Health Management, ineffective self methodone program (Schedule II con- 14. Knowledge, deficient (specify) trolled substance). (2) Buprenorphine (Buprenex, Subu- • Genetic/biologic origins tex)—4 to 8 mg per day (Schedule III Strong evidence exists as to the genetics of alcohol controlled substance)—opioid partial abuse. Gene variants on chromosomes 5 and 8 agonist antagonist—reduces heroin have been identified as contributing to addictive craving; use of opiates and other illicit behavior. drugs such as cocaine thereby retain- 1. Children of alcoholics are three to four times ing clients in treatment longer; ad- more likely to experience alcohol and/or drug verse effects include constipation and problems; family history–positive individuals symptoms of opiate withdrawal. have less sensitivity to effects of alcohol (high (3) Clonidine (Catapres)—0.4 to 0.6 mg tolerance). per day in two divided doses (an alpha 2. Certain individuals, particularly those with adrenergic agonist); may also be use- Asian heritage, have a genetic inactivity of ful adjunct treatment for autonomic enzyme, aldehyde dehydrogenase, which re- hyperactivity in alcohol withdrawal— sults in a build up of toxic alcohol metabolite, Caution: may cause hypotension. acetaldehyde, causing symptoms of flushing, (a) Clonidine transdermal patch—0.1 headaches, tachycardia, and discomfort. to 0.3 mg per day reduces exces- 3. Chemical imbalance in neurotransmitter lev- sive noradrenergic activity in the els leads to self-medication with substances locus ceruleus of the brain; has of abuse in an attempt to correct imbalance; no effect on craving, insomnia, pharmacotherapy interventions act on de- or muscle aches or pains; adverse pleted neurotransmitter levels. effects include hypotension, sedation, dry mouth, and dizziness. • Biochemical interventions—act on depleted (4) Propanolol (Inderal)—10 mg q 6 neurotransmitter systems (serotonin, dopamine, hours—a beta-adrenergic antagonist GABA) (APA, 2006). with the same effects as clonidine; 1. Agents to treat withdrawal (detoxification) has also shown promise in reducing a. Alcohol, sedative/hypnotics symptoms of cocaine withdrawal; (1) Benzodiazepines—short-acting lora- Caution: may cause hypotension— zepam (Ativan) 1 to 4 mg every 2–6 decreases blood pressure, tachycardia, hours, or oxazepam (Serax) 15 to 60 diaphoresis, and tremors. 70 Chapter 4 Substance-Related Mental Disorders

2. Agents to decrease craving—used with psy- and glutamate; 666 mg PO three times chosocial therapy daily is most effective when treatment a. Alcohol goal is complete abstinence. (1) Naltrexone (ReVia)—50 mg per day b. Opioids/Narcotics (not only increases abstinence, but (1) Methadone—opioid agonist; 40–120 also reduces days of heavy drinking); mg decreases high-risk behaviors as- opioid antagonist reduces the rein- sociated with heroin use (criminal forcement value of alcohol by decreas- activity, prostitution, IV drug use); ing the activity of the opioid system adverse effects include sweating, con- that is activated by alcohol; side ef- stipation, nervousness, insomnia, defects include increased liver enzymes, creased sex drive, difficult ejaculation, nausea, abdominal distress, joint and and low grade opioid withdrawal— muscle pain, early insomnia, and must be part of methodone program. anxiety (also available in once-weekly (2) Buprenorphine—partial opioid ago- injectable—Vivatrol). nist; 4–8 mg per day blocks narcotic (2) SSRIs (fluoxetine, paroxetine, serta- effects. line, citalopram) have demonstrated 4. Agents to decrease consumption—used with efficacy in reducing consumption, psychosocial therapies promoting abstinence, and preventing a. Alcohol relapse through the medication’s ef- (1) Disulfiram (Antabuse)—aversive or

fect on the (5-HT3) serotonin system. alcohol-sensitizing agent; 250–500 mg b. Cocaine/Crack daily interferes with the metabolism (1) Bromocriptine (Parlodel)—2.5–10.0 of alcohol, producing unpleasant mg daily (a dopamine agonist); is side effects when mixed with alcohol; more effective in acute phases of symptoms include facial flushing, treatment, replenishing depleted neu- heart palpitations, increased heart rotransmitters; side effects include rate, dyspnea, nausea, vomiting, and dizziness, headache, nausea, GI dis- decreased blood pressure; clients tress, orthostatic hypotension, and should be instructed to avoid over- sleepiness. the-counter cough medicines, after- (2) Amantidine (Symmetrel)—200–400 shave lotions, vinegar, mouthwashes, mg daily. The same mechanism of ac- nonalcoholic beer (contains small tion and side effects of bromocriptine amount of alcohol) and food cooked (see previous paragraph). with alcohol while taking this drug (3) Carbamazepine (Tegretol)—200–1000 and for 14 days after drug has been mg daily; blocks the dopamine re- discontinued. ceptor sensitivity caused by chronic b. Opioids/Narcotics cocaine use; side effects include seda- (1) Naltrexone—50 mg daily or three tion, dizziness, nausea, and vomiting, doses weekly of 100 mg on Monday hepatotoxicity, agranulocytosis, plate- and Wednesday and 150 mg on Friday let dysfunction, thrombocytopenia, will block the euphoric effects. and tremors. 5. Agents to treat protracted abstinence—contin- (4) Despramine (Norpramine)—tricyclic ued unpleasant state of low grade withdrawal, antidepressant, 2.5 mg per kg daily; including sleep disruption, anhedonia, aner- used to reverse cocaine-induced neu- gia, irritability, nervousness, restlessness, con- rochemical damage with anhedonia ditioned cravings and depression; adverse effects in- a. SSRIs—fluoxetine, paroxetine, sertraline, clude arrhythmias, insomnia, anxiety, citalopram dry mouth, and additive cardiotoxicity b. Tricyclic antidepressants—imipramine, when taken with cocaine; delayed on- desipramine set of action is a drawback. 3. Maintenance agents—used with psychosocial • Intrapersonal origins/Psychotherapeutic therapies interventions a. Alcohol 1. Psychodynamic Theory (1) Acamprosate (Campral)—thought a. Substance use is an adaptive attempt to to balance neuronal excitation and cope with, or compensate for psychologi- inhibition through effects on GABA cal deficits such as dysregulation of affect, Substance-Related Disorders 71

poor object relations, internal conflicts emotional states, interpersonal conflict, and impaired judgment and self-care. and social pressure. Interventions include: b. Substance abuse is a response to an un- (1) Identifying high risk people, places, derlying internal conflict. This conflict is situations between an internal need and an external (2) Identifying negative emotions—bore- limitation. dom, loneliness, depression, anxiety, c. Substances are used to avoid feelings of anger, guilt, shame, self-depreciation anxiety, anger, shame, depression, low (3) Monitoring thinking associated with self-esteem. feelings d. Use of immature, rigid defense mecha- (4) Planning in advance successful avoid- nisms such as denial, dependency, re- ance and coping strategies gression, displacement, and depression (5) Using slips, lapses, and relapses as accompany substance addiction. corrective learning experiences not as e. Psychological dysfunctions are often the treatment failures consequence of substance use rather than c. Evidence-Based Behavior Therapies for the cause. Drug & Alcohol Treatment (See Table 4-2) 2. Social Learning Theory views addiction as the (National Institute on Drug Abuse, 2009) result of maladaptive coping skills. a. Personal experience and past learning • Family dynamics/Family therapy—identifies sub- b. Situational antecedents stance abuse as the presenting symptom of an un- c. Biologic make-up derlying family system dysfunction (Bowen, 1978). d. Cognitive processes 1. Families are undifferentiated. Members can- e. Reinforcement contingencies not act independently of the whole. 3. Psychotherapeutic interventions 2. Family system is highly stressed and basic nur- a. Interventions linked to Psychodynamic turing needs are unmet. There is suppression Theory include: and denial of emotional expression. Commu- (1) Promoting identification as a “recov- nication is indirect, inconsistent, and con- ering” person flictual. Boundaries are weak and constantly (2) Fostering expression of honest feel- changing. Families accommodate the addic- ings and reinforcing efforts to cope in tion, thus “enabling” or making it easier for the more appropriate ways addicted member to continue using. (3) Helping client explore, accept, and 3. Substance abuse is the central theme around own both positive and negative as- which family life is organized. Family rituals pects of self and routines, interactional patterns, and prob- (4) Helping client identify aspects of self lem solving revolve around the addict (Stein- that he/she would like to change glass et al., 1987). (5) Helping client regain a feeling of 4. Codependency is a condition afflicting the empowerment by pointing out the significant other that is characterized by pre- choices he/she has available occupation, dependency on and obsession (6) Helping client recognize and focus on with the addicted individual. Codependent strengths and accomplishments individuals are often adult children of alcohol- (7) Confronting and exploring defense ics (ACOA) and/or share the following similar mechanisms such as denial, minimi- characteristics: zation dependency, regression, pro- a. Low self-esteem and loss of identity jection and displacement b. Seeking external sources of fulfillment (8) Establishing parameters such as struc- c. Need for approval from others ture and clear boundaries d. Fear of abandonment b. Interventions linked to Social Learning e. Inability to express anger Theory consist of cognitive-behavioral/ f. Possible behavior that is controlling, rigid, relapse prevention and behavioral thera- perfectionistic, and overresponsible pies; goals of treatment are to facilitate g. Meeting others’ needs at the expense of changes in personal habits and lifestyle their own needs so that clients may anticipate and cope 5. Strategies in family therapy with problems and high-risk situations; a. Assessing the family system—level of de- most common high-risk situations associ- nial, level of education and insight—use ated with 75% of relapses include negative genogram b. Looking for strengths to reinforce 72 Chapter 4 Substance-Related Mental Disorders

Table 4-2 Evidence-Based Behavior Therapies for Drug & Alcohol Treatment

Efficacy with Therapy Name Brief Description Strategies Used Substance Cognitive Behavioral Based on the theory Exploring positive and Alcohol Therapy (CBT) that learning processes negative consequences Marijuana play a critical role in the of continued use, self- Cocaine development of maladaptive monitoring to recognize behavioral patterns. Using drug cravings and to identify Methamphetamine various strategies to enhance high-risk situations for use, Nicotine self-control, individuals and developing strategies learn to identify and correct for coping with high-risk problematic behaviors by situations and the desire to applying a range of different use. A central element of skills that can be used to stop this treatment is anticipating drug abuse and to address a likely problems and helping range of other problems that patients develop effective often co-occur. coping strategies. Community Reinforcement An intensive 24-week Patients attend one to Alcohol Approach (CRA) Plus outpatient therapy for two individual counseling Cocaine Vouchers treatment of cocaine and sessions weekly that focus on alcohol addiction. Treatment improving family relations, goals are twofold: learning skills to minimize 1. To maintain abstinence drug use, vocational long enough for patients counseling, and developing to learn new life skills new recreational activities 2. To reduce alcohol and social networks. Patients consumption when submit urine samples 2 or drinking is associated 3 times weekly and receive with cocaine use—clinic- vouchers for cocaine- monitored disulfiram negative results. The value of (Antabuse) therapy may the vouchers increases with be used consecutive clean samples and may be exchanged for retail goods that are consistent with a cocaine-free lifestyle. Contingency Management Involves giving patients an Incentives include prizes Alcohol Interventions/Motivational opportunity to earn low-cost given immediately or Stimulants Incentives incentives in exchange for vouchers exchangeable for Opioids drug-free urine samples. food items, movie passes, and other personal goods. Marijuana Nicotine Matrix Model Provides a framework for Uses detailed treatment Stimulants engaging stimulant abusers manuals with worksheets (e.g., cocaine, in treatment and helping for individual sessions; other methamphetamine) them achieve abstinence. components include family Addresses issues critical to education groups, early addiction and relapse with recovery skills groups, relapse direction and support from a prevention groups, combined trained therapist. sessions, urine tests, 12-step programs, relapse analysis, and social support groups. Substance-Related Disorders 73

Table 4-2 Evidence-Based Behavior Therapies for Drug & Alcohol Treatment (continued)

Efficacy with Therapy Name Brief Description Strategies Used Substance Motivational Enhancement A patient-centered Motivational interviewing Alcohol Therapy (MET) counseling approach for principles are used to Marijuana initiating behavior change by strengthen motivation and Nicotine helping individuals resolve build a plan for change. ambivalence about engaging Coping strategies for high- in treatment and stopping risk situations are suggested drug use. and discussed. Therapist Evokes rapid and internally monitors change, reviews motivated change, rather cessation strategies used, than guiding people stepwise and continues to encourage through the recovery process. commitment to change or sustained abstinence. 12-Step Facilitation An active engagement Three key aspects: (1) Alcohol Therapy strategy designed to increase acceptance that drug Stimulants the likelihood of a substance addiction is a chronic, Opioids abuser becoming affiliated progressive disease over with and actively involved in which one has no control, 12-step self-help groups and, and that abstinence is the thus, promote abstinence. only alternative; (2) surrender of oneself to a higher power; and (3) active involvement in 12-step meetings and related activities.

(National Institute on Drug Abuse, 2009)

c. Discouraging blaming members excessive alcohol and drug use. Thus, a vicious d. Educating family about chemical depen- addiction cycle develops that maintains the dency and referring to AL-ANON/ problematic alcohol and drug use. AL-ATEEN for support e. Assisting with the process of emotional • Sociocultural Theories include factors such as separation and reactiveness to the sub- ethnic use patterns, religious beliefs and rituals, stance abuse behavior gender issues, and peer pressure as influencing f. Modeling effective communication and alcohol and drug use. attitudes g. Supporting/reinforcing healthy change • Group approaches—used more frequently in substance abuse treatment. Advantages include: • Disease model 1. Peer support and confrontation 1. Substance abuse is a medical and spiritual 2. Reflection on family of origin issues disease. 3. Place to practice newly learned interpersonal 2. There is a biomedical internal causation for skills chemical dependency that prevents certain 4. Specific groups include: individuals from being able to control and pre- a. Psychoeducational groups—didactic dict their drinking in a consistent manner. lectures and discussions on such topics 3. Bio-psycho-social-spiritual maintenance model as the disease concept of addiction, the asserts that excessive alcohol and other drug addictive cycle, biopsychosocial conse- use leads to profound biologic, social, psycho- quences of substance abuse, dual diagno- logical, and spiritual negative consequences. sis, relapse prevention, communication The distress associated with these multidimen- skills, assertiveness, and relaxation sional negative consequences leads to further b. Self-help groups 74 Chapter 4 Substance-Related Mental Disorders

(1) Grounded in the conception that sub- more accurately and safely quantify the stance abuse is a medical and spiri- amount of detoxification medication that tual disease. The belief is that there is administered. is an internal causation for chemical b. Assess and monitor level of consciousness, dependency beyond the individual’s orientation, thought processes and sen- control. sory perceptual alterations. (2) Groups offer support and mutual c. Assess for tremulousness and agitation. sharing. The group is open to all who d. Provide a quiet, dimly lit environment share the common goal of recovery with low stimulation. from a variety of substances and e. Implement fall precautions. conditions. f. Implement seizure precautions for al- (3) The following 12 steps provide the cohol, benzodiazepines, and sedative/ roadmap one must follow to reach hypnotics. recovery: g. Provide nutritional support—administer (a) Admit powerlessness and unman- vitamin and mineral supplements as or- ageability of life dered; alleviate gastrointestinal distress. (b) Look to Greater Power to restore h. Maintain hydration—monitor intake and sanity output, assess water loss from diaphoresis. (c) Turn life and will over to God i. Implement measures to help client sleep (d) Take a moral inventory and relax: stress management, breathing (e) Admitting nature of wrongs retraining, progressive muscle tension re- (f) Be ready to have God remove laxation, yoga, meditation, acupuncture, character defects therapeutic touch. (g) Ask God to remove shortcomings j. Convey acceptance and reassurance. (h) Make a list of people harmed and k. Reorient when indicated. willingness to make amends 2. Psychosocial supportive measures during re- (i) Make amends habilitative phase of recovery include: (j) Continue personal inventory a. Formulating treatment goals and expected (k) Improve conscious contact with outcomes with patient God b. Role modeling self-acceptance, assertive- (l) Carry message of spiritual awak- ness, and responsibility ening to other alcoholics c. Maintaining consistency in care—requires (4) Critics of the twelve steps believe a high degree of communication among this approach is not appropriate for staff everyone and complain about the d. Confronting in an empathetic, respectful reference to God. Proponents endorse manner, always focusing on the dysfunc- a broader, more spiritual versus re- tional behavior and not the individual ligious definition of God or Higher e. Identifying and working through counter- Power. transference issues f. Providing structure—use daily activity • Milieu interventions—based on staff providing a schedule safe, corrective environment that enhances the g. Use of self disclosure only when appropri- development of more adaptive coping skills and ate and in the context of therapy interpersonal behaviors. h. Use of behavioral contracts with 1. Management of withdrawal—detoxification contingencies occurs in the early phase of recovery and (1) Reinforce compliance and involves safely tapering off of substance of achievement abuse, thereby minimizing the physical dis- (2) Administer consequences for comfort associated with withdrawal. Guide- noncompliance lines for withdrawal management include: i. Providing on the spot conflict a. Monitor vital signs and severity of with- management drawal (see symptoms associated with j. Assisting with task assignments and specific drugs) and medicate as ordered. homework Use Clinical Instrument for Withdrawal k. Using rehearsal and role playing of newly from Alcohol (CIWA) to measure both learned skills objective and subjective symptoms of 3. Psychiatric and mental health advanced prac- withdrawal. This enables the nurse to tice nurse interventions include: Substance-Related Disorders 75

a. Theory-based psychotherapy—individual, 3. Role strain and work stress (long working group, family hours, physical and emotional exhaustion) b. Evaluation, treatment recommendation 4. Treatment approaches include: and appropriate referral a. Intervention—structured method of pen- c. Consultant as an expert in the field of etrating the delusional system of chemi- chemical dependency cally dependent persons for the purpose d. Staff support and management functions of facilitating insight into the addictive e. Interventions for the patient presenting problem and entry into treatment with complex problems (1) Use team approach, nonpunitive at- f. Staff education and supervision titude; 2–10 professional associates g. Preventative functions—community of impaired colleague who share a awareness and education nonjudgmental attitude (to include h. Research functions—participation in one recovering peer and one with ex- and/or initiation of protocols that may perience in chemical dependency if improve future interventions and care of possible). the substance abusing population (2) Present documented evidence, always i. Professional development—committee prefacing testimony with positive memberships, publications, presenta- remarks. tions, learning opportunities (3) Give impaired nurse a chance to j. Medication evaluation and monitoring if respond. psychiatric and mental health advanced (4) State available options and allow an practice nurse granted prescriptive opportunity for voluntary entry into authority treatment. (a) Diversion programs—facilitate • Community resources reentry into practice without li- 1. Self-help support group meetings censure sanctions. a. Alcoholics Anonymous (AA) (b) Regulatory legal action—nurse b. Narcotics Anonymous (NA) reported to the state board for c. Cocaine Anonymous (CA) suspected chemical dependency d. Secular Organizations for Sobriety (SOS); is dealt with under the State Nurse geared more toward individuals with ag- Practice Act and the Administra- nostic view of spirituality tive Procedure Act. e. AL-ANON, NAR-ANON and AL-ATEEN— (c) Criminal legal action—nurse who family/significant others and teenagers diverts a control substance from living with or involved with a substance a facility or obtains a controlled abuser substance by fraud is in violation f. Adult Children of Alcoholics (ACOA) of the Controlled Substance Act. 2. Prevention groups—special-interest groups (5) Make arrangements to monitor developed for community awareness and progress. education, public policy making, introducing c. Specialized inpatient program, AA and/or and changing legislation related to alcohol and NA meetings for healthcare professionals substance use d. Employee assistance programs a. Drug Abuse Readiness Education (DARE) e. Peer assistance support from state and b. Mothers Against Drunk Drivers (MADD) district associations f. Reentry back into the workplace • Impaired nurses—a resolution passed at the (1) Restrictions on handling medications American Nurses’ Association (ANA) Congress in for a certain period of time 2002 advocates for the use of an “alternatives to (2) Urine drug screening discipline” model (also known as peer-assistance (3) Regular documented attendance for programs) in addressing a nurse’s needs when outpatient treatment and AA/NA substance-related or psychiatric disorders interfere meetings with the practice of nursing. According to Cahill (4) Stable work shifts (minimize variable (1992) nurses are at higher risk due to: shift work) 1. Accessibility to drugs and addictive substances (5) Clear job performance expecta- 2. Mistaken belief that health professionals can tions with supervision and regular “self-medicate safely” evaluations 76 Chapter 4 Substance-Related Mental Disorders

Questions c. Seizures d. Stroke Select the best answer 7. Ms. D. is admitted to the emergency room with 1. Ms. P. presents to the community substance suicidal ideations. Urine drug screen reveals the abuse center for an evaluation. She states that presence of cocaine in the urine. When ques- she does not have a substance abuse problem tioned with this finding, Ms. D. denies any use of but agreed to the evaluation at her husband’s cocaine. The most appropriate nursing response insistence. The appropriate initial statement would be: would be: a. “This test is very accurate, Ms. D., you must a. “Do you drink often?” not be telling the truth.” b. “Your husband is concerned about your b. “You are depressed because you have used drinking?” cocaine.” c. “What makes you think that you do not have c. “Were you in a room with other people who a drinking problem?” were smoking crack?” d. “How much do you drink?” d. “Have you ever used drugs in the past?” 2. According to Prochaska and DiClemente, at what 8. Which of the following questions would NOT be stage of change would Ms. P. be in? important in assessing potential withdrawal from alcohol? a. Contemplation b. Action a. “When was your last drink and how much c. Denial did you consume?” d. Precontemplation b. “Have you experienced any ‘blackouts’?” c. “During the last month, what is the longest 3. Mr. C., a 40-year-old male with a diagnosis of period of time that you have gone without alcohol dependence, is admitted to the inpatient alcohol?” unit for detoxification. Which of the following d. “Do you experience any physical discom- measures would NOT be implemented at this fort when you go without alcohol for a few time? hours or a few days?” a. Monitor vital signs 9. Mr. G., a 50-year-old chronic alcoholic, is recently b. Provide quiet, dimly lit atmosphere admitted to the inpatient unit. It has been 48 c. Confront denial hours since his last drink. Mr. G. states that d. Encourage fluids by mouth he feels strange and everything around him 4. Mr. C. completes detoxification and rehabilita- seems unreal. The nurse notices that Mr. G. tion and is discharged on Disulfiram (Antabuse), has scratches on both arms. The nurse should 250 mg to be taken every morning. Which of suspect: the following substances can Mr. C. continue to a. Drug seeking behavior take? b. Onset of psychosis a. Mouthwash c. Onset of delirium tremens b. Cough elixirs d. Wernicke-Korsakoff syndrome c. Nonalcoholic beer 10. Which laboratory value is NOT necessarily altered d. Antidepressant medication by alcoholism? 5. When assessing whether or not a patient has a a. Aspartate aminotransferase (AST) problem with alcohol or drugs, which criterion is b. Gamma-glutamyltransferase (GGT) the best indicator: c. Mean corpuscular value (MCV) a. How much a person uses d. White blood cell count (WBC) b. How often a person uses 11. Genetic studies in alcoholism support which of c. The level of interference with physical, emo- the following statements: tional, and social functioning d. Positive laboratory findings a. Alcoholism is mostly influenced by environmental factors. 6. Which of the following is NOT a sign of delirium b. Children of alcoholics are four times more tremens? likely to have problems with alcohol or a. Confusion drugs. b. Tactile hallucinations Questions 77

c. There is no definitive research that links a. Call her parents and inform them of her drug alcoholism to genetic etiology. use d. If both parents have alcoholism there is a b. Tell her she will be expelled if she does not 75% chance that each child will have an quit using alcohol or drug problem. c. Refer to substance treatment and monitor compliance and progress 12. Mr. F. is participating in a 6-week intensive out- d. Do not intervene, as patient probably needs patient substance abuse treatment program to suffer the consequences of her use for his crack/cocaine addiction. During the third week of treatment he tests positive for cocaine 17. Which of the following medical complications in his urine. The most appropriate intervention is NOT necessarily associated with cocaine/crack would be to: abuse: a. Refer to inpatient treatment a. Kidney failure b. Dismiss from the intensive outpatient b. Seizures program c. Stroke c. Meet with the patient individually to discuss d. Cardiac Arrhythmias the slip/relapse 18. Sedatives/hypnotics are cross-addicted with: d. Confront the patient in group a. Alcohol 13. Which of the following is NOT necessarily an b. Opiates alcohol-related medical complication? c. Stimulants a. Arteriosclerosis d. Hallucinogens b. Cardiomyopathy 19. Mr. L. is a 50-year-old male with a history of c. Cirrhosis of the liver chronic back pain from a car injury that occurred d. Gastritis 5 years ago. He has been taking Darvocet-N 100 14. There has been an increase in the number of over the past several years and reports taking up infectious diseases associated with the current to 15 tablets a day. His medical doctor no longer drug epidemic. Which of the following infectious feels comfortable giving Mr. L. prescriptions for diseases is NOT necessarily associated with addic- pain and refers him to substance abuse treat- tive behavior? ment. Mr. L. is admitted to the inpatient unit for narcotic detoxification. He is very fearful that he a. Sexually transmitted diseases will be denied pain medication and left to suffer. b. HIV, AIDS The most appropriate nursing intervention c. Hepatitis would be to: d. Encephalitis a. Reassure Mr. L. that his pain will be managed 15. Nurse K. is a nurse counselor working for a uni- while his narcotic is being slowly tapered versity. Ms. G. is a 22-year-old sophomore who b. Explain to Mr. L. that he is addicted to nar- has been referred to nurse K. for an evaluation cotics and must not use them anymore because of her declining grades and poor class c. Explain to Mr. L. that his pain threshold has attendance. What would be the most appro- been lowered due to his narcotic abuse and priate line of questioning for nurse K. to pursue? he will not need pain medication a. “Your advisor tells me that you are doing d. Tell Mr. L. that he will have Tylenol and poorly in school?” aspirin available for pain management b. “Have you been spending more time 20. Which of the following is NOT a symptom of partying than concentrating on your opiate withdrawal? schoolwork?” c. “Can you tell me what has been happening a. Muscle cramps around you that may be affecting your b. Tachycardia school work?” c. Pupillary constriction d. “Are you using any drugs?” d. Diarrhea 16. Ms. G. continues to smoke marijuana, and her 21. Which of the following nursing diagnoses school problems are getting worse. Your best would be the least appropriate for Mr. L.’s plan intervention would be to: of care? 78 Chapter 4 Substance-Related Mental Disorders

a. Injury, potential for a. Heart defects b. Comfort, alteration in b. Facial dysmorphology c. Self-care deficit c. Growth retardation d. Knowledge deficit d. Central nervous system dysfunction 22. The benefit of methadone maintenance over 27. The advanced practice nurse in PMH leads a heroin use is that it: multifamily group. Ms.T. is a 40-year-old house- wife who is very angry at her husband because a. Serves as an anticraving agent he recently spent the couple’s entire savings b. Diminishes risky behavior associated with on cocaine. Ms.T. feels very frustrated with her heroin use husband’s addiction and would like to learn to c. Is effective as a detoxification agent support him in his recovery. The APN-PMH’s best d. Has no adverse effects suggestion would be for Ms. T.: 23. Mr. T. is a 37-year-old male admitted for depres- a. To leave her husband sion. When the nurse admitting Mr. T. asked him b. To take charge of the family finances about his alcohol use, he stated he had a couple c. To not get involved in her husband’s recovery of beers after work every day. He also said that d. To attend AL-ANON meetings to explore his wife was threatening to leave him. When how significant others cope with their loved Mrs. T. came to the hospital to visit her husband, one’s addiction his primary nurse met with them together. Mrs. T. stated that she was tired of putting Mr. T. to 28. From a family systems perspective, chemical bed every night and calling his job stating he was dependency can be viewed as: sick when he was really hung over. Mrs. T. states a. A lack of the family’s ability to problem solve that she also makes herself available at all times b. Lack of communication to pick up Mr. T. if he has been out drinking. She c. Lack of family organization and interactional states that she cares about her husband and does patterns not want to see him get hurt. This behavior is d. A symptom of underlying family dysfunction typical of: 29. Ms. R. is a 50-year-old women married to an a. Caring alcoholic. During individual counseling Ms. R. b. Supporting states that her husband’s drinking interferes with c. Controlling their social activities. His behavior when drinking d. Enabling embarrasses and humiliates her. An appropriate 24. Ms. K., a 30-year-old female, has finished a cog- response would be to advise Ms. R. to: nitive behavioral intensive outpatient treatment a. Stop going to activities program for her crack/cocaine addiction. For b. Continue to go to activities without focusing follow-up she plans to attend a weekly process on her husband’s drinking, letting him take group. According to Prochaska and DiClemente, responsibility for the consequences of his what stage of change would this client be drinking behavior entering? c. Encourage Ms. R. to keep a watchful eye on a. Action her husband, frequently reminding him how b. Maintenance much he has had to drink c. Aftercare d. Make sure she is available at activities so that d. Preparation she can drive her husband safely home 25. Which of the following is less likely to be a limi- 30. Which of the following goals would NOT be tation of urine drug testing for substances of appropriate for the milieu management of a resi- abuse? dential substance abuse program? a. Often produces false positives a. To maintain a restricted environment b. “Short” window of detection of metabolites b. To maintain the safety of the patient c. Intermittent abuse patterns of abusers c. To provide consistent, structured care d. Issues of civil liberties d. To support the patient’s recovery effort 26. Which of the following characteristics is NOT necessarily present in fetal alcohol syndrome? Questions 79

31. Ms. G. is a 67-year-old female with a long history a. Disease model of alcoholism. She currently has cirrhosis of the b. Nursing Light model liver. In order to be put on a list to receive a liver c. Social Learning theory transplant, she must complete an inpatient sub- d. Family Systems theory stance abuse program. Additionally, she must 36. AL-ANON would most probably recommend to sustain 6 months of abstinence. On admission the spouse of an alcoholic individual: Ms. G. states that the only reason she is here is to receive a new liver. An appropriate initial a. To continue the same behavior response would be: b. That you are powerless over the alcoholic individual, so take care of yourself a. “How did you get cirrhosis of the liver?” c. To learn how you can change the alcoholic b. “You sound angry about having to partici- individual pate in substance abuse treatment.” d. To get a divorce c. “Treatment requires having insight into your alcoholism.” 37. A common physical complication of alcohol d. “You are concerned about your liver dependence, which contributes to memory disease?” impairment is: 32. An evaluation criterion for Ms. G.’s plan of care a. Decreased serotonin levels would be to: b. Elevated liver enzymes c. B-vitamin deficiency a. Understand the reasons for her drinking d. Gastritis b. Verbalize her dependence on alcohol c. Recognize situations that put her at high risk 38. The 12 steps of Alcoholic and Narcotics Anony- for drinking mous describe: d. Discuss her alcoholism openly in group a. A spiritual approach to living 33. An example of a violation of the Controlled Sub- b. How the organizations were developed stance Act would be: c. What goes on in meetings d. God as a higher power a. Driving under the influence of alcohol b. Drinking or using drugs at work 39. What are the characteristics of therapists who c. Possession of an illegal substance outside of are most successful in treating substance use work disorders? d. Diverting a controlled substance from a a. They confront and challenge the client’s facility denial. 34. RJ is a 16-year-old who presents to the county b. They take control, and clearly tell their emergency room one night accompanied by two clients what they need to do to recover. of his peers. His friends state that RJ just started c. They show high levels of empathy. acting very weird while they were attending d. They are recovering from addiction a concert. The nurse notices that RJ is anxious, themselves. agitated, confused, paranoid, and that his pupils 40. Mr. J. is a 28-year-old male with a diagnosis of are dilated. RJ is convinced that everything is polysubstance dependence and panic disorder. changing shape and color. Based on this informa- Mr. J. states that if his anxiety were treated he tion, the nurse should suspect: would have no need to abuse addictive sub- a. Schizophrenia stances. Which statement best supports the b. A brief psychotic episode nurse’s understanding about the treatment of c. A panic attack dual diagnosis? d. Hallucinogen intoxication a. The anxiety is probably caused by drugs and 35. The primary nurse is assigned a 24-year-old will remit with cessation of drug use. women with a crack cocaine dependence. The b. The substance abuse is an attempt by the nurse meets with the client to discuss a plan of patient to self-medicate his panic disorder. care. The nurse and client decide on an activity c. Both the substance abuse and the panic that will enhance the client’s self-esteem and disorder must be treated concurrently to empowerment. Which of the following models maximize treatment outcome. is providing the theoretical framework for this d. The patient who is adequately treated for intervention? panic disorder can return to controlled drug use. 80 Chapter 4 Substance-Related Mental Disorders

41. The efficacy of Motivational Enhancement American Psychiatric Association. (2007). Guideline Therapy has been demonstrated with: watch (April 2007). Practice guideline for the treatment of patients with substance use disorders (2nd ed.). Ar- a. Alcohol abuse lington, VA: American Psychiatric Publishing. [elec- b. Narcotic abuse tronic version available at: http://www.psychiatry c. Nicotine dependence online.com/pracGuide/pracGuideTopic_5.aspx] d. Both a and c are correct American Psychiatric Association. (2006). Practice guide- 42. CBT is an evidence-based therapy shown to be line for the treatment of patients with substance use effective in treating substances of abuse. disorders (2nd ed.). Arlington, VA: American Psychiat- ric Publishing. Retrieved from http://www.psychiatry a. True for all substances of abuse online.com/pracGuide/pracGuideTopic_5.aspx b. True for most substances of abuse American Psychiatric Association. (2000). Diagnostic c. False because there is insufficient empirical and statistical manual of mental disorders (4th ed., evidence related to CBT text revision). Washington, DC: Author. d. Absolutely false Anderson, M. D., & Smereck, A. B. (1992). Conscious- 43. MJ is a 29-year-old male seeking assistance in ness rainbow: An explication of Rogerian field pat- reducing episodes of heavy alcohol consumption. tern manifestations. Nursing Science Quarterly, 5(2), The best medication to consider and discuss with 72–79. him is: Bowen, M. (1978). Family therapy in clinical practice. New York, NY: Jason Aronson. a. Disulfiram (Antabuse) Cahill, J., Cassidy, K., Daly, S., Deutisch, D., Hodgson, b. Naltexone (ReVia, Vivitrol) B., Hodgson, J., Johnson, P. & McMahon, E. (1992). c. Both a and b are correct Nurses handbook of law and ethics. Springhouse, PA: d. Neither medication should be used with Springhouse. alcohol Galanter, M. J., & Kleber, H. D. (1994). Textbook of substance abuse treatment. Washington, DC: American Answers Psychiatric Press. Hughes, A., Sathe, N., & Spagnola, K. (2009). State esti- 1. b 23. d mates of substance use from the 2006-2007 National 2. d 24. b Surveys on Drug Use and Health. (Office of Applied 3. c 25. a Studies, Substance Abuse and Mental Health Services 4. d 26. a Administration (SAMHSA), NSDUH Series H-35, 5. c 27. d HHS Publication No. SMA 09-4362). Rockville, MD: 6. d 28. d SAMHSA-HHS. 7. d 29. b Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). 8. c 30. a Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. 9. c 31. d Miller, N. S., & Gold, M. S. (1995). Pharmacological therapies for drug and alcohol addictions. New York, NY: 10. d 32. b Marcel Dekker, Inc. 11. b 33. d Miller, W. R., & C’de Baca, J. (1995). What every mental 12. c 34. d health professional should know about alcohol. Jour- 13. a 35. b nal of Substance Abuse Treatment, 12(5), 355–365. 14. d 36. b Naegle, M. A. (1992, 1993). Substance abuse educa- 15. c 37. c tion in nursing (Vol. I, II, III). New York, NY: National 16. c 38. a League for Nursing. 17. a 39. c NANDA International. (2009). Nursing diagnoses: Defi- 18. a 40. c nitions & classifications, 2009-2011. West Sussex, UK: 19. a 41. d Wiley & Sons. 20. c 42. b National Institute on Drug Abuse. (2009). Principles of 21. c 43. b drug addiction treatment: A research-based guide. (NIH Publication No. 09-4180). Bethesda, MD: 22. b Author. National Institute on Drug Abuse. (2008). National re- Bibliography port series: Comorbidity: Addiction & other mental ill- Allen, K. M. (1996). Nursing care of the addicted client. nesses. (NIH Publication No. 08-5771). Bethesda, MD: Philadelphia, PA: Lippincott. Author. Bibliography 81

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. Substance Abuse and Mental Health Services Adminis- (1992). In search of how people change: Applications tration, Office of Applied Studies. (March 19, 2009). to addictive behavior. American Psychologist, 47, The NSDUH report: Concurrent illicit drug and alco- 1102–1114. hol use. Rockville, MD: Author. Rotgers, F., Keller, D. S., & Morgenstern, J. (1996). Treat- Substance Abuse and Mental Health Services Adminis- ing substance abuse: Theory and technique. New York, tration. (2008). Results from the 2007 National Survey NY: Guilford Press. on Drug Use and Health: National findings. (Office of Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sa- Applied Studies, NSDUH Series H-34, DHHS Publica- dock’s synopsis of psychiatry (10th ed.). Philadelphia, tion No. SMA 08-4343). Rockville, MD: Author. PA: Lippincott. Steinglass, P., Bennett, L., Wolin, S., & Reiss, D. (1987). Stahl, S. M. (2008). Stahl’s essential psychopharmacol- The alcoholic family. New York, NY: Basic Books. ogy: Neuroscientific basis & practical applications (3rd Sullivan, E. J. (1995). Nursing care of clients with sub- ed.). New York, NY: Cambridge University Press. stance abuse. St. Louis, MO: Mosby. Stahl, S. M. (2009). Stahl’s essential psychopharmacology: The prescriber’s guide (3rd ed.). New York, NY: Cambridge University Press.

5 Anxiety and Stress- Related Disorders

Anxiety Disorders 2. Palliative—anxiety is transient with temporary relief allowing for problem solving. • Overview 3. Maladaptive—anxiety is constant with limited Anxiety disorders are among the most common success at problem solving. mental disorders in the general population, affect- 4. Dysfunctional—anxiety is constant with det- ing about 40 million (18.1%) adults (aged 18 and rimental effects on general functioning; new older) in the United States (Kessler, Chiu, Demler, problems develop. & Walters, 2005). This cluster of disorders is characterized by the type, degree, and duration of anxiety Phobias or worry experienced in response to one or more perceived stressors. The most common anxiety dis- • Definition—persistent, excessive, irrational fear orders are specific (simple) phobias (8.7%), social of a particular object or situation that can lead to anxiety (phobia) (6.8%), posttraumatic stress dis- avoiding the feared object or situation order (3.5%), generalized anxiety disorder (3.1%), and panic disorder (2.7%); other anxiety disorders • Signs and symptoms occur in less than 2% of the population (Kessler, 1. Specific phobias Chiu, Demler, & Walters, 2005). a. Fear of animals (snakes, spiders, dogs) b. Claustrophobia • Levels of anxiety (Videbeck, 2006) c. Fear of air travel I. Mild—slight physical arousal, sharp percep- d. Usually limited impairment tions, ability to learn well 2. Social Phobia (social anxiety)—fear of being II. Moderate—physical symptoms apparent, nar- exposed to scrutiny, humiliated, or embar- rowing of perceptual field, selective attention rassed by others III. Severe—physical symptoms problematic, dif- a. Specific fears—choking on food in restau- ficulty concentrating, very apprehensive, may rant, trembling when writing develop ritualistic behavior b. General fears—saying foolish things IV. Panic—terror, little ability to concentrate, dif- c. Usually mild impairment ficulty breathing, palpitations, fear of dying, 3. Agoraphobia—fear of being in a place or situ- may be suicidal ation from which there might be difficult or embarrassing escape, or in which, should • Types of coping (Keltner, Schwecke, & Bostrom, symptoms become very embarrassing or inca- 2007) pacitating, there might be no help available— 1. Adaptive—active problem solving is attempted such as: with limited experience of anxiety.

83 84 Chapter 5 Anxiety and Stress-Related Disorders

a. Fears of heart attack, depersonalization, 2. Possible genetic component with higher con- loss of bladder control, etc. cordance in first-degree relatives b. Limits on travel, crowds, or being out- 3. Serotonergic abnormality side the home alone to avoid symptom 4. Possible limbic system responsibility in gener- development ating anticipatory anxiety c. Mild (some avoidance or tolerance of anxiety) to severe (housebound or un- • Biochemical interventions (Stahl 2008, 2009; Sa- able to leave the house unaccompanied) dock & Sadock, 2007) impairment 1. Antianxiety agents in combination with behavioral approaches • Differential diagnosis 2. Antianxiety agents if behavioral approaches 1. Panic Disorder with Agoraphobia ineffective (See Table 5-1) 2. Avoidant Personality Disorder a. Antidepressants, particularly selective 3. Obsessive-Compulsive Disorder serotonin reuptake inhibitors (SSRIs) and 4. Posttraumatic Stress Disorder serotonin norepinephrine reuptake in- 5. Schizophrenia (with delusions) hibitors (SNRIs) are effective antianxiety agents (See Table 5-2). • Mental status variations b. Short-acting benzodiazepines (alprazo- 1. Appearance and behavior—normal unless lam) may be useful for specific phobias. faced with feared stimulus, then exhibits c. Beta-adrenergic antagonists that block the symptoms of severe anxiety sympathetic response (e.g., propranolol) 2. Mood—commonly depressed, often related to are helpful in situational anxiety such as degree of impairment stage fright. 3. Thought—persistent, irrational fear of object d. Other antidepressants may be useful if or situation first-line agents do not effectively reduce anxiety symptoms: • Nursing diagnoses (NANDA, 2009) (1) MAOIs in particular for social phobias 1. Anxiety (specify level) (2) TCAs such as imipramine for panic 2. Insomnia disorders with agoraphobia 3. Coping, ineffective 4. Fear • Intrapersonal origins/Psychotherapeutic 5. Powerlessness, risk for interventions 6. Relationships, readiness for enhanced 1. Origins 7. Hopelessness a. Psychodynamic—phobia as an outward 8. Resilience, risk for compromised manifestation of inner, unresolved child- 9. Self-Esteem, situational low hood conflicts 10. Resilience, impaired individual (1) Anxiety is displaced (when repression 11. Resilience, readiness for enhanced fails) upon an object or situation that 12. Role Performance, ineffective symbolizes the conflict. 13. Coping, compromised family (2) Conflicts are often sexual (oedipal) or related to separation anxiety. • Genetic/Biologic origins (3) Disorder includes disturbance of in- 1. Biologic inability to habituate to certain terpersonal attachment & coping. situation

Table 5-1 Recommended First-line Medications for Selected Anxiety Disorders

Anxiety Disorder SSRI SNRI Benzodiazepine Other Social Phobia/Social Anxiety Disorder X X X Posttraumatic Stress Disorder (PTSD) X X Generalized Anxiety Disorder (GAD) X X X Buspirone Panic Disorder X X X Obsessive-Compulsive Disorder (OCD) X

(Sadock & Sadock, 2007; Stahl, 2008) Anxiety Disorders 85

Table 5-2 First-line Antianxiety Medications

Generic Name Usual Daily Dose Drug Class (Brand Name) (mg/day) Comments Antidepressants SSRI Escitalopram (Lexapro) 10 to 20 SSRIs are first-line agents for Fluoxetine (Prozac) 20 to 80 anxiety spectrum disorders Fluvoxamine CR (Luvox CR) 100 to 300 Paroxetine (Paxil, Pexeva) 20 to 50 Sertraline (Zoloft) 50 to 200

SNRI Duloxetine (Cymbalta) 60 Venlafaxine (Effexor, Effexor 75 to 225 XR) Anxiolytics Azapirone Buspirone (BuSpar) 20 to 30 May take up to 4 weeks for therapeutic effect

Benzodiazepine Triazolam (Halcion) SA 0.125 to 0.25 Generally, benzodiazepines Alprazolam (Xanax) IMA 0.75 to 6 are used short term (about one month) Lorazepam (Ativan) IMA 2 to 6 Oxazepam (Serax) IMA 30 to 60 Flurazepam (Dalmane) LA 15 to 30 Clonazepam (Klonopin) LA 0.5 to 2 Chlordiazepoxide (Librium) LA 15 to 100 Diazepam (Valium) LA 4 to 40

Legend for benzodiazepines: SA = short acting; IMA = intermediate acting; LA = long acting (Sadock & Sadock, 2007; Stahl, 2008, 2009)

b. Behavioral (b) Teach progressive muscle re- (1) Classical conditioning response— laxation (PMR) to induce deep phobia develops when anxiety occurs relaxation. as one is confronted with a naturally (c) Induce/maintain relaxed state, frightening stimulus and becomes while client imagines each paired with a neutral stimulus. anxiety-provoking stimulus. (2) Operant theories—person learns to (d) When desensitized to one stimu- avoid a stimulus for anxiety, and the lus, move up the scale, until reduction in anxiety reinforces the relaxation can be maintained behavior. throughout entire list of stimuli. 2. Psychotherapeutic interventions (e) Apply technique in vivo. a. Psychodynamic—insight-oriented therapy (2) Flooding—use intensive exposure to to resolve childhood conflicts, understand stimulus in vivo or through imagery secondary gain, and to find healthy ways until fear can no longer be felt. to deal with anxiety (3) Neurolinguistic Programming b. Behavior (most effective treatment) c. Hypnosis—used to support acceptance (1) Systematic desensitization that the phobic object/situation is not (a) Design, with client, list of anxiety- dangerous, or to assist in relaxation provoking stimuli related to the when confronted with the feared object/ object/situation from the least to situation most frightening. 86 Chapter 5 Anxiety and Stress-Related Disorders

• Family dynamics/Family therapy—used in the fol- • Signs and symptoms lowing situations: 1. Stressors may include war experiences, as- 1. Role performance (work, family, social con- sault, rape, serious accidents, abuse, and natu- tacts) is impaired, family dynamics are al- ral catastrophes (van der Kolk, McFarlane, & tered, and other members assume additional Weisaeth, 1996). responsibilities. 2. Common trauma experience symptoms in- 2. Children sense fears of outside world or clude overwhelming fear, loss of control, help- objects. lessness, and fear of being annihilated. 3 There is need for role restructuring, support of a. Person witnesses or experiences events therapy and change, and reduction of second- that involve actual or threatened death or ary gain of all members. severe physical harm. b. Person reacts with fear, helplessness, or • Group approaches horror (APA, 2000). 1. Therapy 3. Recurrent intrusive thoughts of trauma oc- a. Psychodynamic insight-oriented group cur in dreams, thoughts, flashbacks, or events therapy similar to stressor. b. Psychoeducational group—focus on un- 4. Numbing or constriction (avoidance) re- derstanding phobic disorders and learning sponses include: relaxation techniques a. Avoidance of thoughts/feelings/ c. Social skills training—modeling, rehears- recollections about trauma ing, coaching to improve communication b. Avoidance of persons/situations that pro- d. Supportive therapy to provide reality test- voke memory of original trauma ing and feedback within a group of others c. Psychogenic amnesia, dissociation seeking to make similar changes—may d. Marked diminished interest in significant provide “here and now” experience in fac- activities, persons, or the future ing phobic social situations 5. Increased arousal responses include sleep dis- 2. Self-help groups (affiliated with Phobia Society turbances, temper outbursts, hypervigilance of America, Rockville, MD) may be present in and difficulty concentrating, and exaggerated some communities. startle response (APA, 2000). 6. Response may be delayed by weeks to many • Milieu interventions (unlikely to be hospitalized years. unless severely impaired) 7. Standard definition of PTSD (DSM) tends bet- 1. Provide safe, supportive environment, free of ter to fit survivors of circumscribed events ridicule for phobia. and fails to address symptoms and personality 2. Institute goal-oriented contract for treatment. manifestation resulting from prolonged, re- 3. Employ anxiety-reducing techniques (PMR, peated trauma (Herman, 1992). breathing, etc.) to decrease general arousal. 8. Posttraumatic Stress Disorder, dissociation, so- 4. Conduct systematic desensitization (imagined matization, and affect dysregulation are highly or in vivo). interrelated (van der Kolk, Peclovitz, Roth, 5. Engage in activities that increase feelings of Mandel, McFarlane, & Herman, 1997). power and self-esteem. 6. Reinforce what is learned in individual, group, • Differential diagnosis and family sessions. 1. Factitious Disorder 7. Provide referrals to outpatient support groups. 2. Borderline Personality Disorder 3. Schizophrenia • Community resources 4. Depression 1. Outpatient therapy 5. Panic Disorder 2. Support groups 6. Generalized Anxiety Disorder 7. Acute Stress Disorder (APA, 2000) Posttraumatic Stress Disorder (PTSD) a. Similar origin and presentation as PTSD, but occurs within 4 weeks of traumatic • Definition—a response resulting from exposure to event. a severe emotionally or physically traumatic event b. Symptoms last from 2 days to 4 weeks. characterized by: (1) intrusive reexperiencing of 8. Frequently misdiagnosed due to symptoms— the trauma; (2) avoidance behaviors and emotional hallucinations, depression, addiction, and so- numbing; and (3) increased arousal (American matic complaints (Symes, 1995) Psychiatric Association [APA], 2000) 9. High rates of comorbidity (Friedman, 1996) Anxiety Disorders 87

• Mental status variations option (duloxetine (Cymbalta), venlafax- 1. Behavior—vigilant, restless ine (Effexor)) 2. Mood—anxious, depressed, blunted affect, c. Tricyclic antidepressants (TCAs) guilty d. Monoamine oxidase inhibitors (MAOIs) 3. Perceptual Experiences—flashbacks, dereal- 2. Other pharmacologic options ization, dissociation a. Propranolol (Inderal) 4. Thought—preoccupation with trauma b. Carbamazepine (Tegretol) 5. Memory—impaired c. Gabapentin (Neurontin) 6. Concentration—impaired d. Benzodiazepines (Ativan, Valium, Xanax, etc.) • Nursing diagnoses (NANDA, 2009) 3. Avoid MAOIs/benzodiazepines if abusing 1. Anxiety (specify level) drugs/alcohol 2. Insomnia 3. Coping, ineffective • Intrapersonal origins/Psychotherapeutic 4. Fear interventions 5. Rape-Trauma Syndrome 1. Origins 6. Hopelessness a. Psychodynamic view—trauma reactivates 7. Self-Esteem, situational low previous, unresolved childhood conflicts. 8. Post-Trauma Syndrome (1) Regression, repression, denial and un- 9. Suicide, risk for doing defense mechanisms 10. Violence, (actual/) risk for self-directed, or (2) Secondary gain when dependency other-directed needs met b. Cognitive—brain attempts to process • Genetic/Biologic origins through alternate blocking and acknowl- 1. Increased baseline sympathetic arousal may edging the event until a new mental predispose; after trauma, baseline elevated. scheme that incorporates the trauma is 2. Trauma response includes the following: devised (Herman, 1992). a. Immediate, excessive arousal, espe- c. Personal resilience—persons who con- cially cardiovascular and neuromuscular struct meaning out of the event, make systems connections with others, who actively at- b. Arousal of sympathetic system that leads tempt to cope, and who have strong inter- to difficulty in distinguishing perceptual nal locus of control withstand trauma with cues fewer symptoms (Herman, 1992). c. Original hyperarousal easily evoked after d. There is some evidence that those who trauma by variety of cues. dissociate at time of trauma have higher d. Autonomic arousal becomes neurologi- risk for PTSD. cally entrained (van der Kolk, McFarlane, e. Epidemiological studies—27% of women & Weisaeth, 1996). and 16% of men experienced sexual abuse 3. Regulation of endogenous opioids altered as children; 33% of survivors who had a. When stressor subsides, opioids may physical contact without penetration, and decrease. 64% of those with penetration developed b. Opioid withdrawal symptoms similar to PTSD (Rodriguez, Ryan, Vande Kemp, & PTSD. Foy, 1997). c. Individual may be “addicted” to trauma. 2. Psychotherapeutic interventions: (Sadock & Sadock, 2007) • Biochemical interventions (Stahl, 2008) a. Interventions for Acute Stress Disorder 1. Antidepressants (ASD) involve crisis intervention strategies a. Serotonin selective reuptake inhibitors with support, education, enhancement of (SSRIs)—first-line treatment option coping mechanisms, and acceptance of (1) SSRIs may not be as effective for the event (Sadock & Sadock, 2007). combat veterans—alpha-adrenergic b. The two most common and effective ther- antagonist-prazosin (Minipress) has apies used for PTSD are: shown promise in treating combat- (1) Exposure therapy—employs strategies related PTSD (Benedek, Friedman, (imagery, in vivo exposure) that pro- Zatzick, & Ursano, 2009). mote reexperiencing of the traumatic b. Serotonin norepinephrine reuptake in- event (e.g., exposure-based cognitive hibitors (SNRIs)—first-line treatment 88 Chapter 5 Anxiety and Stress-Related Disorders

behavioral therapy, implosive therapy, c. Group as surrogate family and systematic desensitization). (1) Victims often blamed by family for (2) Stress management—used to teach disclosing or over-reacting. relaxation techniques and cognitive (2) Group serves as training ground for restructuring such that one’s ability to new behaviors. cope with stress is improved. (a) Analyze effect of family’s mes- c. Other psychotherapeutic interventions sages and beliefs on view of self used in treating PTSD include: and world. (1) Psychoeducation regarding the re- (b) Learn and practice assertive covery process (tailored to particular behaviors. traumas) (c) Do not reinforce helplessness or (2) Expressive therapies (art, dance, mu- powerlessness. sic) to translate visual and sensorimo- (3) Support and validate strengths/worth. tor memories, especially those not (4) Handle successfully the displaced encoded in cognitive systems, into hostility, regression, dissociation, meaningful symbols and verbal repre- extreme, anxiety or depression, self sentations to be integrated destructive behaviors. (3) Eye Movement Desensitization and (5) Use 12-step group programs. Reprocessing (EMDR) to decrease (6) Teach short-term stress management. symptoms of trauma—continues to (7) Trauma—use focused groups. be researched (Benedek, Friedman, 2. Combat trauma groups Zatzick, & Ursano, 2009) b. Goals (1) Share experiences. • Family dynamics/Family therapy (2) Work through problems in social 1. Family roles can be altered as PTSD symptoms adaptation. are experienced. (3) Manage aggression toward others. 2. Some children develop affective symptoms, (4) Make sense of trauma in life. become rescuers or disengage from a parent who has PTSD. • Milieu interventions 3. Family may expect more rapid recovery than is 1. Create a safe environment, including a trusting possible. relationship with staff and no-harm contract. 4. Family can help clarify events, listen, and cor- 2. Educate client about recovery process. rect distortions. 3. Assist client to employ stress management 5. Abusive families-of-origin may deny, punish, techniques (relaxation techniques, exercise, and attempt to enforce conspiracy of silence. cognitive strategies). 6. Family therapy guidelines a. Reduce general arousal. a. Support victim in recovery. b. Employ techniques when anxiety in- b. Meet needs of all family members. creases or with intrusive memories. c. Maintain awareness of how trauma affects 4. Support client’s ability to gain control over views of self, family, and world. memories, to: d. Develop shared frame of reference for a. Retrieve during therapy. trauma. b. Set aside. e. Bring out central issues of blame, respon- 5. Teach client to manage physiological symp- sibility, and trust. toms of PTSD, including sleep disorders. 6. Listen to client’s story, respecting ability to dis- • Group approaches (group experiences with survi- close and to stop remembering. vors of similar traumas can be helpful, variable in 7. Engage in activities that promote self-esteem. length) 8. Assist in making plans to use leisure time. 1. Adult survivors of childhood sexual abuse 9. Encourage social interaction. a. Long-term group therapy, usually 10. Address spiritual issues. outpatient 11. Develop system of social support in b. Goals community. (1) Reduce isolation, shame, guilt, and 12. Assist to devise realistic plans for future, in- sense of deviance. cluding therapy, occupation, and relationships (2) Restructure family-induced behaviors. (solution-focused plan). (3) Develop new, more realistic patterns of interaction. Anxiety Disorders 89

• Community resources Generalized Anxiety Disorder (GAD) 1. Twelve-step programs (useful with co- occurring substance use disorder) • Definition—unrealistic or excessive anxiety or 2. Community outreach program worry about several events or activities accompa- 3. Battered Women’s Shelter for Domestic nied by symptoms of motor tension, autonomic (Spouse) Abuse arousal, and vigilance a. Abuse includes physical battery, verbal threats, intimidating gestures, forced • Signs and symptoms sexual activity, isolation, and economic 1. Motor tension—shaky, muscle tension, deprivation (Campbell, Harris, & Lee, fatigability 1995). 2. Autonomic arousal—shortness of breath, b. Women are more commonly hurt than tachycardia, dry mouth, dizziness, nausea, dimen; 16% of pregnant women are abused arrhea, dysphagia (McFarlane, Parker, & Soeken, 1995). 3. Vigilance—insomnia, feeling “keyed up” c. Models of explanation 4. Not limited to discrete periods or discrete (1) Perpetrator psychopathology, includ- stimuli ing substance abuse 5. Often accompanied by depression or another (2) Family violence with generational anxiety disorder transmission, and violence within en- 6. Considerable impairment in quality of life tire system (abused wives use severe violence in conflicts with children) • Differential diagnosis (3) Violence instead of appropriate 1. Physical disorders such as hyperthyroidism coping by perpetrator in stressful and mitral valve prolapse situation 2. Caffeine or stimulant abuse (4) Gender relations in which men choose 3. Withdrawal from alcohol or sedatives violence when control over women is 4. Panic Disorder or Obsessive-Compulsive threatened Disorder d. Phases of domestic violence (Weingourt, 5. Anxiety Disorder due to a general medical con- 1996) dition (APA, 2000) (1) Escalation (tension building) phase— broad spectrum of coercive tactics by • Mental status variations perpetrator; isolation of victim 1. Appearance—sweating, cold, clammy hands, (2) Incident (battering) phase—intense, exaggerated startle response, flushing, or chills dramatic show of force to instill fear of 2. Psychomotor activity—restlessness, trembling, repetition if victim resists control twitching (3) De-escalation (honeymoon) phase— 3. Mood—irritable, anxious, apprehensive perpetrator assuages guilt, expresses 4. Concentration—difficult to concentrate remorse, and reassures that this will 5. Insight—impaired; clients often seek treat- never happen again; victim wants to ment for physical symptoms and do not as- believe, desires the relationship, and sociate physical and emotional responses with looks to self for responsibility for the anxiety. relationship e. Assessment for abuse essential • Nursing diagnoses (NANDA, 2009) f. Safety planning for family member 1. Anxiety (specify level) g Discussion of options 2. Insomnia h. Referral to community resources for shel- 3. Coping, ineffective ter, legal and support services, and case 4. Fear management 5. Powerlessness, risk for i. Treatment of emotional responses to 6. Coping, compromised family abuse—anxiety, depression, guilt, sub- 7. Knowledge, deficient (specify) stance abuse, isolation 8. Role performance, ineffective 4. National Organization for Victim Assistance 9. Sleep pattern, disturbed (Washington, DC)—a clearinghouse for all victim assistance (http://www.trynova.org) • Genetic/Biologic origins (Sadock & Sadock, 2007) 1. Some evidence exists of genetic link (25% first- degree relatives). 90 Chapter 5 Anxiety and Stress-Related Disorders

2. Persons with GAD have increased sympathetic parental anxiety responses or reinforced tone, greater response, and slower adaptation by others). to stress. c. Cognitive—anxiety results from faulty 3. Gamma aminobutyric acid (GABA), which is or dysfunctional thoughts about events. a principle inhibitory CNS neurotransmitter, Individuals: may have diminished activity. (1) Overestimate danger. 4. Decreased activity occurs in basal ganglia and (2) Underestimate ability to cope. limbic system, and frontal cortex; increased 2. Psychotherapeutic interventions activity in cerebellum and some cortical a. Psychodynamic structures. (1) Long-term, insight-oriented therapy 5. Possible genetic link exists between alcohol- (2) Focus on resolution of conflicts, un- ism and anxiety disorders, particularly in derlying anxiety males. b. Behavioral 6. Worry is negatively reinforced by decrease in (1) Relaxation training—Progressive aversive somatic activation (autonomic hyper- Muscle Relaxation (PMR) or Autogenic activity) (Freeston, Dugas, & Ladouceur, 1996). Training Techniques (2) Breathing techniques • Biochemical interventions (Stahl, 2008) (3) Biofeedback 1. SSRI (avoid fluoxetine) & SNRI antidepres- (4) Identification of physical responses sants, and buspirone (BuSpar) are considered that trigger anxiety first-line agents in treating GAD. (5) Training components such as prob- 2. After failure of trials with the above agents, lem solving and social skills (Harvey & sedating antidepressants such as mirtazap- Rapee, 1995) ine, trazodone, or tricyclic antidepressant c. Cognitive (TCAs), or sedating antihistamines such as hy- (1) Identifying and challenging dysfunc- droxyzine may be useful. tional thoughts (self-statements) that 3. Benzodiazepines (BZDs) may be used as a trigger anxiety first-line treatment or as an augmenting agent (2) Replacing with positive coping for GAD. statements a. Reluctance in using benzodiazepine exists (3) Evaluating accurately presence of due to the potential for abuse and depen- danger dence, and the long-term nature of GAD. (4) Encouraging use of log (diaries) and However, these agents have been useful homework for subsequent analysis of in reducing anxiety while achieving thera- relationship between thoughts and peutic responses from first-line agents; feeling of anxiety augmenting the therapeutic response of d. Solution-focused therapy other GAD medications; and in providing relief when intermittent surges of anxiety • Family dynamics/Family therapy are experienced. 1. Children of parents with GAD are likely to see the world as dangerous and themselves as vul- • Intrapersonal origins/Psychotherapeutic nerable. Children may be: interventions a. Excessively protected. 1. Origins b. Excessively dependent. a. Psychodynamic—anxiety results from 2. Family member with GAD may exhibit altered unconscious conflict or emergence of un- role performance and require other family acceptable drives (often related to depen- members to assume greater or inappropriate dent, sexual, or aggressive content). responsibility (Barloon, 1993). (1) Anxiety serves as a signal that repres- 3. Family member with GAD may become fam- sion of drive or conflict is not working. ily’s “weak one,” or the scapegoat. (2) If repression doesn’t contain drives, 4. Family treatment emphasizes the following: then other defense mechanisms em- a. Knowledge of GAD and treatment ployed (conversion, displacement, b. Cognitive restructuring for all family regression). members to challenge and correct collec- b. Behavioral—anxiety is a conditioned re- tive assumptions about danger and coping sponse to a specific stimulus, or a learned, c. Promotion of differentiation, especially in internal response (perhaps from imitating children Anxiety Disorders 91

d. Reestablishment of healthy role 3. Teach how to access general community re- performance sources to enhance support base.

• Group approaches Panic Disorder 1. Therapy—group therapy offers opportunities for feedback, realistic self-appraisal, and sup- • Definition—recurrent, unexpected, intense peri- port when changing behavior patterns. ods of extreme apprehension and terror without a. Insight-oriented approach to resolve unclear precipitant conscious conflicts b. Psychoeducational approaches to increase • Signs and symptoms understanding of nature of GAD and to 1. Attack begins with rapidly increasing symp- learn coping strategies toms of fear and doom, palpitations, tachycar- c. Cognitive group therapy to challenge and dia, dyspnea, sweating, hyperventilation. correct dysfunctional cognitions 2. Attack lasts 30 to 60 minutes; may include d. Assertiveness training symptoms of depersonalization, derealization, paresthesia, fainting, dizziness, choking, nau- • Milieu interventions sea, chest pain, flushes or chills. 1. Create a safe, supportive environment. a. First attacks are often in phobogenic 2. Use goal-oriented contract to focus treatment. situation. 3. Use diary/logs to record manifestation of b. Subsequent attacks are spontaneous (un- anxiety (thoughts, emotions, physiological cued, unexpected). responses), the situation, course of events, ef- 3. Clients usually try to seek help, focusing on ficacy of intervention. cardiac or respiratory symptoms. Clients often: 4. Teach role of dysfunctional cognitions (danger a. Believe they are dying. and inability to cope) in creating/maintaining b. Are seen in emergency room. anxiety. c. Fear going “crazy.” 5. Teach analysis of negative self-statements and 4. Panic response may be accompanied by ago- replace with rational, positive statements and raphobia, fearing panic attacks will occur in receive feedback from other clients. setting without help. 6. Teach relaxation techniques, monitor practice 5. Between episodes client exhibits anticipatory of relaxation techniques, and assist to imple- anxiety, vigilant for onset of another attack. ment when experiencing anxiety. 6. Attacks range from mild (one attack per month a. Breathing techniques or limited number of symptoms), to severe b. Progressive muscle relaxation (eight panic attacks per month). c. Autogenic training 7. Attacks are often accompanied by depression. 7. Assist to develop alternative means of coping such as exercising, taking warm baths, or talk- • Differential diagnosis ing to staff and other clients. 1. Note whether Panic Disorder is or is not ac- 8. Promote activities that increase self- companied by agoraphobia. confidence through progressively more 2. Physical disorders such as mitral valve pro- difficult challenges. lapse, hyperthyroidism, hypoglycemia, or 9. Plan leisure activities to deal with “free time.” pheochromocytoma 10. Encourage resumption of family, work, and 3. Withdrawal from psychoactive substances social roles. 4. Caffeine or stimulant abuse 11. Refer to partial hospitalization program or 5. Alcohol abuse outpatient services. 6. GAD, Posttraumatic Stress Disorder (PTSD) 7. Somatization Disorder • Community resources 1. GAD often treated by primary care providers • Mental status variations such as family doctors and nurse practitioners. 1. Appearance—anxious, perspiring, choking, a. Advanced practice PMH nurse may pro- difficulty breathing vide consultation, individual, group, and 2. Behavior—trembling, hyperventilation family therapy. 3. Mood—may be depressed (including suicidal) b. Work collaboratively. 4. Speech—stammering, difficulty speaking 2. Provide support groups or parenting classes 5. Thought—ruminating, preoccupation with for persons with anxiety disorders. fear of death or doom 6. Memory—impaired 92 Chapter 5 Anxiety and Stress-Related Disorders

7. Concentration—decreased, confusion psychotherapeutic methods may be of great- 8. Orientation—confused est benefit for those diagnosed with a Panic Disorder. • Nursing diagnoses (NANDA, 2009) 1. Anxiety (specify level) • Intrapersonal origins/Psychotherapeutic interven- 2. Powerlessness tions (APA, 2009; Sadock & Sadock, 2008) 3. Fear 1. Origins 4. Hopelessness a. Psychodynamic—panic occurs when 5. Self-Esteem, chronic low defenses against anxiety (repression, dis- 6. Role Performance, ineffective placement, and avoidance) are ineffective. 7. Knowledge, deficient (specify) (1) Symbolic nature is often related to 8. Violence, (actual/) risk for self-directed abandonment and separation anxiety. 9. Social Isolation (2) Traumatic separations in childhood 10. Coping, ineffective may increase vulnerability by producing autonomic nervous system stimu- • Genetic/Biologic origins (APA, 2009; Sadock & Sa- lation (Shear, 1996). dock, 2007) (3) Interpersonal problems in assertive- 1. First-degree relatives of clients with Panic ness and sociability may contribute Disorder are 4-to-8 times more likely to experi- (Battaglia, 1995). ence a panic attack and with early onset (be- b. Behavioral fore age 20) the rate increases to 17. (1) Parental behavior modeling or classi- 2. A genetic link has been implicated with a cal conditioning higher concordance rate among monozygotic (2) Demonstration of cognitions of exag- twins; although no specific chromosomal loca- gerated vulnerability, inability to cope, tion has been identified. and general negative views of self; 3. Abnormal regulation of the noradrenergic sys- catastrophic interpretations of anxiety tems in the brain is involved with panic attacks symptoms that provide more arousal and Panic Disorder. and symptoms 4. Neurotransmitters involved in Panic Disor- (3) Stressful life events—persons with der include: serotonin, norepinephrine, and Panic Disorder report greater fre- GABA. quency of life events that pose danger 5. Brain imaging studies have implicated patho- and threat. logical involvement in several regions of the c. Cognitive brain (temporal lobe, hippocampus, and (1) Worry about recurring panic attacks amygdala), and cerebral vasoconstriction— (2) False beliefs and cognitive distortions possible relationship of CNS lesions with 2. Psychotherapeutic interventions abnormal signal activity or asymmetric right a. Psychodynamic—insight-oriented therapy temporal lobe atrophy, abnormal activity in to focus on origin of anxiety, symbolism, hippocampus and right frontal cortex. secondary gain, and resolution of early 6. An association between mitral valve prolapse conflicts and panic has been dismissed as a result of b. Behavioral existing evidence. (1) Psychoeducation regarding origin and maintenance of panic attacks • Biochemical interventions (APA, 2009; Stahl, 2008) (2) Desensitization—real or imagined 1. First-line treatment agents are antidepres- phobic situation sants (SSRIs & SRNIs), and benzodiazepines. (3) Cognitive restructuring to decrease Although equally effective, TCAs are not a self-statements that promote anxi- first-line option, due to significant cardiac and ety and to increase positive, coping anticholinergic side effects. statements, coupled with exposure 2. Other psychopharmacologic treatments that to avoided situations or to somatic may be helpful (as second-line &/or aug- sensations of anxiety (Otto & Whittal, menting agents) include sedating antidepres- 1995) sants (mirtazapine, trazodone) and atypical (4) Reinforcement of mastery antipsychotics. (5) Relaxation techniques—breathing, 3. While pharmacologic interventions may PMR, and imagery be successful in eliminating primary (6) Continued vulnerability and episodic symptoms, combined pharmacologic and exacerbations after successful symptom removal Anxiety Disorders 93

c. Cognitive and cognitive behavior thera- 7. Assist client’s use of cognitive strategies to pies have been successful in treating panic decrease anticipatory anxiety. associated with symptoms. possible future panic attacks. (1) Cognitive therapy—focus on false 8. Reinforce learning from individual, group, and beliefs and information about one’s family sessions. panic attacks 9. Refer to outpatient therapy. (2) Cognitive behavioral therapy (CBT)— seeks to identify and refute mistaken • Community resources beliefs and about physical symptoms 1. Outpatient therapy and their consequences. 2. Support groups (a) Panic-focused CBT—frequently incorporates the following treat- Obsessive-Compulsive Disorder (OCD) ment components: psychoeducation, self-monitoring, cognitive • Definition—recurrent persistent obsessions restructuring, exposure strategies and/or compulsions that interfere with functional (to reduce fear cues), behavior abilities, occupation, social activities, and interper- modification (targeting anxiety sonal activities reduction), and relapse prevention (APA, 2009). • Signs and symptoms 1. Obsession—unwanted, repeated, and uncon- • Family dynamics/Family therapy trollable thoughts, images, or impulses 1. Clients with agoraphobia may always require a. Inability to break thought cycle through family members to stay close by, resulting in: distraction in conversation or other tasks a. Marital discord b. Common themes of losing things, blas- b. Dependence upon children phemy, fears of disease, contamination, 2. Altered role performance (work, family, social sexual behavior, or aggression situations) increases responsibility of other c. Increased anxiety if resisted family members. 2. Compulsions—repeated, unwanted pat- Therapeutic approaches include: terns of behavior that are often responses to a. Family education about origin, nature, obsessions and treatment of disorder a. Excessive cleaning, washing, checking, b. Family therapy to restructure communica- counting, or repeating tion and roles to support change b. Increased anxiety and dread if compul- 3. Family is work essential due to chronic nature sions are resisted of Panic Disorder (Pollak & Smoller, 1995; 3. Intervention usually not sought until basic Shear, 1995). needs are not met or when physical and/or emotional exhaustion occurs of either client or • Group approaches significant other. 1. Therapy to improve coping and/or social a. Most clients present with both obsessions support and compulsions. a. Insight-oriented therapy b. Individuals often delay treatment for sev- b. Cognitive therapy eral years. c. Support groups where stable, intimate relationships can buffer anxiety • Differential diagnosis 2. Self-help—community self-help groups en- 1. Obsessive-Compulsive Personality Disorder courage acceptance and improved life func- 2. Major depression with obsessive thoughts tioning when residual symptoms persist. 3. Hypochondriasis 4. Tourette’s Syndrome • Milieu interventions 5. Temporal lobe epilepsy 1. Provide safe, supportive environment. 6. Schizophrenia 2. Establish goal-oriented treatment contract. 3. Assist client to employ relaxation and cogni- • Mental status variations tive techniques when panic attack first begins. 1. Appearance—special dress pattern, abraded 4. Label experience as a “panic attack” and hands anxiety. 2. Behavior—ordering and arranging environ- 5. Promote socialization with peers. ment of examiner, touching, licking, spitting, 6. Engage in activities that promote self-esteem. repeating rituals 94 Chapter 5 Anxiety and Stress-Related Disorders

3. Mood—depressed, anxious a. Insight-oriented, psychodynamic therapy 4. Thought—intrusive sounds, words, music, has little evidence to support its use in sexual images or impulses; thoughts of doom, OCD treatment. concerns with germs, dirt, etc. b. Behavioral and cognitive behavioral thera- 5. Insight—understands that obsessions and pies have greatest effectiveness. compulsions are irrational (1) Combine exposure with response delay (ERD) with pharmacotherapy. • Nursing diagnoses (NANDA, 2009) (2) Employ gradual extinction of ritu- 1. Anxiety (specify level) als by exposure to anxiety-producing 2. Powerlessness situations until habituation occurs 3. Powerlessness, risk for with strict abstinence from perform- 4. Role Performance, ineffective ing rituals (Abramowitz, 1997). 5. Coping, compromised family (3) Reduce obsessive thoughts by 6. Loneliness, risk for thought-stopping (such as snapping a 7. Social Isolation rubber band on the wrist when obses- 8. Coping, ineffective sive thought appears). (4) Reduce obsessive thoughts through • Genetic/Biologic origins (APA, 2007; Sadock & Sa- semantic satiation (write a few words dock, 2007) of the obsession and then rewrite or 1. Serotonin is implicated by observations that say aloud many times until fear is no OCD symptoms decrease with selective sero- longer evoked). tonin reuptake inhibitors (SSRIs) and increase with serotonin antagonists. • Family dynamics/Family therapy 2. Some evidence suggests increased prevalence 1. Family members may constantly reassure the of OCD in first-degree relatives with the dis- client, which reinforces the obsession. order; and a genetic linkage on chromosome 2. Family may assist patient to avoid situations 9p24. that trigger OCD, which worsens the fear cycle. 3. Therapeutic approaches include: • Biochemical interventions (APA, 2007; Stahl, 2008) a. Emphasize remaining neutral (not rein- 1. SSRIs are the first-line treatment agent for forcement through reassurance). OCD. b. Avoid reasoning with client (increases 2. TCAs , specifically clomipramine & SNRIs anxiety). may be considered with multiple failed SSRI c. Avoid ridicule. response. d. Assist with response delay. e. Design with family, ways to use time freed • Intrapersonal origins/Psychotherapeutic up by successful treatment of symptoms interventions (Shear, 1995). 1. Origins a. Psychodynamic—unacceptable thoughts • Group approaches and impulses are isolated, but threaten to 1. Supportive group therapy break through into consciousness so that 2. Self-help groups in community are often affili- compulsive acts are performed to undo ates of Obsessive Compulsive Foundation Inc. the possible consequences, should the unacceptable become conscious. • Milieu interventions (Keltner et al., 2007) (1) Symptoms may arise during anal stage 1. Incorporate relaxation exercises, recreational since much OCD involves cleanliness or social skills development, and successful or aggressive preoccupation. problem-solving opportunities. (2) Note both ambivalence and magical 2. Promote stress management (provide educa- thinking. tion and practice exercises). b. Behavioral 3. Conduct CBT, communication, or assertive- (1) Obsessions act as conditioned stimu- ness training groups. lus to anxiety. 4. Always focus care upon the needs of the (2) Compulsions arise when a behavior patient/client. reduces the anxiety associated with 5. Promote activities that reduce anxiety such as the obsessions. physical activity, and vary sufficiently in order 2. Psychotherapeutic interventions (APA, 2007) not to reinforce or promote developing a new ritual. Somatoform Disorders 95

• Community resources—OCD Foundation (http:// • Biochemical interventions—none indicated www.ocdfoundation.org) • Intrapersonal origins/Psychotherapeutic interven- Somatoform Disorders tions (Sadock & Sadock, 2007) 1. Origins • Definition—“Soma” is the Greek term for body. a. Conversion of anxiety into physical Somatoform disorders are characterized by bodily symptom signs and symptoms for which there is no discern- (1) Conflict is usually sexual or aggressive. able physiological cause. (2) Symptom allows both disguising impulse and partially expressing it. Conversion Disorder (3) Symptoms have symbolic relationship to conflict. • Definition—loss or change in physical functioning (4) Symptoms communicate special not explained by any known pathophysiological needs. disorder b. Symptoms reinforced by family or society, plus secondary gain. • Signs and symptoms c. Symptoms replace verbal language. 1. Temporally related to psychological factors 2. Psychotherapeutic interventions 2. Fulfills a need or deals with a conflict a. Psychodynamic insight-oriented psycho- 3. Not under voluntary control therapy is used to explore conflicts. 4. Examples—paralysis, blindness, mutism, par- b. Focus therapy on stress and coping. esthesias, pseudocyesis, vomiting c. Employ brief, solution-focused psychotherapy. • Differential diagnosis d. Hypnosis, anxiolytics, and relaxation exer- 1. Rule out medical disorders, especially neuro- cises may be useful. logic diseases. e. Telling patient that their symptoms are 2. Schizophrenia imaginary can make them worse. 3. Depression 4. Somatization Disorder • Family dynamics/Family therapy 5. Hypochondriasis 1. Family rules negate direct expression of conflict. • Mental status variations 2. Illness may be family-accepted means to avoid 1. Mood—la belle indifference, inappropriate for taking action. physical symptoms 3. Family may encourage secondary gain. 2. Perceptual disturbances—may be blind, but 4. Employ therapy to improve verbal communi- does not bump into objects; stocking or glove cation, conflict resolution, and restructuring of anesthesia family interactional patterns. 3. Insight—unaware of relationship between • Group approaches psychological conflict and appearance of 1. Emphasis on coping with stress symptoms 2. Assertiveness training

• Nursing diagnoses (NANDA, 2009) • Milieu interventions 1. Anxiety (specify level) 1. Minimize sick role behavior. 2. Knowledge, deficient (specify) 2. Encourage verbal expression of needs and 3. Family Processes, dysfunctional conflicts. 4. Coping, ineffective 3. Assist staff and patients to reinforce verbaliza- 5. Communication, impaired verbal tion and functional behavior, and ignore im- 6. Possibly—Sensory Perception, disturbed pairments to reduce secondary gain. 4. Help client understand relationships between • Genetic/Biologic origins (Sadock & Sadock, 2007) conflict, symptoms, and gain. 1. CNS arousal disturbance may diminish aware- 5. Teach new coping skills to decrease anxiety. ness of bodily sensations. 2. Subtle impairments in verbal communication, memory, alteration, suggestibility noted in Hypochondriasis neuropsychological testing. • Definition—preoccupation with, and unrealistic interpretation of, physical symptoms and sensations as a serious disease lasting 6 months or more 96 Chapter 5 Anxiety and Stress-Related Disorders

• Signs and symptoms misinterpret symptoms of emotional 1. Preoccupation with health state in spite of arousal and to think in concrete rather medical reassurance than emotional terms 2. Not of delusional quality (can admit possibility c. Sick role as respite from responsibilities of of exaggeration) life 3. May be organ-system related or related to a d. May begin with physical illnesses in child- particular bodily function hood or following a severe medical prob- 4. Experience of anguish over physical state lem as an adult 5. Tendency to see multiple practitioners e. Atonement for real or imagined wrong do- ings (Ford, Katon, & Lipkin, 1993) • Differential diagnoses 2. Psychotherapeutic interventions 1. Medical disorders with multiple organ system a. Usually resistant to psychiatric treatment involvement (AIDS, endocrine disorders, MS, unless it occurs in medical setting. Systemic lupus erythematosus (SLE), some b. Focus on stress reduction and coping. neoplasms) c. Avoid reinforcements of sick role as a solu- 2. Generalized Anxiety Disorder tion to life problems. 3. Panic Disorder 4. Conversion Disorder and Somatization • Family dynamics/Family therapy Disorder 1. Family may reinforce sick role behavior. 2. Family conflict occurs over client distress and • Mental status variations medical treatment. 1. Appearance—apprehensive, anguished 3. Family roles may be altered. 2. Mood—depressed, anxious 4. Family may have low ability to deal directly 3. Thought—preoccupied with seriousness of with stressful situations or obligations. physical symptoms 4. Insight—impaired • Group approaches 1. Social support • Nursing diagnoses (NANDA, 2009) 2. Social interaction 1. Anxiety (specify level) 2. Fear • Milieu interventions 3. Role Performance, ineffective 1. Clients often treated on medical unit. 4. Coping, ineffective 2. Teach rational interpretation of bodily 5. Social Interaction, impaired sensations. 3. Assist to identify relationship between physi- • Genetic/Biologic origins cal symptoms and stress. 1. Some evidence of increased prevalence in 4. Teach techniques to cope with anxiety in- twins cluding talking, exercise, and relaxation 2. Physiologically lower threshold tolerance for techniques. discomfort 5. Meet physical needs, but avoid reinforcing. 6. Encourage social interaction and constructive • Biochemical interventions (Sadock & Sadock, use of leisure time. 2007) 7. Teach problem-solving techniques for per- 1. Medication only for coexistent anxiety or sonal difficulties. depression 8. Refer to outpatient therapy. 2. Avoid reinforcing through medication Somatization Disorder • Intrapersonal origins/Psychotherapeutic interventions • Definition—a chronic relapsing syndrome of 1. Origins multiple somatic symptoms for which there is no a. Repression of aggressive and hostile im- medical explanation pulses with displacement into somatic complaints • Signs and symptoms (1) Anger originates in past losses. 1. Symptoms include gastrointestinal, pain, car- (2) Displacement solicits help (which diopulmonary, conversion, sexual, and female later is rejected). reproductive. b. Cognitive schema focusing on bodily 2. History of several years’ duration, beginning sensations—tendency to amplify and before age 30. Somatoform Disorders 97

3. High utilization of health services—physician 4. Female clients often choose alcoholics or visits, excessive surgery, psychiatric services, men with antisocial personality disorders as multiple medications partners. 4. Association with changes in life style due to 5. Focus therapy on clear, congruent communi- illness cation, role restructuring, and increasing self- 5. Typically, new symptoms arise during times of esteem of family members. emotional distress. • Group approaches • Differential diagnosis 1. Time-limited group therapy with emphasis 1. Rule out medical disorders. on improving socialization skills and ability to 2. Schizophrenia cope 3. Depression 2. Group therapy with emphasis on how to cope 4. Substance use with multiple medical problems 5. Other somatoform disorders • Milieu interventions • Mental status variations 1. Monitor and assess client’s physical status. 1. Insight—unawareness of relationship between 2. Attend to physical needs in supportive, but psychological conflict and appearance of nonreinforcing way. symptoms 3. Reinforce verbal expression of needs and feelings. • Nursing diagnoses (NANDA, 2009) 4. Assist other staff and patients to understand 1. Anxiety (specify level) that physical complaints are experienced as 2. Coping, readiness for enhanced family “real” (Ford et al., 1993). 3. Coping, ineffective 5. Help client realize connection between 4. Possibly—Sensory Perception, disturbed psychological stress and onset of somatic symptoms. • Genetic/Biologic origins (Sadock & Sadock, 2007) 6. Teach new coping skills including use of social 1. Possible neuropsychological basis character- relationships and other techniques to decrease ized by attention and cognitive impairments anxiety. 2. Brain imaging studies suggest decreased me- 7. Maintain consistent approach by all tabolism in frontal lobes and nondominant personnel. cerebral hemisphere. 8. Support self-care abilities and appropriate role 3. An increased risk (10–20%) for Somatization performance, including occupational. Disorder among first-degree relatives Pain Disorder • Biochemical interventions—none indicated • Definition—severe prolonged pain where there is • Intrapersonal origins/Psychotherapeutic interven- no organic basis for the pain and/or the intensity tions (Sadock & Sadock, 2007) 1. Origins—The cause of Somatization Disorder • Signs and symptoms is not known. From a behavioral perspective, 1. Various manifestations—low back pain, head- the disorder is thought to be learned from a ache, or chronic pelvic pain parent, or result from unstable or physically 2. Preoccupation with pain abusive homes. 3. Often a follow-up to physical trauma 2. Psychotherapeutic interventions—include 4. Analgesics usually not helpful consistency in the therapeutic alliance, regu- 5. Frequent visits to physicians for relief larly scheduled appointments, psychotherapy 6. Client refusal to consider psychological origins to enhance coping, and crisis intervention. 7. Depression usually present 8. Difficulties in diagnosing because of diverse • Family dynamics/Family therapy definitions of pain 1. Children taught to somatize, rather than to deal with issues verbally. • Differential diagnosis 2. Readjust roles to accommodate symptoms and 1. Organic disorders illness behavior. 2. Depression 3. Clients use somatization as means to mediate 3. Hypochondriasis relationships. 4. Conversion Disorder 98 Chapter 5 Anxiety and Stress-Related Disorders

• Mental status variations g. Transcutaneous nerve stimulation 1. Appearance—antalgic position, diaphoretic, h. Exercise programs/physical therapy tense i. Acupuncture 2. Behavior—restless j. Pain control program 3. Mood—depressed 4. Thought—preoccupied with pain • Family dynamics/Family therapy 5. Concentration—impaired 1. Family as a whole may be stabilized by pain 6. Insight—unaware of psychological factors experience. 2. Teach family members how to respond to cli- • Nursing diagnoses (NANDA, 2009) ent’s pain. 1. Anxiety (specify level) 3. Discuss secondary gain and power in sick role 2. Hopelessness behavior. 3. Role Performance, ineffective 4. Restructure roles, communication patterns, 4. Knowledge, deficient (specify) and responsibilities. 5. Pain, chronic 5. Deal with issues of individual and family self- 6. Coping, ineffective esteem. 7. Social Interaction, impaired 8. Mobility, impaired physical • Group approaches 1. Pain support groups • Genetic/Biologic origins (Sadock & Sadock, 2007) 2. Exercise groups 1. Serotonin is implicated in the modulation of 3. Psychoeducational (pain management) groups pain. 4. Assertiveness training 2. Endorphin deficiency • Milieu intervention • Biochemical interventions (Sadock & Sadock, 1. Help client apply relaxation and cogni- 2007) tive techniques for pain relief and tension 1. Analgesics and antianxiety agents are ineffec- reduction. tive; possibility of addiction. 2. Encourage social interaction and participation 2. Antidepressants (TCAs & SSRIs—e.g., ami- in activities. triptyline, imipramine, doxepin; anafranil, 3. Teach about relationship between stress and sertraline) pain, and effects of relaxation. 3. Amphetamine, with analgesic effects, might 4. Encourage verbal, rather than somatic, be a useful augmenting agent with SSRIs— communications. use this with caution and monitor dosages 5. Avoid reinforcing pain behaviors. carefully. 6. Encourage self-care in ADLs. 4. Some evidence suggests SNRIs as useful in 7. Help client to find ways of assisting others. treating Pain Disorder (Stahl, 2008) 8. Design plan for use of leisure. 9. Refer to pain control program—rehabilitation, • Intrapersonal origins/Psychotherapeutic pain management, and vocational training. interventions 1. Origins • Community resources—pain management clinics a. Punishment for guilt b. Pain behavior reinforcement by at- Factitious Disorders tentiveness or avoidance of unwanted responsibilities • Definition—physical or psychological symptoms c. Control of others intentionally produced or feigned (APA, 2000) d. Stabilization of marriage/family relationships • Signs and symptoms 2. Psychotherapeutic interventions 1. Desire for role of patient a. Rehabilitating client to usual social/ 2. Compulsive quality occupational roles 3. Traveling from hospital to hospital, seeking ad- b. Discussion of psychological causes and mission for different illnesses under different secondary gain common to all pain names c. Cognitive restructuring 4. Extremely convincing in presentation of physi- d. Relaxation techniques cal or psychological symptoms e. Supportive psychotherapy a. With physical presentation of symptoms, f. Biofeedback may be called “Munchausen” syndrome. Dissociative Disorders 99

b. Another person (child, parent, ward) is b. Avoid setting client up as adversary. presented as the ill one by a caregiver— c. No specific therapy has been found to be known as fictitious disorder by proxy effective. (Sadock & Sadock, 2007). • Family dynamics/Family therapy • Differential diagnosis 1. Provide psychoeducation about disorder. 1. True physical disorder 2. Assist family not to enable client, but to sup- 2. Somatoform Disorder port therapy. 3. Personality disorders 4. Schizophrenia • Group approaches—none 5. Malingering 6. Substance abuse • Milieu interventions 7. Ganser’s syndrome—Persons with this disor- 1. Create a safe environment. der respond to questions with astonishingly 2. Assist caregivers to understand nature of incorrect answers (e.g., 2 plus 2 equals “13”). disorder. Most commonly associated with prison in- 3. Avoid reinforcing gain from illness. mates, may be a variant of malingering. 4. Assist to find means to meet needs for nurturance. • Mental status variations 1. Variance depends upon symptoms produced Dissociative Disorders 2. Thoughts—conflicts and discrepancies in content • Definition—Dissociative disorders are character- 3. Information not corroborated by significant ized by disturbances in the integrated functions of other consciousness, identity, memory, and/or perception. The onset of these disorders may be sudden • Nursing diagnoses (NANDA, 2009) or gradual, and the duration transient or chronic 1. Communication, impaired (APA, 2000; Sadock & Sadock, 2007). 2. Coping, ineffective 3. Role Performance, ineffective Dissociative Amnesia

• Genetic/Biologic origins—none identified • Definition—dissociative disorder in which person is suddenly unable to recall memories of important • Biochemical interventions personal events that were stressful or traumatic in 1. SSRIs may be of limited use in decreasing as- nature (Keltner et al., 2007) sociated impulsive behavior when present. 2. All medications should be monitored carefully, • Signs and symptoms because of potential for abuse. 1. Not ordinary forgetfulness 2. Client can recall other information, learn, and • Intrapersonal origins/Psychotherapeutic function coherently. interventions 3. Most commonly occurs during wars and natu- 1. Origins ral disasters. a. Discovery of caretakers or hospital as car- 4. Amnesia types ing with previous illnesses and seeking a. Localized—short time period continuance b. Generalized—for whole lifetime of b. History of parental deprivation experiences c. Seeking punishment through surgery or c. Selective—amnesia for some, but not all painful treatment events d. Identifying with relatives with genuine d. Continuous—forgets successive events as illnesses they occur, but alert at the time e. Defenses employed—repression, identifi- 5. Primary and secondary gain cation, identification with aggressor, and 6. Terminates abruptly symbolization 2. Psychotherapeutic intervention • Differential diagnosis a. Early recognition and referral for Facti- 1. Medical conditions—delirium, dementia, neo- tious Disorder is important in order to plasms, infections, epilepsy, postconcussion avoid unnecessary medical treatment. 2. Wernicke-Korsakoff syndrome 3. ECT 100 Chapter 5 Anxiety and Stress-Related Disorders

4. Substance-related amnesia (LSD, steroids, • Milieu intervention benzodiazepines, barbiturates) 1. Treat primarily on outpatient basis or in gen- 5. Transient global amnesia usually caused by TIAs eral hospital. 6. Dissociative Disorders (DID) 2. Create safe environment. 7. Acute or Posttraumatic Stress Disorder 3. Mutually develop contract for care. 4. Provide opportunities to talk about traumatic • Mental status variations event and its meaning. 1. Mood—often depressed 5. Teach coping strategies to deal with anxiety 2. Memory—impaired actively (rather than by dissociation). 3. Orientation—variable 6. Assist in devising realistic future plans. 4. Insight—impaired

• Nursing diagnoses (NANDA, 2009) Dissociative Fugue 1. Anxiety • Definition—dissociative disorder characterized by 2. Coping, ineffective physically traveling away from one’s usual environ- 3. Powerlessness ment, the inability to recall important aspects of identity or the assumption of a new identity • Genetic/Biologic origins—no definitive (Keltner et al., 2007) explanations

• Biochemical interventions—none indicated • Signs and symptoms (APA, 2000; Keltner et al.) 1. Old and new identities do not alternate. • Intrapersonal origins/Psychotherapeutic interven- 2. New identity may be partial or complete. tions (Sadock & Sadock, 2007) 3. Client does not appear to be wandering or 1. Origins confused. a. Psychoanalytic—expressed or fantasized 4. Dissociation is usually accompanied by forbidden wish amnesia. (1) Usually sexual or aggressive 5. Dissociation lasts hours to days; rarely (2) Cannot deal with, so uses repression months. and denial b. Emotional trauma • Differential diagnosis (1) Strong emotional response 1. Organic mental disorders such as temporal (2) Psychological conflict lobe epilepsy 2. Psychotherapeutic intervention 2. Psychogenic amnesia a. Psychotherapy to deal with emotional re- 3. Malingering sponses to trauma b. Psychotherapy aimed at resolution of un- • Mental status variations acceptable impulses or behavior 1. Memory—amnesia for identity and important c. Psychotherapy to correct cognitive distor- aspects of life tions (cognitive therapy) 2. Insight—unaware of memory impairment d. Hypnosis to aid in controlled recall of dis- sociated memories • Nursing diagnoses (NANDA, 2009) e. Stress management 1. Anxiety 2. Coping, ineffective • Family dynamics/Family therapy 3. Identity, disturbed personal 1. If natural disaster affected all family members, reconstruct collective memory. • Genetic/Biologic origins 2. All family members affected by client’s distress. 1. Origins—no definitive explanation a. Family education to understand condition 2. Heavy alcohol abuse may predispose, but may of individual client be primarily psychological effect. b. Family therapy to help family members make sense of trauma and/or impulse • Biochemical interventions—amobarbital or thio- expression pental for interviews to uncover identity

• Group approaches • Intrapersonal origins/Psychotherapeutic interven- 1. If traumatic event, may benefit from support tions (Sadock & Sadock, 2007) group of survivors. 1. Origins 2. Group psychotherapy usually not indicated. Dissociative Disorders 101

a. Response of withdrawal (by dissociation) • Differential diagnosis to psychological stressors—war, family, 1. Organic disorder—neurologic, metabolic marital, and occupational 2. Schizophrenia 2. Psychotherapeutic interventions 3. Anxiety disorders a. Hypnosis to uncover memories/identity 4. Substance-Related Disorder b. Psychotherapy 5. Another dissociative disorder (a) Uncover identity and memories. (b) Deal with sources of stress more • Mental status variations effectively. 1. Mood—anxious, depressed c. Couples therapy if marital situation a 2. Perception—feelings of detachment from source of stress self and/or environment, feeling of physical d. Stress management change in body 3. Insight—impaired • Family dynamics/FamilyTherapy 1. Family of origin or current family setting may • Nursing diagnoses (NANDA, 2009) be source of conflict. 1. Anxiety a. Family rules may prohibit overt expression 2. Coping, ineffective of distress. 3. Identity, disturbed personal b. All family members affected by behavior 4. Sensory Perception, disturbed and loss (for some period of time) of family member. • Genetic/Biologic origins (Sadock & Sadock, 2007) 2. Provide psychoeducation to understand cli- 1. Organic disease—migraine, neoplasms, epi- ent’s condition. lepsy, and metabolic disorders 3. If family dynamics are source of stress, family 2. Sensory deprivation therapy can be used to improve communica- 3. Drug-induced psychoactive drugs, especially tion, solve problems, and deal with crisis. hallucinogens, cannabis

• Group approaches—if trauma victim (war, natural • Biochemical interventions (Sadock & Sadock, disaster), support groups 2007) 1. SSRIs (fluoxetine, fluvoxamine) may be • Milieu interventions helpful. 1. Treat primarily on outpatient basis. 2. Treatment of underlying organic disorder 2. Create safe environment. 3. Help to reconstruct memories and identity. • Intrapersonal origins/Psychotherapeutic 4. Assist to create meaning out of fugue episode. interventions 5. Teach coping skills to deal with anxiety. 1. Origins 6. Refer for therapy or other continued assistance a. Internal conflict in managing stressors. b. Disturbance in ego functioning c. Severe emotional distress • Community resources—support groups for man- 2. Psychotherapeutic interventions (Sadock & aging specific stressors Sadock, 2007) a. Insight-oriented psychotherapy (limited Depersonalization Disorder success with most psychotherapeutic interventions) • Definition—dissociative disorder in which client b. Stress management experiences recurrent alterations in perception of c. Relaxation training and physical exercise self • Family dynamics/Family therapy • Signs and symptoms 1. Family may exhibit poor coping mechanisms 1. Client describes self as “detached from reality,” to deal with internal family conflict or outside “dreamlike,” or detached from body. stressors. 2. Self feels strange, unreal. a. Family myths of strength may prohibit ad- 3. Client is able to function during the mission of family pain. experience. b. Family rules may prohibit verbal expres- 4. Client is distressed about depersonalization sion of feelings. experience. 2. Provide psychoeducation about disorder. 5. Depersonalization may be episodic or chronic. 102 Chapter 5 Anxiety and Stress-Related Disorders

3. Family therapy is appropriate if family dy- • Differential diagnosis namics are stressors or influence coping with 1. Neurologic or seizure disorders anxiety. 2. Psychogenic fugues 3. Psychogenic amnesia • Group approaches 4. Schizophrenia 1. Support groups for specific stressors (parent- 5. Anxiety disorders ing, occupational) 6. Cognitive disorders 2. Stress management group 7. Other dissociative disorder 8. Borderline Personality Disorder • Milieu interventions (rarely treated inpatient) 1. Create safe environment. • Mental status variations 2. Educate about disorder. 1. Appearances—dress style, grooming, manner- 3. Assist client to examine relationship between isms may vary from session to session; marked anxiety and depersonalization. changes in nonverbal behavior, handedness 4. Teach stress management and problem-solv- within sessions; blinking, eye roll, twitches ing techniques. with switching 5. Plan for use of leisure time. 2. Speech—marked changes within brief period of time (style, accent, vocabulary) Dissociative Identity Disorder (DID) or 3. Mood—depressed, anxious; switches rapidly Multiple Personality Disorder (MPD) within sessions 4. Thought processes—loose association with • Definition—dissociative disorder in which person rapid switches has two or more separate, distinct personalities 5. Perceptual—hallucinations (auditory/visual); (alters), each with relatively enduring pattern of voices usually experienced within patient’s perceiving, relating to, and thinking about, self and head environment 6. Memory—some long-term memory deficits, blackouts or loss of time • Signs and symptoms 7. Judgment—erratic, depending upon age, 1. At least two personalities dominant, recurrent personality (APA, 2000). 8. Insight—initially not aware of alter 2. Core personality usually unaware of alters personalities when first seeks treatment. 3. Personalities may represent different ages, • Nursing diagnoses (NANDA, 2009) genders, races; most have at least one child 1. Anxiety alter. 2. Coping, ineffective 4. Personalities present with different influence 3. Identity, disturbed personal and power over one another. 4. Self-mutilation, high risk for 5. Personalities communicate with one another 5. Violence, high risk for, directed at self and/or through executive alter or through inner others dialogue. 6. Amnesic symptoms for childhood experiences, • Genetic/Biologic origins or “lose time” when alternate personality pres- 1. Possible psychobiologic ability to dissociate or ent for period of time. to be hypnotized 7. Sleep disturbances, self-mutilation, substance 2. Self-mutilation, possibly biologically entrained abuse, headaches presented. 3. Extreme stress has long term effect on memory 8. Physiological responses (including allergies) through release of neuropeptides/neurotrans- vary in different alters. mitters that interfere with laying down of 9. Issue of therapists “creating” memories and memory (Bremmer, Krystal, Charney, & South- alters presented (North, Ryall, Ricci, & Wetzel, wick, 1996). 1993). a. Verbal/nonverbal behavior of therapist • Biochemical interventions—antidepressants may create false memories in suggestible (SSRIs, TCAs, MAOIs), clonidine, anticonvulsants, client. and benzodiazepines have been reported as effec- b. Public as well as some health care provid- tive in reducing intrusive symptoms, hyperarousal, ers doubt validity of the diagnosis. and anxiety symptoms associated with DID (Sadock & Sadock, 2007). Dissociative Disorders 103

• Intrapersonal origins/Psychotherapeutic (3) Recovery can occur even if the truth of interventions the past remains obscure. 1. Origins (4) Memory retrieval techniques may a. Prolonged and severe physical, emotional, compromise client’s credibility in legal or sexual abuse as a child proceedings. b. Dissociation helps child cope by creating (5) Determination of what the client will new personalities to experience and deal come to believe about his/her past with various aspects of time periods of the must be made by the client, not the trauma. therapist. c. Alters serve various purposes (protection, (6) Techniques of memory retrieval expression of anger, organizer). (a) Clinical interviews 2. Psychotherapeutic interventions (b) Hypnosis a. Individual therapy stages (Putnam, 1989) (c) Drug-facilitated interviews (1) Making diagnosis (d) Dream interpretation (2) Initial interventions (e) Reinstatement of contextual cues (a) Meet personalities. (f) Keeping a journal (b) Take history. (7) Distortions more likely if client sub- (c) Develop working relationship ject to suggestion through leading with system. questions, interviewer bias, reinforce- (3) Initial stabilization ment of subject/material, or focus on (a) Contract with alters. material difficult to verify. (b) Contract with entire system. c. Hypnosis uniformly endorsed (Putnam & (c) Stabilize uncontrollable Lowenstein, 1993). behaviors. (4) Acceptance of diagnosis • Family dynamics/Family therapy (a) Some alters do not accept pres- 1. Family-of-origin characteristics ence of others. a. United front to community, but internal, (b) Issue throughout treatment severe conflict (5) Development of communication and b. Socially isolated cooperation c. One caretaker with severe pathology; one (a) Encourage internal abuses, one labels communication. d. Contradictory messages to child, inconsis- (b) Establish cooperation toward tent expectations common goals. e. Rigid religious/mystical beliefs (c) Encourage development of inter- f. Secrecy and denial nal decision-making process. 2. Family therapy with family of origin; adjunct (d) Facilite switching. to primary individual therapy (6) Metabolism of the trauma a. Complicated by severe family pathology (a) Becomes major treatment task. and secrecy (b) Uncover trauma. b. Occasionally includes selected family (c) Facilitate abreaction. members (7) Resolution and integration c. Abusers not included in therapy (a) Some elect integration. 3. Family therapy with partners and children (b) Others remain multiples. a. Marital therapy is helpful adjunct. (8) Development of postresolution cop- b. Help family members avoid promoting ing skills dissociation. (a) Learn new coping skills. c. Help to deal with hostile personalities. (b) Take on tasks previously split. d. Understand process of therapy and (c) Deal with reactive depression. integration. b. Preparation of patient for therapy re: e. Evaluate children and treat for abuse (if memory (Kluft, 1996) present). (1) Clarify that what emerges in therapy f. Confirm children’s experience with paren- is “food for thought” not grounds for tal behavior and label DID symptoms as taking action. illness. (2) Recovery presented as a healing process, not detective work. 104 Chapter 5 Anxiety and Stress-Related Disorders

• Milieu interventions 6. Manifestations vary: 1. Hospitalize when self-harm or danger toward a. Depressed mood others is indicated. (1) Sadness a. Support during abreaction. (2) Tearfulness b. Provide structure and safety. (3) Hopelessness c. Create mutually designed contract so that b. Anxiety treatment goals understood by alters. (1) Palpitations d. Establish primary nurse for each shift. (2) Agitation 2. Maintain consistent, accurate understanding (3) Jitteriness of DID and client by all staff members to avoid c. Conduct disturbances splitting. (1) Violating rights of others 3. Provide safe, consistent environment. (2) Violating social norms 4. No-harm contract—homicide, suicide, self- d. Combinations of the above mutilation 7. Physical complaints such as headache or back- 5. Teach techniques to provide: ache are more common in the elderly. a. Anxiety reduction b. Personal, emotional safety • Differential diagnosis (Sadock & Sadock, 2007) c. Control of switching 1. Anxiety disorders (GAD, ASD/PTSD) d. Avoidance of self-mutilation, based upon 2. Depression particular meaning of the behavior 3. Uncomplicated bereavement 6. Educate about nature of disorder, existence 4. Brief psychotic disorder and function of personalities, course of ther- 5. Substance-Related Disorder apy, and integration. 6. Somatization Disorder 7. Assist staff and clients to treat alters as they 7. Conduct Disorder present. 8. Help other clients understand DID client’s be- • Mental status variations havior, attention from the staff, and their own 1. Varies considerably, depending upon reactions—include inward nontherapy activi- manifestation. ties, but exclude from general group sessions. 2. Appearance—visibly distressed 3. Psychomotor activity—restless, agitated Adjustment Disorder 4. Mood—anxious and/or depressed 5. Concentration—impaired • Definition—maladaptive or pathological response 6. Thought—preoccupation with stressors or to a psychosocial stressor (Strain, Hammer, Huer- physical symptoms tas, Lam, & Fulop, 1993) 7. Insight—may attribute symptoms to onset of stressor • Signs and symptoms 1. Sources of stressors—events, such as job loss, • Nursing diagnoses (NANDA, 2009) acute or chronic illness, divorce, or specific 1. Anxiety (specify level) developmental milestones (beginning school, 2. Powerlessness, risk for getting married, etc.) 3. Resilience, risk for compromised a. The more numerous or more disturb- 4. Self-Esteem, situational low ing the stressors, the greater effect on 5. Post-Trauma Syndrome, risk for adjustment. 6. Knowledge, deficient (specify) b. Previous history of Adjustment Disorder 7. Coping, ineffective puts person at more risk. 2. Distress experienced is in excess to what is • Genetic/Biologic origins (Sadock & Sadock, 2007) expected. 1. Possible constitutional predisposition 3. Significant impairment presents in social, oc- 2. Contribution of environmental and genetic cupational, or school functioning (APA, 2000). factors likely in developing an Adjustment 4. Symptoms occur within 3 months of stressor’s Disorder onset. a. Symptoms may be delayed. • Biochemical interventions—no evidence to sup- b. Disorder may continue with prolonged port the efficacy of pharmacologic interventions stressor or inability to adapt. (Sadock & Sadock, 2007) 5. Commonly diagnosed in medical settings. Questions 105

• Intrapersonal origins/Psychotherapeutic 2. Self-help groups developed to deal with par- interventions ticular stressors (e.g., divorce, death, stroke, 1. Origins diabetes) a. Psychoanalytic—early parent-child rela- a. Common bond tionship shapes ability to respond to stres- b. Experience in adjusting sors in later life. c. Chance to share coping techniques b. Cognitive/Behavioral d. Source of continuing support (1) Cognitive coping styles reflect per- e. Pragmatic in nature sonal attitude and meaning of the event. • Milieu interventions (inpatient or home setting) (2) Field independent persons use isola- 1. Protect from excessive stimulation. tion and intellectualization. 2. Provide structure in activities, environment, (3) Field dependent persons use repres- and safety. sion and denial. 3. Teach about adjustment process. 2. Psychotherapeutic interventions (intervention 4. Support biologic functioning (eating, sleeping, of choice for adjustment disorders) etc.). a. Crisis intervention/brief therapies 5. Emphasize trust in the future, social support, (1) Clarify meaning of the event. and self-efficacy. (2) Engage social support. 6. Focus on active recollection, retelling story (3) Create active interventions to amelio- while differentiating between reality and fan- rate the stressor. tasy (group and/or family helpful). b. Processing of memories/associations elic- 7. Reinforce increased communication with ited by the stressor others. (1) Initiate dose-by-dose approach to dif- 8. Reduce external demands to allow for work on ficult topics. stressors. (2) Teach techniques to keep emotions at 9. Reinforce conscious control over ruminations tolerable level. or recollections. c. Cognitive/Behavioral 10. Deal with recurrent stressors, shame over vul- (1) Desensitization nerability, anger, and sadness. (2) Flooding (3) Stress management techniques • Community resources (a) Autogenic Training/PMR 1. Refer to community self-help groups. (b) Hypnosis 2. Refer to community resources to deal with (c) Meditation specific stressors. (4) Assertiveness Training 3. Mobilize neighbors, churches, and other natu- (5) Cognitive restructuring rally occurring groups to lend help. d. Interpersonal support and reassurance Questions • Family dynamics/Family therapy 1. Family members affected by client’s response Select the best answer to stressors, or may have experienced the stressors themselves. 1. Ms. Smith, who has panic attacks, comes to 2. Family therapy where you, the PMH nurse, are sitting and says, a. Clarify meaning of the event. “It’s happening again. I can’t breathe. I know I’m b. Support effective coping techniques of going to die.” She is breathing with difficulty. individuals and entire family system. She has been attending a group to learn more c. Decrease secondary gain system-wide. about panic attacks and how to avert them. Your d. Facilitate decision-making and reality- best response is: testing. a. “Let me take your blood pressure.” e. Educate about the course of adapting to a b. “You know what to do—start your stressor. exercises.” c. “You’re experiencing anxiety; that’s what • Group approaches you are feeling.” 1. Short-term group psychotherapy with d. “Tell me what’s been going on.” problem-solving, supportive focus 106 Chapter 5 Anxiety and Stress-Related Disorders

2. Persons with recurrent Panic Disorder usually 9. Jerry, a miner, was injured a year ago and hasn’t present with: been able to return to work because of severe low back pain. His neurologist could find no a. High level of general anxiety organic reason for his continuing pain. Which b. Cardiac/respiratory symptoms of distress of the following psychiatric diagnoses best fits c. La belle indifference Jerry’s clinical picture? d. Clear precipitants a. Factitious Disorder 3. A priority nursing diagnosis for Sandra, an agora- b. Hypochondriasis phobic, who will not leave her house without her c. Pain Disorder husband accompanying her is: d. Conversion Disorder a. Posttrauma response 10. Nursing diagnoses for Jerry might include all but: b. Parenting, altered c. Fear a. Role Performance, ineffective d. Denial, ineffective b. Pain, chronic c. Posttrauma Syndrome 4. Mr. Lee has a Generalized Anxiety Disorder. You d. Coping, ineffective will be teaching him some relaxation techniques. When is the best time for him to learn? 11. An explanation for Jerry’s continued pain in spite of his neurologist’s findings is: a. When he is only mildly anxious b. Immediately after feeling severe distress a. Secondary gain c. In the middle of a time of moderate distress b. High endorphin levels d. After taking an antianxiety agent c. High serotonin levels d. Repression of unacceptable impulses 5. Jim, who suffers from severe flashbacks of war experiences, and has just been admitted, sits on 12. Treatment of Jerry’s chronic pain is likely to the lounge, apart from other clients. Your best include all but which of the following? response is: a. Exercise program a. Let him remain apart until he’s ready to b. Biofeedback-assisted relaxation disclose c. Pain support group b. Introduce him to two other veterans on the d. Antianxiety agents unit with similar problems 13. John has been preparing for running a marathon c. Suggest that he work on a crossword puzzle for over a year. “It’s my 40th birthday present to until dinner myself,” he explains. The morning of the race, d. Observe him for flashbacks his wife finds him still in bed, his legs paralyzed. 6. Symptoms of autonomic arousal in the PTSD John tells her that he guesses he can’t race after client include: all. What mental status variations might you expect? a. Hypersomnia b. Tachycardia a. Mood—depressed, anxious c. Alexithymia b. Mood—la belle indifference d. Hypotonic musculature c. Mood—blunted affect d. Mood—relieved 7. Which mental status variations would you expect for a client diagnosed as having PTSD? 14. The symptoms of a Conversion Disorder may be related to: a. Thought—delusion of grandeur b. Perceptual—derealization a. Heightened autonomic arousal c. Memory—impaired recent memory b. Displacement of aggression d. Mood—inappropriate, silly c. Mid-life crisis d. Symbolic relationship with conflict 8. Physiological monitoring of clients using benzodiazepines includes: 15. Mae has an intense argument with her 15-year- old daughter who visits her daily in the hospital a. CBC with differential where Mae is being treated for hypochondriasis. b. Kidney function studies Mae sends her daughter home and asks the c. Blood pressure nurse for medication for her stomach. d. Serum benzodiazepine levels “I wonder if she’ll regret this when I’m dead of stomach cancer?” she states. Your best reply is: Questions 107

a. “Let’s talk about what just happened.” the accident or attend activities, and says, “I just b. “This antacid will help.” want my nerve pills.” Your best response is: c. “Teenagers just go through those phases.” a. “Nerve pills are highly addictive. You need to d. “Mae, there is no sign of stomach cancer. learn to relax.” You’re not about to die.” b. “I can see why you’d like to put it behind 16. A client with a Conversion Disorder hospital- you. It must have been very scary.” ized in a psychiatric facility will require which c. “You are right. It’s important to carry on and approach by nursing staff? not dwell on the past.” d. “I hope you’ll talk to your doctor about a. Anticipate and meet self-care needs of client. this.” b. Encourage attendance at expressive therapies. 22. Mrs. Peters asks why she has to go to art therapy c. Reinforce verbal expression of needs. this morning. “I’m no artist. My hobby is gar- d. Remind the client that his difficulties are not dening. I’d rather go gardening. I’d rather just real. stay here and watch a little television.” Which is your best response? 17. When a DID client is hospitalized for serious self-inflicted cuts, the no-harm contract should a. “Art therapy is one way to express your- include: self. You don’t have to be an artist—just be willing to try the activity.” a. Ward privileges gained for no self-harm b. “Art therapy may give you an idea about b. Clear alternatives to follow when feeling the undiscovered talents. You just might be a urge to cut great artist inside.” c. Provision of antipsychotics for increased c. “Art therapy is good, but I’ll see if we can’t agitation schedule you for the green house activity d. Discharge from the hospital if there is self- instead.” harm d. “I’ll stay here and talk with you while you 18. Which is true about the resolution of DID? watch TV.” a. Clients must integrate alters. 23. Mrs. Peters finally decides to participate in b. All traumatic incidents must be remembered. art therapy. She returns to the unit red-eyed c. Many clients experience a reactive and clutching a paper covered with heavy red depression. scrawls. She stops and shows it to you. The best d. Some alters always exist, although hidden. response would be: 19. Given the diagnosis of Depersonalization Dis- a. “That’s really good. That red must be the order, which nursing diagnosis is most likely to fire.” result from assessment? b. “Let’s put this up for the other patients to see.” a. Powerlessness c. “This is very strong—tell me about it.” b. Grieving, dysfunctional d. “If art therapy was too troubling, I do have c. Identity, disturbed personal some medication for you.” d. Depersonalization alteration 24. Mary has been diagnosed as having a De-person- 20. Treatment of Dissociative Amnesia includes all alization Disorder. Which experience might she modalities except: relate during your initial nursing assessment? a. Hypnosis a. “This feeling is so weird—I feel just ‘unreal.’ “ b. Stress management b. “I haven’t been able to take care of the kids; c. Antianxiety agents I just sit around.” d. Psychotherapy c. “It’s no big deal.” 21. Mrs. Peters, who has experienced a traumatic d. “I have dreams that I just can’t get out of.” automobile accident in which three persons were 25. Joe, now age 34, was sexually abused by a burned to death, tells you that she just wants youth group leader when he was 14. Joe is most to “put it behind me.” She refuses to talk about likely to present with which of the following statements? 108 Chapter 5 Anxiety and Stress-Related Disorders

a. “I have really close friends, both males and b. “I think there is a different problem. PTSD females.” occurs much sooner.” b. “I’ve told so many people my story that it is c. “She has symptoms of PTSD that are difficult getting a little old.” not just for her, but for all of you.” c. “I don’t see how some little thing that hap- d. “The problem is rooted in the past, family pened 20 years ago is influencing my life can do nothing now.” now.” 30. Family therapy for the PTSD client and her family d. “I have a great sex life.” will meet all but one of the following goals: 26. Mary is thinking about entering a women’s a. Develop a shared frame of reference for the shelter if her husband starts to abuse her one trauma more time. Her chief concern should be to: b. Support the victim in recovery a. Try to make the relationship work since he c. Reduce secondary gain by limiting trauma has promised to stop abusing her. talk to therapy session only b. Develop a safety plan for her and her chil- d. Address issues of trust, responsibility, and dren if he begins to escalate. blame c. Let him know she is pregnant because a man 31. Now, three weeks after the hurricane, Charley is unlikely to hurt a pregnant woman. cannot remember anything about his 36- d. Acknowledge her role in causing the abuse. hour ordeal, trapped under debris from his 27. Chris, a successful music major, is preparing for house until he was finally rescued. This is best his recital next week. He has experienced severe described as: stage fright in the past and once, refused to a. Dissociative Amnesia, localized perform at all. Which of the following biochem- b. Dissociative Amnesia, generalized ical approaches is most likely to be employed c. Dissociative Amnesia, continuous in conjunction with behavioral therapy for his d. Dissociative Amnesia, selective difficulty? 32. A community support group for flood victims a. Mono-amine oxidase inhibitor asks you, the advanced practice PMH nurse, to b. Tricyclic antidepressant talk about symptoms of PTSD. The group has c. Beta-adrenergic antagonist been meeting since the disaster 6 months ago. d. Antiparkinsonism agent One woman asks why she continues to have peri- 28. Your client, Fred, attends a men’s group for adult odic, recurrent dreams and thoughts about the survivors of childhood sexual abuse. Some men in flood. Which is your best reply? the group are currently confronting their fami- a. “Your mind is attempting to work through lies, but Fred is unsure of his course of action. what happened, a little bit at a time.” Your best response is: b. “You are probably thinking too much. Try to a. “Most families welcome the honesty as dif- stop these thoughts.” ficult as it is for everyone.” c. “You could be guilty about surviving.” b. “You’ve been learning to be assertive. This is d. “At this time, you have a serious problem. probably the next step.” Have you seen your doctor?” c. “If you don’t confront your father now, 33. One hypothesis about why PTSD clients may con- you’ll always feel powerless. tinue to engage in dangerous activities and have d. “That’s a difficult decision. What would you recurrent interpersonal difficulties is related to: like to have happen with your family?” a. Serotonin excesses 29. A Vietnam veteran who served at a field hospital b. Autonomic entrainment late in the war becomes symptomatic of PTSD c. Endogenous opioid withdrawal after a long period of what seemed excellent d. Dysregulation of GABA adjustment. Her husband and children have joined her in your office to talk about what’s 34. Leonard has recently avoided going out to eat happening. They ask if she has PTSD. What is with his family at restaurants. He claims the your best response? food is better at home, and that other people may watch him eat and critique his table a. “Yes, she has PTSD, but we are going to let “bygones be bygones” and work on other things in therapy.” Questions 109

manners. The most appropriate psychiatric diag- c. Understanding why stimuli are anxiety nosis is: provoking d. Cognitive coping self-statements a. Schizophrenia with delusions b. Agoraphobia 41. Peggy is hospitalized because of emotional c. Avoidant Personality Disorder exhaustion. Her husband reports that she has d. Social Phobia become increasingly preoccupied with cleaning the house over the past year. Always a meticu- 35. The client presenting with a Somatization Dis- lous housekeeper, she is now afraid that the order typically: house is contaminated by environmental toxins. a. Exaggerates the seriousness of minor symp- She is up most of the night, trying to clean and toms into major health problems decontaminate. When her husband attempts to b. Refuses medication, preferring to “work it have her rest, she becomes distraught. The most out alone” accurate psychiatric diagnosis is: c. Has a chaotic social life a. Obsessive-Compulsive Disorder d. Understands the stress-physical symptoms b. Obsessive-Compulsive Personality Disorder relationship c. Schizophrenia, paranoid type 36. Joan, who obsessively thinks about her children d. Major Depression dying in a house fire, is learning to use thought- 42. Probable nursing diagnoses include all but: stopping techniques. Such techniques include: a. Coping, ineffective a. Practicing progressive muscle relaxation b. Anxiety b. Discussing with a staff member the likeli- c. Role Performance, ineffective hood of a house fire d. Home Maintenance Management, impaired c. Snapping a rubber band on her wrist when the thought of fire occurs 43. Clomipramine (Anafranil), 250 mg every d. Reminding herself of the home fire alarm morning, is ordered for Peggy. After taking the system medication for a week, she complains of being too sleepy to participate in morning activi- 37. Anxiety-reducing techniques such as autogenic ties. Which of the following actions might the training or progressive muscle relaxation are advanced practice nurse suggest? best employed by a person who fears flying on airplanes: a. Tell her the sleepiness will soon disappear. b. Recommend the medication be taken at a. When anxiety rises to intolerable levels bedtime. b. When the plane takes off and lands c. Request the medication be discontinued c. Prior to feeling autonomic arousal immediately. d. Only in practice settings d. Reschedule her activities to late afternoon. 38. The psychoanalytic explanation for a phobic dis- 44. The most effective treatment of Panic Disorder is: order involves: a. Reworking previous traumatic separations a. Classical conditioned responses b. Family therapy b. Reaction formation c. Cognitive restructuring c. Displacement d. Provision of a stress-free environment d. Avoidance 45. Persons prone to high levels of anxiety tend to 39. Group therapies for the treatment of agora- have which dysfunctional thoughts? phobia include: a. Negative views about the self, world, and a. Social skills training future b. Medication education b. Overestimation of the support of others c. Art or movement therapies c. Overestimation of danger d. Gestalt approaches d. “Black or white” thinking 40. Systematic desensitization includes all but which 46. Mrs. Stevens has been taking alprazolam of the following? (Xanax) 2.0 mg/day for six months. She wants to a. In vivo exposure become pregnant and, in preparation, goes off b. Deep muscle relaxation the medication. She currently experiences little anxiety. She has learned a variety of coping 110 Chapter 5 Anxiety and Stress-Related Disorders

techniques in therapy. Your best response to her 52. Seth, age 72, has almost doubled the amount of desire to discontinue the Xanax is: diazepam (Valium) prescribed for him, claiming that his “nerves are shot” and the medicine a. “Since you are doing so well, go ahead and doesn’t do enough for him. Which sign of tox- stop taking your Xanax.” icity is the nurse likely to see? b. “You should remain on benzodiazepines for at least one year.” a. Nausea and vomiting c. “Should you decide to discontinue Xanax, it’s b. Rapid speech with flight of ideas important to very slowly reduce the dose.” c. Psychomotor excitation d. “You might want to try a shorter-acting d. Short-term memory impairment medication like Oxazepam (Serax) as a 53. Ellie has a past history of cutting and burning substitute.” her arms and ankles when anxious or dissoci- 47. Susan was admitted at 3 a.m. to the emergency ating. She admits to “little cuts” last night when department of a medical center, complaining of thinking about working with a new therapist. stomach pain that she believes is cancer. Although Which is the best initial strategy of the advanced she admits to having eaten some “real spicy food” practice nurse when beginning therapy with the evening before, she is insistent on having Ellie? an upper and lower GI series immediately. She is a. Assist Ellie to identify the patterns and func- anxious, despite her doctor’s reassurance. Which is tion of self-injury. a likely psychiatric diagnosis? b. Give her telephone numbers so that the a. Conversion Disorder nurse can be reached whenever Ellie begins b. Hypochondriasis to feel self-injurious. c. Pain Disorder c. Define self-injury as unacceptable and as d. Generalized Anxiety Disorder grounds for termination of the therapeutic relationship. 48. A primary focus of treatment for Susan will be: d. Ignore the behavior so as not to reinforce it. a. Dietary instructions and antacids 54. Mild–to-moderate anxiety in response to a b. Stress management techniques stressor is most likely to present in patients with: c. Insight-focused psychotherapy d. Rehabilitation efforts a. Generalized Anxiety Disorder b. Adjustment Disorder with anxiety 49. Upon questioning your client during the intake c. Acute Stress Disorder interview, she relates that she hears voices inside d. Obsessive Compulsive Disorder her head, as if in a conversation. Which psychiatric diagnosis best fits these experiences? 55. Buspirone (BuSpar) is: a. Schizophrenia a. An effective SNRI used in treating anxiety b. PTSD b. An effective anxiolytic used in treating c. DID anxiety d. Panic Disorder c. A controlled substance due to the potential for abuse and dependence 50. Family therapy with partners and children of DID d. Both a and c are correct clients is aimed at which of the following? 56. SSRIs are first-line agents for treating anxiety in a. Help children access child alters. the following disorder(s): b. Help children deal with hostile alters. c. Help children ignore inconsistent parental a. Generalized Anxiety Disorder behavior. b. Panic Disorder d. Help children parent the child alters. c. Obsessive-Compulsive Personality Disorder d. Both a and b are correct 51. The most efficacious approach for dealing with a client who has a Somatization Disorder is to: 57. Which medication would be least beneficial in treating PTSD? a. Use antidepressants. b. Closely collaborate with the primary care a. Fluvoxamine provider. b. Fluoxetine c. Confront the unreality of the symptoms. c. Alprazolam d. Provide brief, problem-focused therapy. d. Paroxetine Bibliography 111

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6 Schizophrenia and Other Psychotic Disorders

Overview of Disorders are inserted into one’s mind through external means (Sadock & Sadock, Schizophrenia 2007) b. Hallucinations—false sensory perceptions • Definition—a clinical syndrome characterized by that involve one or more of the five senses disturbances in perception, thought process, real- (most common: auditory and visual), and ity testing, affect, behavior, attention, and motiva- are inconsistent with reality tion; typically appears in late adolescence or early c. Disorganized speech—derailment or adulthood and is considered a chronic disorder incoherence with alternating periods of exacerbation and re- d. Grossly disorganized or catatonic behavior mission (Keltner, Schwecke, & Bostrom, 2007) e. Presence of negative symptoms—affective flattening, alogia or avolition • Epidemiology (National Institute of Mental Health, 2. NOTE: Only one of the above symptoms is 2006) necessary in the presence of: 1. Diagnosis rate for US population is 1.1%. a. Bizarre delusions—involving a phenom- 2. Prevalence rate is equal among men and enon that would be considered completely women, although age of onset is later in fe- implausible in the person’s culture males than in males. (Sadock & Sadock, 2007) b. Hallucinations of a voice with running • Signs and symptoms (American Psychiatric Asso- commentary about the person’s behavior ciation [APA], 2000) or thoughts 1. The DSM-IV-TR criteria for diagnosis of c. Two or more voices conversing with each Schizophrenia includes the presence of two (or other more) of the following for a significant portion 3. Diagnosis also includes evidence of social/ of time during a 1-month period (or less if suc- occupational dysfunction for a significant por- cessfully treated): tion of time since onset of symptoms. a. Delusions—fixed false beliefs that are a. In adults—work, interpersonal relations or inconsistent with one’s culture (See also self-care below level achieved before onset Delusional Disorder) and include: b. In children or adolescents—failure to (1) Thought broadcasting—belief that achieve expected level of interpersonal, one’s thoughts are being transmitted academic, or occupational achievement such that one’s thoughts are being 4. Continuous signs of the disturbance for at perceived by others least 6 months, including: (2) Thought insertion—belief that one’s thoughts are not one’s own, but rather 115 116 Chapter 6 Schizophrenia and Other Psychotic Disorders

a. At least one month of active symptoms (or 1. Nonpsychiatric condition causing psychotic less if successfully treated) and symptoms—medical work-up is important b. Prodromal and residual phases including to rule out conditions including neoplasm, the following negative symptoms: cerebrovascular disease or trauma, emboli, (1) Withdrawal or social isolation narcolepsy, encephalitis, Huntington’s disease, (2) Impairment in role functioning temporal lobe epilepsy, heavy metal poison- (3) Odd behavior (e.g., talking to self in ing, neurosyphilis, vitamin B12 deficiency, and public) AIDS. (4) Little attention to personal hygiene, 2. Mood disorder with psychotic features bathing, manner of dress, overall self- 3. Substance-induced psychosis—acute intoxica- care, and activities of daily living tion with legal and illegal substances and/or (5) Odd speech characterized by cir- drug reactions to medicinal drugs may induce cumstantiality, tangentiality, poverty psychotic behaviors and thought disorders, of speech, or poverty of content of e.g., alcohol hallucinosis/withdrawal, alka- speech loids, amphetamines, barbiturate withdrawal, (6) Magical thinking including ideas of hallucinogens. reference 4. Personality disorder—personality disorders (7) Recurrent illusions or other percep- with features similar to Schizophrenia, e.g., tual experiences Schizotypal, Schizoid, and Borderline Person- (8) Decrease in motivation, energy, or ality Disorders initiative 5. Other Psychotic Disorders c. Prodromal and residual phase may also a. Delusional Disorders consist of two or more active phase symp- b. Schizophreniform Disorder toms in an attenuated form (e.g., odd be- c. Schizoaffective Disorder liefs, unusual perceptual experiences) or d. Brief Psychotic Disorder only negative symptoms. 6. Dementias and delirium—especially in the elderly; may be manifested by irritability, anxi- • Subtypes of Schizophrenia ety, isolation, and agitation 1. Paranoid Schizophrenia—characterized by preoccupation with one or more delusions Schizophreniform Disorder that may be persecutory, or by frequent auditory hallucinations • Definition/Signs and symptoms 2. Disorganized Schizophrenia—characterized 1. Episode of symptoms of schizophrenia that by a flat or incongruous affect; exhibits bizarre lasts at least 1 month but less than 6 months mannerisms and social isolation; onset occurs 2. Good prognosis indicated by: early in life and often has persistent symptoms a. Psychotic symptoms within 4 weeks of 3. Catatonic Schizophrenia—identified by in- onset tense psychomotor disturbance; disturbance b. Confusion during psychosis may take the form of stupor or excitement c. Good social and occupational functioning and is manifested by such psychomotor dis- before onset turbances as posturing, immobility, catalepsy, d. Blunted or flat affect absent (APA, 2000) mutism, and negativism 4. Undifferentiated Schizophrenia—person • Differential diagnosis clearly meets the diagnostic criteria but does 1. Schizophrenia, schizoaffective, substance use, not fit into one subtype or another (Sadock & and mood disorders Sadock, 2007). 2. Medical illness or medication response 5. Residual Schizophrenia—absence of hallucinations and delusions; two or more residual Delusional Disorder symptoms are continued • Definition/Signs and symptoms—active phase • Differential diagnosis/Related disorders (Sadock & 1. Nonbizarre delusions Sadock, 2007) 2. None of the following for more than a few It is important that the presence of psychotic hours: symptoms be assessed in relationship to nonpsy- a. Hallucinations chiatric/medical conditions and other related, b. Disorganized speech concomitant, or neurologic disorders. c. Grossly disorganized or catatonic behavior d. Negative symptoms Overview of Disorders 117

3. Functioning is not markedly impaired except 4. Presence or absence of marked stressors for the impact of the delusions. should be noted, as should onset within four 4. In the elderly, mood may be manifested by weeks postpartum. anger, paranoia, and anxiety; behaviors may include suspiciousness, aggression, and • Differential diagnosis isolation. 1. Medical condition including epilepsy and delirium • Types of delusions (APA, 2000; Sadock & Sadock, 2. Other psychotic disorders—Schizophreniform 2007; Videbeck, 2006) Disorder, Schizophrenia, Schizoaffective Dis- 1. Persecutory/paranoid—belief that others are order, Delusional Disorder attacking, harassing, cheating, or conspiring 3. Substance-induced psychosis against them (or a person close to them); e.g., 4. Dissociative Identity Disorder belief that one is being followed by the CIA or 5. Mood disorder with psychotic features that others are poisoning their food 2. Jealousy—belief that one’s sexual partner is Shared Psychotic Disorder (Folie à deux) unfaithful 3. Erotomanic—belief that someone, usually in a • Signs and symptoms (APA, 2000) position of higher status or authority, is in love 1. Delusional system develops in the context of with them a close relationship with a person who already 4. Grandiose—belief that they have special has a psychotic disorder with delusions. knowledge, worth, or powers; may believe they 2. Delusion is similar in content to that of the are or have a special relationship with a deity person who already has the established or famous person delusion. 5. Somatic—vague or unrealistic belief that one’s appearance, health, or physical functioning is • Differential diagnosis deficient or unique 1. Medical conditions associated with delusions 6. Mixed type—a combination of more than one and/or delirium of the above delusions in which no one theme 2. Schizophrenia or another psychotic disorder outweighs another 3. Substance-induced psychosis

• Differential diagnosis—Schizophrenia Psychotic Disorder Due to a General Medical Condition Schizoaffective Disorder • Signs and symptoms (APA, 2000)—delusions or • Definition—major depressive episode, or manic hallucinations that: episode that occurs concurrently with active phase 1. Do not occur exclusively during the course of schizophrenia symptoms; during same period of delirium or dementia. illness, there have been delusions or hallucinations 2. Are the direct consequence of an identified for at least 2 weeks in the absence of prominent medical condition as determined by mood symptoms, but mood symptoms are present a. History during a substantial part of the illness (APA, 2000) b. Physical examination c. Laboratory findings Brief Psychotic Disorder 3. Are not better accounted for by another mental disorder. • Definition/Signs and symptoms 1. One of the following is present and not cultur- Substance-Induced Psychotic Disorder ally sanctioned: a. Delusions • Definition (APA, 2000)—delusions or hallucina- b. Hallucinations tions (these are not included if the client has in- c. Disorganized speech sight that they are substance induced) that: d. Grossly disorganized or catatonic behavior 1. Develop during or within a month of signifi- 2. Onset is generally sudden with duration of cant substance intoxication. symptoms of 1 month or less, but at least 1 2. Are in excess of what would be expected for day. the amount and type of substance abused. 3. Individual recovers to a normal level of 3. Do not occur during the course of delirium or functioning. dementia. 118 Chapter 6 Schizophrenia and Other Psychotic Disorders

• Differential diagnosis: • Genetic/Biologic theories (Sadock & Sadock, 2007) 1. Delirium 1. Genetic 2. Dementia a. The lifetime risk of developing schizo- 3. Other psychotic disorders phrenia when one has a parent, identical twin or sibling with schizophrenia is much Psychotic Disorder Not higher than in the population at large. Otherwise Specified b. Torrey et al. (1994) studied 66 pairs of identical twins and noted that 27 pairs • Definition (Sadock & Sadock 2007)—a variety of were discordant for schizophrenia and 13 clinical manifestations with psychotic features that pairs were concordant for schizophrenia. do not meet the criteria of another DSM-IV-TR c. An exact genetic linkage has not been es- psychotic disorder tablished. However, multiple common genetic polymorphisms have been suggested • Examples (APA, 2000): with several genes implicated in schizo- 1. Postpartum psychosis that does not meet the phrenia vulnerability. Multiple genes on criteria for another medical or mental disorder several chromosomes have been identified 2. Persistent auditory hallucinations with no including: chromosomes 6, 2, 11, 13, 12, other symptoms 22 (Tandon, Keshavan, & Nasrallah, 2008b; 3. Persistent nonbizarre delusions with intermit- Wong, Arcos-Burgos, & Licinio, 2008). tent periods of overlapping mood episodes 2. Neuroanatomic models—structural func- present for a substantial portion of the delu- tional abnormalities according to magnetic sional disturbance resonance imaging (MRI) and computerized 4. Psychosis where a more specific diagnosis is tomography (CT) scans impossible a. Ventricular enlargement (lateral & 3rd 5. Psychotic symptoms that have lasted for less ventricular enlargement) than 1 month but have not yet remitted, so (1) Neurofetal development factors—en- that the criteria for Brief Psychotic Disorder larged lateral and third ventricles, de- are not met crease in cranial, cerebral, and frontal brain tissue, delivery complications Information Common to (may affect fetal neural development) Schizophrenia and Other (Fox & Kane, 1996) Psychotic Disorders b. Prominence of cortical sulci c. Defects in limbic brain structure • Nursing diagnoses—several of the 2009–2011 d. Cortical atrophy/decrease in number NANDA International (2009) nursing diagnoses of cortical neurons (usually more pro- can be applied to Schizophrenia and other psy- nounced in the left hemisphere) possibly chotic disorders, including: linked with negative symptoms (Walker, 1. Behavior, risk-prone health 1997) 2. Coping, defensive e. Subtle neuroanatomical differences in 3. Coping, ineffective part of the thalamus, septum, hypothala- 4. Denial, ineffective mus, hippocampus, amygdale, and cingu- 5. Powerlessness late gyrus (Bendik, 1996) 6. Neglect, self f. Reduction of 5% in brain weight and slight 7. Violence, (actual/) risk for self-directed decrease in brain length (Keltner & Folks, 8. Social Interaction, impaired 1997) 9. Social Isolation g. Decrease in volume of temporal lobe 10. Self-Esteem, chronic low structures and decrease in substantia ni- 11. Resilience, impaired individual gra and putamen (Walker, 1997) 12. Sensory Perception, disturbed (specify) h. Thickening of corpus callosum on MRI 13. Confusion, acute or chronic i. Abnormalities in brain density and 14. Violence, (actual/) risk for other-directed symmetry 15. Environmental Interpretation Syndrome, j. Atrophy of portion of cerebellum impaired 3. Neurotransmitter models—theories/ 16. Communication, impaired verbal hypotheses about schizophrenia include 17. Health Behavior, risk-prone specific and interconnected roles of various 18. Health Management, ineffective self neurotransmitters: 19. Knowledge, deficient (specify) Inforrmation Common to Schizophrenia and Other Psychotic Disorders 119

a. Serotonin (5HT2) deficiency may create source of development changes be responsible for some forms of that present risk factor for schizophrenia schizophrenia. (Cannon & Marco, 1994) b. Glutamate—specifically, deficiency me- b. Risk factors associated with schizophrenia diated excitatory neurotransmission by (1) Studies of childhood encephalitis, N-methyl D-apartate (NMDA) receptors head trauma younger than age 10, may be involved. This hypothesis is sup- hemorrhage into the ventricles, isch- ported by psychosis triggered by NMDA emic damage to cortex associated antagonists (phencyclidine and ketamine) with schizophrenia. (Keshavan, Tandon, Boutros, & Nasrallah, (2) Twin studies established indicators of 2008). liability, but do not predict the disease c. GABA—Reduced levels of GABA in prefron- (Torrey, Bowler, Taylor & Gottesman, tal cortex may account for alterations in 1994). neuronal synchrony leading to memory im- 6. Theory of two types of schizophrenia pairment in schizophrenia (Keshavan et al.). a. Type I—characterized by positive symp- d. Norepinephrine (NE) may be insufficient toms of schizophrenia, e.g., delusions, in clients with schizophrenia that display hallucinations, disorganized thinking; prominent negative symptoms. responds well to typical antipsychotic e. Dopamine (DA) is likely to be excessive medications at certain receptor sites, or persons with b. Type II—characterized by negative symp- schizophrenia may have more dopamine toms, including withdrawal, flattening of

receptors. D2 receptors are present in lim- affect, decreased motivation; respond bet- bic and motor neuron center; overactivity ter to newer antipsychotics (clozapine and

of D2 receptors may be related to positive risperidone); negative symptoms may be symptoms of schizophrenia (Harris & more related to structural defect and not McMahon, 1997). Although direct evi- dopamine function (Keltner & Folks, 1997) dence in support of the dopamine hypothesis of schizophrenia is sparse (Keshavan, • Biochemical interventions Tandon, Boutros, & Nasrallah, 2008). 1. Typical antipsychotics (Sadock & Sadock, 2007; f. Also implicated in schizophrenia are ace- Stahl, 2008, 2009) tylcholine muscarinic and nicotinic re- a. Used to decrease psychotic symptoms ceptors, which play a role in regulation of including hallucinations, delusions, and neurotransmitters involved in cognition. paranoia g. The interaction of various neurotrans- b. Used short term in Schizophreniform mitters has also been studied relative to Disorder schizophrenia. c. Mode of action—block dopamine recep- h. Recent studies have examined effect of tors in post-synaptic neuron interactions between hormones and neu- (1) Potency related to D2 receptor affinity rotransmitters in schizophrenia; patterns in primarily four major pathways in of dopamine-thyroid interactions and the brain. dopamine pituitary hormone secretions (2) Blockade of dopamine receptors in were found to be related to symptoms of the cortex potentially makes negative schizophrenia. symptoms worse. 4. Neurophysiological models (3) D2 receptor blockade responsible for a. Decreased cerebral blood flow (as mea- many side effects of typical antipsy- sured by Single Photon Emission Com- chotics (Sherr, 1996). puted Tomography (SPECT)) (Keltner & d. Medications (See Table 6-1) Folks, 1997) and decreased glucose me- (1) Fluphenazine (Prolixin), 12.5 to 50 mg tabolism in the frontal lobes (as measured every 6 hours, and haloperidol (Hal- by Positron Emission Tomography (PET)) dol), 6 to 20 mg daily are available in b. Hypofrontality may be related to changes intramuscular, injectable forms that in abstract thinking and social judgment. are long-acting and released over two- 5. Immunologic/Risk factor models to-three weeks. a. Exposure to viruses, especially influenza (a) Reduces need to take daily oral prenatally—theorized that such exposure medications may create maternal antibodies that be- (b) Helps reduce ambivalence come auto-antibodies in the fetus and (2) Dosages vary widely among patients. 120 Chapter 6 Schizophrenia and Other Psychotic Disorders

Table 6-1 Typical Antipsychotics

Acute Adult Dose Range Maintenance Dose Range Classification Generic (Trade Name) (mg/day) (mg/day) Phenothiazines Chlorpromazine (Thorazine) 100 to 1600 PO 50 to 400 PO 25 to 200 IM Thioridazine (Mellaril) 200 to 800 PO 100 to 300 PO Mesoridazine (Serentil) 100 to 400 PO 30 to 150 PO 25 to 200 IM Perphenazine (Trilafon) 12 to 64 PO 8 to 24 PO 15 to 30 IM Trifluoperazine (Stelazine) 4 to 40 PO 5 to 20 PO 4 to 10 IM Fluphenazine (Prolixin) 2.5 to 40.0 PO 1.0 to 15.0 PO 5 to 20 IM 12.5 to 50 IM (decanoate or enanthate, weekly or biweekly) Thioxanthenes Thiothixene (Navane) 6 to 100 PO 6 to 30 PO 8 to 30 IM Butyrophenones Haloperidol (Haldol) 5 to 20 PO 1 to 10 PO 12.5 to 25 IM (decanoate) 25 to 200 IM (decanoate, monthly) Dibenzoxazepines Loxapine (Loxitane) 20 to 250 PO 20 to 100 PO 20 to 75 IM Dihydroindolones Molindone (Moban) 50 to 225 PO 5 to 150 PO

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009)

e. Potential side effects of typical v. Severe spasms of tongue antipsychotics and larynx can result in dys- (1) Anticholinergic effects occur due to phagia (difficulty swallowing) interference of nerve impulses by ace- and compromised airway. tylcholine and epinephrine; include vi. Treatment—anticholinergic constipation, dry mouth, blurred vi- drugs; severe painful symp- sion, urinary retention and hesitancy; toms benefit from IM dose bethanecol is sometimes given for cogentin 2 mg or benedryl 50 urinary retention. mg that may be repeated in (2) Extrapyramidal symptoms can occur 30 minutes if no resolution of due to medication’s effects on the ex- symptoms. trapyramidal tracts of central nervous (b) Neuroleptic-induced pseudopar- system. kinsonism—dopamine blockade (a) Acute dystonia—muscle spasms in nigrostriatal pathways results may occur early in treatment, in clinical symptoms such as: sometimes after first dose; occur i. Tremors in up to 10% of clients: ii. Bradykinesia/akinesia (slow- i. Blepharospasm (eye closing) ness, absence of movement) ii. Torticollis (neck muscle con- iii. Cogwheel rigidity (slow, regu- traction, pulling head to side) lar, muscular movements) iii. Oculogyric crisis (severe iv. Postural instability, shuffling upward deviation of the gait, loss of mobility in the eyeballs) facial muscles (mask-like iv. Opisthotonos (severe dorsal faces), hypersalivation and arching of neck and back) drooling Inforrmation Common to Schizophrenia and Other Psychotic Disorders 121

v. Pill-rolling of fingers iv. Careful assessment of symp- vi. Affects up to 15% of clients toms of TD using standard (c) Akathisia—may occur weeks or instruments, such as Abnor- months after treatment; occurs mal Involuntary Movement in approximately 25% of persons Scale (AIMS), is a nursing treated with neuroleptics. responsibility. i. Objective symptoms— v. Pathophysiology of TD is restlessness, pacing, rocking only partially understood, (shifting from one foot to an- but includes an understand- other), and foot tapping ing of possible increase in ii. Subjective symptoms— dopamine receptors after descriptions of inner restless- long-term blockade with ness, tension, irritability, and neuroleptics and/or develop- inability to sit still or lie down ment of hypersensitivity of iii. Differentiation between dopamine receptors. akathisia and anxiety and vi. Discontinuing drug may psychomotor agitation of result initially in withdrawal worsening psychosis is dyskinesia. important. vii. Benzodiazepines may bring iv. May respond to reduction of temporary relief. antipsychotic medication. viii. Approximately 50% will not v. Anticholinergic treatment return to normal movement generally has limited effect even after withdrawal of except in high doses that are drug. often not well tolerated. ix. Some clients seem to re- vi. Beta-blockers may be most spond to treatment with clo- effective adjunctive treat- zapine (Clozaril). ment—propanolol (Inderal) (3) Treatment of EPS and 160 mg/day; nadolol (Cor- Pseudoparkinsonism gard) 80 mg/day. (a) Anticholinergic drugs (d) Tardive Dyskinesia (TD)—(tardive i. Contraindication—narrow means “late”—dyskinesia in- angle glaucoma volves difficulty performing ii. Relative contraindications— movements)—TD is abnormal dehydration, cardiac arrhyth- repetitive movement that is irre- mias, and benign prostatic versible in 50% of cases even after hypertrophy withdrawal of drug; TD tends to iii. Caution—older clients and occur later in treatment with an- those on additional medica- tipsychotic agents. tions with anticholinergic i. Oral (lip smacking, pucker- effects must be monitored. ing), buccal, lingual (tongue iv. Excess anticholinergic protrusion) masticatory, and medication may result in eyelid (blinking) movement; urinary retention, paralytic choreiform movements that ileus and memory problems, may at first occur anywhere sometimes called anticho- in the body, including arms, linergic delirium (includes legs, fingers, feet, and trunk. disorientation). ii. Less commonly involves v. Other side effects may in- muscles in swallowing reflex clude blurred vision, dry or diaphragm—can lead mouth, and tachycardia. to choking or respiratory (b) Dopamine agonists (See Table 6-2 compromise. for medications to treat extrapyra- iii. Clients are often less aware midal symptoms) of the movements than those (4) Neuroleptic Malignant Syndrome around them who generally (NMS)—rare, potentially fatal idiosyn- report them. cratic reaction to antipsychotics 122 Chapter 6 Schizophrenia and Other Psychotic Disorders

Table 6-2 Medications Used to Treat Extrapyramidal Symptoms (EPS) & Pseudoparkinsonism

Classification Generic Name Trade Name Dose & Route Anticholinergics Benztropine Cogentin 1 to 4 mg PO/IM/IV, 1 to 3 times/day Trihexypheridyl Artane 2 to 5 mg PO, 3 to 4 times/day Antihistamine Diphenhydramine Benadryl 25 to 50 mg PO/IM/IV, every 4 to 6 hrs Dopamine Agonist Amantadine Symmetrel 100 mg PO, 2 times daily

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009)

(a) Characterized by muscular rigid- erection, inhibition of orgasm and ity, hyperthermia, autonomic amenorrhea instability. (f) Orthostatic hypotension, seda- (b) Laboratory findings can include tion, weight gain leukocytosis (15,000 to 300,000), (g) Cholestatic jaundice—in chlor- elevated creatinine phosphoki- promazine, usually self-limiting nase (CPK) (may be > 3000 IU/ (h) Agranulocytosis—signs of an mL); myoglobinuria. infection such as sore throat, flu- (c) May occur any time during treat- like symptoms, and fever may ment but is more frequent shortly indicate medical emergency and after initiation of antipsychotics require immediate evaluation. or dose increases; rapid adminis- (6) Treatment of side effects—dose re- tration of a high potency antipsy- duction, changing to another drug chotic and an increased number and adding an adjunctive agent are of IM injections may increase risk. considered in light of efficacy of anti- (d) Treatment of NMS requires dis- psychotic drug and side effect profile continuation of antipsychotic of individual client. drugs and maintenance of nutri- 2. Atypical antipsychotics (Sadock & Sadock, tion, cooling, and hydration. 2007; Stahl, 2008, 2009) (See also Table 6-3) (e) Ventilation may be required for a. Clozapine (Clozaril) respiratory failure; renal dialysis (1) Indicated for treatment of refractory for renal failure. schizophrenia (Littrell, 1994) (f) Muscle relaxant IV can be admin- (a) Found to improve response in istered to reduce rigidity. clients who have failed to respond (g) Dopaminergic drugs such to two antipsychotics of different as bromocriptine (Parlodel), chemical classes given at doses of amantadine (Symmetrel) and 800 chlorpromazine equivalents a anticholinergics day for at least 6 weeks (5) Other side effects of typical (b) Restricted indication due to 1% antipsychotics risk of agranulocytosis (Littrell, (a) Reduction of seizure threshold, 1994) especially with the use of low- (2) Mode of action—blocks dopamine re- potency agents ceptors; considerable 5HT2 blockade (b) ECG changes (conduction delays); (3) Side effects and rarely sudden death; more (a) Agranulocytosis common with low-potency drugs i. Take complete blood count (c) Photosensitivity—may con- prior to therapy and white tinue up to a month after drug blood cell count (WBC) discontinued. weekly for duration of (d) High doses of thioridazine (Mel- treatment. laril) can lead to pigmentary retin- ii. Greatest risk period is first opathy and permanent blindness. 6 months of treatment, and (e) Sexual dysfunction, including risk peaks at approximately 3 retrograde ejaculation, impaired months; cases have occurred after 2 years of treatment. Inforrmation Common to Schizophrenia and Other Psychotic Disorders 123

Table 6-3 Atypical Antipsychotic Agents

Monitoring & Generic Name Trade Name(s) Oral Dosage Range Maximum Dose Other Comments Aripiprazole Abilify 15 to 30 mg/day 30 mg/day Increased suicide risk Available in disintegrating tablet form Clozapine Clozaril 300 to 450 mg/day 900 mg/day Only drug for treatment FazaClo (ODT) resistant schizophrenia Monitor WBCs due to agranulocytosis risk Monitor weight Olanzapine Zyprexa 10 to 20 mg/day 20 mg/day Increased suicide risk Zyprexa Zydis (ODT) Monitor weight Quetiapine Seroquel, 300 to 800 mg/day 800 mg/day Increased suicide risk Seroquel XR (may divide dose) Monitor for cataracts Paliperidone Invega 6 mg/day 12 mg/day Extended-release preparation Risperidone Risperdal 2 to 8 mg/day 16 mg/day Long-acting depot dose: 25–50 mg IM q 2 weeks Ziprasidone Geodon 80 to160 mg in 100 mg/day IM form (10–20 mg, max. divided dose 40 mg/day), discontinue IM dose within 3 days) Prolongs QTc interval more than other antipsychotic medications— monitor ECG if cardiac condition

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2008, 2009)

iii. Recovery usually complete ity of decreased white blood if drug stopped before clini- cell count. cal symptoms of infection iv. Myoclonic jerking may pre- appear. cede seizures and may indi- iv. If agranulocytosis occurs, cate need to hold or reduce drug is not restarted. total daily dose. (b) Because there is less penetra- (d) Anticholinergic effects—generally tion into the striatum where EPS moderate, however, there is a occur, there is minimal EPS or 30% incidence of hypersalivation; tardive dyskinesia compared to dose reduction or addition of an- typical antipsychotics. ticholinergics may help nighttime (c) Seizures—dose-related side effect hypersalivation. i. Maximum daily dose is 900 (e) Rapid changes in clozapine dose mg. or sudden discontinuation can ii. Overall seizure incidence is result in serious rebound psycho- approximately 3%. sis and anticholinergic rebound iii. Valproate (Depakote), most (nausea, vomiting, and diarrhea). common antiseizure medica- (f) Noncompliance for several days tion, may be added; carba- and reintroduction at previous mazepine (Tegretol) is dose could result in syncopal epi- avoided because of possibil- sodes, orthostatic hypotension, or seizures. 124 Chapter 6 Schizophrenia and Other Psychotic Disorders

(g) Other side effects (a) Unlikely to cause tardive dyski- i. Sedation, tachycardia, hy- nesia; however clients should be potension, GI upset, benign monitored over time hyperthermia, constipation, (b) EPS—dose-related side effects headaches (most diminish (c) Does not cause agranulocytosis substantially with time) (d) Has mild alpha blockade and ii. Tachycardia (increases of 25 histamine blockage, resulting in beats/minute) may persist— some risk of orthostatic hypoten- can be treated with beta- sion and sedation blockers. (e) Other side effects—anxiety, dizzi- iii. Benign hyperthermia usually ness, constipation nausea, tachy- develops in first 3 weeks of cardia (Keltner and Folks, 1997); treatment; usually remits on insomnia, agitation, headache, its own. rhinitis, weight gain iv. Some clients complain of (3) Dosage and efficacy vague burning in stomach; (a) Starting dose in adults is 1 mg may be relieved by food with b.i.d. increased by 1 mg b.i.d. daily resultant weight gain. to initial daily dose of 4 to 6 mg/ (4) Dosage and efficacy day. (a) Start at 12.5 mg with increases of (b) In geriatric clients, dosing should 25 mg each day for 5 to 7 days; be reduced by half, starting at 0.5 low dose initiation reduces risk of mg b.i.d. titrating to 1.5 mg. orthostatic hypotension. (c) In doses beyond 8 mg/day poten- (b) Most clients respond to 300 to tial loss of improvement in nega- 600 mg/day, usually given in di- tive symptom response. vided dose 2 times per day or at (d) May take up to 6 to 8 weeks to be- bedtime. come maximally effective. (c) Medication is distributed to out- (e) Absorbed well orally, IM form not patients for 7 days if WBC > 3000. available. (d) Effective with both “positive” c. Olanzapine (Zyprexa) and “negative” symptoms of (1) Mode of action schizophrenia. (a) Like risperidone is a serotonin/ (e) Gradual improvement over sev- dopamine antagonist (Littrell, eral months with possibility of 1997) and is known as a Multi- continued improvement through- Acting Receptor Targeted Antipsy- out first year. chotic (MARTA). (f) Some clients have remarkable (b) Binds to both serotonin 5HT2 response in psychotic symptoms, and dopamine D2 receptors, with daily function and social orga- a greater affinity for serotonin, nization; report “thinking more decreasing positive and negative clearly” leading to medication symptoms. and treatment compliance. (2) Side effects (g) Nurse is pivotal in setting up (a) Decreased risk for causing EPS atmosphere that improves (b) Minimal risk of prolactin compliance. elevation b. Risperidone (Risperdal, Consta) (c) Neurologic side effects—limited (1) Mode of action to akathisia (5%), tremor (47%), (a) Blocks serotonin and dopamine and hypertonia (4%) (D2) receptors in limbic tract that (d) Other side effects include somno- improves positive symptoms lence (26%), agitation (23%), and (b) Also blocks 5HT2 receptors in insomnia (20%) cortical regions of brain; frees (e) Nervousness and dizziness also dopamine in area and improves reported negative symptoms (Keltner & (f) To date, no reported cases of tar- Folks, 1997) dive dyskinesia (2) Side effects (3) Dosage and efficacy Inforrmation Common to Schizophrenia and Other Psychotic Disorders 125

(a) Recommended initial dose is 5 to (1) Mode of action 10 mg with a target dose of 10 mg (a) Antagonizes serotonin 2A recep- within a few days. tors; partial agonism at D2 recep- (b) Because of the relatively short tors, and serotonin 1A receptors time to steady state, recom- (2) Side effects mended that patient remain (a) Headache on a dose for 5 to 7 days before (b) Agitation increasing. (c) Anxiety (c) Mean 30-hour half-life of olan- (d) Somnolence/Insomnia zapine allows for once-a-day dos- (e) Akathisia ing, usually at bedtime. (f) Dizziness (d) Effective in treating positive and (g) Nausea/Vomiting negative symptoms (3) Dosage and efficacy d. Ziprasidone (Geodon) (a) Recommended initial dose is 10 (1) Mode of action to 15 mg daily; increasing dose (a) Antagonizes D2 receptors and every 2 weeks to a maximum rec- 5HT2 receptors ommended 30 mg/day dose (2) Side effects (b) Anticholinergics may be useful in (a) Hypotension reducing akathisia when present. (b) Dizziness 3. Medications used for Schizoaffective Dis- (c) Sedation order—include atypical antipsychotics and (d) Extrapyramidal symptoms mood stabilizers (such as lithium, Tegretol, (e) Nausea and Depakote), as well as antidepressants, de- (f) Dry mouth pending on presenting problems. (3) Dosage and efficacy (a) Recommended initial oral dose is • Intrapersonal origins/Psychotherapeutic 20 mg 2 times per day interventions (b) Available in IM formulation—rec- 1. Interactional model for schizophrenia delin- ommended adult dose: 10 mg ev- eates that biologic vulnerability along with en- ery 2 hours or 20 mg every 4 hours vironmental factors, social skills, and support as needed for agitation associated of individual are factors in development of the with schizophrenia illness. (c) Effective in treating positive and 2. Psychotherapeutic intervention—acute negative symptoms a. Nursing interventions during inpatient e. Paliperidone (Invega) hospitalization (1) Mode of action (1) Nurse should set a tone of quiet con- (a) Like risperidone is a serotonin/ fidence in treatment process that dopamine antagonist conveys a sense of caring rather than (b) Blocks D2 and serotonin 2A re- judgment. ceptors, decreasing positive and (2) Delivery of simple and short instruc- negative symptoms tions about the facility, daily schedule (2) Side effects and treatment process are important (a) Orthostatic hypotension to building a relationship that conveys (b) Hyperprolactinemia respect and concern for individual as (c) Sedation well as their illness. (d) Weight gain with increased risk (3) Expected outcome of patient care for for diabetes and dyslipidemia persons experiencing schizophrenia (e) Tachycardia is patient will live, learn, and work at a (f) Dose-dependent EPS maximum possible level of success as (3) Dosage and efficacy defined by individual (Moller & (a) Recommended initial oral dose Murphy, 1995). is 6 mg daily (extended-release (4) Initial treatment efforts are directed at tablet) correcting instability related to major (b) Can increase by 3 mg/day every symptoms experienced and resulting 5 days to a maximum dose of 12 disruption in activities of daily living. mg/day (5) Medication management is joint f. Aripiprazole (Abilify) effort, and must include careful 126 Chapter 6 Schizophrenia and Other Psychotic Disorders

attention to observed behaviors, cli- (2) Note if patient talks or smiles to ent description, and client response to himself/herself. medication therapies. (3) Encourage involvement in real (6) Careful recordkeeping of descriptive conversations and/or structured information and use of Brief Symp- activities. tom Rating Inventory (BSRI) assists in (4) Administer medication as ordered and initial assessment phase of treatment observe response. and determines client outcome profile (5) Assess for content of hallucination; if related to treatment and medication. patient is having command hallucina- (7) Treatment milieu is organized to tions to harm self or others, provide reduce sensory stimulation, while for safety. providing opportunities for simple (6) Utilize judgment when providing for and brief social and professional increased levels of observation as pa- interactions. tient with command hallucinations (8) Schedule should provide time for rest, may not be able to contract for safety. structured activity, and set times to e. Delusions—delusional individual may speak with providers. have delusions of grandeur, paranoia, or (9) Use of soft lighting, uncluttered space, poverty; may think he is a public figure or and sound control can create an envi- may believe he is being followed by CIA. ronment for recovery. (1) Do not argue with client or deny be- b. Nursing intervention during the early lief; does not eliminate delusion nor is acute stage of unstable neurobiologic trust gained by this approach. responses requires constant observation (2) Focus on reality and talk about reality- and monitoring. Nursing interventions oriented issues in order to redirect the should focus on restoration of adaptive client from delusional topics. neurobiologic responses while providing (3) Accept client’s need for belief without for safety and well being (Moller & actually reinforcing the belief. Murphy, 1995). (4) For paranoid client, it is helpful to as- (1) Assess and monitor health status and sign same staff member consistently medications. to build trust. (2) Identify symptoms of relapse and/or (5) Note stressors or any escalation in factors that increase symptoms. anxiety that may precipitate delu- (3) Assist in management of delusions sional thinking; assist individual in and hallucinations. anxiety reduction. (4) Allow for sufficient rest for brain re- (6) If client feels food is poisoned, serve sponses to stabilize. food in sealed containers. (5) Provide a safe, protective, quiet (7) Paranoid thinking may cause elderly environment. to need assistance with nutrition and (6) Reduce pressure to perform. hydration. (7) Allow client to verbalize fears, f. Withdrawn behavior concerns. (1) Assist with food and fluid intake as (8) Use clear, concise, concrete well as hygiene. communication. (2) An accepting attitude and uncondi- (9) Facilitate communication with signifi- tional positive regard may decrease cant others. sense of isolation. (10) Assist with activities of daily living as (3) Gradually introduce patient into needed. activities. (11) Assist with anger, anxiety manage- (4) Give positive reinforcement for ment, and problem solving. participating. (12) Simplify decision making. (5) Allow time for being alone as well as (13) Assess client’s risk to self and others. structure. c. Communication—patient may communi- g. Potential for harm to self cate in symbols; listen actively for theme. (1) Inquire about suicidal thoughts. d. Hallucinations (2) Create safe environment by removing (1) Observe patient attending to internal sharp and other harmful objects. stimuli. (3) Encourage patient to contract for safety; if command hallucinations Inforrmation Common to Schizophrenia and Other Psychotic Disorders 127

are present, contracting may not be as a last resort; may not be used as feasible. punishment. h. Social isolation (h) If seclusion or restraint is neces- (1) Spend time with patient. sary: the need for continuing the (2) Make brief, frequent contacts. restrictive intervention must be (3) Gradually encourage participation in evaluated within 1 hour through activities. face-to-face contact by the at- (4) Encourage structure in the day. tending physician/licensed inde- i. Alteration in nutrition pendent practitioner (LIP), or a (1) Encourage balanced diet with high trained and approved registered fiber. nurse or physician assistant and (2) Monitor intake, output, and caloric the physician/LIP treating that count when needed. patient must be consulted as soon (3) Limit caffeine intake. as possible. (Also see discussion on (4) Provide small, frequent meals. seclusion and restraint in Chapter j. Potential for injury 11, page 259.) (1) Decrease stimulation in environment. (i) Protocol for restraints include: (2) Encourage quiet time in room. i. Position client to prevent (3) Promote safe environment. aspiration. k. Management of violent behavior ii. Glasses, jewelry, shoes, or (1) Violence against self may be in the belts are removed to prevent form of suicide or self-mutilation, injury. particularly if there are command hal- iii. Constant observation is rec- lucinations present. ommended due to possibil- (2) Violence towards others is also ity of laryngeal spasms from possibility. neuroleptic medications. (3) Assess characteristics such as in- iv. Range-of-motion to extremi- creased pacing, clenched fists, tense ties should be performed expression, irritability, agitation, every two hours and pulses, threatening verbalizations. color, and temperature as- (4) Early intervention is important, keep- sessed and documented; ing in mind use of least restrictive at risk for thromboembolic measures. events. (a) Decrease stimulation in the v. Nursing care includes hydra- environment. tion, nutrition, and attention (b) Administer medications per to elimination. protocol/instruction and observe vi. Need for seclusion and/or re- response. straint must be documented. (c) Provide for safe environment by vii. Assessment is ongoing, removing dangerous objects. and patient may gradu- (d) Encourage patient to spend quiet ally be moved from 5-point time in room or in quiet room. restraints to 3-point and (e) When approaching patient, do so 2-point restraints; patient from the side and not in a direct should never be left in only manner. one restraint. (f) When efforts to calm and diffuse viii. Client is released from seclu- are not successful, for safety of sion when behavior is under the patient and others, a show control and he/she is not of force may be necessary and is in danger of hurting self or sometimes sufficient in redirect- others. ing the client and de-escalating a 3. Psychotherapeutic situation. interventions—maintenance (g) If redirection and medication as a. In combination with pharmacologic man- well as decrease in stimulation are agement, a number of psychosocial thera- not effective, and client is at risk peutic methods have been successful in of harming self or others, seclu- promoting independent living, including sion and restraint may be needed (Sadock & Sadock, 2007): 128 Chapter 6 Schizophrenia and Other Psychotic Disorders

(1) Social skills training (behavioral skills 10. Environment for medication compliance is training) used to enhance empathy also important; 70% relapse rate if medications and rapport with others, improve are not taken regularly and 30% relapse rate if verbal/nonverbal communication and medication regimen is followed. conversational skills, increase com- 11. Family members can be taught to recognize fort in recreational and occupational symptoms that may require medication ad- activities justment or hospitalization. (2) Individual therapy (generally some 12. Family can provide responsibilities for client, insight into their illness is important such as simple chores, to introduce a sense of to the success of therapy) such as CBT routine and accomplishment. to address cognitive distortions, re- 13. Family should encourage participation in vo- duce distractibility, and correct errors cational rehabilitation and other therapeutic in judgment activities. 14. Role of the Psychiatric/Mental Health Ad- • Family dynamics/Family therapy vanced Practice Nurse (PMH-CNS & PMHNP) 1. No evidence that schizophrenia or other psy- a. Various roles exist in advanced PMH nurs- chotic disorders are caused by family interac- ing practice related to psychotherapy or tion patterns; therefore, family therapy is not pharmacologic management, and com- used; important that family is involved in care bined pharmacologic management and of individual; family is an integral part of treat- psychotherapy (as allowed by state law/ ment plan and has best knowledge of indi- nurse practice act). vidual’s illness and ability to function. b. Psychotherapeutic actions of the ad- 2. Illness affects entire family system including vanced practice nurse may include: careers, finances, schedules, and social life; (1) Help client and family learn more problems that recur most frequently are: about illness, treatment options, and a. Failure to care for personal needs/hygiene ways to live with disease in a produc- b. Difficulty handling finances tive fashion. c. Withdrawal (2) Plan psychoeducational approaches d. Odd personal habits that maximize times when client e. Suicide threats symptoms are relatively stable. f. Concern for safety of client and family (3) Simplify instruction, reduce distract- 4. Eliminating blame is important if family mem- ing stimuli, provide both visual and bers blame each other; acceptance of illness verbal information, and provide is first step toward management of illness; ex- instruction in small segments with pectations of patient should be realistic. frequent reinforcement (Moller & 5. Anger may have to be addressed. Murphy, 1995). 6. Other questions to consider include: (4) Initiate family education that accen- a. Devotion of time to other family members tuates the family’s belief in their own b. Respite for caregiver expertise, and focuses on symptom c. Home care versus boarding home or half- management and self-care skills for way house client. 7. Family members require education and in- (5) Discuss with client and family, ra- struction; discharged client may require rein- tionale for selection of medication tegration within family and role shifting may regimen, options available, expected occur; nurse should assess family attitudes to- benefits, side effects and time lag in ward client, overall atmosphere in family, and response. available emotional/social supports. (6) Establish a partnership with client, 8. Some aspects of family life have been linked to family members, and other health relapse in schizophrenia; concept of expressed care professionals to develop treat- emotion is implicated; three main compo- ment and rehabilitative goals. nents of expressed emotion are: criticism, (7) Provide case management that may hostility, and over-involvement; for individuals include any/all of the following: with schizophrenia with high expressed emo- (a) Identifying and coordinating tion, there is a higher probability of relapse services (Haber, 1997). (b) Understanding appropriate use 9. Family needs to be educated on the role of of day treatment programs, club- stress in the exacerbation of symptoms. house programs, and companion Questions 129

programs etc., so they may be 8. Transportation services are key resources to used as part of comprehensive promote access. treatment program 9. Psychiatric home care: (c) Making appointments and ac- a. Allows for careful identification and moni- companying client if needed toring of target symptoms and relapse (d) Assisting during crises prevention. b. Promotes involvement of client in self- • Group approaches and self-help assessment. 1. Traditional group therapy, insight-oriented c. Focuses on attainment of specific goals groups or groups that are primarily interac- related to rehabilitation and maximization tional in nature are generally not helpful, as of functional ability. the individual has difficulty filtering stimuli. d. Nurse in psychiatric home care is essen- 2. Self-help groups may be more beneficial— tially a “guest” in client’s home, which is focus on educational issues, support, and de- an empowering position for the client and stigmatization of mental illness. family and supports process of continuing 3. Social skills training can occur in groups and outpatient care for persistent but treatable would include introducing oneself, starting a mental illness. conversation, and listening skills; staff act as e. Nurse in psychiatric home care uses a role models for implementation of these skills. rehabilitative model that supports client self-care and develops appropriate goals • Milieu interventions for successful, feasible outcomes that are 1. Regular daily activities can provide a sense of compatible with the limitations of illness predictability as well as sense of accomplish- and abilities of client. ment and reward. 2. Treatment environment should emphasize Questions involvement, organization and standards of safety; there should be established norms and Select the best answer rules. 3. Client may feel safer if periods of time are 1. Mr. Jones is a patient diagnosed with schizo- scheduled to be spent in his/her room. phrenia who is hospitalized on a psychiatric unit. 4. If client feels threatened by milieu activities, You notice him standing motionless on one leg encourage involvement with only one other in the day area. This would most likely be an client. example of: a. Attention-seeking behavior • Community resources b. Catatonic posturing 1. The National Alliance for the Mentally Ill c. A side effect of neuroleptic medication (NAMI) and Friends and Family of the Men- d. Catatonic stupor tally Ill provide advocacy, support groups, and educational programs. 2. During the initial assessment, the nurse inquires 2. Local chapters of Companion Peer (COM- of Mr. Jones, “What brought you to the hos- PEER) develop community connections by pital?” Mr. Jones replies, “An ambulance.” This is providing companion matching services. an example of: 3. Local community services boards plan, imple- a. Deductive reasoning ment, and evaluate a variety of programs b. Abstract thinking including outpatient, day treatment, case c. Concrete thinking management, crisis services, club houses, em- d. Poverty of content of speech ployment, and job coaching. 4. Local community mental health center is also 3. Mr. Jones is informed during his hospital stay valuable resource; patient is followed on an that his brother has been diagnosed with cancer outpatient basis through mental health center and will be undergoing surgery. Mr. Jones laughs and receives medication through this setting. upon hearing the news. Your understanding of 5. Day treatment programs this is: 6. Possibilities for residential placement include a. Mr. Jones is obviously not close to his halfway houses or boarding homes depending brother. on patient’s abilities and skills. b. Mr. Jones possibly has a mood disorder. 7. Supplementary security income can provide c. Mr. Jones is obviously anxious and upset by small, fixed income and may pay residential this news. costs in boarding home. 130 Chapter 6 Schizophrenia and Other Psychotic Disorders

d. Mr. Jones is displaying incongruence 8. You notice during the assessment period that Mr. between content of communication and his Brown is rocking back and forth on his feet and emotions. appears to be restless. This could be an indication of: 4. Mr. Jones comments that he hears voices of men telling him “bad things about myself. They say a. Extreme anxiety I should hurt myself.” Your most appropriate b. Neuroleptic malignant syndrome initial response would be to: c. Catatonic rigidity d. Acute dystonia a. Reassure Mr. Jones of his safety and security by telling him the voices aren’t real 9. Ms. Smith was recently admitted to an inpatient b. Provide for Mr. Jones’ comfort and security psychiatric facility. During the assessment she by reminding him that he has never hurt seems to be mimicking your body movements. himself in the past This is an example of: c. Assess the command hallucinations for a. Echopraxia potential destructiveness by asking specifi- b. Echolalia cally for the content c. Mirroring the therapist d. Tell him to ignore the voices and administer d. Akathisia prn medications 10. Several hours after being admitted, Ms. Smith 5. When John, a 25-year-old graduate student diag- complained of feeling bugs crawling on her skin. nosed with Paranoid Schizophrenia, is ready for This could be indicative of: discharge, which of the following is important for the client and his family? a. Alcohol withdrawal b. A hallucination common among patients a. To understand all of the causal explanations with schizophrenia of the illness so they can be discussed at c. A side effect of neuroleptic medications home d. A seizure disorder b. To set up a plan to improve the outlook of the client that includes daily rules for accept- 11. Ms. Smith displays paranoid behavior on the able behaviors unit and becomes particularly suspicious. She c. To understand the treatment plan, including comments that she suspects the food is being prescribed medication, expectations con- poisoned. A possible intervention would be to: cerning effects and plans for continuity of a. Serve the food in sealed containers care, and professional resources b. Serve small, frequent meals d. To understand that all activity is to be c. Have Ms. Smith eat away from the other avoided, so that John will not get upset patients 6. The patient remarks repeatedly that he believes d. Have Ms. Smith prepare her own meals he is Jesus Christ and has come to save the world. 12. Mr. Brown has been treated for the past This can best be described as: several years with Prolixin. You notice that he a. Defense of identification is drooling, has a tremor, and there is slight b. A delusion of grandeur pill-rolling of the fingers. These are the extrapy- c. An illusion ramidal symptoms known as: d. An idea of reference a. Anticholinergic side effects 7. Mr. Brown continues to remark that the CIA is b. Pseudoparkinsonism following him and that they are waiting outside c. Tardive dyskinesia the door to the emergency room. Your best d. Dystonic reaction response would be: 13. Several days into the hospitalization, Mr. a. “Mr. Brown, the CIA is not following you.” Brown complains of urinary retention, an anti- b. “We’ve told the CIA to leave you alone.” cholinergic side effect. Which of the following c. “I understand you feel that they are outside, medications would be best to ease the urinary but the CIA is not there and you’re safe retention? here.” a. Cogentin d. “Why do you think the CIA is out there?” b. Artane c. Lasix d. Bethanecol Questions 131

14. Mr. Brown has been on cogentin along with d. The onset may be sudden and can occur after haloperidol. You notice that in addition to the the first dose of the medication. urinary retention, his face is flushed, and he has 19. Mr. Jones has not been eating and has difficulty become disoriented. This is an example of: bringing food to his mouth. The most appro- a. An exacerbation of the psychosis priate intervention would be to: b. Anticholinergic delirium a. Place the spoon in the patient’s hand, scoop c. Early-onset dementia food into it and say, “Eat a bite of this apple d. Brief reactive psychosis sauce.” 15. Mr. Johnson is being treated with haloperidol. b. Place the patient on a liquid supplement as He develops a fever of 102ºF, muscular rigidity, this may be more easily tolerated altered mental status, and diaphoresis. It is c. Spoon feed the patient determined that he is suffering from neuroleptic d. Allow patient to eat in his room as he will malignant syndrome. Which laboratory findings be more comfortable away from the other are most likely to occur? patients a. An elevated haloperidol level 20. Which best describes the action of antipsychotic b. A decrease in the CPK level and an elevated medications? white blood cell count a. They block dopamine receptors. c. An increase in the CPK level and an elevated b. They decrease available amounts of sero- white cell count tonin and norepinephrine. d. A decrease in the white cell count c. They enhance the availability of dopamine. 16. Possible complications from neuroleptic malig- d. They block reuptake of dopamine to increase nant syndrome include the following: availability at receptor sites. a. Muscle rigidity, hyperthermia, autonomic 21. As a nurse employed at the community mental instability health center, you are a case manager for several b. Liver failure patients taking clozapine. Compared with con- c. Increased intracranial pressure ventional antipsychotics, the advantages of d. Agranulocytosis taking clozapine include: 17. Nursing care for the patient with neuroleptic a. Follow-up is less frequent since tardive dyski- malignant syndrome will include: nesia does not occur. b. It is less likely to cause orthostasis. a. The discontinuation of the neuroleptic, c. Restlessness and tremors are less likely to maintenance of skin integrity and hydration, occur. and administration of bromocriptine d. It is more potent than phenothiazines. b. The gradual tapering of the neuroleptic, the administration of cogentin, and maintenance 22. Medication teaching about clozapine should of skin integrity and hydration include which of the following: c. The gradual tapering of the neuroleptic, a. Cautioning the patient to report any signs of administration of bromocriptine, and main- infection including sore throat, flu-like symp- tenance of skin integrity and hydration toms and fever d. The discontinuation of the neuroleptic, b. The importance of being compliant with maintenance of skin integrity and hydration, having a complete blood count drawn at and the administration of cogentin least monthly 18. Which of the following statements best describes c. Notifying the physician immediately about characteristics about the onset and development lip-smacking or vermiform movements of the of neuroleptic malignant syndrome? tongue d. Notifying the physician immediately at the a. It is noted most commonly in female patients onset of diarrhea and hand tremors taking haloperidol, so they are most at risk. b. The initial onset is insidious and is therefore 23. You are caring for a patient who suffers from difficult to detect. epilepsy and has been diagnosed recently as c. It develops only after months to years of having schizophrenia. Teaching should include treatment with neuroleptic medications. which of the following: 132 Chapter 6 Schizophrenia and Other Psychotic Disorders

a. Antipsychotic medications should be used a. “I’ll notify the physician right away as your cautiously as they increase seizure threshold. dose is probably too high.” b. Antipsychotic medications should be used b. “Those are possible side effects to the medi- cautiously as they decrease seizure threshold. cation and tolerance usually develops in c. Antipsychotic medications do not affect several weeks. We can order a bulk diet for seizure threshold. you.” d. Antipsychotic medications are c. “I’ll notify the physician right away and see contraindicated. if we can try a different medication.” d. Administer an anticholinergic medication. 24. The following is indicative of a dystonic reaction: 29. A common hypothesis regarding the biologic a. Oculogyric crisis and spasms of the back origin of schizophrenia is: muscles b. Cogwheel rigidity and lip-smacking a. Dopamine hypothesis, which postulates movements that some cases may be due to excess of c. Shuffling gait and mask-like faces dopamine in the brain and/or an excessive d. Urinary retention and leg stiffness number of dopamine receptors b. Disease is caused by enlarged lateral ven- 25. Nursing actions during a dystonic reaction may tricles in the brain. include: c. Norepinephrine hypothesis, which states that a. Turning patient on side schizophrenia is due to an excess of this neu- b. Notifying physician, administration of rotransmitter, which causes hallucinations cogentin, and making certain respiratory d. All cases of schizophrenia are caused by support equipment is available viruses contracted in utero. c. Administration of IM physostigmine and 30. The most current Family Theory states: bethanecol d. Decreasing stimulation in environment as a. Research has indicated schizophrenia is dystonia and agitation may appear similar a direct result of dysfunctional family interaction. 26. Which of the following statements about tardive b. The individual with schizophrenia withdraws dyskinesia is most accurate? and hallucinates as a defense against a a. Symptoms are generally reversible, particu- hostile family environment. larly in younger patient population. c. There is no proof that schizophrenia is b. Symptoms may appear 1–10 days following caused by family interaction patterns. administration of neuroleptic medication. d. An individual with schizophrenia is most c. Occurs most often in dehydrated patients. likely to be product of a cold, aloof mother d. All patients on long-term neuroleptic and absent, distant father. therapy are at risk. 31. According to genetic studies of schizophrenia: 27. Your patient on a conventional neuroleptic a. Genetic factors are not important to one’s medication complains of dizziness. Your initial risk of developing schizophrenia. intervention would be: b. A twin of a monozygotic (identical) twin a. Taking the patient’s blood pressure sitting with schizophrenia has a greater chance and standing of having schizophrenia than the general b. Forcing fluids population. c. Prompt discontinuation of the medication c. A twin of a monozygotic (identical) twin and notifying the physician with schizophrenia has a lesser chance of d. Instructing patient to place their head having schizophrenia than the general between knees population. d. Genetic inheritance is most likely the only 28. You are working with Mr. Green who has cause of schizophrenia since family interac- recently been prescribed Thorazine (chlorpro- tional patterns cannot be empirically studied. mazine). He comes to the nurses’ stations and complains of blurred vision and constipation. 32. Mr. Jones reports that he is hearing voices telling Your most appropriate response would be: him to cut his wrists and he is highly agitated Questions 133

with complaints of fear and anxiety. The most if he misses more than two doses of medication appropriate intervention would be to: because: a. Administer medication, as per protocol, and a. He will need to begin the titration process encourage Mr. Jones to contract for safety from the beginning. and to notify nursing staff should voices b. Noncompliance for several days and rein- increase statement at the previous dose could result b. Administer medication, as per protocol, and in syncopal episode, orthostatic hypotension encourage Mr. Jones to spend time in his or seizure. room, after checking for sharp objects and c. His doctor will discontinue the medication. ensuring the environment is safe d. He is at risk for immediate acute exacerba- c. Administer medication, as per protocol, tion of psychosis. remove dangerous objects from patient’s 36. The advanced practice PMH nurse assesses the environment, and place him on constant relationship between David and his family, and observation together they work out a plan for David to d. Administer medication, as per protocol, attend a social club house program 3 afternoons and place him in closed door seclusion with a week, and a referral to COMPEER. His family safety checks every 15 minutes is told about the meeting times for the local 33. Ms. Williams, who was admitted to the unit yes- chapter of the Alliance for the Mentally Ill. The terday, is withdrawn and keeps to herself on the purpose of the Alliance for the Mentally Ill is to: unit. An appropriate intervention would be: a. Provide a companion matching service to a. Encouraging Ms. Williams to attend all activi- develop community connections for those ties as prescribed in order to integrate into with mental illness the milieu and feel a part of the group b. Provide advocacy and support programs for b. Encouraging Ms. Williams to spend all day clients and their families and early evening on the unit and locking c. Provide housing and supervision on a con- the door to her room tinuum from professional caregivers to c. Encouraging Ms. Williams to attend activities managed properties gradually with a supportive staff member d. Provide transportation 24 hours a day d. Electing Ms. Williams as the patient repre- 37. Mr. Parker has been diagnosed with Paranoid sentative to increase her sense of confidence Schizophrenia and has stated that he believes 34. Ms. Williams has difficulty trusting the staff that other patients are out to get him. Mr. Parker members on the unit. Which of the following has escalated to the point where he is threat- interventions is most likely to promote trust? ening others, and he is having difficulty staying in his room. The decision is made to assist Mr. a. Using therapeutic touch in order to convey Parker by having him spend some time in the caring and concern for Ms. Williams quiet room. Which of the following interventions b. Encouraging patient to engage in a one-to- will most likely promote safety? one session for an hour on both morning and evening shifts to convey acceptance of a. Approach Mr. Parker with several other staff her members in a quiet manner and escort him c. Assigning the same staff to work with Ms. to the quiet room. Williams as often as possible b. Approach Mr. Parker alone as he may feel d. Encouraging Ms. Williams to play a game of more threatened with more than one staff cards with the other patients member. c. Place Mr. Parker in 4-point restraints and 35. David has responded well to clozapine with a check on him every 15 minutes. maintenance dose of 400 mg per day. The psy- d. Force-medicate him according to hospital chiatric home health nurse draws blood for a policy. weekly WBC and distributes a week’s supply of medication if the WBC > 3,000. She explains the 38. Mr. Parker begins banging his head against the importance of compliance to the daily dose as wall. It becomes necessary to place Mr. Parker prescribed and instructs David to call his doctor in mechanical restraints in order that he not hurt himself. Nursing care should include the following: 134 Chapter 6 Schizophrenia and Other Psychotic Disorders

a. Checking on Mr. Parker at least once an hour c. Flat affect b. Performing range-of-motion exercises every d. Both a and b are correct 2 hours and assessing circulation to the 43. Which of the following is most effective in extremities treating both positive and negative symptoms of c. Removing all restraints if Mr. Parker becomes schizophrenia? less agitated within 10 minutes d. Gradually removing restraints until Mr. a. Risperidone Parker has only one restraint remaining b. Ziprasidone c. Haloperidol 39. The individual with schizophrenia may benefit d. Both a and b are correct from a group-oriented approach. Which of the following groups would be most appropriate? Answers a. A didactic as well as supportive group that provides social skills training 1. b 23. b b. Insight-oriented 2. c 24. a c. Cognitive-behavioral in order to assist with 3. d 25. b difficulties with self-care 4. c 26. d d. Any of the above, depending on the indi- 5. c 27. a vidual patient 6. b 28. b 40. Mr. Williams who has been hospitalized for over 7. c 29. a a month due to exacerbation of schizophrenia 8. a 30. c will soon be discharged to his home where 9. a 31. b he will live with his parents and one younger 10. a 32. c brother. Which of the following recommenda- 11. a 33. c tions will be most helpful to the family? 12. b 34. c a. Provide Mr. Williams with a structured 13. d 35. b routine, including chores and other 14. b 36. b responsibilities. 15. c 37. a b. Do not encourage spending time alone as 16. a 38. b this will increase a sense of isolation from 17. a 39. a the family. 18. d 40. a c. Encourage Mr. Williams to take complete responsibility for medications and follow-up 19. a 41. b appointments. 20. a 42. c d. Set goals for Mr. Williams as he may have dif- 21. c 43. d ficulty doing this for himself. 22. a 41. After a short period on a typical antipsychotic, a client complains that she can’t sit still and taps Bibliography her foot continuously. The nurse should: American Nurses Association, American Psychiatric a. Administer a prn dose of medication because Nurses Association, & International Society of Psy- she is still agitated chiatric-Mental Health Nurses. (2007). Psychiatric- b. Understand that these symptoms are akath- mental health nursing: Scope and standards of prac- isia, and consider use of diphenhydramine tice. Silver Springs, MD: Author. and/or reduce the dosage of medication American Psychiatric Association. (2000). Diagnostic c. Help client relax in bed and obtain an order and statistical manual of mental disorders (4th ed., for an antianxiety medication text revision). Washington, DC: Author. d. Provide for vigorous activities until she Bendik, M. (1996). The schizophrenias. In K. Fortinash settles down & P. Holoday-Worret (Eds.), Psychiatric mental health nursing (pp. 285–316). St. Louis, MO: Mosby. 42. Which of the following symptoms is considered a Burgess, A. W. (Ed.). (1997). Psychiatric nursing: Promot- “negative symptom” of schizophrenia? ing mental health. Stamford, CT: Appleton & Lange. a. Auditory hallucinations Cannon, J., & Marco, E. (1994). Structural brain abnor- b. Delusions malities as indicators of vulnerability to schizophrenia. Schizophrenia Bulletin, 20(1), 89–102. Bibliography 135

Chesla, C. (1992). Applying the nursing process for cli- NANDA International. (2009). Nursing diagnoses: Defi- ents with schizophrenia and other psychotic disor- nitions & classifications, 2009-2011. West Sussex, UK: ders. In H. S. Wilson & C. R. Kneisl (Eds.), Psychiatric Wiley & Sons. nursing (pp. 258–284). Redwood City, CA: Addison- National Institute of Mental Health. (2006). Schizophre- Wesley Nursing. nia. (NIH publication No. 06-3517). Bethesda, MD: Dutra, L, Stathopoulou, G., Basden, S. L., Leyro, T. M., Author. Powers, M. B., & Otto, M. W. (2008). A meta-analytic Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sa- review of psychosocial interventions for substance dock’s synopsis of psychiatry (10th ed.). Philadelphia, use disorders. American Journal of Psychiatry, 165(2), PA: Lippincott. 179–187. Sherr, J. (1996). Psychopharmacology and other bio- Farnsworth, B., & Biglow, A. (1997). Psychiatric case logic therapies. In K. P. Fortinash & Holoday-Worret management. In J. Haber, B. Krainovich-Miller, A. (Eds.), Psychiatric mental health nursing (pp. 532– McMahon, & P. Price-Hoskins (Eds.), Comprehensive 563). St. Louis, MO: Mosby. psychiatric nursing (5th ed., pp. 318–331) St. Louis, Stahl, S. M. (2009). Stahl’s essential psychopharmacol- MO: Mosby. ogy: The prescriber’s guide (3rd ed.). New York, NY: Fortinash, K., & Holoday-Worret, P. (Eds.). (1996). Psy- Cambridge University Press. chiatric mental health nursing. St. Louis, MO: Mosby. Stahl, S. M. (2008). Stahl’s essential psychopharmacol- Fox, J. C., & Kane, C. F. (1996). Information process- ogy: Neuroscientific basis & practical applications (3rd ing deficits in schizophrenia. In A. B. McBride & J. K. ed.). New York, NY: Cambridge University Press. Austin (Eds.), Psychiatric mental nursing: Integrat- Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008a). ing behavioral and biological sciences (pp. 321–347). Schizophrenia, “just the facts” what we know in 2008. Philadelphia, PA: W. B. Saunders. 1. Overview. Schizophrenia Research, 100, 4–19. Haber, J. (1997). Psychiatric homecare. In J. Haber, B. Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008b). Krainovich-Miller, A. McMahon & P. Price-Hoskins Schizophrenia, “just the facts” what we know in 2008. (Eds.), Comprehensive psychiatric nursing (5th ed., 2. Epidemiology & etiology. Schizophrenia Research, pp. 366–381). St. Louis, MO: Mosby. 102, 1–18. Harris, B., & McHahon, A. (1997). Psychobiology. In J. Tandon, R., Nasrallah, H. A., & Keshavan, M. S. (2009). Haber, B. Krainovich-Miller, A. McManon, & P. Price- Schizophrenia, “just the facts” 4. Clinical features Hoskins (Eds.), Comprehensive psychiatric nursing & conceptualization. Schizophrenia Research, 110, (5th ed., pp. 219–238). St. Louis, MO: Mosby. 1–23. Johnson, B. (1993). Thought disorder: The schizo- Torrey, E. F., Bowler, A., Taylor, E., & Gottesman, I. phrenic disorders. In B. Johnson (Ed.), Adaptation (1994). Schizophrenia and manic-depressive disorder: and growth: Psychiatric mental health nursing (3rd The biological roots of mental illness as revealed by ed., pp. 463–494). Philadelphia, PA: J. B. Lippincott the landmark study of identical twins. New York, NY: Co. Basic Books. Kanter, J. (1989). Clinical case management: Definition, Townsend, M. C. (2005). Essentials of psychiatric mental principles, components. Hospital and Community health nursing (3rd ed.). Philadelphia, PA: F. A. Davis. Psychiatry, 40, 361–367. Townsend, M. C. (1993). Nursing diagnosis in psychiat- Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). ric nursing: A pocket guide for care plan construction. Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Philadelphia, PA: F. A. Davis. Keshavan, M. S., Tandon, R., Boutros, N. N., & Nasral- Vallone, D. (1997). Schizophrenia. In A. W. Burgess (Ed), lah, H. A. (2008). Schizophrenia, “just the facts”: What Psychiatric nursing: Promoting mental health (pp. we know in 2008. Part 3: Neurobiology. Schizophrenia 503–517). Stamford, CT: Appleton & Lange. Research, 106, 89–107. Videbeck, S. L. (2006). Psychiatric mental health nurs- Laraia, M., & Stuart, G. (1995). Quick Psychopharmacol- ing (3rd ed.). Philadelphia, PA: Lippincott, Williams & ogy Reference (2nd ed.). St. Louis, MO: Mosby. Watkins. Littrel, K. (1994). Clozaril: Guide to clozaril therapy. East Walker, M. (1997). Schizophrenia and other psychotic Hanover, NJ: Sandoz Pharmaceuticals Corp. disorders. In J. Haber, B. Krainovich-Miller, A. Mc- Moller, M., & Murphy, M. (1995). Neurobiological re- Mahon, P. Price-Hoskins (Eds.), Comprehensive psy- sponses and schizophrenia and psychotic disorders. chiatric nursing (5th ed., pp. 567–604). St. Louis, MO: In G. W. Stuart & S. J. Sundeen (Eds.), Principles & Mosby. practice of psychiatric nursing. (5th ed., pp. 475–507 St. Louis, MO: Mosby.

7 Mood Disorders

Mood Disorders—Overview with daily functioning and include the presence of delusions or hallucinations • Definition (American Psychiatric Association (1) Mood-congruent—delusions/ [APA], 2000; Sadock & Sadock, 2007)—Mood dis- hallucinations consistent with mood orders are characterized by mood disturbances on themes such as guilt, deserved pun- a continuum from depression to mania (See Table ishment for depression or power, 7-1). Mood is an internally experienced feeling knowledge for manic themes tone, distinguished from affect, which is an exter- (2) Mood-incongruent—delusions/ nal expression of the internal feeling tone. hallucinations inconsistent with 1. Generally involves single or recurring de- mood themes such as guilt, depressive (unipolar) and/or manic (bipolar) served punishment for depression or episodes power, knowledge for manic themes 2. Also occurs as part of other nonmood condi- (e.g., thought insertion, thought tions (anxiety, cognitive, eating, psychotic, or broadcasting) substance-related disorders) 3. Occurs as a consequence of nonpsychiatric • Prevalence (U.S.) (Kessler, Chiu, Demler, & Walters, medical conditions (cerebrovascular accident 2005; Sadock & Sadock, 2007) (CVA), diabetes, cancer, acquired immunode- 1. Mood disorders are among the most prevalent ficiency syndrome (AIDS), chronic fatigue syn- mental disorders diagnosed in the general drome (CFS), fibromyalgia, multiple sclerosis population (17% lifetime prevalence rate); 50% (MS)) or as a consequence of some medica- of suicides are associated with depression. tions or their combined use. 2. Major depressive episode prevalance is 12% 4. Levels of severity include: lifetime, 6.7% one year. a. Mild—limited symptomatology beyond 3. Bipolar illness prevalence is , 1% lifetime, those needed for diagnosis 2.6% one year. b. Moderate—intermediate severity between 4. Dysthymia prevalence is 5% lifetime, 1.5% one mild and severe year. c. Severe without psychotic features—most of the diagnostic criteria have been met, • Sex distribution and these symptoms significantly interfere 1. Unipolar Disorder—females to males 2:1 with daily functioning 2. Bipolar Disorder—equal male-female distribu- d. Severe with psychotic features—most of tion; women have higher rate of depressive the diagnostic criteria have been met, and episodes and rapid cycling (4 or more manic these symptoms significantly interfere episodes in 12-month period)

137 138 Chapter 7 Mood Disorders

Table 7-1 Features of Mood Disorders

Predominant Mood Evidence Evidence Evidence Comments/Special Features Mood Disorder Type of MDE of HE of ME Features Depressed Major Depressive X Use severity specifiers Dysthymic Depressed mood for 2 or more years Adjustment Mild depressive Disorder with symptoms associated Depressed Mood with known stressor Double Depression X MDE with dysthymia— not a current diagnosis in DSM-IV-TR Depressive Pervasive pattern of Personality Disorder depressed behavior and thoughts, tends to be pessimistic—Not a current diagnosis in DSM-IV-TR Depressed and Bipolar I X X Use severity specifiers elevated, expansive Bipolar II X X Note hypomanic rather or irritable than manic features Cyclothymic X Two or more years of hypomanic symptoms and periods of depressed mood Mood symptoms Schizoaffective X X Prominent features subside while Disorder, bipolar of delusions or psychotic symptoms type hallucinations in absence continue of mood symptoms Schizoaffective X Disorder, depressed type Variable/ Due to General Possible Possible Possible Mood symptoms are the Nonspecific Medical Condition direct result of a medical condition Substance Induced Possible Possible Possible Mood symptoms are Mood Disorder the direct result of a substance (medication, toxin, or substance of abuse) Not otherwise Criteria for other specified mood disorders are not completely met

HE 5 Hypomanic Episode; MDD 5 Major Depressive Disorder; MDE 5 Major Depressive Episode; ME 5 Manic Episode (APA, 2000; Sadock & Sadock, 2007) Depressive Disorders 139

• Age distribution 5. Feelings of worthlessness or excessive or inap- 1. Onset of Bipolar Disorder is earlier (childhood propriate guilt to age 50) than for major depressive episode. 6. Diminished ability to think or concentrate or 2. Mean age of onset is 30 years for Bipolar indecisiveness Disorder. 7. Recurrent thoughts of death (not just fear of 3. Mean age of onset is 40 years for Depressive death); recurrent thoughts of suicide without Disorder (evidence suggests a younger onset a plan, a suicide attempt, or a specific suicide age among those involved in substance use). plan

• Other etiologic factors • Differential diagnosis 1. Both Depressive Disorder and Bipolar Disorder 1. Substance-related disorder (e.g., withdrawal occur less frequently among those involved in from alcohol, cocaine) close interpersonal relationships. 2. Physical health problems or disease that 2. Higher incidence of Bipolar Disorder exists may cause or be associated with depressive among noncollege graduates of higher socio- symptoms economic status (no relationship for Depres- 3. Nonmood psychiatric disorders sive Disorder). 4. Prior episodes of unipolar depression or Bipo- 3. Depressive Disorder is more common in rural lar Disorder and/or suicide attempts vs urban areas. 5. Nodal events/stressful life events (postpartum, death of a spouse, job loss, geographic move, Depressive Disorders illness) 6. Bereavement (symptoms persist longer than Major Depression (unipolar, 2 months after loss of a loved one or include endogenous/depression in absence of psychotic symptoms) external stress) 7. Mixed state episode (unipolar plus bipolar symptoms) • Definition—Depressed mood or loss of interest or pleasure in all or almost all activities (anhedonia) • Additional Features of Depressive Disorder that and associated symptoms for a period of at least 2 may be specified (APA, 2000) weeks, persisting and representing a change from 1. With melancholic features—a severe form previous functioning; can be mild, moderate or of major depressive episode occurring more severe, with or without psychotic features; occurs commonly in older persons; believed to be in the absence of manic features. particularly responsive to somatic therapy; applied to the current episode only if it is the • Signs and symptoms—in addition to the presence most recent episode of a persistent depressed mood or anhedonia, the 2. With seasonal pattern (Seasonal Affective DSM-IV-TR criteria for a major depressive episode Disorder)—regular temporal relationship include the presence of at least four of the follow- between the onset of an episode of Major De- ing (APA, 2000): pression or Bipolar Disorder, recurrent during 1. Significant weight loss or gain when not diet- a particular period of the year; in the absence ing (.5% of body weight in a month) of obvious seasonal stressor such as regular 2. Insomnia or hypersomnia winter unemployment; full remissions or a a. Initial insomnia/difficulty falling asleep change from depression to hypomania or ma- (DFA) nia also occur at a characteristic time of the b. Middle insomnia (waking up during sleep year and difficulty falling back to sleep) 3. With atypical features—characterized by the c. Terminal insomnia/early morning awak- following features: ening (EMA) a. Mood brightening during positive events 3. Psychomotor retardation or agitation (observ- (mood reactivity) able by others) b. Increased appetite (and possible weight a. Slowed speech/pressured speech/mute- gain) ness/poverty of thought c. Increased sleep (hypersomnia) b. Slowed body movements/pacing, hand- d. Feeling weighed down (leaden paralysis) writing, inability to sit still, rubbing of hair, e. Persistent pattern of interpersonal rejec- skin, clothing tion sensitivity 4. Fatigue or loss of energy 4. With postpartum onset—depressive episode, ranging from moderate to severe, following 140 Chapter 7 Mood Disorders

childbirth with or without psychotic features (3) Flight of ideas/thoughts racing/loose- and/or manic episodes; onset of episode ness of associations within 4 weeks postpartum (4) Distractibility (5) Increase in goal-directed activity rang- Dysthymic Disorder ing to frantic, disorganized activity (6) Excessive involvement in pleasurable • Definition—Chronic depressed mood for most of activities with harmful consequences the day, for more days than not, as indicated by (i.e., spending sprees, promiscu- subjective account or observations made by oth- ity, reckless business decisions and ers, for at least 2 years and that causes clinically investments) significant distress or impairment in school, oc- (7) Decreased need for sleep cupation, or other important areas of functioning; c. Differential diagnosis frequently occurs in the presence of a coexisting (1) Mixed-state episode personality disturbance. (2) Schizoaffective Disorder (3) Substance abuse • Signs and symptoms—in addition to a chronic de- (4) Response to somatic antidepressant pressed mood, the presence of at least two of the treatment (e.g., ECT, light therapy, an- following are described in the DSM-IV-TR (APA, tidepressant medication) 2000): 2. Hypomanic episode 1. Low self-esteem a. A distinct period of sustained, elevated, 2. Feelings of hopelessness expansive, or irritable mood, lasting 3. Poor concentration or difficulty making throughout 4 days, that is clearly different decisions from the nondepressed mood 4. Low energy or fatigue b. At least three of the following symptoms 5. Insomnia or hypersomnia have been present to a significant degree: 6. Poor appetite or overeating (1) Inflated self-esteem or grandiosity (2) Decreased need for sleep • Differential diagnosis (3) More talkative or pressure to keep 1. Major depressive disorder talking 2. Depressive symptoms due to a medical condi- (4) Flight of ideas/thoughts racing tion or substance-related disorder (5) Distractibility (6) Increase in goal-directed activity Bipolar Disorders (7) Excessive involvement in pleasurable activities • Definition—a disorder of mood in which there is at c. Associated with: least one or more manic or hypomanic episodes, (1) Unequivocal change in functioning usually with a history of one or more major depres- (2) Disturbance in mood and change in sive episodes (APA, 2000) functioning are observable by others (3) Episode not severe enough to cause Bipolar I Disorder (BPD I) (APA, 2000, marked impairment in social or occu- Sadock & Sadock, 2007) pational functioning, or to necessitate hospitalization • Definition—frank manic or hypomanic episodes (4) No psychotic features with or without major depressive episodes that oc- d. Differential diagnosis—medication, sub- cur in an alternating pattern separated by hours, stance abuse or general medical condition weeks, months, or years, interspersed with periods (e.g., hyperthyroidism) of euthymia (normal mood) 3. Depressive episode 1. Manic episode a. Definition—previously has had at least a. A distinct period during which the pre- one manic episode, but currently in a ma- dominant mood is elevated, expansive, or jor depressive episode irritable, causing marked impairment in b. Signs and symptoms—see Major occupational functioning, social activities, Depression and relationships for at least one week b. Presence of at least three of the following Bipolar II Disorder (BP II) (APA, 2000, during the same period of time: Sadock & Sadock, 2007) (1) Inflated self-esteem or grandiosity (2) Loquaciousness/pressure of speech • Definition—one or more major depressive episodes with at least one episode of hypomania that Suicide 141

cause clinically significant distress or impairment distress or impairment in social, occupational, or in social occupational or other important areas of other important areas of functioning functioning • Signs and symptoms • Differential diagnosis 1. Depressed mood or anhedonia 1. Has never had a mixed episode 2. Elevated, expansive or irritable mood 2. Has never had a manic episode 3. Evidence from history, physical exam, or labo- 3. Mood symptoms not accounted for by Schizo- ratory findings that the mood disturbance is affective Disorder; not superimposed on the direct physiological consequence of a gen- Schizophrenia, Schizophreniform Disorder, eral medical condition Delusional Disorder, or Psychotic Disorder Not Otherwise Specified • Differential diagnosis 4. Not precipitated by somatic antidepressant 1. Not better accounted for by another mental/ treatment psychiatric disorder 2. Does not occur exclusively during the course Cyclothymic Disorder (APA, 2000, of delirium Sadock & Sadock, 2007) Substance-Induced Mood • Definition—a chronic mood disturbance of at least Disorder (APA, 2000, Sadock & Sadock, 2-years duration involving numerous hypomanic 2007) episodes and periods of depressed mood or loss of interest or pleasure • Definition—permanent and persistent disturbance in mood that is judged to be due to the direct • Differential diagnosis physiological effects of substance; e.g., drug abuse, 1. Not without hypomanic or depressive symp- medications, somatic treatments for depression, toms for more than 2 months during a 2-year toxin exposure that arises only in association with period intoxication or withdrawal states causing clinically 2. Has not met criteria for a major depressive, significant distress or impairment to social, occu- mixed or manic episode pational, or other important areas of functioning

• Signs and symptoms • Signs and symptoms 1. For symptoms of depression, see Depressive 1. Prominent and persistent mood disturbance Disorders that predominates the majority of time; char- 2. For symptoms relating to hypomania, see Bi- acterized by either depressed mood or anhe- polar Disorders donia, and/or elevated, expansive or irritable mood • Therapeutic interventions (Sadock & Sadock, 2007) 2. Evidence from history, physical exam, and/ 1. Biologic therapy is fundamentally the same or laboratory results that either occurrence as for bipolar disorders. Studies support the within a month of intoxication or withdrawal use of antimanic agents such as valproate of medications is etiologically related to the (Depakene) and carbamazepine; there is lim- disturbance ited data available for the use of lithium with cyclothymia • Differential diagnosis 2. Psychotherapy is best used to address edu- 1. Mood disorder that is not substance induced cational and coping needs of patients with 2. Does not occur exclusively during a delirium cyclothymia Suicide (Sadock & Sadock, 2007) Mood Disorder Due to ... (Indicate General Medical • Definition—a self-directed act to end one’s life that Condition) (APA, 2000, Sadock & Sadock, may be associated with: 2007) 1. Major Depression 2. Bipolar Disorder • Definition—prominent and persistent disturbance 3. Schizophrenia (command hallucinations) in mood judged to be due to direct physiological 4. Alcohol and drug use or withdrawal effects of a general medical condition; e.g., stroke, 5. Impulse control disorders endocrine or autoimmune conditions, viral or other infections, which causes clinically significant 142 Chapter 7 Mood Disorders

• Involves: 2. Recent genetics studies have focused on iden- 1. Behavior changes tifying specific susceptibility genes for mood 2. Anxiety disorders. Linkage studies suggest the involve- 3. Insomnia ment of several specific genes (from http:// 4. Anorexia www.ncbi.nlm.nih.gov/sites/entrez?db=Gene) 5. Expression of anger, helplessness, or a. Depression—chromosomes 2, 5, 11, and hopelessness 17 have been implicated. 6. Giving away personal possessions, closing (1) SLC6A4 (also known as: 5HTT, bank accounts 5-HTTLPR, SERT) on chromosome 7. Sudden calmness or improvement in a de- 5—Encodes protein that transports pressed client serotonin. The encoded protein termi- 8. Questions about guns, poisons, or other lethal nates the action of serotonin and recy- instruments cles it. A repeat length polymorphism 9. Social withdrawal/isolation (physical or social) in the promoter of this gene has been 10. Stress (e.g., loss of health, significant other, shown to affect the rate of serotonin job) uptake and may play a role in depres- 11. Feelings of worthlessness (e.g., everyone sive symptoms. would be better off without me) (2) BDNF (brain-derived neurotrophic factor) on chromosome 11—may • Lethality of suicide threat—direct relationship with play a role in the regulation of stress the risk of death from suicide gesture response and in the biology of mood 1. Low lethality—low death risk (holding breath, disorders. superficial cutting of wrists) b. Mania—chromosomes 5, 10, 11, and 13 2. Moderate lethality—moderate death risk have been implicated. (overdose of drug or toxic agent) (1) DAOA (D-amino acid oxidase acti- 3. High lethality—death is likely (hanging, gun- vator) on chromosome 13—poly- shot, driving into a train) morphisms in this gene have been implicated in susceptibility to Schizo- • Risk factors related to suicide: phrenia and Bipolar Affective Disor- 1. Caucasian/White race der, possibly due to decreased levels 2. Male gender of D-serine and decreased NMDA 3. Advanced Age (3:1 risk for $75 years) receptor functioning. 4. Current depression (2) BDNF (see depression, 2.c above) 5. Living alone/Isolation 3. Neurotransmitter hypotheses 6. Lethality of suicide plan a. Imbalances in nerve cells whose neu- 7. Previous suicidal behavior rotransmitters are biogenic amines (e.g., 8. Presence of psychotic symptoms serotonin (5 HT), norepinephrine (NE), 9. Physical illness and dopamine (D)); and other related 10. Hopelessness modulating neurohormones, acetyl- 11. Family history of substance abuse choline and gamma acetyl buteric acid 12. Family history of suicide (GABA); the feedback between messenger hormones and target organs suggest Etiology of Mood Disorders many types of defective neuroendocrine secretion • Genetic/Biologic origins (Levinson, 2005; Sadock b. Overactivity of the limbic hypothalamic- & Sadock, 2007; Stahl, 2008; Wong, Arcos-Burgos, & pituitary-adrenal axis (LHPA) leading to Licinio, 2008) hypercortisolism 1. Data consistently demonstrate high concor- 4. Circadian rhythm hypothesis dance rates among first-degree relatives of a. A disturbance in regulation of biologic people with unipolar depression and Bipolar rhythms that synchronize body functions Disorder and among monozygotic versus is congruent with rhythmical cyclical na- dizygotic twins—the more family members ture of mood disorders. affected with a mood disorder, the more likely b. Depressed individuals may be in a other first-degree family members will be chronic state of sleep satiety (arousal) affected. leading to REM sleep abnormalities. Screening Instruments 143

Acetylcholine may be involved in short- differentiating unipolar from bipolar disorders ened REM latency in depression (phase and mania from Schizophrenia. advance of circadian rhythms) leading 3. Urinary MHPG—A major metabolite of nor- to advances in cortisol secretion (which epinephrine (NE) is 3-methoxy 4-hyroxy- normally surges in early morning to pre- phenylglycol (MHPG); because this me- pare for wakefulness). tabolite crosses the blood-brain barrier, its c. Depressed individuals may dispense ear- CNS activity can be estimated by measur- lier with central nervous system (CNS) ing MHPG elimination in urine (peripheral programs that promote vegetative func- MHPG is also secreted in urine); proposed tions or overcome the restraints of arousal that patients with low MHPG have less systems sooner than nondepressed norepinephrine to metabolize and would individuals. respond to antidepressants that block norepi- d. The phase delay hypothesis posits that nephrine reuptake; patients with normal or for individuals with seasonal affective high NE levels may have a serotonin deficient disorder (SAD), circadian rhythms occur depression and may respond to drugs that at a later time relative to sleep onset and block serotonin reuptake. temperature, and predicts an antidepres- 4. Sleep EEG (REM latency measurement)—sleep sant response to morning photo-therapy. EEGs indicate that depressed patients spend This shifts the onset of melatonin produc- less time in the more refreshing slow-wave tion and secretion to an earlier time in the phases of sleep and have a shorter pre-REM evening, which results in a correction of phase (decreased REM latency) of 2-30 min- the disrupted relationship between sleep, utes versus 90 minutes. temperature, and circadian rhythms. e. Bipolar patients in the manic phase may have phase shifting, loss of patterning, and Screening Instruments disorders of amplitude. • Patient self-report questionnaires 1. Center for Epidemiological Studies—Depres- Diagnostic Studies/Tests sion Scale (CES-D) 2. Beck Depression Inventory-II (BDI-II) • General recommendation—General medical 3. Zung Self-Rating Depression Scale (ZSRDS) evaluation with standard laboratory tests to 4. Geriatric Depression Scale (GDS) rule out medical cause(s) of mood symptoms, 5. Mood Disorders Questionnaire (MDQ) as well as thyroid function tests (some thyroid 6. General Health Questionnaire (GHQ) illness is present in 8% of patients with depressive disorders), and toxicology screening (when substance-related effects are known/suspected); • Clinician-completed rating scales there are no definitive tests for mood disorders. 1. Hamilton Rating Scale for Depression While the clinical utility of the following tests is (HAM-D, HRSD) unknown, they have received attention in the 2. Montgomery-Asberg Depression Rating Scale literature: (MADRS) 1. The dexamethasone suppression test 3. Schedule for Affective Disorders and Schizo- (DMST) has been suggested as a useful test phrenia (SADS) for depression; limited support for clinical 4. Inventory for Depressive-Symptomatology- use of this test has been reported. Underly- Clinician Rated (IDS-C) ing premise: dexamethasone is an exog- 5. Symptom Checklist-90 Revised (SCL-90-R) enous steroid that suppresses blood levels 6. Young Mania Rating Scale (YMRS) of cortisol. Based on the premise that many depressed patients exhibit hypersecretion • Nursing diagnoses—several of the 2009-2011 of cortisol, a single (11 p.m.) dose of cortisol NANDA International (2009) nursing diagnoses does not depress late afternoon cortisol lev- can be applied to mood disorders, including: els. If the postdexamethasone cortisol level 1. Fatigue is 5 mg/mL, then it has escaped suppression, 2. Insomnia and support is added for a diagnosis of bio- 3. Sleep Pattern, disturbed logic depression. 4. Anxiety 2. Thyrotropin releasing hormone (TRH) 5. Coping, ineffective stimulation test and corticotropin-releasing 6. Hopelessness hormone (CRH) are thought to be useful in 144 Chapter 7 Mood Disorders

7. Powerlessness Interventions 8. Self-Esteem, chronic low 9. Sorrow, chronic • Biochemical interventions 10. Neglect, self 1. Antidepressant drugs (NOTE: Evaluate per- 11. Sensory Perception, disturbed sonal and family history of Bipolar Disorder 12. Suicide, risk for prior to initiating treatment and monitor sui- 13. Self-Mutilation, risk for cidality of all patients) 14. Self-Mutilation a. Selective serotonin reuptake inhibitors 15. Role Performance, ineffective (SSRIs) (See Table 7-2), norepinephrine do- 16. Health Behavior, risk-prone pamine reuptake inhibitors (NDRIs) dual 17. Knowledge, deficient (specify) serotonin, and norepinephrine reuptake 18. Health Management, ineffective self inhibitors (SNRIs) (See Table 7-3) are considered to be first-line agents in treating depression.

Table 7-2 Selective Serotonin Reuptake Inhibitors (SSRI)

Maximum Generic Name Trade Name(s) Oral Dosage Range Daily Dose Comments Citalopram Celexa 20 to 60 mg/day 60 mg/day Few drug interactions (thus a good augmenting agent) Recommended SSRI for post-MI depression History of seizure, use with caution Escitalopram Lexapro 10 to 20 mg daily 20 mg/day Few drug interactions (thus a good augmenting agent) May be better tolerated than any other antidepressant History of seizure, use with caution Fluoxetine Prozac 20 to 60 mg/day 80 mg/day First SSRI Prozac Weekly 90 mg/week Long half-life Sarafem Initiate other antidepressants up to 5 weeks after discontinuation Fluvoxamine Luvox CR 100 to 200 mg/day 300 mg/day Luvox—immediate release form removed from US market due to severe liver toxicity No warning for hepatotoxicity for controlled-release form Significant withdrawal effects Avoid abrupt discontinuation Initiate other antidepressants up to 2 weeks after discontinuation Paroxetine Paxil 20 to 40 mg/day 50 mg/day Significant withdrawal effects Paxil CR Avoid abrupt discontinuation Pexeva Initiate other antidepressants up to 2 weeks after discontinuation Paxil CR dosing: 25 to 62.5 mg in am Sertraline Zoloft 50 to 200 mg/day 200 mg/day Significant withdrawal effects— avoid abrupt discontinuation Initiate other antidepressants up to 2 weeks after discontinuation

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009) Interventions 145

Table 7-3 NDRIs, SNRIs, & Other Common Antidepressants

Maximum Generic Name Trade Name(s) Class Oral Dosage Range Daily Dose Comments Buproprion Wellbutrin NDRI 200 to 450 mg/day 450mg/day History of in divided doses seizures—use with caution Zyban used for smoking cessation Wellbutrin SR 200 to 450 mg/day 400 mg/day (sustained-release) in divided doses Wellbutrin XL 150 to 450 mg/day 450 mg/day (extended-release) in single dose Zyban 150 mg/day in 300 mg/day divided doses Duloxetine Cymbalta SNRI 40 to 60 mg/day in 120 mg in divided History of seizures— 1 to 2 doses doses over 60 mg use with caution Venlafaxine Effexor, Effexor XR SNRI 75 to 250 mg/day 375 mg/day Usually start with 37.5 mg dose increasing by 75 mg as tolerated Nefazodone Serzone SARI 100 to 600 mg/day 600 mg/day Risk of (brand not in US) hepatotoxicity— monitor LFTs Trazodone Desyrel SARI 50 to 400 mg/day 600 mg/day Also used for in divided dose insomnia (25 to 50 mg @ bedtime, increased as tolerated) Mirtazapine Remeron Other 15 to 45 mg daily 45 mg daily Dual serotonin & norepinephrine actions

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009)

b. Tricyclic antidepressants (TCAs) (See (b) Occasional stimulant effect (in- Table 7-4) and monoamine oxidase inhibi- somnia, restlessness, anxiety) tors (MAOIs) are considered second-line (c) Hypomania in patients with Bipo- agents. lar Disorder (35%) c. MAOIs—inhibit the action of monoamine (d) Parasthesias (tingling at pe- oxidase, an enzyme that metabolizes neu- riphery, electric-shock-like rohormones responsible for stimulating sensations) physical and mental activity (serotonin, (e) Hypertensive crisis (See Tables 7-6 norepinephrine, and epinephrine); usually & 7-7) used when client is unresponsive to non- 2. Mood stabilizers—antimanic medications— MAOI antidepressants (See Table 7-5). See Table 7-8 (1) Side/Adverse effects of MAOIs a. Lithium—WARNING: Toxic levels are (a) Most common effects: constipa- near therapeutic levels—need to monitor tion, anorexia, nausea, vomiting, closely for signs of toxicity (tremor, ataxia, dry mouth, urinary retention, diarrhea, vomiting, sedation) skin rash, transient impotence, (1) Obtain blood levels drawn drowsiness, headache, dizziness, (a) 7 days after tx begins (12 hours orthostatic hypotension after last dose) (b) 23 weekly 3 2 weeks 146 Chapter 7 Mood Disorders

Table 7-4 Common Tricyclic Antidepressants

Common Maximum Generic Name Trade Name Oral Dosage Range Daily Dose Comments Amoxapine Asendin 200 to 300 mg/day 600 mg/day TCAs block transporter site for Amitriptyline Elavil 50 to 150 mg @ 300 mg /day divide norepinephrine & serotonin bedtime doses over 75 mg Significant side effects: Clomipramine Anafranil 100 to 200 mg/day 250 mg/day —Anticholinergic side effects Desipramine Norpramin 100 to 200 mg/day 300 mg/day (dry mouth, blurred vision, constipation, urinary hesitancy) Doxepin Sinequan 75 to 150 mg/day 300 mg/day —Sedation Imipramine Tofranil 50 to 100 mg/day 300 mg/day —Orthostatic hypotension Nortriptyline Pamelor 75 to 150 mg/day in 300 mg/day Significant drug interactions divided doses Do not use if cardiac condition exists May be lethal in overdose

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009)

Table 7-5 Monoamine Oxidase Inhibitors (MAOIs)

Maximum Generic Name Trade Name(s) Class Dosage Range Daily Dose Comments Isocarboxazid Marplan MAOI 20 to 60 mg/day 60 mg/day Avoid use with: PO in divided —Tyramine-rich products dose —SSRIs Phenelzine Nardil MAOI 45 to 90 mg/day 90 mg/day Significant side effects: PO in divided —Anticholinergic effects dose —Orthostatic hypotension Selegiline Eldepryl MAO B 10 mg daily PO 10 mg daily Hepatic and hematologic inhibitor dysfunction (monitor blood EMSAM Selective 6 to 12 mg/day 12 mg/day counts & LFTs) (transdermal) MAOI EMSAM—no diet restrictions with # 12 mg transdermal Tranylcypromine Parnate MAOI 30 mg/day PO in 60 mg/day patch divided dose

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009) Interventions 147

Table 7-6 Signs & Symptoms of Hypertensive Crisis and Nursing Interventions

Signs and Symptoms Nursing Intervention Warning Signs Increased blood pressure Hold next MAOI dose Palpitations Do not lie client in supine or prone position (elevated Frequent headaches BP in head) Symptoms of Hypertensive Crisis Sudden elevation of blood pressure Monitor vital signs Explosive headache (occipital radiating frontally) Chlorpromazine 100 mg IM (blocks norepinephrine, Palpitations; chest pain repeat if necessary) Phentolamine slowly administered in 5 mg IV doses Sweating (binds with norepinephrine receptor sites, blocking Fever norepinephrine) Nausea; vomiting Manage fever with external cooling techniques Dilated pupils Assess intake of tyramine-containing foods Photophobia Neck stiffness Nosebleed Intracranial bleeding

Moller, M. (1998). Mood disorders. In C. Houseman (Ed.). Psychiatric certification review guide for the generalist and clinical Specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.). Potomac, MD: Health Leadership Associates, Inc.

(c) 13 weekly 3 2 weeks (c) Effective in inhibiting seizures (d) q 3 months 3 6 months kindled from repeated stimula- (e) q 6 months thereafter tion of limbic structures (2) Therapeutic range—0.6–1.4 mEq/L (d) GABA antagonist activity for adults; 0.6–0.8 mEq/L in geriatric (3) Administration clients or those with medical illness (a) Fourteen days before peak effect (3) Lithium toxicity—usually dose re- (b) Dose guided by plasma levels lated—See Table 7-9 (c) Complete laboratory tests prior to (4) Significant side effects—See Table beginning therapy 7-10 i. CBC b. Anticonvulsants ii. Liver function tests (1) Depakote is approved for first-line iii. Serum electrolytes treatment for mood stabilization in iv. EKG Bipolar Disorder (4) Blood tests q 2 weeks 3 3 months; q 3 (a) When lithium is contraindicated months thereafter to monitor hemato- or ineffective poetic suppression and hyponatremia (b) For rapid cyclers (. 4 episodes/ (5) Reinforcement of teaching after each year) treatment (c) For prevention of recurrence 3. Additional considerations regarding (2) Mode of action pharmacotherapy (a) Structurally related to tricyclic a. Assess suicidality and presence of manic antidepressants or psychotic symptoms at each contact/ (b) Anticonvulsant activity mediated visit. through a “peripheral” type ben- b. Monitor clients treated with antidepres- zodiazepine receptor sants for signs of overstimulation of serotonin receptors causing Serotonin 148 Chapter 7 Mood Disorders

Table 7-7 Dietary Restrictions for Patients Taking MAOIs

Food and Beverages to Avoid Safe Food, Beverages, and Medication Cheese, especially aged or matured (Cheddar, Cottage Cheese Mozzarella, Parmesan, Gruyre, Stilton, Brie, Swiss, blue, Farmer’s Cheese Camembert) Cheese Whiz Fermented or aged protein (salami, mortadella, Ricotta sausage, bologna, pepperoni) Havarti Pickled or smoked fish Boursin Beer, red wine, Sherry, Cognac, liqueurs Fresh fruits Yeast or protein extracts (Marmite, Oxo, Bovril) Bread products raised with yeast (bread) Broad bean pods Beef or chicken liver Yogurt Sauerkraut Overripe fruit Foods/Beverages to Be Consumed in Moderation Chocolate Sour cream Avocado Clear spirits and white wine Soy sauce Caffeine drinks Medications to Avoid Safe Medications Cold medications Aspirin, Tylenol Nasal and sinus decongestants Pure steroid asthma inhalants Allergy and hay fever remedies Codeine Narcotics, especially meperidine Plain Robitusin or Terpin-hydrate with codeine Inhalants for asthma All laxatives Local anesthetics with epinephrine All antibiotics Weight-reducing pills Antihistamines

Moller, M. (1998). Mood disorders. In C. Houseman (Ed.). Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.) Ed. Potomac, MD: Health Leadership Associates. Interventions 149

Table 7-8 FDA Approved Medications Used in Treating Bipolar Disorder

Generic Name Trade Name(s) Oral Dosage Range Maximum Dose Monitoring & Other Comments Aripiprazole Abilify 15 to 30 mg/day 30 mg/day Increased suicide risk Available in disintegrating tablet form Carbamazepine Tegretol, 400 to 1200 mg/day 1200 mg/day Serum level (4–12 mcg/ml) Tegretol XR, in divided doses Monitor serum level, LFTs, for signs Equetro of bleeding/bruising Lamotrigine Lamictal 50 to 200 mg/day 200 mg daily Risk of serious rash Increased suicide risk May cause photosensitivity Lithium Eskalith, Cibalith, 900 to 1200 mg/day 1800 mg/day Serum level (0.6–1.2 mEq/L) Lithane, Lithobid in divided doses Monitor serum level and toxicity (See Table 7-10) Olanzapine Zyprexa 10 to 20 mg/day 20 mg/day Increased suicide risk Monitor weight Olanzapine Symbyax olanzapine/ 18 mg/75 mg/day Increased suicide risk & Fluoxetine fluoxetine Monitor weight (combination) 6 mg/25 mg to Avoid abrupt discontinuation 12 mg/50 mg Oxcarbazepine Trileptal 600 to 2400 mg/day 2400 mg/day Hyponatremia risk—monitor fluid in divided dose and Na May decrease efficacy of oral contraceptives Quetiapine Seroquel, 300 to 800 mg/day 800 mg/day Increased suicide risk Seroquel XR (may divide dose) Monitor for cataracts Valproate/ Depakene, 750 to 1500 60mg/kg/day Serum level (target: 50–125mg/ml) Valproic Acid/ Depakote, mg/day Monitor serum level, LFTs, platelet, Divalproex Depakote ER Acute mania: dose coagulation Sodium Depakote = 250 to 1000 mg Liver toxicity (malaise, facial Sprinkles edema, anorexia, jaundice) & suicidality Ziprasidone Geodon 80 to 160 mg in 160 mg/day IM form (10–20 mg, max. 40 mg/ divided dose day), discontinue IM dose within 3 days

(Keltner et al., 2007; Sadock & Sadock, 2007; Stahl, 2009) 150 Chapter 7 Mood Disorders

Table 7-9 Lithium Toxicity & Related Treatment

Mild At lithium levels of 1.5–2 mEq/L—occasionally occurs at normal levels Develops gradually over several days Symptoms—ataxia, coarse tremor, confusion, diarrhea, drowsiness, fasciculation, slurred speech Treatment Hold all lithium doses Obtain lithium blood level Check vital signs Patient education Moderate to Severe At lithium levels . 2 mEq/L Gradual or sudden onset Symptoms—muscle tremor, hyperreflexia, pulse irregularities, hyper or hypotension, EKG changes, visual or tactile hallucinations, oliguria, or anuria, seizures, coma, death Treatment—rapid assessment of clinical signs and symptoms of lithium toxicity Hold all lithium doses Monitor vital signs and LOC Protect airway and provide standby oxygen Obtain lithium level stat; BUN, creatinine, urinalysis; CBC; monitor electrolytes EKG; monitor cardiac states Limit lithium absorption; provide an emetic—N–G suctioning may be appropriate Vigorously hydrate 5 to 6 L/day IV—indwelling catheter; monitor intake and output; ROM; deep breathing Maintain bed rest

Table 7-10 Lithium Side Effects & Nursing Interventions

Side Effect Symptom Nursing Intervention Polyuria, with possible progression to Type II Reassure client that increased urination is common and diabetes benign. Urine output is large in volume and so dilute that it may be colorless. Client may complain of urinating so frequently that Urine volume may diminish if the physician reduces the it interferes with activities of daily living, including lithium dose or changes to a slow-release form or a single sleep. daily dosage. When severe, the physician usually orders 24-hour urine volume. If volume is greater than 3 L, a further renal workup is usually requested. When severe, polyuria is often treated by the physician with a thiazide or potassium-sparing diuretic (taking care to reduce the lithium dose). Lithium is contraindicated for clients with renal dysfunction. Increased thirst Recommend that clients quench their thirst and maintain a fairly stable intake of liquids from day to day. The best thirst quencher is water or a low-calorie beverage that will not cause weight gain when taken in large amounts. Gum or hard candies may help moisten the mouth. (continues) Interventions 151

Table 7-10 Lithium Side Effects & Nursing Interventions (continued)

Side Effect Symptom Nursing Intervention Tremor—a fine tremor that worsens with Reassure that this is benign and may be temporary. In intentional movements. It can make writing, some clients it is persistent. The physician may order a drinking hot beverages, and many other motor reduction in dose, more frequent doses, or a change tasks difficult. to a slow-release form. When the tremor is severe or incapacitating, the physician may treat it with a beta blocker, usually propranolol (Inderal). Recommend that the client reduce or eliminate caffeine-containing beverages. Nausea, abdominal discomfort, diarrhea, or soft Reassure that this is benign and usually temporary. stools Recommend that the client take lithium with meals, a glass of milk, or a snack. If symptoms persists, the physician may change to another lithium preparation. Muscle weakness or fatigue Reassure that this is benign and usually temporary. Since this is not a very common side effect of lithium, ascertain whether it is being caused by another medication being taken by the client. Encourage the client to remain active and get regular physical exercise. If symptom persists, the physician may reduce the dose, order more frequent divided doses, change to slow-release, or reduce the dose and more gradually increase to the present dose level. Edema of the feet or other body parts Reassure that this is benign and may be temporary. A moderate salt restriction may reduce the edema. If moderate salt restriction is undertaken, the serum lithium level usually rises somewhat. It then becomes necessary to monitor for signs of toxicity and keep the physician informed in case it becomes necessary to reduce the lithium dose. Hypothyroidism (5%) Explain that this is reversible and treatable. The physician usually orders thyroid hormone replacement, such as levothyroxine (Synthroid) or desiccated thyroid. Weight gain (60%) Explain that this is fairly common and benign. Moderate calorie restriction and increased exercise usually help. Advise against fluid restriction or sodium restriction unless undertaken with knowledge of the physician and nurse, since either intervention can cause the serum lithium level to rise. Hair thinning or loss Explain that this may be temporary. Since hair loss can be a symptom of hypothyroidism, inform the physician so that thyroid function can be checked. If hair does not return, lithium is usually stopped so that hair can regrow. During periods of hair loss, encourage the client to consider wearing a wig. Benign, reversible granulocytosis Explain that this is benign. This side effect is the basis for its use as a treatment in some granulocytopenic conditions. Decreased libido Suggest timing sexual activity to not coincide with peak action time of medication. Explore strategies for continuing relationship intimacy.

Moller, M. (1998). Mood disorders. In C. Houseman (Ed.). Psychiatric certification review guide for the generalist and clinical specialist in adult, child, and adolescent psychiatric and mental health nursing (2nd ed.) Potomac, MD: Health Leadership Associates, Inc. 152 Chapter 7 Mood Disorders

Syndrome (SS)—a potentially fatal phe- c. Clients are unresponsive to or cannot tol- nomenon usually resulting from drug- erate medications. drug interactions (severe risk when SSRIs d. Manic episodes—avoid with lithium are combined with MAOIs, lithium, trypto- treatment. phan, St. John’s wort) (Keltner et al., 2007; e. Schizophrenia—used for acute (marked Sadock & Sadock, 2007) positive symptoms, catatonia, or affec- (1) Most frequent signs and symptoms of tive symptoms that are likely to respond SS are: to ECT), not chronic, symptoms of (a) Mental status changes such as Schizophrenia. confusion or hypomania 3. Treatment (following pretreatment evaluation) (b) Agitation or restlessness a. 6–12 treatments on alternate days (c) Myoclonis b. Atropine sulfate administered for vagolytic (d) Hyperthermia effect 30–60 minutes prior to treatment (e) Diaphoresis c. Short-acting barbiturate (Brevital Sodium) (f) Chills administered IV to induce anesthesia (g) Abdominal cramping, diarrhea, d. Succinylcholine (Anectine) administered nausea IV as muscle relaxant after anesthetic

(h) Headache e. 100% O2 administered 1–2 min. to prepare (i) Tremor for apneic period from muscle relaxant (j) Ataxia or incoordination and convulsion (k) Hyperreflexia f. Client positioned in supine position; (2) Treatment interventions for SS consist mouth gag inserted; jaw supported as of removing the offending agent(s) needed and prompt treatment of all associ- g. Electrodes applied unilaterally (less amne- ated symptoms, which may include sia) at nondominant side temple or bilat- nitroglycerine, cyproheptadine, ben- erally (more amnesia) at temples zodiazepines, anticonvulsants, cool- h. Fingers and toes observed for twitching

ing blankets, mechanical ventilation, i. O2 administered by bag breathing when and paralyzing agents (Sadock & Sa- twitching stops until spontaneous respira- dock, 2007). tion resumes (3) Note also that abrupt discontinuation j. Patent airway maintained; client posi- of SSRIs can lead to SSRI withdrawal, tioned on side also called Discontinuation Syndrome k. Vital signs monitored until stable (DS)—rare with fluoxetine. l. Patient begins to respond in 10–15 (a) Signs and symptoms of DS in- minutes. clude dizziness, weakness, flu-like 4. Side effects symptoms, headache, anxiety, a. Anoxia during seizure cognitive dulling, and recurrence b. Memory loss—temporary—most return to of depressive symptoms (rebound baseline within 6 months; approximately depression) 75% of ECT patients indicate this as the (b) To avoid DS slowly taper most worst adverse effect SSRIs when discontinuing c. Headache d. Marked confusion in about 10% of ECR • Electroconvulsive therapy (Sadock & Sadock, 2007) patients 1. Mechanism of action—Much of the research e. Cardiac arrhythmias has focused on changes in neurotransmitter f. Mortality: 1:10,000 patients receptors and second-messenger systems— 5. Nursing intervention every neurotransmitter system is affected, but a. Complete physical assessment including like antidepressants, a series of ECTs leads to EKG, EEG, X-rays of spine and chest. downregulation of post-synaptic beta- b. Provide opportunity to express feelings adrenergic receptors. about ECT. 2. Indications c. Assess client’s response. a. Most common indication for ECT is Major d. Client education guildelines Depressive Disorder (MDD). (1) Assess patient and family anxiety level b. Emergency therapy for suicidal or hyper- and ability to understand. active clients who are in physical danger is indicated. Interventions 153

(2) Individualize amount of information priate and are unacceptable to the shared (i.e., treatment, post-ECT con- superego. fusion, memory loss, etc.). (3) The person may develop a pattern of (3) Provide time to discuss concerns and containing angry/aggressive feelings answer questions. and directing them inward against the (4) Instruct accompanying adult in self leading to self-hatred. dealing with the following post-ECT (4) Suicide is viewed as a strike against effects: the hated and loved object as well as (a) Orienting to time, place, and the self; manic episode is viewed as a person defense against depression. (b) Headache (c) Nausea • Interpersonal interventions 1. Objectives • Other brain stimulation interventions (Sadock & a. Insuring safety with reduced potential for Sadock, 2007) self-harm 1. Repeated transcranial magnetic stimulation— b. Increasing appropriate expression of a noninvasive procedure that stimulates cells thoughts and feelings of the cerebral cortex c. Increasing self-esteem and social 2. Vagal nerve stimulation—stimulation of the interaction left vagus nerve through a multiprogrammable 2. Facilitating the expression of feelings bipolar pulse generator implanted in the left a. Acknowledge client pain and despair. chest wall b. Reinforce that depression is self-limiting. 3. Deep brain stimulation—involves creating a c. Convey hope for future. small hole in the skull into which small wire is d. Do not give false reassurance. passed into the selected brain regions; the wire e. Engage in active listening. is attached to a pacemaker device implanted f. Demonstrate acceptance of thoughts and in the chest wall and the pace maker is used to feelings. stimulate the selected brain region. g. Facilitate expression of positive and nega- 4. Psychosurgery—involved surgery to modify tive thoughts and feelings. areas of the brain; goal is to reduce symptoms h. Assist client in identifying strategies for ex- of severely ill patients who have not responded pressing and coping with negative feelings to less invasive treatment interventions. (anger, guilt, aggressiveness, etc.). i. Provide objective feedback and positive • Intrapersonal origins/Psychotherapeutic reinforcement. interventions j. Increase self-esteem. 1. Psychoanalytic theory (1) Schedule regular sessions with client. a. Object loss hypothesis—Infants experi- (2) Accept negativism without judgment. encing loss of the maternal love object in (3) Minimize time focused on real or per- infancy experience separation anxiety and ceived failures. grief related to loss of the primary love ob- (4) Focus on identifying strengths and ject; early loss is thought to predispose the accomplishments. adult to respond abnormally to losses that (5) Collaborate with client in identifying occur later in life, becoming depressed factors maintaining low self-esteem. significantly more often than those not experiencing such early losses. • Cognitive interventions b. Aggression-turned-inward hypothesis— 1. Theoretical foundations depression is proposed to be a turning a. Depression is a cognitive problem origi- inward of the aggressive instinct that is not nating from disturbed thinking in which directed at the appropriate object, with the depression-prone person explains an accompanying feelings of guilt. adverse event as a personal shortcoming. (1) This process is initiated by loss of an b. Developmental experiences sensitize cer- object toward whom a person feels tain people and make them vulnerable to love and hate (ambivalence). depression. The constellation of negative (2) The person is unable to express thoughts that characterizes depression the angry feelings because they are remains dormant until a person becomes thought to be irrational or inappro- depressed. When depression occurs after a life stressor, the dormant cognitive set 154 Chapter 7 Mood Disorders

appears; negative cognitive processes re- (2) Considers attention span, distractibil- place objective thinking. ity and motivation. c. Cognitive elements of depression (3) Contains realistic goals and (1) Cognitive triad—the person’s negative expectations. view of self, the world and the future, (4) Provides opportunities for which is a distortion of reality performance-based positive (2) Silent assumptions—irrational beliefs reinforcement. or rules that significantly affect the de- c. Involve clients in the following activities: pressed person’s cognitive, affective, (1) Assertiveness training and behavior patterns (2) Role playing (3) Logical errors—faulty information (3) Social skills training processing and errors in thinking that (4) Stress management maintain the person’s belief in the (5) Relaxation exercises validity of his/her negative concept (6) Meditation despite contradictory evidence (7) Physical fitness/exercise 2. Objectives d. Increase client’s present versus past or fu- a. Increasing client’s sense of control over ture orientation. his/her goals/behavior b. Increasing self-esteem • Hopelessness theory of depression (learned c. Assisting client in modifying negative helplessness) expectations 1. Based on attribution theory—a chain of per- 3. Guidelines ceived negative life events are hypothesized to a. Assist in exploring feelings to elicit pa- be the “occasion setter” for people to become tient’s view of problem(s). hopeless and depressed. b. Assist client in identifying negative 2. Depression consists of four classes of defi- thoughts. cits: motivational, cognitive, self-esteem, and c. Accept client perceptions, not affective. conclusions. 3. Three types of influences determine whether d. Teach thought interruption or a person will become hopeless, and, in turn substitution. depressed, when negative life events are e. Encourage client to increase realistic experienced: thinking by appraising personal as- a. When highly desired outcomes are be- sets, strengths, accomplishments, and lieved improbable or when highly aversive opportunities. outcomes are perceived probable, and the f. Encourage formulation of realistic versus person anticipates that no response in unrealistic goals. his or her repertoire will positively affect the outcome (helplessness), depression • Behavioral interventions occurs. 1. Objectives b. When negative life events are attributed to (1) Activating clients in a realistic goal- stable versus unstable and global versus directed way specific causes, and are viewed as impor- (2) Developing alternative problem- tant, helplessness, low self-esteem, and solving and coping strategies depression ensue. (3) Increasing self-esteem c. Inferred negative consequences are (4) Instilling hope most likely to lead to depression. The (5) Increasing client responsibility for consequence is viewed as important, change not remediable, likely to change, and af- (6) Gradual redirection of self- fecting many areas of life. When inferred preoccupation to interests in characteristics about the self (self-worth, outside world abilities, desirability, etc.) are negative and 2. Guidelines will interfere with attainment of important a. Assess client strengths and weaknesses outcomes, hopelessness and depression and personal and environmental factors may ensue. that maintain depression. 4. Improvement of depression is contingent b. Work with client to develop a structured upon one’s perceived control and mastery of daily program of activities that: their environment. (1) Considers probability of succeeding. Interventions 155

• Family dynamics/ Family therapy • Group approaches 1. Developmental experiences within the family 1. Devise a structured plan of therapeutic activi- system (abuse, conflict, divorce, death) can be ties that considers client’s level of depression antecedents of depression. or mania. a. Nodal events (significant exits and entries 2. Encourage attendance at group sessions and of people, places, objects, activities, and activities. roles in a family system), especially those 3. Accept nonverbal participation. perceived as undesirable, can precipitate 4. Set limits on disruptive behavior. depression, especially when an event gen- 5. Positively reinforce appropriate participation. erates stress or anxiety not openly dealt 6. Encourage sharing of common feelings, with in the family system. thoughts, behaviors, life experiences among b. Multiple nodal events occurring within a clients. brief period may escalate the likelihood of 7. Promote problem solving within group. stress (cluster stress) and depression. 8. Promote modification of dysfunctional expec- c. Anniversary reactions (affective responses tations of self and others. around anniversary of nodal event), which 9. Teach stress management strategies. reactivate feelings associated with original 10. Instruct and model social skills. nodal event, can take form of depression, 11. Use role playing and rehearsal of social suicidal thoughts, gestures, attempts, and interactions. other stress-related symptoms. 12. Encourage initiation of socialization in an ex- d. Family precursors of mood disorders panded social environment. include early developmental family experiences related to strong nurturing in • Milieu interventions early childhood followed by cutting off 1. Objectives of nurturing supplies in early childhood, a. Maintaining client safety coupled with unrealistic expectations, b. Decreasing manipulation unquestioning acceptance of parental val- c. Increasing self-responsibility ues, and frustrated efforts to obtain family 2. Intervention guidelines approval and love. Underlying resentment a. Engage client in developing functional toward parents may erupt briefly, fol- coping strategies. lowed by quiet and fear of rejection. Manic b. Utilize stress management strategies. episode masks guilt, loss, and rejection. (1) Exercise Depressive episode represents internal- (2) Relaxation training ization of disappointment, loss, and per- (3) Meditation ceived failure. (4) Nutritional diet 2. Objectives (5) Adequate sleep a. Increasing functional family interaction c. Teach abilities to differentiate normal patterns mood response and stress from illness b. Increasing family effectiveness in coping symptoms. with grief, loss, stress 3. Family education, including: • Community resources c. Community resources (medical, social, 1. Interventions vocational, support groups) a. Discharge from inpatient setting. d. Positive support and knowledge to antici- b. Collaborate with team for discharge plan- pate and avoid problems ning to include: 4. Refer to or conduct family therapy sessions. (1) Appropriate living arrangements 5. Conduct family intervention when suicide is (a) Family attempted or completed. (b) Solo a. Explore family response to stress. (c) Halfway house b. Explore family relationships re: isolation, (d) Group home scapegoating, estrangement. (2) Employment/vocational planning c. Explore family communication patterns. (3) Referral to psychoeducation programs d. Promote grief rituals and customs. (a) Vocational rehabilitation e. Facilitate open expression of feelings (b) Social skills training (guilt, anger, sadness, helplessness, etc.). (c) Mental health education programs 156 Chapter 7 Mood Disorders

(4) Referral to day treatment programs way, Mr. B. states that he frequently thinks about (5) Referral to support/self help groups taking his life. The advanced practice PMH nurse (a) National Alliance for the Mentally would probably give him which of the following Ill (NAMI) diagnoses? (b) Manic-Depressive and Depressive a. Bipolar Disorder, depressed Association b. Major Depression, recurrent (c) Recovery, Inc. c. Major Depression 2. Professional involvement in advocacy groups, d. Seasonal Affective Disorder community and professional organizations, self-help groups, political coalitions lobbying 5. Mrs. C., age 42, calls the Mental Health Center for mental health resources and rights with the following complaint: “I’ve been taking venlafaxine, 75 mg bid for depression, and now Questions I can’t sleep, am running around getting all distracted, and talking a mile a minute.” The Select the best answer advance practice PMH nurse must rule out:

1. Susan Z. age 20, was at a bar in the town where a. The emergence of hypomania she went to college. Always an outgoing, life- b. Non-compliance with venlafaxine dosing of-the-party type, Susan became loud and c. No relationship of symptoms with abusive to people at the bar, jumped on the bar venlafaxine and began doing a strip dance, singing loudly, d. The need for electroconvulsive therapy knocking over everything in sight. The police 6. In addition to assessment for specific signs and were called and at the station house, Susan symptoms of Major Depressive Disorder, it is loudly rambled on about how all the women in essential for the advanced practice PMH nurse to her family were life-of-the-party types. The com- assess the patient’s _____ in planning appropriate munity mental health nurse interviewing Susan treatment interventions. understands that: a. prior episodes of unipolar depression or a. Bipolar Disorder does not have a higher Bipolar Disorder rate in families with relatives who have the b. risk for suicide disorder c. concurrent substance abuse b. Bipolar Disorder does have a higher rate in d. non-psychiatric physical health problems families with relatives who have the disorder c. Bipolar disorder is inherited 7. A priority feature of the assessment process with d. Bipolar disorder is not recurring the depressed patient is: 2. People at highest risk for suicide are: a. Assessment of family history b. Assessment of suicide risk a. Married, white males younger than 60 c. Assessment of concurrent substance abuse b. Single, white males older than 60 d. Assessment of stressful life events c. Black males d. Males younger than 24 and older than 50 8. When assessing the depressed patient, a frequently used patient self-report questionnaire is: 3. What percentage of the annual suicides is associated with depression? a. The Beck Depression Inventory b. Hamilton Rating Scale for Depression a. 20% c. Schedule for Affective Disorders and b. 30% Schizophrenia c. 50% d. Minnesota Multiphasic Personality Inventory d. 80% 9. An experimental laboratory test to assess levels 4. Mr. B. has experienced depressed mood and dif- of norepinephrine in depressed patients prior to ficulty sleeping over the past 6 weeks. He reports initiating pharmacotherapy is: having no appetite and has lost 15 pounds during this time. Mr. B. describes a loss of interest a. CBC test in most of the activities he used to find pleasur- b. Urinary MHPG test able and a diminished ability to concentrate. c. TRH stimulation test Although this is the first time he has felt this d. Dexamethasone suppression test Questions 157

10. Which laboratory test is proposed to differen- 14. Carl W., 60 years old, has been hospitalized on a tiate unipolar depression from Bipolar Disorder? medical unit for various aches and pains he has been experiencing for several weeks. He feels a. Urinary MHPG test depressed, tense, and unable to sleep at night. b. Dexamethasone suppression test In talking to the nurse, he reveals that his wife c. TRH and CRH stimulation test died 8 months ago, and he has not adjusted to d. SMAC test the loss. To maximize the opportunity to deter- 11. At an appointment with the psychiatric and mine the extent of Mr. W.’s bereavement versus mental health advanced practice nurse in depression, the nurse should: private practice, Edward K. reports that for the a. Ask the internist for a psychiatric consulta- past 3 or 4 years he has become depressed in tion for Mr. W. as soon as possible October after golf season is finished, begins b. Continue the discussion about his wife’s to feel better in April, and feels totally normal death and happy again by May. He says to the nurse, c. Explore his ambivalence toward his wife “Maybe I need other meaningful things in d. Inform the head nurse about Mr. W.’s my life.” The advanced practice nurse would feelings probably give him which of the following diagnoses? 15. D., age 33, is brought to the local hospital by her husband, who tells the nurse that she has been a. Major Depression, recurrent involved in a whirlwind of activity that began b. Major Depression several months ago when she quit her job to c. Bereavement write the “Great American Novel.” At the same d. Seasonal Affective Disorder time, she began painting her house. When he 12. Marcia S., age 53, describes herself as being tried to get her to slow down, her activity just depressed for as long as she can remember. increased; she took little time to sleep or eat, She describes it as “living under a gray cloud.” and began spending huge amounts of money. Marcia describes waking up 3 weeks ago feeling Her husband brought her to the hospital fol- like the gray cloud had turned black. She feels lowing a call from the bank informing him that sad, hopeless, worthless, guilty about something she had just tried to cash a check for $500,000. she cannot identify, and pessimistic about things On admission, D. is agitated, speaking loudly and getting better for her. The nurse would probably challenging the nurse. give her which of the following diagnoses? The nurse would probably give D. which of the following diagnoses? a. Dysthymia b. Double depression a. Bipolar Disorder. depressed phase c. Depression, recurrent type b. Bipolar Disorder, manic phase d. Depression, melancholic type c. Bipolar Disorder, hypomanic phase d. Bipolar Disorder, recurrent type 13. Karen K. called the office of the advanced practice PMH nurse in private practice saying 16. Two days ago, G. arrived on the psychiatric she had to have an appointment now or she unit in a manic episode, exhibiting extreme was going to fall apart. During the assessment excitement, disorientation, incoherent speech, interview, Karen described herself as becoming agitation, frantic, aimless physical activity, and increasingly depressed following the birth of grandiose delusions. Which assessment finding is her first child 9 months ago in April. At first most characteristic of this stage of mania? she felt blue, then increasingly despondent, a. Expansive mood sleeping a lot, hardly able to get out of a chair, b. Depressed mood crying all the time. She is now fearful that she c. Hypersomnia might hurt the baby if she doesn’t get some d. Low self-esteem help. The advanced practice nurse would probably give her which diagnosis? 17. Jason King, age 55, is admitted to the psychiatric unit of the general hospital. His wife states a. Major Depression that he has gradually become withdrawn over b. Major Depression, melancholic type the last month, refusing to bathe or change c. Major Depression, psychotic type clothes, eating little, failing to go to work and d. Major Depression, postpartum type sleeping only 3 to 4 hours per night. This evening 158 Chapter 7 Mood Disorders

Mrs. King heard a shot from the basement and help a patient develop more healthy coping found Mr. King bleeding from a superficial chest mechanisms by: wound. To assess Mr. King’s current potential for a. Promoting interpersonal relationships with suicide, the nurse should: peers a. Ask Mr. King why he feels like killing himself b. Allowing her to assume responsibility for her b. Observe Mr. King for scars on his wrists or decisions other signs of previous attempts c. Promoting the external expression of anger c. Ask Mrs. King about any previous suicide d. Setting realistic limits on her maladaptive attempts or threats by Mr. King behavior d. Determine if there is a family history of 24. When assessing a depressed person’s premorbid suicide personality characteristics, the nurse would 18. To further assess Mr. King’s suicide potential, the expect that he/she demonstrated: advanced practice PMH nurse should be particu- a. Vulnerability to loss larly alert to his expression of: b. Overmeticulousness a. Frustration and impatience c. Stubbornness b. Anger and resentment d. Vulnerability to anger c. Anxiety and loneliness 25. Blanche, 26 years old, is admitted to the d. Helplessness and hopelessness psychiatric unit with a diagnosis of Bipolar 19. The neurotransmitter hypothesis proposes that Disorder, manic episode. She is brought in depression occurs as a result of: by her husband, who states that she was fine until 3 days before admission. At that a. Depletion of dopamine at the postsynaptic time she decided to plan a huge high school receptor site reunion and began calling all her classmates. b. Imbalance of norepinephrine at the postsyn- Her speech became louder, more rapid, and aptic receptor site insulting when the idea was not greeted with c. Disturbance in regulation of biologic enthusiasm. Yesterday she went on a shopping rhythms spree and charged clothing worth $7000. This d. Shift in melatonin production and secretion morning she went into her husband’s office 20. Genetic linkage studies suggest commonalities and began reorganizing his files. She became between mania and which of the following? quite agitated, and her husband brought her to the emergency room. a. Schizophrenia In assessing Blanche, the nurse is aware that b. Major Depressive Disorder the manic episode is in reality an: c. PTSD d. Dissociative Identity Disorder a. Attempt to block unconscious feelings of depression 21. The circadian rhythm hypothesis proposes that b. Incorrect interpretation of environmental people with unipolar depression may: stimuli a. Be in a chronic state of sleep satiety c. Exaggerated response to an elating situation b. Have chronic hypo-arousal d. Uncontrolled acting out of uncensored id c. Have REM phase delay drives d. Be in an acute state of hypersomnia 26. Laurie M., age 32, is married and is a very suc- 22. The circadian rhythm hypothesis proposes that cessful attorney. She and her husband have a people with unipolar depression may: Victorian house they have restored. They ski, play tennis, and have an active social life. Yet a. Be in a chronic state of somnolence Laurie reports feeling depressed all the time. b. Have a disturbance in regulation of biologic She perceives herself as “never measuring up.” rhythms Despite having friends, she thinks they are only c. Have circadian rhythms that occur at a time nice to her because they like her husband. She late for sleep onset never enjoys the sports she does, because she d. Be in a chronic state of under-arousal never performs as well as she thinks she should. 23. Based on an understanding of the psychoana- According to cognitive theory, Laurie’s symptoms lytic theory of depression, the nurse can best are most likely related to: Questions 159

a. Logical errors night and says she just wants to crawl under a b. Negative feedback cover and not come out. c. Developmental trauma The psychiatric and mental health advanced d. Distorted self-concept practice nurse understands that Fran’s depression may be precipitated by: 27. Laurie’s cognitive, affective, and behavior patterns are maintained by irrational beliefs and a. Cluster stress events rules called: b. Anniversary reaction c. Stress reaction a. Logical errors d. Lack of social support b. Silent assumptions c. Cognitive distortions 31. If Fran S. began to feel depressed around the d. Developmental trauma time of year when her husband was killed, this would be called a(n): 28. Ted H., age 26, dropped out of college once, failed out twice, and currently works nights as a. Nodal event a janitor in a factory. Both Ted and his family b. Stress reaction regard him as the family disappointment. Ted c. Anniversary reaction calls the mental health clinic because he feels d. Life cycle stressor depressed and very worried that he is going 32. Bipolar patients frequently report family rela- to lose his job. He states that his company is tionship patterns that consist of: laying people off, and despite good evaluations, he knows that he will, as usual, be one of the a. Open communication patterns unlucky who get fired. b. Realistic expectations According to the Hopelessness Theory of c. Closed communication patterns Depression, the psychiatric and mental health d. Unrealistic expectations advanced practice nurse understands that Ted’s 33. When a manic patient exhibits extreme excite- symptoms are most likely to occur when negative ment, disorientation, frantic, aimless physical life events are perceived to be: activity, and grandiose delusions, which nursing a. Stable, global, important diagnostic category would hold the highest b. Unstable, global, important priority? c. Stable, specific, important a. Coping, ineffective d. Unstable, global, important b. Hopelessness 29. Ted’s ability to affect the outcome of potentially c. Violence, risk for self-directed negative life events, like losing his job, is per- d. Identity, disturbed personal ceived by him to be: 34. Carl W., age 70, is hospitalized for depression. His a. Nonexistent wife died 1 year ago. He has felt sad and tense b. Low ever since. He has lost 40 pounds this year, has c. Moderate difficulty getting up in the morning, has missed d. High numerous days of work and says to the nurse, “What’s the use of talking? I’d rather be dead. I 30. Fran S., age 57, is brought to the hospital can’t go on without my wife.” Emergency Department by her daughter. The psychiatric and mental health nurse makes She sits crying in a chair saying, “How much the nursing diagnosis of complicated grieving can a person take? I cannot take anymore.” associated with the loss of his wife. She makes Her daughter reports that Mrs. S.’s husband this nursing diagnosis because of was killed in a car accident 3 years ago, and Mr. W.’s: her 80-year-old mother was diagnosed with Alzheimers last year. Six months ago, her son a. Prolonged period of grief and mourning revealed that he is homosexual and last week after his wife’s death told the family that he has been HIV positive b. Difficulty expressing his loss for 3 years and was just diagnosed as having c. Inability to talk about his loss Kaposi’s sarcoma. Since that time, Fran has been d. Inability to sleep and symptoms of mute other than when she is crying and mut- depression tering. She refuses to eat, bathe, or change her 35. Which of the following is not an initial objec- clothes. She has not slept more than 3 hours a tive of pharmacological intervention in unipolar depression or Bipolar Disorder? 160 Chapter 7 Mood Disorders

a. Symptom reduction c. Citrus fruit b. Improved function d. Processed cheese c. Recurrence prevention 41. The nurse should teach a depressed patient on d. Seizure prevention MAOIs that failure to adhere to dietary restric- 36. The role of the nurse in pharmacological tions can result in: interventions that facilitates postdischarge com- a. Hyperglycemic episodes pliance with the medication regimen is: b. Bradycardia a. Collection of assessment data c. Hypertensive crisis b. Coordination of treatment modalities d. Snycope c. Monitoring of side effects 42. A psychiatric and mental health advanced prac- d. Patient education tice nurse orders lithium carbonate, 300 mg four 37. M., a depressed patient, is started on imipramine times a day and chlorpromazine, 100 mg four (Tofranil), 75 mg orally at bedtime. The nurse times a day for a manic patient who has just should tell the patient that: been admitted to the inpatient psychiatric unit exhibiting extreme excitement, disorientation, a. The medication may be habit forming, so frantic, aimless activity, and grandiose delusions. it will be discontinued as soon as she feels Which statement best explains the reason for better. ordering chlorpromazine? b. The medication has no serious side effects. c. She should avoid eating such foods as aged a. A lower dose of lithium can be given. cheese, yogurt, and red wine while taking b. Chlorpromazine helps control the manic the medication. symptoms until the lithium takes effect. d. The medication may initially cause some c. Joint administration makes both drugs more tiredness, which should become less bother- effective. some over time. d. Joint administration decreases the risk of lithium toxicity. 38. M., a depressed patient, will be started on a tricyclic antidepressant. The psychiatric and mental 43. The physician plans to order lithium carbonate health advanced practice nurse understands that for a manic patient. Before beginning the this type of medication: lithium treatment regimen, the nurse performs a physical assessment. She is aware that lithium is a. Blocks the transporter site for norepineph- contraindicated when a patient exhibits dysfunc- rine and serotonin tion of the: b. Increases reuptake of serotonin and norepinephrine a. Renal system c. Increases metabolism of neurotransmitters b. Reproductive system d. Regulates the frontal cortex where norepi- c. Endocrine system nephrine is made d. Respiratory system 39. D., a severely depressed patient, has not 44. Early signs of lithium toxicity include: responded to tricyclic antidepressants. Prior to a. Coarse tremors, ataxia, drowsiness, diarrhea beginning ECT, a decision is made to initiate a b. Ataxia, confusion, and seizures trial of another antidepressant. The drug family c. Elevated white blood cell count and ortho- of choice would be: static hypotension a. Heterocyclics d. Restlessness, shuffling gait, and involuntary b. Monoamine oxidase inhibitors (MAOIs) muscle movements c. Selective Serotonin Reuptake Inhibitors 45. One week after a manic patient begins taking (SSRIs) lithium, this nurse notes that his serum lithium d. Lithium level is 1 mEq/liter. How should the nurse 40. The physician orders tranylcypromine sulfate respond? (Parnate) for D. The nurse would be aware that a. Call the physician immediately to report the D. understood the teaching about the drug laboratory results. when the patient states, “While taking the medi- b. Observe the patient closely for signs of cine, I should avoid eating”: lithium toxicity. a. Fish b. Red meat Questions 161

c. Withhold the next dose and repeat the c. Hypotension blood work. d. Hyponatremia d. Continue administering the medication as 51. The most serious side effect of ECT is: ordered. a. Memory loss 46. A first-line pharmacologic treatment modality b. Cardiac arrhythmias for mood stabilization of Bipolar Disorder is: c. Hypotension a. Clonazepam d. Agitation b. Risperidone 52. The most effective approach to meeting a manic c. Valproate patient’s hydration and nutrition needs would be d. Serentil to: 47. Two weeks after a manic patient begins taking a. Leave finger foods and liquids in her room carbamezapine (Tegretol), the nurse notes that and let her eat and drink as she moves about her serum Tegretol level is 14 mg/1. How should b. Bring her to the dining room and encourage the psychiatric and mental health advanced prac- her to sit and eat with calm, quiet tice nurse respond? companions a. Call the physician immediately to report the c. Explain mealtime routines and allow her to laboratory results. make her own decisions about eating b. Observe the patient closely for signs of d. Provide essential nutrition through high- toxicity. calorie tube feedings c. Withhold the next dose and notify the 53. A depressed patient has difficulty sleeping at physician. night. She reports feeling fatigued and unre- d. Continue administering the medication as freshed. The nurse should NOT encourage the ordered. patient to: 48. M., a patient with severe depression, does not a. Limit intake of caffeinated drinks respond to several trials of antidepressant medi- b. Take sedatives hs cations. At a team conference, a decision is made c. Take daytime naps to initiate a series of electroconvulsive therapy d. Receive back rubs (ECT) treatments. When should nursing intervention begin? 54. The nursing staff request a consultation with the psychiatric and mental health advanced a. As soon as the patient and family are pre- practice nurse about a manic patient who dem- sented with this treatment alternative onstrates resistive behavior in relation to hygiene b. The night before ECT is scheduled activities. He refuses to bathe, brush his teeth, c. Immediately after ECT is administered or change his clothes. The advanced practice d. When the patient returns to the unit after PMH nurse suggests which of the following ECT therapy interventions? 49. The interdisciplinary team is considering elec- a. Matter of factly assist with hygiene troconvulsive therapy (ECT) treatments for M., a activities. patient with severe depression. The psychiatric b. Ignore the behavior. and mental health advanced practice nurse c. Confront the patient about his behavior. knows that which of the following are not d. Suggest that his medication be augmented appropriate indications for ECT as a treatment with a neuroleptic. approach: 55. Andrew M., age 42, is brought to the psychi- a. Emergency therapy for suicidal patients atric unit by his parents and a sister who states, b. Patients who are unresponsive to “He’s just not himself since his wife died 2 years antidepressants ago. He has no interests and doesn’t care for c. Use during time lag between initiation of himself any more, just sitting alone when he’s pharmacotherapy and onset of not working. The nurse discusses the plan of care effectiveness with Andrew. The nurse recognizes that it would d. Effectiveness in treatment of relatives be most helpful to: 50. The most distressing side effect of ECT is: a. Memory loss b. Ataxia 162 Chapter 7 Mood Disorders

a. Involve him in outdoor group games each check for $500,000 in an account that had a $5 day balance. D.’s husband states that she has hardly b. Encourage him to do relaxation exercises slept or eaten in the past 2 weeks. On admission, c. Encourage him to talk about and plan for D. is agitated, speaking loudly and challenging the future the nurse. Which approach would be most thera- d. Talk with him about his wife and the details peutic in working with D.? of her death a. Teaching the patient about banking 56. Andrew attends group therapy in which the procedures psychiatric and mental health advanced prac- b. Confronting the patient about her inappro- tice nurse is the leader. During one session, priate behavior another client talks about his wife leaving c. Kindly but firmly guiding the patient into and his feeling of abandonment. When the such activities as bathing and eating members are leaving the session, the APN-PMH d. Showing the patient that she is in a con- notices that tears are running down Andrew’s trolled environment face. Considering his problems, the APN-PMH 60. When developing a care plan for a manic should: client, which of the following are NOT impor- a. Ask the group members to return and discuss tant to consider when designing behavioral Andrew’s feelings interventions: b. Observe Andrew’s behavior carefully over a. Attention span the next few hours b. Distractibility c. Go to Andrew’s room and ask him to discuss c. Unit resources his thoughts and feelings d. Medication supply d. Ask another patient to stay and spend time talking with Andrew 61. Ms. W. is admitted to the psychiatric unit with a diagnosis of severe depression. One morning, Ms. 57. In planning activities for Mr. R., a depressed W. says to the nurse, “God is punishing me for patient, the nurse finds him very resistive and my past sins.” The nurse’s best response is: complaining about his inadequacies and worthlessness. The best approach by the nurse would a. “God is punishing you for your sins, Ms. W.?” be to: b. “Why do you think that, Ms. W.?” c. “You really seem upset about this.” a. Involve Mr. R. in activities in which he will be d. “What sins would he be punishing you for?” assured of success b. Listen to Mr. R. and delay the planned 62. Ms. W. tells the nurse that she has an unhappy activity for another time marriage and has had several affairs. Although c. Schedule activities that Mr. R. can complete she feels that her husband ignores her, she independently blames herself for having had these affairs. The d. Encourage Mr. R. to select an activity in most appropriate response to assist Ms. W. in which he has some interest exploring her thoughts and feelings is: 58. Which of the following responses reflects a a. “Help me to understand how these affairs cognitive approach to dealing with low self- are all your fault?” esteem? b. “Tell me why the affairs are your fault.” c. “It sounds like your husband ignores you. a. “For each negative trait you list about Who could blame you for having an affair?” yourself, I will ask you to give me a positive d. “Tell me about your husband.” trait.” b. “Can you recall six positive things about 63. James R., a manic patient, is approaching yourself?” discharge. He is to be discharged on lithium c. “What do you think interferes with your carbonate. In the family teaching plan for disability to view yourself in a positive charge, the nurse should stress the importance manner?” of: d. “What do you think would enable you to see a. Watching his diet to avoid aged cheese, yourself in a positive way?” yogurt, and caffeinated beverages 59. D., age 33, was brought to the hospital by b. Taking the pills with milk her husband following a call from the bank informing him that she had just tried to cash a Questions 163

c. Having a CBC done once a month a. Demand that she stop what she is doing d. Having his blood levels checked as ordered b. Firmly tell her that her behavior is unacceptable 64. The psychiatric and mental health advanced c. Ask her what is bothering her practice nurse is meeting with a group of recur- d. Increase her medication or have additional rent bipolar patients and their families. A key medication ordered preventive intervention designed to maintain family function is: 69. Mr. M., a 50-year-old man who has been treated for double-depression during the past two years, a. Recognition of relapse signs and symptoms states to the psychiatric and mental health b. Referral for family therapy advanced practice nurse “They’ve tried every c. Referral to NAMI medicine, nothing works, even the ones you d. Recognition of early signs of lithium toxicity can’t eat cheese with.” In reviewing his history, 65. Mrs. K. is admitted to the psychiatric unit fol- the APN-PMH notes the distinct absence of which lowing a suicide attempt. Mrs. K. does not of the essential laboratory tests that may explain answer any of the nurses’ questions. To assess his lack of response to pharmacological agents: Mrs. K.’s current potential for suicide, the nurse a. Blood gases should: b. Cardiac enzymes a. Ask Mrs. K. why she feels like killing herself c. Free thyroxine b. Observe Mrs. K. for scars on her wrists or d. White blood cell count other signs of previous attempts 70. T. R., a 46-year-old woman, is admitted to your c. Ask Mr. K. about any previous suicide inpatient psychiatric unit after a suicide attempt. attempts or threats by Mrs. K. She has a history of multiple psychiatric hos- d. Determine if there is a family history of pitalizations due to depression with similar suicide presentations. The following symptoms are also 66. In teaching an orientation group about nursing present: anhedonia, decreased sleep, difficulty care of the suicidal patient, the psychiatric and concentrating, low energy, hopelessness, and mental health advanced practice nurse teaches decreased appetite. The appropriate DSM diag- that the suicidal risk for a depressed patient is nosis for the clinical condition described is: often greatest: a. Major Depressive Disorder, single episode a. When the depression is most severe b. Major Depressive Disorder, recurrent b. Before any kind of somatic treatment is c. Dysthymic Disorder started d. Borderline Personality Disorder c. When the patient begins to express anger Case for 71 & 72: d. When the patient makes a sudden and dramatic improvement B. V., a 48-year-old male recovering from an acute myocardial infarction (MI), develops depressive symp- 67. A manic patient is assigned to a private room toms: decreased energy, anhedonia, poor appetite. that is somewhat removed from the nurse’s station. The primary reason for this room assign- 71. The most likely diagnosis is: ment is to: a. Bipolar Disorder, most recent episode a. Decrease environmental stimuli depressed b. Prevent the patient’s excessive activity from b. Major Depressive Disorder, single episode disturbing others c. Major Depressive Disorder, recurrent c. Deter the patient from disturbing the nurses d. Mood Disorder Due to MI, with depressive d. Provide the patient with a quiet environ- features ment for thinking about his problems 72. The best pharmacologic treatment option for 68. On the unit, a manic patient is elated and sar- B. V. is: castic. She is constantly cursing and using foul a. Citalopram language. She has the other clients on the units b. Imipramine terrified. The psychiatric and mental health c. Bupropion advanced practice nurse, who has been asked d. Venlafaxine to consult in the management of this patient, advises the staff to: 164 Chapter 7 Mood Disorders

Answers Bertrus, P. A., & Elmore, S. K. (1991). Seasonal affective disorder, part I: A review of the neural mechanisms 1. b 37. d for psychosocial nurses. Archives of Psychiatric Nurs- 2. b 38. a ing, 5(6), 357–364. 3. c 39. b Bezchlibnyk-Butler, K. Z., & Jeffries, J. J. (1996). Clinical 4. c 40. d handbook of psychotropic drugs (5th ed.). Lewiston, NY: Hogrefe & Huber Publishers. 5. a 41. c Gold, P. W., Goodwin, F. K., & Chrousos, G. P. (1988). 6. b 42. b Clinical and biochemical manifestations of depres- 7. b 43. a sion—part one. New England Journal of Medicine, 8. a 44. a 319, 348–353. 9. b 45. d Goodwin, F. K., & Jamison, K. R. (1990). Manic-depres- 10. c 46. c sive illness. New York, NY: Oxford University Press. 11. d 47. c Haber, J., Krainovich-Miller, B., Leach-McMahon, A. & 12. a 48. a Price-Hoskins, P. (1997). Comprehensive psychiatric 13. d 49. d nursing (5th ed.). St Louis, MO: C.V. Mosby Co. 14. b 50. a Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. 15. b 51. b (2005). Prevalence, severity, and comorbidity of 16. a 52. a twelve-month DSM-IV disorders in the National Co- morbidity Survey Replication (NCS-R). Archives of 17. c 53. c General Psychiatry, 62(6), 617–627. 18. d 54. a Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). 19. b 55. d Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. 20. a 56. c Levinson, D. F. (2005). Meta-analysis in psychiatric ge- 21. a 57. a netics. Current Psychiatry Reports, 7, 143–151. 22. b 58. a Moller, M. D., & Murphy, M. F. (1998). Recovering from 23. c 59. c psychosis: A wellness approach. Nine Mile Falls, WA: 24. a 60. d Psychiatric Rehabilitation Nurses, Inc. 25. a 61. c NANDA International. (2009). Nursing diagnoses: Defi- 26. a 62. a nitions & classifications, 2009–2011. West Sussex, UK: 27. b 63. d Wiley & Sons. 28. a 64. a Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sa- dock’s synopsis of psychiatry (10th ed.). Philadelphia. 29. a 65. c PA: Lippincott. 30. a 66. d Simmons-Ailing, S. (1987). New approaches to manag- 31. c 67. a ing affective disorders. Archives of Psychiatric Nurs- 32. d 68. b ing. 1(4), 219–224. 33. c 69. c Smith, P. F., & Darlington, C. L. (1996). Clinical pharma- 34. d 70. b cology: A primer. NJ: Lawrence Erlbaum Associates. 35. d 71. d Stahl, S. M. (2009). Stahl’s essential psychopharmacol- 36. d 72. a ogy: The prescriber’s guide (3rd ed.). New York, NY: Cambridge University Press. Bibliography Stahl, S. M. (2008). Stahl’s essential psychopharmacology: Neuroscientific basis & practical applications (3rd Agency for Healthcare Policy and Research (1993). ed.). New York, NY: Cambridge University Press. Depression in primary care. Rockville, MD: U.S. De- Stuart, G. W., & Sundeen, S. J. (1995). Principles and partment of Health and Human Services. AHCPR practice of psychiatric nursing (5th ed.). St. Louis, Publication No. 93-0551. MO: C. V. Mosby Co. American Psychiatric Association. (2000). Diagnostic Ugarriza, D. N. (1992). Postpartum affective disorders. and statistical manual of mental disorders (4th ed., Journal of Psychosocial Nursing. 30(5), 29–31. text revision). Washington, DC: Author. Wong, Arcos-Burgos, & Licinio, (2008). Frontiers in psy- Antai-Otong, D. (1995). Psychiatric nursing: Biological chiatric research. Psychiatric Times, 25(7). Retrieved and behavioral concepts. Philadelphia: W. B. Saun- March 3, 2009, from http://www.psychiatrictimes. ders Company. com/display/article/10168/1163054?pageNumber=2 Arana, G. W., & Hyman, S. E. (1991). Handbook of psychiatric drug therapy (2nd ed.). Toronto, Canada: Lit- tle, Brown and Company. 8 Behavioral Syndromes and Disorders of Adult Personality

Eating Disorders 2. Intense fear of gaining weight or becoming fat 3. Weight less than 85% of expected weight Fear of obesity and the pursuit of thinness repre- 4. Distorted body image sent the driving force in both Anorexia and Bulimia 5. At least three consecutive missed menstrual Nervosa, two of the most common eating disorders periods (Stuart & Sundeen, 1995). There is also consid- 6. Excessive exercising eration of including a diagnosis of obesity (body 7. Preoccupation with food mass index/BMI . 30) in the next revision of the 8. Bodily changes DSM (Devlin, 2007; Volkow, & O’Brien, 2007). a. Emaciated appearance b. Lanugo growth on face, extremities and Anorexia Nervosa (AN) trunk c. Bradycardia, hypotension, hypothermia • Definition (American Psychiatric Association are common [APA], 2000; Sadock & Sadock, 2007)—a severe d. Delayed gastric motility preoccupation with food and refusal to maintain a e. Dry skin, dry and falling hair weight within the normal range for age and height. f. Dental decay AN is divided into two predominate types: 1. Binge-eating/purging type—characterized by • Laboratory & other diagnostic tests (APA, 2006; Sa- intermittent episodes of rigorous/strict diet- dock & Sadock, 2007) ing and episode of binge-eating (eating more 1. Recommended laboratory tests for all eating than intended, but not enormous amounts) disordered patients: or purging (most often self-induced vomiting a. CBC, including differential and may include overuse of laxatives, and/or b. Blood chemistry studies diuretics or emetics) c. Serum electrolytes 2. Restricting type—characterized by avoiding d. BUN the intake of food as well as no evidence of e. Serum creatinine (interpretations must binge-eating or purging behavior—usually incorporate assessments of weight) trying to consume less than 300 calories per f. TSH test; if indicated, free T4, T3 day and no fat grams, may be compulsively g. Erythrocyte sedimentation rate overactive h. Aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase • Signs and symptoms (APA, 2000, 2006; Keltner, i. Urinalysis Schwecke, Bostrom, 2007; Sadock & Sadock, 2007) 2. Additional testing may be warranted, in- 1. Refusal to eat cluding an electrocardiogram for severely

165 166 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

malnourished patients, radiologic tests for GI 3. Dieting/fasting or excessive exercise to control bleeding, etc. weight 3. Screening tests (APA, 2006) 4. Weight usually within normal range a. Clinician-administered 5. Dehydration, electrolyte imbalance (1) Eating Disorder Examination (EDE) 6. Gastric acid in vomitus contributing to erosion (2) Yale-Brown-Cornell Eating Disorder of tooth enamel Scale (YBC-EDS) 7. Psychoactive substance abuse/dependence b. Self-report 8. Perceived inability to control binging (1) Diagnostic Survey for Eating Disorders 9. Average of at least 2 binges a week for at least 3 (DSED) months (2) Bulimia Test—Revised (BULIT-R) 10. Depressed mood and self-deprecatory (3) Eating Attitudes Test (EAT) thoughts following binges (4) Eating Disorder Examination—Ques- 11. Exaggerated concern about body shape and tionnaire (EDE-Q) weight (5) Eating Disorders Inventory-2 (EDI-2) 12. Enlargement of face and cheeks due to swell- (6) Eating Disorders Questionnaire (EDQ) ing of salivary glands (7) Questionnaire on Eating and Weight 13. Changes in EKG—cardiac arrhythmias leading Patterns (QEWP) to renal problems

• Mental status variations (Keltner, Schwecke, • Mental status variations (Keltner, Schwecke, Bostrom, 2007; Sadock & Sadock, 2007) Bostrom, 2007; Sadock & Sadock, 2007) 1. Mood and affect 1. Judgment and insight a. Dysphoric mood with crying spells a. Recognition that eating behavior is b. Emotionally lability abnormal c. Anxiety b. Problems with impulse control (stealing, d. Low self-esteem drug and/or alcohol abuse, self- 2. Sleep disturbance (insomnia or hypersomnia) mutilation, suicide attempt) 3. Thought processes c. Manipulative and untruthful behavior a. Distorted body image d. Difficulty identifying and dealing with b. Delusional thinking about body size emotions c. Concrete thinking 2. Thought processes d. Overpowering fear of losing control a. Overly concerned with body shape and e. Hypochondriasis weight f. Obsession with food and cooking b. Obsessional ideas g. Decreased concentration 3. Mood—depressed (feels sad and lonely, empty 4. Appearance—emaciated and isolated, with self-criticism and guilt 5. Defense mechanisms feelings) a. Repression 4. Orientation—lethargy and confusion due to b. Regression extreme dehydration caused by self-induced c. Denial vomiting and excessive use of laxatives d. Manipulation—untruthful about food intake and methods of losing weight Information Common to Anorexia 6. Impaired judgment related to food and Bulimia 7. Impaired insight a. Intellectualization • Differential diagnosis b. Perfectionistic attitude 1. Depressive disorders 8. Behavior a. Absence of distorted body image a. Ritualistic b. Absence of intense fear of obesity b. Compulsive c. True loss of appetite 2. Obsessive-Compulsive Disorder Bulimia Nervosa 3. Schizophrenic disorders a. Bizarre eating patterns present without • Signs and symptoms (APA, 2000, 2006) eating disorder syndrome or concern with 1. Recurrent episodes of binge eating the caloric content of food 2. Self-induced vomiting or abuse of laxatives/ b. Refusal to eat diuretics Eating Disorders 167

4. Somatization Disorder • Intrapersonal origins/Psychotherapeutic a. Absence of fear of becoming overweight interventions b. Amenorrhea for 3 months or more is 1. Origins unusual a. Unresolved conflicts during childhood 5. Medical illnesses b. Inconsistent parental response to child’s a. Hyperthyroidism needs b. Neoplasms c. Disturbance of self-esteem c. Anemia d. Food serving as a means to express d. Diabetes mellitus feelings e. Crohn’s disease e. Separation, individuation, and control is- f. Neurological diseases sues (Anorexia Nervosa) 6. Borderline Personality Disorder f. Independence/dependence struggle between woman and parent(s) • Nursing diagnoses (NANDA, 2009) g. Avoidance of sexuality 1. Body Image, disturbed 2. Psychotherapeutic interventions (NOTE: 2. Fluid Volume, risk for deficient Hospitalization for medical stabilization and 3. Nutrition—less than body requirements, restoration of nutritional state (dehydration, imbalance starvation, electrolyte imbalance) may be re- 4. Nutrition—more than body requirements, quired.) (APA, 2006; Sadock & Sadock 2007) imbalanced a. Objectives 5. Nutrition—risk for more than body require- (1) Addressing eating disordered behavior ments, imbalanced (restoration to a healthy weight, and 6. Anxiety (moderate to severe) elimination of binge/purge behaviors); helping client reestablish nor- • Genetic/Biological origins mal eating behavior, avoid excessive 1. Decreased hypothalamic norepinephrine exercise, avoid self-induced vomiting activation or laxative abuse 2. Dysfunction of lateral hypothalamus (2) Treating any physical complications 3. Abnormal dexamethasone suppression test and associated psychiatric conditions findings (3) Enhancing patient’s motivation to 4. Low serum serotonin level (Bulimia Nervosa) cooperate in the restoration of healthy 5. Hereditary predisposition eating patterns and participation in 6. Excess endorphins shutting down the feeding treatment system and inhibiting release, thus initiating (4) Educating patient regarding healthy amenorrhea nutrition and eating patterns 7. Chronic deficit of endorphins initiating feed- (5) Helping patient to reassess and ing to stimulate this down-regulated system change core dysfunctional cognitions, attitudes, motives, conflicts, and feel- • Biochemical interventions (APA, 2006; Sadock & ings related to the eating disorder Sadock, 2007; Stahl, 2008) (6) Enlisting family support and provid- 1. There are no medications yielding efficacious ing family counseling and therapy results in treating Anorexia Nervosa. There is where appropriate limited evidence of success with cyprohep- (7) Helping to develop a plan to prevent tadine (Periactin) and amitriptyline (Elavil). relapse There is additional evidence for effectiveness b. Individual psychotherapy (insight- of medications used to address associated oriented therapy) symptoms of depression, anxiety, and agita- (1) Establish realistic thinking process. tion. In Anorexia Nervosa, patients can be (2) Increase self-esteem. concerned about the side effect of weight gain (3) Establish a healthy sense of control associated with any medication; this topic and autonomy. must be addressed sensitively. (4) Deal with underlying psychological 2. Antidepressants have been effective in ad- conflicts. dressing symptoms of Bulimia Nervosa. SSRIs 3. Cognitive/Behavior therapy (very effective (specifically fluoxetine) have the highest em- in treating Bulimia Nervosa—most effective pirical support and lowest side effect profile when combined with SSRI (fluoxetine)) for these patients. a. Establish contract b. Describe expected behaviors 168 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

c. Eliminate power struggle 3. Counteract effects of starvation by promoting d. Initiate consistency from staff to coordi- weight gain and restoring normal nutritional nate treatment balance. e. Positive reinforcement 4. Include dietitian in treatment plan. f. Informational feedback 5. Encourage client to share feelings with staff. g. Progressive desensitization focusing on 6. Maintain consistency of responses among staff feelings prior to an episode of binge eating members. 4. Relaxation techniques 7. Document intake and output. 8. Involve dietitian in treatment planning and • Family dynamics/Family therapy teaching of proper nutrition. 1. Overly strict environment and disagreement 9. Reduce focus on food or eating with client concerning discipline once protocol established; art and other ex- 2. Chaotic, conflictual environment with marital pressive therapies may be useful in helping discord and hostility client express feelings. 3. Power and control issues 10. Use behavioral reinforcement. 4. High value placed on perfectionism 11. Provide group interaction with peers. 5. Parental criticism that promotes perfectionis- 12. Address adolescent development issues. tic and obsessive behavior in child 13. In hospital, give client opportunity to be re- 6. Feelings of helplessness and ambivalence sponsible for own weight gain and reward for 7. Perceived loss of control in life conforming to treatment regimen. 8. Family unable to resolve problems that arise 14. Encourage behavioral diaries. with the family 15. Teach to recognize cues for hunger and 9. Need for “sick” member to enable the other satiation. family members to communicate with each 16. Limit exercising in treatment. other 17. Avoid keeping food records, weighing fre- 10. Less understanding and nurturant and more quently, constantly counting calories, cooking belittling, blaming, rejecting, and neglectful for others, and reading recipes. 11. Sexual abuse 12. Family therapy • Community resources a. Educate family about the disorder. 1. Eating disorder groups b. Support family as they deal with guilt and 2. Family support groups stigma of having member with disorder. 3. Twelve-step programs c. Focus on fostering open, healthy interaction patterns. Sexual and Gender Identity Disorders • Group approaches 1. Types Paraphilias (Sadock & Sadock, 2007) a. Supportive b. Self-help • Definition—repetitive or preferred sexual fantasies c. Small group therapy or behaviors that involve giving or receiving pain, d. Support group for parents or activity with a nonconsenting partner, to experi- e. Outpatient ence full sexual arousal and satisfaction (Wilson 2. Group functions & Kneisl, 1996). Paraphilias include the following a. Fostering self-esteem subcategories: b. Gaining insight 1. Fetishism—use of clothing or other nonliving c. Sharing concerns object as source of sexual arousal (not clothing d. Providing constructive support from peers of opposite sex—see transvestic fetishism) 2. Exhibitionism—exposure of genitals to unsus- • Milieu interventions (Keltner, Schwecke, Bostrom, pecting stranger 2007) 3. Frotteurism—body contact with strangers in 1. Provide for safety and physical needs. public places—usually involves the rubbing 2. Closely observe with appropriate interven- of the clothed body of a stranger with male tions for avoidance behaviors (hiding food in genitalia napkin to discard later, intentionally spilling 4. Pedophilia—sexual contact with prepubescent food while eating). child 5. Sexual masochism—receiving physical/mental pain from sexual partner Sexual and Gender Identity Disorders 169

6. Sexual sadism—inflicting physical/mental • Milieu interventions—nurse’s role is primarily pain on sexual partner associated with prevention of problems, which 7. Transvestic fetishism—recurrent cross- focuses on the development of adaptive coping dressing by heterosexual male strategies to deal with stressful life events. 8. Voyeurism—watching others undressing/ engaged in sexual activity Gender Identity Disorder

• Differential diagnosis • Definition—persistent discomfort with one’s as- 1. Rule out nonpathogenic sexual signed gender and a feeling that it is inappropriate experimentation. or inaccurate (Sugar, 1995) 2. Rule out public urination. 3. Rule out exposure as prelude to sexual activity • Signs and symptoms—DSM-IV-TR Criteria (APA, with child. 2000) 4. Rule out poor judgment due to: 1. A strong and persistent cross-gender identifi- a. Mental retardation cation (not merely a desire for any perceived b. Organic personality syndrome cultural advantages of being the other sex) c. Alcohol intoxication a. In children, manifested by at least four of d. Schizophrenia the following: (1) Repeatedly stated desire to be, or in- • Mental status variations sistence that he or she is, the other sex 1. Inadequate social skills (2) In boys, preference for cross-dressing 2. Depressed mood and anxiety accompanying or simulating female attire; in girls, the behaviors insistence on wearing only stereotypi- 3. Poor judgment and impulse control cal masculine clothing (3) Strong and persistent preferences for • Genetic/Biologic origins cross-sex roles in make-believe play or 1. Limbic system or temporal lobe abnormalities persistent fantasies of being the other 2. Abnormal levels of androgens sex (4) Intense desire to participate in the ste- • Biochemical interventions reotypical games and pastimes of the 1. Antiandrogenics—medroxyprogesterone other sex (depo-Provera)—5 to 10mg/day induces a re- (5) Strong preference for playmates of the versible chemical castration. other sex 2. Serotonergic agents (SSRIs) have been used b. In adolescents and adults, manifested by with limited success. symptoms such as: (1) Stated desire to be the other sex • Intrapersonal origins/Psychotherapeutic (2) Frequent passing as the other sex interventions (3) Desire to live or be treated as the other 1. Origins sex a. Unresolved Oedipus complex leading to (4) The conviction that one has the typi- identification with opposite gender parent cal feelings and reactions of the other or object for libido cathexis sex b. Castration anxiety 2. Persistent discomfort with one’s sex or sense 2. Psychotherapeutic interventions of inappropriateness in the gender role of that a. Psychodynamic psychotherapy sex (1) Explore thoughts, feelings, and behav- a. In children, manifested by any of the ior that precede paraphiliac behavior following: in order to control occurrences. (1) In boys, assertion that his penis or tes- (2) Eliminate anxiety or depression that tes are disgusting or will disappear or accompanies behavior. assertion that it would be better not to b. Behavior therapy have a penis (1) Systematic desensitization (2) In boys, aversion toward rough-and- (2) Aversive techniques tumble play and rejection of male ste- (3) Assertiveness training reotypical toys, games, and activities c. Combination of psychodynamic and be- (3) In girls, rejection of urinating in a havioral techniques sitting position or assertion that she does not want to grow breasts or 170 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

menstruate, or marked aversion to- b. In girls—Mother lacks self-esteem as a ward normative feminine clothing woman and derogates femininity as infe- b. In adolescents and adults, manifested by rior. Mother rejects girl who turns to father symptoms such as preoccupation with who nurtures and protects from the ag- getting rid of one’s primary and second- gressive mother. ary sex characteristics (e.g., request for c. In both boys and girls—separation hormones, surgery, or other procedures threats and behavior as defense against to alter physical sexual characteristics to separation simulate the other sex) or belief that one 2. Psychotherapeutic interventions was born the wrong sex a. Psychotherapy 3. Not concurrent with a physical intersex condi- (1) Assist to individuate from mother. tion (e.g., androgen insensitivity syndrome or (2) Aid in developing diverse perceptions congenital hyperplasia) of women and femaleness. 4. Clinically significant distress or impairment in (3) Work through loss of the attachment social, occupational, or other important areas figure. of functioning b. Behavioral therapy (1) Systematically arrange that rewards • Differential diagnosis follow sex-appropriate behaviors. 1. Schizophrenia—clients rarely develop delu- (2) Target behaviors, such as selection sion that focuses on sex change; may have hal- of toys and dress-up play, exclusive lucinations or ideas of reference. affiliation with opposite sex, and 2. Late adolescents who are uncomfortable with mannerism. own bodies but feel guilty because of attrac- (3) Enhance behavior deficiencies such as tion to members of own sex. May feel homo- poor athletic ability. sexuality is worse than transsexualism and (4) Focus on overt sex-type behaviors want sex reassignment to lead normal hetero- rather than gender identity or gender sexual lives. dysphoria. 3. Nonconformity to stereotypical sex role (5) Provide social attention or social behavior—cross-gender wishes due to reinforcement. nonconforming (6) Encourage self-monitoring 4. Transvestic fetishism—cross-dressing behav- procedures. ior for sexual excitement • Family dynamics • Mental status variations 1. Strong interest in opposite-gender role be- 1. Dysphoric mood havior and weak reinforcement of normative 2. Anxiety gender-role behavior by parents 2. Extreme physical and psychological closeness • Genetic/Biologic origins with son by the mother 1. Prenatal estrogen and androgen levels a. Parental encouragement of cross-gender 2. Chromosomal abnormalities behavior—mothers of feminine boys themselves had gender identity conflicts • Intrapersonal origins/Psychotherapeutic as children that led them to devalue men interventions and masculinity 1. Origins b. Father as physically absent or psycho- a. In boys logically peripheral—no counterforce to (1) Physical or psychological loss of the pathogenic mother-son relationship mother that results in separation anxiety in the child Sexual Dysfunctions (2) Severe disruption or distortion in mother-son relationship that results • Definitions (APA, 2000) in the mother’s withdrawal, which 1. Male Erectile Disorder—persistent or recur- leads to separation anxiety and femi- rent inability to maintain an erection until nine behavior completion of sexual activity (3) Feminine behavior and/or identifica- 2. Female Sexual Arousal Disorder—persistent or tion caused by excessive closeness to recurrent inability to attain or maintain an ad- mother equate lubrication-swelling response of sexual Sleep Disorders 171

excitement until completion of the sexual c. Sexual phobias activity d. Depression 3. Dyspareunia—pain before, during, and after e. Fear of becoming pregnant sexual intercourse f. Traumatic sexual experiences in childhood 4. Vaginismus—recurrent or persistent invol- g. Negative conditioning that sex is dirty untary spasm of the musculature of the outer 2. Psychotherapeutic interventions third of the vagina that interferes with sexual a. Cognitive therapy—changing maladaptive intercourse beliefs 5. Orgasmic Disorder—persistent or recurrent b. Psychodynamic therapy—resolving intra- delay in, or absence of, orgasm following a psychic conflicts normal sexual excitement phase c. Behavioral therapy 6. Premature Ejaculation—persistent or recur- (1) Systematic desensitization rent ejaculation with minimal sexual stimula- (2) Sensate focus exercises tion before, upon, or shortly after penetration (3) Masturbatory training and before the person wishes it (4) “Squeeze” technique for premature 7. Hypoactive Sexual Desire Disorder—per- ejaculation sistently or recurrently deficient (or absent) d. Marital/sex therapy to treat dysfunctions sexual fantasies and desire for sexual activity of sexual response cycle 8. Sexual Aversion Disorder—persistent or recur- e. Hypnotherapy rent extreme aversion to and avoidance of all (or almost all), genital sexual contact with a • Family therapy—Couples/Marital therapy sexual partner 1. Homework assignments or exercises 2. Observing and responding to homework • Differential diagnosis 1. Central nervous system tumors • Group approaches 2. Mood disorder 1. Discussion of problems and concerns 3. Rape trauma syndrome 2. Homework for individual and couple 4. Neuroendocrine disorders exploration 5. Penile, prostate, or testicular cancer 3. Group support and reassurance 6. End-stage renal disease • Milieu interventions • Mental status variations—affect may be sad, de- 1. Use nondirective approach in completing pressed, or anxious assessment. 2. Use language that is understandable to the • Nursing diagnoses (NANDA, 2009) client. 1. Sexual Dysfunction 3. Convey attitude of warmth, openness, honesty, 2. Sexuality Pattern, ineffective and objectivity. 4. Remain nonjudgmental. • Genetic/Biologic origins 1. Decreased levels of serum testosterone • Community resources 2. Elevated levels of prolactin 1. Sex Addicts Anonymous 3. Physical changes due to: 2. American Association of Sex Educators, Coun- a. Surgery, aging, or trauma selors, and Therapists (AASECT) b. Drug abuse or medication side effects c. Neurological disorders Sleep Disorders d. Infection and poor hygiene Primary Insomnia • Biochemical interventions—the primary medications used in treating erectile dysfunction are the • Definition—the inability to initiate or maintain PDE-5 inhibitors—sildenafil (Viagra); vardenafil adequate sleep not due to any other cause (e.g., (Levitra) and tadalafil (Cialis). psychiatric illness, medical illness, or drug use)

• Intrapersonal origins/Psychotherapeutic • Differential diagnosis interventions 1. Physical conditions 1. Origins 2. Medication—withdrawal from CNS stimulants a. Religious orthodoxy 3. Dysthymia—mood disturbance b. Gender identity or sexual preference 4. Cyclothymia—insomnia due to hypomania 172 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

5. Normal aging—changes in sleep pattern 2. First-line options for sleep onset and sleep 6. Psychiatric disorder maintenance problems: 7. Constant pain a. Zolpidem CR (Ambien CR) —12.5 mg PO 8. Obstructive lung disease at bedtime 9. Neurological diseases b. Eszopiclone (Lunesta)—1 to 3 mg PO at bedtime • Mental status variations 3. Second-line treatment options include: 1. Anxiety a. Benzodiazepines 2. Depression (1) Triazolam—0.125 to 0.25 mg PO at 3. Appearance of fatigue (e.g., sleepy, dark circles bedtime under eyes) (2) Temazepam—15 to 30 mg PO at 4. Difficulty concentrating bedtime (3) Estazolam—1 to 2 mg PO at bedtime • Nursing diagnoses (NANDA, 2009) (4) Flurazepam—15 to 30 mg PO at bed- 1. Coping, ineffective time for 7 to 10 days 2. Fatigue (5) Quazepam—15 to 30 mg PO at 3. Insomnia bedtime 4. Sleep Deprivation b. Trazodone—25 to 50 mg PO at bedtime, 5. Sleep Pattern, disturbed may need to increase to 50 to 100 mg (or 6. Walking, impaired full antidepressant dose) PO at bedtime c. Antihistamine (diphenhydramine)—25 to • Genetic/Biologic origins 50 mg PO at bedtime; hydroxyzine—50 to 1. Two primary neurotransmitters involved in the 100 mg PO at bedtime sleep/wake cycle a. Histamines • Intrapersonal origins/Psychotherapeutic b. GABA interventions 2. Increased autonomic activity 1. Origins 3. Increased physiologic activation as evidenced a. Higher levels of depressed mood and anxi- by increased heart rate, core body tempera- ety than normal individuals ture, skin conductance b. Increased cognitive activity for clients 4. Increased levels of stress without medical or psychiatric disorder 5. Other psychopathology other than anxiety caused by stress a. Mood disorders 2. Psychotherapeutic interventions (Williams, b. Psychoactive Substance-Abuse Disorder Karacan, Moore & Hirshkowitz, 1995) 6. Physical disorders that cause pain/discomfort, a. Sleep hygiene training such as arthritis, angina b. Stimulus control instructions 7. Hormonal disturbances c. Sleep restriction 8. Lifestyle that includes frequent changes or ir- d. Chronotherapy regular sleep-wake patterns e. Bright light therapy 9. Febrile illness in childhood associated with f. Relaxation, meditation, biofeedback sleep terror disorder and sleep walking g. Cognitive therapy disorder (1) Alter view of sleep problem (2) Paradoxical intention with thought • Biochemical interventions (selection of agent de- stopping and identification of irratio- pends upon the specific sleep problems) (Stahl, nal beliefs about sleep 2008) 1. Sleep-onset-only problem first-line agents: • Family dynamics/Family therapy—none described a. Zolpidem (Ambien)—10 mg PO at bedtime for 7 to 10 days; or Ambien CR—12.5 • Group approaches mg PO at bedtime 1. Self-hypnosis b. Eszopiclone (Lunesta)—1 to 3 mg PO at 2. Autogenic training bedtime 3. Sharing concerns c. Zalplon (Sonata)—10 mg PO at bedtime 4. Gaining insight for 7 to 10 days d. Ramelteon (Rozerem)—8 mg PO at • Milieu interventions bedtime 1. Decrease caffeine and alcohol intake during afternoon and evening. Impulse Control Disorders 173

2. Increase exercise during morning and • Differential diagnosis afternoon. 1. Psychotic disorders—violent behavior may 3. Encourage use of relaxation techniques. result in response to delusions and hallucina- 4. Discourage daytime naps. tions, and there is gross impairment of reality 5. Encourage expression of emotion that might testing. affect sleep. 2. Organic mental disorder—violent behavior 6. Eliminate or diminish environmental factors results from confusion or medical condition. that may disturb sleep. 3. Antisocial or Borderline Personality Disorder— 7. Encourage client to get out of bed for alterna- aggressiveness and impulsivity are part of the tive activities when unable to fall asleep. client’s character and are present between outbursts. • Community resources 4. Conduct Disorder—presents with a repetitive 1. Stress management training and resistant pattern of behavior as opposed 2. Biofeedback training to an episodic pattern. 3. Yoga classes 5. Intoxication with or effects of a psychoactive substance (anabolic steroids) is present. Other Sleep Disorders 6. Bipolar Disorder—manic behavior is present.

• Definitions only are provided for the following • Mental status variations sleep disorders (APA, 2000): 1. Uncontrolled anger 1. Narcolepsy—excessive daytime sleepiness and 2. Impulsivity abnormal manifestations of REM sleep 3. Poor judgment 2. Breathing-related Sleep Disorder—sleep dis- 4. Emotional instability turbance due to sleep-related breathing dif- 5. Paranoia ficulties (e.g., sleep apnea or central alveolar hypoventilation syndrome) • Genetic/Biologic origins (Sadock & Sadock, 2007) 3. Circadian Rhythm Sleep Disorder (Sleep-Wake 1. Low cerebrospinal fluid levels of 5-H1AA Schedule Disorder)—sleep disruption due to 2. Inhibition of serotonin synthesis or antagoniz- mismatch between the sleep-wake schedule ing effects of serotonin required by a person’s environment and his/ 3. Hormonal disturbance (increased her circadian sleep-wake pattern testosterone) 4. Sleep Terror Disorder—recurrent episodes of 4. Prenatal trauma, infantile seizures, head abrupt awakening from sleep without dream trauma, encephalitis, and hyperactivity recall 5. Disordered brain physiology in the limbic 5. Sleepwalking Disorder—repeated episodes system of arising from bed during sleep and walking 6. Hereditary predisposition about 6. Primary Hypersomnia—excessive sleepiness • Biochemical interventions—mixed results with the that results in impairment in social, occupa- following agents (Sadock & Sadock, 2007): tional, or other important areas of functioning 1. Lithium—300 mg tid—qid 2. Carbamazepine—200 mg bid with food Impulse Control Disorders 3. Oxazepam—10 to 30 mg tid or qid 4. Propranolol—60 to 640 mg/day • Definitions—characterized by the failure to resist an impulse, drive or temptation to perform some • Nursing diagnoses (NANDA, 2009) act that is harmful to the individual or others. 1. Coping, ineffective There is increasing tension or arousal before com- 2. Violence, [actual/] risk for other-directed mitting the act and pleasure, gratification, or relief a. Nursing interventions during the act (Sadock & Sadock, 2007). (1) Convey an accepting attitude toward the client. Intermittent Explosive Disorder (2) Maintain low level of stimuli in client’s environment (low lighting, few • Definition—those individuals who have discrete people, simple decor, low noise level). episodes of losing control of aggressive impulses (3) Help client recognize the signs that resulting in serious assault or the destruction of tension is increasing and ways in property which violence can be averted. 174 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

(4) Explain to client that should explosive 1. Pathological Gambling—chronic and pro- behavior occur, staff will intervene in gressive failure to resist impulses to gamble whatever way is required (e.g., tran- and gambling behavior that compromises, quilizing medication, restraints, isola- disrupts, or damages personal, family, or voca- tion) to protect the client and others. tional pursuits (5) Help client identify the true object of 2. Kleptomania—recurrent inability to resist his/her hostility. the impulse to steal objects not needed for b. Outcome criteria personal use or their monetary value; with- (1) Client will not cause harm to self or out premeditation and little thought of legal others. consequences (2) Client will be able to verbalize the 3. Pyromania—deliberate and purposeful fire symptoms of increasing tension. setting on more than one occasion; tension (3) Client will be able to verbalize strate- or an affective arousal before setting the fires; gies to avoid becoming violent. and intense pleasure, gratification, or relief when setting the fires or seeing the fires burn • Intrapersonal origins/Psychotherapeutic 4. Trichotillomania—recurrent failure to resist interventions impulses to pull out one’s own hair; onset 1. Origins—early frustration, oppression and usually occurring before age 17 and affecting hostility as predisposing factors females more often than males 2. Psychotherapeutic interventions (Keltner, Schwecke, & Bostrom, 2007): Personality Disorders—coded a. Cognitive and Behavioral therapies on Axis II of the DSM-IV-TR b. Social skills training multiaxial classification c. Problem solving system d. Relaxation exercises e. Stress management • Definition—An enduring pattern of perceiving, relating to, and thinking about the environment • Family dynamics/Family therapy and oneself to the extent that it leads to inflexible 1. Early chaotic and violent family environment and maladaptive behavior, and either significant with heavy drinking, by one or both parents functional impairment or subjective distress. In 2. Parental brutality, child abuse, and emotional the DSM-IV-TR, personality disorders are clustered and physical unavailability of a father figure into three categories: 3. Family therapy can be helpful when client is 1. Cluster A—subtypes are: schizoid, schizotypal, adolescent or young adult. and paranoid. Cluster A personality disorders are characterized by odd and aloof features. • Group approaches 2. Cluster B—subtypes are: antisocial, borderline, 1. Fostering group loyalty histrionic, narcissistic. Cluster B personality 2. Peer pressure to reinforce expectations and disorders are characterized by impulsive, dra- provide confrontation matic, and erratic features. 3. Cluster C—subtypes are: obsessive- • Milieu interventions compulsive, avoidant, and dependent. Cluster 1. Provide structured outlets for the energy of C personality disorders are characterized by anger. anxious and fearful features. (APA, 2000; 2. Encourage physical activity that allows large Sadock & Sadock, 2007) muscle involvement (e.g.,jogging, swimming, weight lifting). Cluster A Personality Disorders 3. Ensure a safe and therapeutic environment. 4. Teach appropriate expression of anger. Schizoid Personality Disorder 5. Reduce sources of undue anxiety or high levels • Definition—diagnosed in patients who display of anxiety to prevent angry outbursts. a lifelong pattern of social withdrawal; often described as eccentric. • Community resources—mental health centers • Differential diagnosis Other Impulse Control Disorders 1. Schizotypal Personality Disorder—cognitive and perceptual distortions • Definitions only are provided for the following im- 2. Paranoid Personality Disorder—suspicious- pulse control disorders (Sadock & Sadock, 2007): ness and paranoid ideation Personality Disorders—Coded on Axis II of the DSM-IV-TR Multiaxial Classification System 175

3. Avoidant Personality Disorder—social isola- 4. Low levels of platelet monoamine oxidase tion but a strong desire for relationships with (MAO) observed in some individuals with others Schizotypal Disorder. 4. Obsessive-Compulsive Personality Disorder— social detachment due to excessive devotion to • Biochemical interventions—There are no empiri- work and difficulty expressing emotions rather cally supported medications used to treat person- than lack of desire or capacity for intimacy ality disorders. The following medications have been used to treat anxiety, depression, agitation, Schizotypal Personality Disorder and psychotic-like symptoms (Sadock & Sadock, • Definition—Individuals are strikingly odd or 2007): strange, even to laypersons; magical thinking, pe- 1. MAOIs have been used with limited success— culiar ideas, ideas of reference illusions, and dere- social anxiety, social phobia, and depressive alization are part of their everyday world. symptoms. 2. Navane—schizotypal; decreases illusions, • Differential diagnosis ideas of reference, obsessive symptoms and 1. Schizophrenia—has enduring psychosis Phobic Disorder. 2. Paranoid and Schizoid Personality Disorders— 3. Antipsychotics (haloperidol)—in small doses cognitive and perceptual distortion, marked for brief periods can be used for paranoid eccentricity or oddness and profound social thinking, anxiety, and hostility. discomfort 3. Avoidant Personality Disorder—desiring • Intrapersonal origins/Psychotherapeutic relationships interventions 4. Borderline—engagement in social isolation as 1. Origins a result of having intentionally driven others a. Schizoid Personality Disorder—grossly away inadequate, cold, or neglectful early parenting that creates expectation that the Paranoid Personality Disorder relationship would not be gratifying and • Definition—characterized by long-standing suspi- leads to subsequent defensive withdrawal ciousness and mistrust of people in general from others b. Paranoid—recipient of irrational and over- • Differential diagnosis whelming parental rage may lead to an 1. Paranoid Schizophrenia—persistent psy- identification with that rage and its pro- chotic symptoms (hallucinations and bizarre jection onto others delusions) 2. Psychotherapeutic interventions 2. Delusional Disorder, paranoid type—promi- a. Psychotherapy—treatment of choice, fo- nent and persistent delusions of persecution cusing on the client’s feelings rather than 3. Schizotypal Personality Disorder—cognitive intellectualized thoughts and perceptual distortions b. Cognitive therapy—to address faulty thinking Information Common to Cluster A Personality Disorders • Family dynamics—Cluster A (paranoid, schizo- • Nursing diagnoses (NANDA, 2009) typal, schizoid)—subjected to parental antagonism 1. Coping, defensive related to guardedness and by serving as scapegoats for displaced parental secretiveness aggression 2. Social Interaction, impaired 3. Social Isolation • Group approaches 1. Schizoid Personality Disorder—to increase • Genetic/Biologic origins (Sadock & Sadock, 2007) comfort in social situations 1. Hereditary—Cluster A (paranoid, schizotypal, 2. Paranoid Personality Disorder—may not be schizoid)—family history of psychiatric dis- good due to excessive suspiciousness orders such as alcoholism, drug addiction, or Schizophrenia Cluster B Personality Disorders 2. Schizotypal—more often with first-degree biologic relatives diagnosed with Schizophrenia Antisocial Personality Disorder 3. Imbalance in dopamine and serotonin neu- • Signs and symptoms rotransmitter of persons with Schizotypal Per- 1. More common in men sonality Disorder 2. History of irresponsibility and impulsiveness 176 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

3. Lacks remorse for actions • Family dynamics 4. Exploits and manipulates others 1. Chaotic home environment 5. Self-centered 2. Parental deprivation during the first 5 years of 6. Anger that leads to hostile outbursts life 3. Presence of intermittent appearance of incon- • Differential diagnosis sistent, impulsive parents 1. Conduct Disorder—if person younger than 18 4. Traumatic abandonment experiences years with characteristic features present 5. Physical and sexual abuse 2. Psychoactive substance abuse—episodic behavior associated with alcohol/drug intake • Group approaches 3. Mental retardation—may exhibit remorse due 1. Help client assume responsibility for to actions or behavior behaviors. 4. Schizophrenia—presence of prolonged psy- 2. Confront inappropriate and manipulative chotic episodes behaviors. 5. Manic episode—mood changes 3. Allow client to receive parenting not previously 6. Cyclothymic Disorder—periods with hypo- received. manic symptoms and depressive symptoms 4. Allow client to tolerate feelings of emptiness, 7. Borderline Personality Disorder—fear of aban- depression, and anxiety. donment, substance abuse 5. Develop socially appropriate behavioral responses. • Diagnostic studies/tests 1. Neurological work-up • Community resources 2. ECG 1. Alcoholics Anonymous 2. Emotions Anonymous • Mental status variations 3. Narcotics Anonymous 1. Absence of anxiety or depression 2. Suicide threats and somatic preoccupation Borderline Personality Disorder (Sadock & 3. Absence of delusions or other signs of irratio- Sadock, 2007) nal thinking • Signs and symptoms 4. Highly manipulative and untrustworthy 1. Two-thirds of those diagnosed are female. 5. Lacking in remorse 2. Self-mutilation, labile mood (mood swings) 6. Compulsive recklessness 3. Impulsivity 7. Impulsivity 4. Outbursts of intense anger and rage 5. Unstable relationships due to intolerance for • Genetic/Biologic origins (Sadock & Sadock, 2007) being alone 1. Hereditary predisposition—associated with 6. Identity diffusion (lack of consistent sense of substance-use disorders (alcohol). self) 2. Low cortical arousal and reduced level of in- 7. Chronic emptiness, boredom hibitory anxiety may play a role. 8. Depression 9. Frantic efforts to avoid real or imagined • Biochemical interventions (Sadock & Sadock, abandonment 2007)—used to address anger, rage, and depressive 10. Micropsychotic episodes (brief psychotic symptoms, but use with caution due to frequent episodes) comorbid substance-use disorder. • Differential diagnosis • Intrapersonal origins/Psychotherapeutic 1. Cyclothymia—presence of hypomania interventions 2. Schizophrenia—presence of prolonged psy- 1. Origins—arrest in normal psychological de- chotic episodes, thought disorder or other velopment with failure to integrate ambivalent signs feelings originally aroused against the primary 3. Paranoid personalities—extreme caretaker suspiciousness 2. Psychotherapeutic interventions 4. Schizotypes—showing marked peculiarities of a. Confrontation of inappropriate behavior thinking, strange ideation, and recurrent ideas b. Individual psychotherapy of reference c. Structured living with supervision d. Outpatient supportive therapy • Mental status variations 1. Affect—mood swings, anxiety, depression Personality Disorders—Coded on Axis II of the DSM-IV-TR Multiaxial Classification System 177

2. Thought processes • Milieu interventions a. Difficulty concentrating 1. Staff develops self-awareness to avoid negative b. Suicidal gestures and attempts countertransference. 3. Insight lacking—poor judgment 2. Establish trusting relationship with client. 4. Defense mechanisms 3. Institute safety precautions. a. Manipulation 4. Provide structured supportive and consistent b. Splitting environment. c. Projection 5. Apply behavioral limits judiciously. d. Denial 6. Assist client in taking responsibility for conse- e. Rationalization quences of actions. f. Idealization 7. Assist the client in identifying feelings and in g. Devaluation learning how to express them in a socially ac- 5. Memory—recent memory disturbance ceptable manner. 8. Enhance client’s self-esteem and sense of self- • Nursing diagnoses (NANDA, 2009) worth. 1. Coping, ineffective 2. Violence, [actual/] risk for other-directed • Community resources 3. Violence, [actual/] risk for self-directed 1. Day hospital programs 4. Role Performance, ineffective 2. Halfway houses 5. Social Interaction, impaired Histrionic Personality Disorder • Genetic/Biologic origins (Sadock & Sadock, • Definition—characterized by colorful, dramatic, 2007)—related to history of mood disorders, alco- extroverted behavior in excitable, emotional per- holism, and somatization disorders among family sons; accompanying their flamboyant presenta- members tion, however, is often an inability to maintain deep, long-lasting attachments. • Biochemical interventions—useful in treating specific personality features that interfere with • Differential diagnosis functioning 1. Borderline Personality Disorder—may have rapidly shifting emotions and less capacity for • Intrapersonal origins/Psychotherapeutic ambivalence interventions 2. Borderline and Antisocial Personality Dis- 1. Origins order—may crave excitement and become a. Inconsistent and unpredictable parenting frustrated by delayed gratification; more likely b. Unmet need for love to behave impulsively and violate the rights of c. Separation/individuation phase not others accomplished 3. Narcissistic Personality Disorder—craves at- 2. Psychotherapeutic interventions (Sadock & tention but wants to be admired for superior- Sadock, 2007) ity rather than weakness or being dependent a. Reality oriented therapy favored over in- 4. Manic and hypomanic states—episodic in na- depth unconscious interpretations ture and present with other classic symptoms b. Long-term psychotherapy with supportive of mania or hypomania modifications to develop trust a. Persons with histrionic personality dis- c. Behavioral therapy—with limit setting order are often not aware of their own (mutually agreed upon limits) true feelings—clarification of feelings and d. Dialectic Behavior therapy—has shown emotions in psychotherapy can be useful efficacious results, particularly among pa- b. Adjunctive pharmacologic interventions tients with parasuicidal behavior, such as 5. Origins—fixation at the phallic phase leads to cutting (See Chapter 3) seeking sexual involvement with opposite-sex parent and leads to a conflictual relationship • Family dynamics with the same-sex parent 1. Parent may be critical and rejecting, or 2. Parent may be suffocating and smothering and Narcissistic Personality Disorder interferes with optimal progression of • Definition—characterized by a heightened sense attachment-separation sequences. of self-importance and grandiose feelings that they are unique in some way (APA, 2000; Sadock & Sadock, 2007). 178 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

• Differential diagnosis Dependent Personality Disorder 1. Other personality disorders—absence of • Definition—persons with the disorder subordinate grandiosity their own needs to those of others, get others to 2. Borderline personality—unstable self-image, assume responsibility for major areas in their lives, self-destructiveness, impulsivity and aban- lack of confidence, and may experience intense donment fears discomfort when alone for more than a brief pe- 3. Antisocial—insensitive and exploitive, exhibit- riod of time ing impulsivity and more materialistic 4. Schizotypal and paranoid—suspiciousness, • Differential diagnosis social withdrawal and alienation 1. Borderline Personality Disorder—intense at- 5. Manic or hypomanic episodes—presence of tachments, needing others to alleviate a sense grandiosity of emptiness or to provide them with a sense of identity • Genetic/Biologic origins—related to history of 2. Avoidant Personality Disorder—so strongly mood disorders, alcoholism, and somatization dis- fearful of hurt and rejection that they will with- orders among family members draw from relationships, not as likely to cling to others • Biochemical interventions 3. Histrionic Personality Disorder—excessive 1. Lithium—used for mood swings need for reassurances and approval motivated 2. Antidepressants (serotonergic) likely most by a need for praise and desire to be the center useful of attention

• Intrapersonal origins/Psychotherapeutic Obsessive-Compulsive Personality interventions Disorder (OCPD) 1. Origins—Narcissistic Personality Disorder— • Definition—characterized by emotional constric- results from ongoing childhood experiences tion, orderliness, perseverance, stubbornness, and of having fears, failures, dependence, or other indecisiveness—unlike other personality disorders, signs of vulnerability that is responded to with those with OCPD are aware of their suffering and criticism, disdain, or neglect seek treatment on their own. 2. Psychotherapeutic interventions a. Behavioral therapy—no evidence of • Differential diagnosis success. 1. Narcissistic Personality Disorder—attempting b. Group therapy may be most effective. to be perfect primarily as a means of sustain- ing their grandiosity rather than avoiding mis- Cluster C Personality Disorders takes; not as critical of self as they are of others 2. Antisocial Personality Disorder Avoidant Personality Disorder 3. Dependent Personality Disorder—indecisive- • Definition—Persons show extreme sensitivity to ness due to need for help and reassurance rejection, which may lead to a socially withdrawn rather than to a self-inflicted fear of being life; behavior is due to shyness rather than desire inaccurate to be asocial. 4. Obsessive-Compulsive Disorder—characterized by repetitive unwanted thoughts and ritu- • Differential diagnosis alistic behaviors rather than personality traits 1. Schizoid Personality Disorder—social isolation due to interpersonal indifference, insensitivity Information Common to Cluster C to social interactions, lacking in self- Personality Disorders consciousness and indifferent to criticism • Genetic/Biologic origins (Sadock & Sadock, 2007) 2. Dependent Personality Disorder—strong 1. Obsessive-Compulsive Personality Disorder desire for relationships, low self-confidence found with basal ganglia and frontal cortex and interpersonal insecurity, but more secure dysfunctions. when relating to and clinging to others; fear of 2. Children with high innate submissiveness and interpersonal loss low activity and persistence may elicit parental 3. Social Phobia—prominent anxiety in social responses that promote Dependent Personal- setting, consisting only of fear of performing in ity Disorder. social setting Questions 179

3. High anxiety in Avoidant Personality Disorder disorders)—families are over-controlling; child ex- found due to increased cortisol and sympa- pected to live up to impossible standards and then thetic arousal. condemned when fails. 4. Avoidant Personality Disorder—genetically based, temperamental predisposition to social • Nursing diagnoses (NANDA, 2009) avoidance or an inability to perform flexibly in 1. Coping, defensive new situations. 2. Social Interaction, impaired 3. Fear • Biochemical interventions—used to treat anxiety, depression, and psychotic-like symptoms • Group approaches 1. Clonazepam (Klonopin), clomipramine (Ana- 1. Dependent Personality Disorder—encourage franil), and SSRIs have been useful in reducing autonomy and increase social self-confidence symptoms associated with OCPD. 2. Avoidant Personality Disorder—social skills 2. No evidence of significant role in treatment of training avoidant or dependant personality disorders. 3. Obsessive-Compulsive Personality Disor- Treating associated features (anxiety, depres- der—focus on current life situations and sion) has been successful, however. confrontation

• Intrapersonal origins/Psychotherapeutic • Community resources interventions 1. Obsessive-Compulsive Disorder support group 1. Origins 2. Assertiveness training groups and seminars a. Obsessive-Compulsive Personality Dis- order—develops from excessive parental Other Personality Considerations: disapproval and control, which may cause the child to stifle emotional expression • Depressive Personality Disorder—characterized (especially anger), and focus on the details by chronic unhappiness and life-long anhedonia, of childhood tasks, attempting to be per- pessimism, and self-doubting (Sadock & Sadock, fect as a way to win the approval of critical, 2007). Psychological origins—disturbance of early over-controlling, and perhaps obsessional object relations that lead to an excessively severe parents. superego, the inhibited expression of aggression, b. Dependent Personality Disorder—devel- and excessive dependence on the love and accep- ops from under-indulgence and ongoing tance of others. reinforcement patterns during the oral stage; family environments inhibit expres- • Passive-Aggressive Personality Disorder—char- sion of feelings and exhibit high control; acterized by procrastination, stubbornness, inef- excessive dependence may represent a ficiency, covert obstructionism (Sadock & Sadock, reaction formation against the expression 2007). Psychological origins—contradictory and of hostility or assertiveness; cultural and inconsistent training methods are major factors. social factors contribute to excessive dependence in women and minorities • Interventions—Psychotherapy is the treatment of c. Avoidant Personality Disorder—children choice for Depressive Personality Disorder, limited who are rejected, belittled, and censured success with Passive-Aggressive Personality Disor- by their parents may develop feelings of der. Biochemical approaches used to treat anxiety, self-depreciation and social alienation. depression, and psychotic-like symptoms are indi- 2. Psychotherapeutic interventions cated. No evidence of significant role in treatment a. Psychotherapy—treatment of choice: of Dependent Personality Disorder, and Passive- focus on the client’s feelings rather than Aggressive Personality Disorder. intellectualized thoughts b. Cognitive therapy—to address faulty Questions thinking c. Behavioral therapy Select the best answer d. Assertiveness training— maybe useful in OCPD 1. Which of the following characteristics is most typical of bulimia? • Family dynamics—Cluster C (avoidant, passive- aggressive, dependent, obsessive-compulsive 180 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

a. Unsuccessful efforts to control weight a. Maintain behavioral diary. normally b. Promote exercise. b. Persistent over-concern with body shape c. Promote expression of feelings. and weight combined with periods of strict d. Develop adaptive coping. dieting 7. While conducting an initial assessment, the nurse c. Self-induced vomiting alternating with gathered the following sexual history; pain periods of normal eating before, during, and after sexual intercourse. d. Episodes of binge eating and self-induced Which of the following nursing diagnoses would vomiting or other severe weight control be most appropriate for the data described? methods a. Transvestic fetishism 2. The psychiatric and mental health advanced b. Sexual Arousal Disorder practice nurse is giving an inservice on Bulimia c. Sexual Dysfunction Nervosa. Which of the following would be valid d. Altered Sexuality Patterns information to present? Families with a member with Bulimia Nervosa are: 8. According to the premise of Cognitive therapy, which of the following would represent an a. Rigid and inflexible example of cognitive restructuring in the treat- b. Chaotic ment of the client with a Sexual Dysfunction? c. Overprotective d. Abusive a. Maintaining a diary of all stressful events b. Asking someone else to validate negative 3. In order to assess a client’s eating patterns, which thoughts of the following might the nurse use? c. Identifying irrational thoughts and counter a. “Do you often feel fat?” them with rational explanations b. “Who plans the family meals?” d. Practicing affirmations c. “What do you eat in a typical day?” 9. In psychosocial development models, the term d. “What do you think about your present “gender identity” refers to the: weight?” a. Personal perception of being male or female 4. Based on the client’s response to the question b. Outward expression of socially accepted mas- above, what nursing diagnosis is most likely? culine or feminine traits Nutrition, imbalanced: less than body require- c. Sexual classification assigned at birth ment related to: d. Congruence of hormone levels and sexual a. Abuse of laxative as evidenced by electrolyte behavior imbalances 10. Which of the following is true about a person b. Physical exertion in excess of energy pro- with Paraphilia? duced through caloric intake as evidenced by weight loss a. Paraphilia is a sexual dysfunction. c. Self-induced vomiting as evidenced by b. Persons with Paraphilia do not have normal swollen glands sexual habits. d. Refusal to eat as evidenced by loss of 15% of c. Erotic pleasure is received from the activity. body weight d. The Paraphilia tends to be obsessional in nature. 5. When the advanced practice PMH nurse engages the family of a client with a diagnosis of 11. The first intervention in assessment at the initia- Anorexia Nervosa in family therapy, what type of tion of sex therapy is: family dynamics might she/he expect to see? a. Clarification of each member’s perceptions a. Overly strict and disagreement about of the other discipline b. Exploration of each member’s beliefs about b. Overprotective, abusive, rigid sexuality c. Impulsive, rigid, perfectionistic c. Separate assessments to enhance free d. Controlling, impulsive, abusive expression d. Assessment of the couple’s communication 6. Which of the following would NOT be an area patterns for milieu management of Bulimia Nervosa? Questions 181

12. The nurse is assessing a client’s sexual problem. In a. “Have you recently experienced a change in order to assess the client’s feelings and attitudes your self-esteem?” about sex, the nurse might ask: b. “Has anything such as illness, pregnancy, or a health problem interfered with your role as a. The client’s beliefs about alternative a wife/husband?” sexuality c. “Has anything such as a heart attack or b. How the client’s religion views sex surgery changed the way you feel about c. For a description of the client’s earliest sexual yourself as a man/woman?” experiences d. “Has anything such as surgery or disease d. The client’s perception of his/her parent’s changed your body’s ability to function relationship sexually?” 13. As the nurse plans treatment for a sexual 19. A new nurse tells the psychiatric and mental problem, it is important to focus the interven- health advanced practice nurse “I’m unsure tions toward: about my role when clients bring up sexual a. The couple problems.” The psychiatric and mental health b. The identified client advanced practice nurse should give clarification c. Each member individually by saying: d. The partner a. “All nurses qualify as sexual counselors 14. The primary intervention by the nurse in sex because of their knowledge about biopsy- therapy is: chosocial aspects of sexuality throughout the life cycle.” a. Activities for the couple b. “All nurses should be able to screen for b. Homework assignments Sexual Dysfunction and give limited informa- c. Communication clarification tion about sexual feelings, behaviors, and d. Values clarification myths.” 15. Which of the following mental status varia- c. “All nurses should defer questions about sex tions would the nurse expect to see in a patient to other health care professionals because of with a medical diagnosis of Gender Identity their limited knowledge.” Disorder? d. “All nurses who are interested in Sexual Dysfunction can provide sex therapy for indi- a. Dysphoric mood viduals and couples.” b. Poor insight c. Hallucinations 20. The nurse is caring for a client who presents with d. Memory loss a medical diagnosis of Antisocial Personality Dis- order. Which of the following nursing diagnoses 16. Which of the following is a manifestation of would be most appropriate? Gender Identity Disorder? a. Ineffective Family Coping a. Fetishism b. Social Interaction, impaired b. Cross-dressing c. Anxiety c. Sexual sadism d. Altered Sensory Perception d. Masochism 21. Joan, who has a history of conflictual relation- 17. Mr. Cartwright tells the nurse that his sexual ships, expresses the desire for friends but acts in functioning is normal when his wife wears gold alienating ways with people who befriend her. pumps. He states, “Without the gold pumps. I’m Which of the following would be an important not interested in sex.” The advanced practice nursing intervention for Joan? PMH nurse assesses this as: a. Help her find friends who are patient and a. Pedophilia extra caring. b. Exhibitionism b. Establish a therapeutic relationship in which c. Voyeurism role-modeling and role-playing may occur. d. Fetishism c. Accept her as she is, because she can’t 18. Which of the following would be best to change. use when the nurse assesses a client’s sexual d. Point out her difficulties in relationships and functioning? suggested areas for improvement. 182 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

22. Mr. Grady constantly bends rules to meet his 27. Under which of the following circumstances is needs and then gets angry when other patients restraint appropriate? and staff confront him on his behavior. He a. To encourage adherence to unit rules threatens patients and manipulates staff to b. To control difficult interpersonal situations get what he wants. Which is the best nursing c. To establish the consequence of behaviors approach to use with Mr. Grady? d. To prevent harm to self and others a. Administer p.r.n. medication every time Mr. 28. Which of the following mental status variations Bradley does not follow the rules. would the nurse expect to see in a client with a b. Ignore his behavior and privately tell the diagnosis of Borderline Personality Disorder? other patients to let Mr. Grady switch the television channels as much as he wants. a. Euphoria c. Encourage the other staff to take turns b. Good insight and judgment watching Mr. Grady. c. Mood lability d. Set firm limits for Mr. Grady and be consis- d. Hallucinations tent in addressing behaviors and enforcing 29. While you are caring for Jennifer, she tells you unit rules. that she’s afraid her husband will leave her 23. The affect most commonly found in the client because she has no interest in sex anymore. with Borderline Personality Disorder is one of: There is no medical or chemical reason for her decreased libido. Jennifer asks the nurse if any- a. Happiness and elation thing can be done about her lack of interest in b. Apathy and flatness sex. The most appropriate referral by the nurse c. Sadness and depression for this client is: d. Anger and hostility a. Marriage counselor 24. The action by the nurse that would be most b. Psychiatrist appropriate when Mr. Smith states, “I’m no c. Psychoanalyst good, I’m better off dead.” would be: d. Sex therapist a. Stating, “I will stay with you until you are 30. The psychiatric advanced practice nurse is asked less depressed.” to assess a 24-year-old female who reports b. Stating, “I think you are a good person who that she is unable to have intercourse because should think about living.” of involuntary contractions of her vagina. The c. Alerting all staff to provide 24-hour observa- appropriate term is: tion of the client d. Removing all articles that may be potentially a. Arousal disorder dangerous b. Dyspareunia c. Orgasmic dysfunction 25. Limit setting is an intervention strategy to be uti- d. Vaginismus lized with which of the following behaviors? 31. The nurse is evaluating the outcome of mea- a. Manipulation sures to promote sleep. Which of the following b. Repression would indicate that these measures have been c. Reaction formation successful? d. Projection a. Client is able to sleep at least 4 hours each 26. Conrad, 29 years old, is admitted for psychiatric night. observation after being arrested for breaking b. Client states he felt rested the next day. windows in the home of his former girlfriend, c. Client accepts minor interruptions to sleep as who refuses to see him. His history reveals normal. abuse as a child by a punitive stepfather, tor- d. Client is able to verbalize anxieties. turing family pets, and one arrest for disorderly conduct. Which nursing diagnosis should be 32. The sleeping disorder that can be described as considered? excessive daytime sleepiness is which of the following disorders? a. Social interaction, impaired b. Altered thought processes a. Sleep Terror Disorder c. High risk for trauma b. Primary Hypersomnia d. Violence, risk for other-directed c. Circadian Rhythm Sleep Disorder d. Narcolepsy Questions 183

33. The nurse is admitting a client with a diagnosis 39. Ferman, a 15-year-old female, has complained of of Primary Insomnia. Which of the following an intense impulse to pull her hair out, followed assessment findings would be essential to by a sense of relief at having carried out the act. confirm the diagnosis? Which of the following medical diagnoses would be most appropriate for the psychiatric and a. Inability to obtain sleep not due to any other mental health advanced practice nurse to make? cause b. Inability to obtain sleep due to a medical a. Obsessive-Compulsive Personality Disorder disorder b. Tinea capitis c. Disturbance of sleep-wake cycle c. Trichotillomania d. Excessive daytime sleepiness d. Autism 34. You are the psychiatric clinical specialist on a 40. Which of the following would NOT be a mental sleep disorder unit. Which of the following is the status variation for the client with a diagnosis of key aspect of a psychotherapeutic intervention Pathological Gambling? program? a. Anxiety a. Verbalizing feelings b. Impulsivity b. Gaining insight c. Sadness c. Thought stopping d. Poor insight d. Sleep hygiene training 41. Johnson C. Smith is diagnosed with Pyromania. 35. Which of the following nursing diagnoses is most Which of the following behaviors would the appropriate for a client with a sleep disorder? nurse expect to observe in Mr. Smith? a. Perceptual Disturbances a. Aggressiveness b. Impaired Thought Processes b. Sadness c. Sleep pattern, disturbed c. Obsessive-compulsiveness d. Ineffective Family Coping d. Intense pleasure when watching fires 36. Which of the following would NOT be an 42. John is pacing the hall near the nurses’ station example of milieu interventions for Primary swearing loudly. An appropriate initial interven- Insomnia? tion for the nurse would be to say: a. Decrease alcohol and caffeine intake during a. “John, please quiet down.” afternoon and evening. b. “Hey, John, what’s up?” b. Thought stopping. c. “John, you seem pretty upset. Tell me about c. Discourage daytime naps. it.” d. Increase exercise during morning and d. “John, you need to go to your room to get afternoon. control of yourself.” 37. Which of the following phenomena would 43. Which of the following interventions is NOT most likely accompany a diagnosis of Primary appropriate for the nurse to use in the above Insomnia? situation? a. Medication withdrawal a. Telling the client that violence is not b. Situational/Environmental changes acceptable c. Normal aging b. Speaking in a loud, urgent tone of voice d. Mood disorders c. Standing with arms relaxed at sides d. Listening attentively to the client 38. The clinical specialist is implementing a behavior modification plan with a client with a diagnosis 44. It becomes necessary to give an intramuscular of Pathological Gambling. Which of the fol- injection of psychotropic medication to a client lowing family dynamics might he/she expect to who is becoming increasingly more aggressive. observe? The client is in the television room. The nurse should: a. Absent, inconsistent or harsh discipline b. Chaotic and violent environment a. Enter the room; say, “Would you like to c. Rigid and overprotective parents come to your room and take some medica- d. Heavy drinking tion your doctor has ordered for you?” 184 Chapter 8 Behavioral Syndromes and Disorders of Adult Personality

b. Take three staff members with you to the c. Atomoxetine room as a show of solidarity and say, “Mr. d. Both a and b are correct Summer, please come to your room so I can 50. Dialectical Behavior therapy is particularly effec- give you some medication that will help you tive in treating persons with: feel more comfortable.” c. Take a male staff member to the television a. Borderline Personality Disorder room and tell Mr. Summer, “Mr. Summer, b. Antisocial Personality Disorder you can come to your room willingly to take c. Paraphilias your shot or Mr. Crinshaw and I will take you d. Bulimia Nervosa there.” d. Enter the television room; place Mr. Summer Answers in a basket hold and say, “I’m going to take you to your room to give you an injection of 1. d 26. d medication to calm you.” 2. b 27. d 45. Following an incident in which staff interven- 3. c 28. c tion was required to control a client’s aggressive 4. d 29. d behavior, which of the following data would be 5. a 30. d least important to the staff’s evaluation of the 6. b 31. c intervention? 7. c 32. d a. The client’s behavior preceding and during 8. c 33. a the incident 9. a 34. d b. Intervention techniques used 10. c 35. c c. The environment 11. d 36. b d. The staff’s views about theories of the eti- 12. b 37. b ology of aggression 13. a 38. a 46. Based on the client’s potential for violence 14. c 39. c toward others and inability to cope with anger, 15. a 40. c which short-term goal would be most appro- 16. b 41. d priate? The client will: 17. d 42. c 18. d 43. b a. Acknowledge his angry feelings b. Describe situations that provoke angry 19. b 44. b feelings 20. b 45. d c. List how he’s handled his anger in the past 21. b 46. b d. Practice expressing anger 22. d 47. a 23. c 48. b 47. The impulse control disorder that is characterized as the deliberate and purposeful setting of fires 24. c 49. d is which of the following? 25. a 50. a a. Pyromania Bibliography b. Kleptomania c. Trichotillomania American Psychiatric Association. (2006). Practice d. Intermittent explosive disorder guideline for the treatment of patients with eating dis- 48. The impulse control disorder that is character- orders (3rd ed.). Arlington, VA: American Psychiatric ized as the inability to resist the impulse to steal Publishing. Retrieved from http://www.psychiatry- objects is which one of the following online.com/pracGuide/pracGuideTopic_12.aspx American Psychiatric Association. (2000). Diagnostic a. Pyromania and statistical manual of mental disorders (4th ed., b. Kleptomania text revision). Washington, DC: Author. c. Trichotillomania Beemer, B. R. (1996). Gender dysphoria update. Journal d. Intermittent explosive disorder of Psychosocial Nursing, 34(4), 12–19. 49. Some reports support the use of ______in Blair, D. T. (1996). Integration and synthesis of cognitive treating symptoms of Anorexia Nervosa. behavioral therapies within the biological paradigm. Journal of Psychosocial Nursing, 34(12), 26–31. a. Cyproheptadine Burgess, A. W. (1997). Psychiatric nursing promoting b. Amitriptyline mental health. St. Louis, MO: Mosby. Bibliography 185

DeCaria, C. M., Hollander, E., Grossman, R., Wong, McGowan, A., & Whitebread, J. (1996). Out of control— C. M., Mosovich, S. A., & Cherkasky, S. (1996). Diag- the most effective way to help the binge-eating pa- nosis, neurobiology and treatment of pathological tient. Journal of Psychosocial Nursing, 34(1), 30–37. gambling. Journal of Clinical Psychiatry, 57(suppl 8), NANDA International. (2009). Nursing diagnoses: Defi- 80–84. nitions & classifications, 2009–2011. West Sussex, UK: Devlin, M. J. (2007). Is there a place for obesity in the Wiley & Sons. DSM-V? International Journal of Eating Disorders, 40, Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sa- 83–88. dock’s synopsis of psychiatry (10th ed.). Philadelphia, Fichter, M. M., Kruger, R., Rief, W., Holland, R., & PA: Lippincott. Dohne, J. (1996). Fluvoxamine in prevention of re- Stahl, S. M. (2008). Stahl’s essential psychopharmacol- lapse in bulimia nervosa: Effects on eating specific ogy: Neuroscientific basis & practical applications (3rd psychopathology. Journal of Clinical Psychopharma- ed.). New York, NY: Cambridge University Press. cology, 16(1), 9–19. Stahl, S. M. (2009). Stahl’s essential psychopharmacol- Fisher, M., Golden, N. H., Katzman, D. K., Kreipe, R. E., ogy: The prescriber’s guide (3rd ed.). New York, NY: Rees, J., Schebendach, J., Sigman, G., Ammerman, S., Cambridge University Press. & Hoberman, H. M. (1995). Eating disorders in ado- Stuart, G. W., & Sundeen, S. J. (1995). Principles and lescents: A background paper. Journal of Adolescent practice of psychiatric nursing. St. Louis, MO: Mosby. Health, 16, 420–437. Sugar, M. C. (1995). A clinical approach to childhood Greene, H., & Ugarriza, D. N. (1995). Borderline person- gender identity disorder. American Journal of Psycho- ality disorder: History, theory and nursing interven- therapy, 49(2), 260–281. tion. Journal of Psychosocial Nursing, 33(12), 26–30. Townsend, M. C. (1997). Nursing diagnoses in psychiat- Gorman, L. M., Sultan, D. F., & Raines, M. L. (1996). Da- ric nursing. Philadelphia, PA: F. A. Davis. vis’s manual of psychosocial nursing for general pa- Volkow, N. D., & O’Brien, C. P. (2007). Issues for DSM- tient care. Philadelphia, PA: F. A. Davis Co. V: Should obesity be included as a brain disorder? Gunderson, J. G., & Phillips, K. A. (1995). Personality American Journal of Psychiatry, 164, 708–710. disorder. In H. L. Kaplan & B. J. Sadock (Eds.), Com- Williams, R. L., Karacan, I., Moore, C. A., & Hirshkiwitz, prehensive textbook of psychiatry (pp. 1425–1461). M. (1995). Sleep disorders. In Kaplan & Sadock (Eds.). Baltimore, MD: Williams & Wilkins Co. Comprehensive textbook of psychiatry. Baltimore, Kaplan, H. I., & Sadock, B. J. (1995). Comprehensive MD: Williams & Wilkins Co. textbook of psychiatry. Baltimore, MD: Williams & Wilson, H. S., & Kneisl, C. R. (1996). Psychiatric nursing. Wilkins. New York, NY: Addison-Wesley Nursing. Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Linehan, M. M., Oldham, J. M. & Silk, K. (1995). Diagno- sis: Personality . . . now what. Patient Care, 6, 75–91.

9 Cognitive Mental Disorders and Geropsychiatric Nursing

Cognitive Disorders 3. Disturbance in sleep-wake cycle and level of psychomotor activity • Overview (Sadock & Sadock, 2007)—Cognition in- 4. Disorientation to time, place, or persons volves memory, orientation, judgment, language, 5. Reduced ability to focus, shift, or maintain the ability to engage in interpersonal relationships attention and problem solving, and performing actions and 6. Disorganization of thinking (may manifest as abstractions (proverb interpretation). Cognitive irrelevant, rambling, or incoherent speech) disorders are associated with or caused by distur- 7. Perceptual disturbances resulting in illusions bance in the physiological functioning of brain and hallucinations; tissue—structural, hormonal, biochemical, electri- 8. Emotional disturbances constituting lability of cal, etc.—which causes cognitive deficits; ranges affect along continuum from acute (Delirium) to chronic 9. Transient, occurs abruptly, and fluctuates (Dementia of the Alzheimer’s type). throughout the day

Delirium • Differential diagnosis 1. Schizophrenia—due to perceptual, affective, • Definition—A transient (short-term), reversible, and behavioral similarities state of confusion, resulting from a gross disrup- 2. Other psychotic disorders tion in brain physiology and developing from a 3. Dementia—onset of delirium is abrupt and wide variety of factors (Lipowski, 1992); although duration is shorter than with ementia (hours symptoms are similar in their disturbance of con- to weeks/delirium vs months to years/demen- sciousness and cognition, the delirium disorders tia) (Breitner & Welsh, 1995; Lipowski, 1992). are differentiated on etiology (Delirium Due to a Attention fluctuates in delirium (preserved in General Medical Condition, Substance-Induced dementia) (Sadock & Sadock, 2007) Delirium, Delirium Due to Multiple Etiologies, and 4. Depression—sluggishness and depressed af- Delirium Not Otherwise Specified) (American Psy- fect when delirious chiatric Association [APA], 2000); can progress to 5. Anxiety disorders—due to affective and behav- permanent dementia if identifying causes are not ioral similarities diagnosed and treated. • Diagnostic studies/tests—identify underlying • Signs and symptoms (APA, 2000; Sadock & Sadock causes using the following methods: 2007) 1. Complete physical examination 1. Disturbance of consciousness 2. Complete neurological workup (including 2. Change in cognition (memory deficit) electroencephalogram (EEG)

187 188 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

3. Complete battery of laboratory tests includ- • Nursing diagnoses—several of the 2009–2011 ing but not limited to: blood chemistries, CBC, NANDA International (2009) nursing diagnoses serologic tests for syphilis, HIV antibody test, can be applied to delirium, including: urinalysis, blood and urine drug screen, and 1. Insomnia thyroid profile 2. Behavior, risk-prone health 4. Additional testing, when indicated, includes: 3. Coping, ineffective B12 levels, CT scan, and MRI (Sadock & 4. Self-Care Deficit, bathing Sadock, 2007) 5. Self-Care Deficit, dressing 5. Use of screening instruments such as: 6. Confusion, acute a. Delirium Rating Scale (Trzepacz, Baker, & 7. Memory, impaired Greenhouse, 1988) 8. Sensory Perception, disturbed (specify) b. Intensive Care Delirium Screening Check- 9. Social Interaction, impaired list (Bergeron, Dubois, Dumont, Dial, & Skrobik, 2001) • Biologic origins—delirium can be attributed to a wide range of physical disorders ranging from met- • Mental status variations (Keltner, Schwecke, & abolic disturbances to withdrawal from substances Bostrom, 2007; Sadock & Sadock, 2007) such as alcohol or sedative-hypnotic agents (APA, 1. Fluctuating consciousness/cognitive impair- 2000). ment with lucid intervals 1. Risk factors associated with delirium (Sadock 2. Inability to maintain attention or engage in & Sadock, 2007) goal-directed behavior; difficulty following a. Severity of illness—the more severe the questions upon examination; client may per- illness, the more likely delirium will occur. severate in response to earlier questions b. Age and gender—more common in males; 3. Disorganization of thought—difficulty main- the older the patient, the more likely de- taining coherent stream of thought, easily lirium will occur; persons older than age distracted; speech rambling, inconsequential, 70 are most vulnerable. or illogical; faulty reasoning and lack of goal- c. Cognitive impairment or preexisting brain directed behavior damage/disease (tumors, traumatic brain 4. Perceptual disturbances—illusions, hallucina- injury, dementia)—approximately 25% to tions, delusions may be present, but generally 50% of patients diagnosed with Dementia poorly organized; can suffer acute paranoid have been found to have Delirium super- delusions accompanied by fear, anxiety, at- imposed upon the Dementia. tempts to escape or destructive rage episodes d. Diabetes 5. Impairment in the level of consciousness— e. Hearing or visual impairment client falls asleep during the interview f. Malnutrition 6. Disturbed sleep-wake cycle—hypervigilantt g. Systemic infection during the night and sleeps during the day h. Substance-use disorder (alcohol, nicotine, 7. Abnormally increased or decreased psycho- or narcotics) motor activity; may pick at the bed linen 2. The following are common causes of Delirium or be sluggish, resembling catatonia-like (Keltner, Schwecke, & Bostrom, 2007; Sadock & movements; three clinical patterns possible Sadock, 2007): (Lipowski,1992): a. General surgical procedures and pneumo- a. Hypoalert—hypoactive client who is le- nia are associated with Delirium thargic and drowsy b. Substance-related intoxication, with- b. Hyperalert—hyperactive client who is drawal, or toxicity—alcohol, medications restless and agitated (particularly those with anticholinergic c. Mixed variant—shifting between lethargy properties, such as benztropine), or other and agitation substances have been implicated in 8. Disorientation (place, time, and/or person)— Delirium. disorientation to place and time is very com- c. Certain drugs have been implicated in the mon; however, disorientation to person is rare development of Delirium, particularly in 9. Memory impairment—usually short-term older persons. Drugs that can cause de- memory impairment and both anterograde lirium include anticholinergics, antihista- (memory for events just prior to onset of de- mines, antidepressants (tertiary TCAs), GI lirium) and retrograde (memory for events just agents (e.g., cimetidine/Tagamet), and low after the episode) amnesia present potency antipsychotics (Videbeck, 2006). 10. Appears bewildered, and may be anxious and frightened Cognitive Disorders 189

d. Systemic illness (such as infection, dose of 2 to 6 mg of haloperidol, repeated trauma, heart failure, malnourishment)— in hourly intervals if patient remains agi- urinary infection is a common culprit in tated. Switch to oral dose when calm (a the development of delirium in older or daily divided dose of 5 to 40 mg PO may be catheterized patients. needed in patients with delirium). e. Hepatic functioning that decreases with b. Droperidol (has a more rapid onset of se- normal aging; drugs have been shown dation than haloperidol)—monitoring of to have a longer half-life and decreased the electrocardiogram is advised with this plasma clearance. Drugs that require a alternative. high rate of hepatic extraction should be c. Atypical antipsychotic agents may be use- used judiciously (e.g., major tranquilizers, ful (avoid ziprasidone (Geodon) due to tricyclic antidepressants, and antiarrhyth- activating effects). mic agents (Ferrini & Ferrini, 1992). 3. Treat insomnia when present. a. Short- or intermediate-acting benzodiaz- • Biochemical interventions—goals of any interven- epines (e.g., lorazepam, 1 to 2 mg PO at tion are to treat the underlying cause, and to pro- bedtime) are considered to be first-line vide physical, sensory, and environmental support. agents in treating insomnia in delirious 1. Treatment of the underlying cause(s) (Sadock patients. & Sadock, 2007): 4. Avoid barbiturates and long-acting benzodiaz- a. Restore adequate fluid and electrolyte bal- epines unless they are being used to treat the ance, nutrition, and vitamin supply (Lip- underlying cause of delirium, such as alcohol owski, 1992; St. Pierre, 1996). withdrawal or seizures. b. Eliminate medication(s) suspected of affecting mental status. • Psychosocial approaches c. Treat toxicity as indicated—if toxicity from 1. Attend to the client’s concerns and fears, anticholinergics is suspected, the use of which may be expressed in the hallucinations physostigmine reverses the delirium for and/or delusions (Lipowski, 1992). 15 to 30 minutes following a 1 to 2 mg 2. Reorient the client to reality, especially when intravenous dose (repeated doses may be illusions are present. needed). 3. Reduce fear and anxiety by providing a calm d. Treat withdrawal from substances. reassuring manner, assuring the client that (1) Alcohol withdrawal delirium develops you will be sure he is safe. after recent cessation or reduction of 4. Explain all procedures to minimize anxiety. alcohol consumption. 5. If client is extremely agitated, the use of physi- (2) Benzodiazepines are the first-line cal restraints is not recommended since they treatment choice for delirium associ- may increase fear and agitation along with ated with substance-related with- increasing the risk of problems associated with drawal (lorazepam (Ativan) initially immobility. The use of “sitters” or enlisting the 0.25 to 0.5 mg PO/IM/IV, every 6 to 8 family’s help is more efficacious. hours—caution when liver damage is present) (Meagher & Leonard, 2008). • Family dynamics/Family therapy (2) May need to replace thiamine and 1. Involve the family in assessment, planning, other vitamins to prevent permanent intervention, and evaluation of the nursing organic disorder due to deficiency. care plan. 2. Treat psychosis when present. 2. Family can provide useful information as to a. Haloperidol—most commonly used the client’s premorbid cognitive status, the sedative because of low anticholinergic possible causative factor of the delirium, his- side effects, quick sedation, and low inci- tory of the client and other critical data. dence of orthostatic hypotension (Tune & 3. Family can assist in planning psychoso- Ross, 1994; Lipowski, 1992); potential for cial interventions that are likely to be most extrapyramidal symptoms such as “cog- successful. wheel” rigidity in joints (can be seen in 4. Family can assist in interventions by helping to flexing and extending the elbow) and ex- orient and reassure the client. cessive salivation, and dystonic reactions 5. Family needs to be provided with information such as torticollis (extreme turning of and reassurance along with referral informa- head to one side with the inability to cor- tion for use postdelirium. rect posture). Administer an intramuscular 190 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

6. Family members may exhibit grief reactions b. Cerebrovascular disease—in particular, such as anger, hostility, bargaining, depres- stroke and cerebral blood flow problems sion, guilt, avoidance, denial, and ambivalence c. Cerebral oxygenation problems (Barry, 1996). d. Infectious diseases of, or affecting, the central nervous system—syphilis, AIDS • Group approaches—for delirious clients, group e. Brain trauma intervention is contraindicated. f. Toxins g. Metabolic disturbances • Milieu interventions h. Hypoglycemia, diabetes 1. Aimed at providing safety, support, and i. Normal pressure hydrocephalus structure j. Degenerative neurologic diseases 2. Environmental interventions help reestablish k. Drugs & toxins (e.g., alcohol, anticholin- orientation by placing clock, calendar, and fa- ergics, heavy metals, carbon monoxide) miliar belongings in the client’s room. 3. Encourage family visits to assist patient with • Signs and symptoms orientation. 1. Criteria for the diagnosis of a dementia based 4. Correct any sensory deficit that the patient on clinical examination may have by having eyeglasses or hearing aid a. Presence of cognitive deficit (APA, 2000; made available and within close reach. Keltner et al., 2007) 5. Place the client in a room with windows to (1) Memory impairment (required for help orient to day and night. DSM-IV-TR diagnosis of dementia) 6. Keep outside, distracting noises to a minimum (a) Impairment in ability to learn new and keep a low light on at night. information 7. Reduce, but don’t eliminate stimulation, (b) Forgetting previously learned as sensory deprivation also contributes to information delirium. i. Often both forms are present. ii. In later stages, extreme mem- • Community resources—not indicated during the ory impairment is evidenced acute episode, but may be useful as a referral rein inability to recall most or source based on the following factors: all information (e.g., family 1. Etiology of the delirium (i.e., Alcoholics Anon- member’s identity, own birth- ymous; Narcotics Anonymous; social support day, and sometimes their such as senior center, case management, or own name). home health services) (2) In addition to memory deficits, the 2. Need for the client and/or family to resolve following may be present (at least one the emotional trauma associated with the is necessary for DS-IV-TR diagnosis of acute episode of delirium through participa- Dementia): tion in individual, group, or family counseling/ (a) Deterioration of language func- therapy tion (aphasia), evidenced by difficulty in recalling names Dementia of persons or objects may be present. In advanced stages, in- • Definition—Development of multiple cognitive dividual may be mute, or demon- deficits affecting at least three of the following strate echolalia (repeating what mental activities: memory, language, visuospatial is heard) or palilalia (repeating skills, personality, or emotional state, and execu- a sound or word over and over tive function; the decline in cognitive functioning again). causes significant impairment in social or occu- (b) Difficulty in carrying out motor pational functioning, representing a significant function, despite intact motor decline from a previous level of functioning; does abilities (apraxia) may be pres- not routinely occur during the course of a delirium ent. May contribute to difficulties (except Vascular Dementia), and are judged to be in drawing, cooking, activities of related to a causative factor. In most cases demen- daily living. tias are irreversible (APA, 2000, 2007; Flood & Buck- (c) The inability to recognize or iden- walter, 2009). tify objects by name—although 1. Etiology (Sadock & Sadock, 2007) sensory abilities are intact a. Hereditary factors (agnosia)—may be present (e.g., Cognitive Disorders 191

cannot recognize by touch alone, tests for syphilis, HIV antibody test, urinalysis, a wristwatch, keys, or pencil when blood and urine drug screen, B12 and folate placed in hands). level, and thyroid function tests (d) A disturbance in executive func- 2. Screening instruments for cognitive tioning may be present—as functioning evidenced by impaired abstract a. Mini-Mental Status Exam—MMSE thinking, difficulty in shifting (Folstein, Folstein, & McHugh, 1975) from one mental activity to an- b. Clock Drawing Test—CDT (Shulman, other, and problems in perform- Shedletsky, & Silver, 1986) ing serial motor skills. c. Mini-Cog (Borson, Scanlan, Brush, b. Information from patient’s family, friends, Vitaliano, & Dokmak, 2000) and employers d. Alzheimer’s Disease Assessment Scale c. Report of change in personality of a per- (ADAS) son older than age 40 suggests consider- e. Behavioral Pathology in Alzheimer’s Dis- ation of Dementia. ease (BEHAVE-AD) d. Other information suggesting Dementia f. Blessed Dementia Scale (BLS-D) includes change in intellectual ability, forgetfulness, efforts to conceal cognitive Dementia of the Alzheimer’s Type deficits. • Definition—This type of dementia is characterized 2. Criteria for severity of Dementia by a gradual and insidious onset and a generally a. Mild—work or social activities are signifi- progressive deteriorating course for which all other cantly impaired, however the capacity for specific causes have been excluded by the history, independent living, adequate personal physical examination, and laboratory tests (APA, hygiene, and reasonable judgment remain 2000). It is the most prevalent of the dementias and intact. can occur with the following variations: b. Moderate—independent living is hazard- 1. Senile or presenile onset, depending on ous, and some degree of supervision is whether after or before age 65 necessary. 2. Within senile and presenile variants, disease c. Severe—activities of daily living are so can be with delirium, with delusions, with de- impaired that continual supervision is repression, or uncomplicated. quired, (e.g., unable to maintain minimal personal hygiene; largely incoherent or • Signs and symptoms—characterized by multifac- mute). eted loss of intellectual abilities, such as memory, judgment, abstract thought, and other higher • Differential diagnosis: cortical functions; changes in personality and be- 1. Dementia of the Alzheimer’s Type havior, and significant decline and impairment in 2. Vascular Dementia social and occupational functioning (APA, 2000) 3. Dementia Due to HIV Disease 4. Delirium • Differential diagnosis—exclusion of all alternative 5. Dementia Due to Parkinson’s Disease specific causes of Dementia by complete history, 6. Dementia Due to Huntington’s Disease physical examination, and laboratory tests 7. Dementia Due to Pick’s Disease 1. Benign forgetfulness—a common phenom- 8. Dementia Due to Creutzfeldt-Jakob Disease enon among older adults 9. Dementia Due to Other General Medical 2. Subdural hematoma Conditions 3. Normal pressure hydrocephalus 10. Dementia Due to Multiple Etiologies 4. Brain tumors 11. Substance-Induced Persisting Dementia 5. Parkinson’s disease 12. Dementia Not Otherwise Specified 6. Vitamin B12 deficiency 13. Dementia Due to Head Trauma 7. Hypothyroidism 14. Schizophrenia 8. Delirium 15. Major Depressive Disorder 9. Acute psychotic episode 16. Malingering and Factitious Disorder 10. Major depressive episode 11. Multi-infarct dementia (See next secton on • Diagnostic studies/tests Vascular Dementia) 1. Battery of laboratory tests including, but not 12. Medication interactions limited to: blood chemistries, CBC, serologic 13. AIDS dementia complex (ADC) 192 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

• Mental status variations—manifestations include: executive functioning (i.e., planning, organiz- 1. Recent and remote memory deficits ing, sequencing, abstracting), aphasia, apraxia, 2. Short attention span and inability to and/or agnosia are present (APA, 2000). concentrate 3. Clinical or laboratory evidence in support of 3. Impairment in abstract thinking and judgment the diagnosis of vascular dementia includes: 4. Other disturbances of higher cortical function- a. Since the cause is cerebrovascular disease, ing, such as agnosia, apraxia, aphasia, and focal neurologic signs and symptoms (e.g., constructional difficulty exaggeration of deep tendon reflexes are 5. Affective lability an important diagnostic determinant) 6. Perceptual disturbances such as hallucination b. History of stroke or other cerebrovascu- 7. Depressed mood lar insult; presence of carotid bruits is common • Genetic/Biologic origins (APA, 2007; Sadock & 4. A stepwise deteriorating course with “patchy” Sadock, 2007) distribution of deficits (affecting some func- 1. Precise cause(s) of Alzheimer’s disease still tions, but not others) is present early in the unknown course (APA, 2000). 2. Hereditary factors 5. Individual can present with delirium, delu- a. Familial patterns exist. sions, or depression, gait abnormalities, weak- b. Genetic markers on chromosomes 1, 14, ness of an extremity. Different from other and 21 have been identified in early-onset dementias, a diagnosis with the following (younger than age 60) Alzheimer’s disease specifiers is used for vascular dementia (APA, (AD) 2000, 2007): c. An increased risk of late-onset AD has a. With delirium been associated with a variant of apoli- b. With delusions poprotein E (APOE) found on chromo- c. With depressed mood some 19; the risk is specifically associated with the allele APOE-e4 (APOE contains • Differential diagnosis (APA, 2000, 2007) instructions for making the protein that 1. General differential diagnosis of Dementia due carries cholesterol in the bloodstream) to Other General Medical Conditions and De- (Alzheimer’s Disease Education & Referral mentia of the Alzheimer’s Type (See previous (ADEAR) Center, 2008). sections) d. A number of biomarkers are currently un- 2. Impairment due to single stroke der investigation. Of specific interest are tau and beta-amyloid proteins—two bio- • Mental status variations—is differentiated from markers in cerebrospinal fluid (APA, 2007). other primary dementias only by the fact that A recent National Institute on Aging (NIA) the cognitive manifestations may wax and wane, study found that participants with APOE- showing patchy or stepwise deterioration. e4 genes, high levels of tau and low levels of beta-amyloid proteins were most likely • Biologic origins—cerebrovascular diseases to have mild AD, and testing for these biomarkers is currently underway (NIA, Other Dementias 2009). • Dementia Due to General Medical Condition (APA, 2000; Keltner et al., 2007; Sadock & Sadock, 2007) Vascular Dementia (also known as 1. Dementia Due to HIV Disease—The presence multi-infarct dementia) of dementia in a client with a diagnosis of HIV • Definition—direct consequence of cerebrovascular or AIDS. Encephalopathy in HIV is associated disease, characterized by the often abrupt onset of with the type of dementia known as AIDS de- a stepwise deterioration in intellectual functioning mentia complex (ADC) or HIV dementia and that, early in the course, leaves some intellectual occurs in 14% of patients with HIV. functions relatively intact (patchy deterioration) 2. Dementia Due to Pick’s Disease—character- (APA, 2000) ized by atrophy in the fronto-temporal regions of the brain (rather than parietal-temporal re- • Signs and symptoms gions associated with Alzheimer’s disease). 1. Symptoms of vascular dementia are largely the 3. Dementia Due to Traumatic Brain Injury— same as those found in AD. characterized by emotional lability, speech 2. Multiple cognitive deficits manifested by deficits/dysarthria (slurred, slow, and difficult memory impairment and disturbance in to understand), and impulsivity—associated Cognitive Disorders 193

with boxer’s “punch-drunk syndrome” and 13. Role Performance, ineffective combat veterans who have experienced con- 14. Neglect, self cussion and other serious head injuries 15. Wandering [specify sporadic or continual] 4. Dementia Due to Lewy Body Disease—char- 16. Health Management, ineffective self acterized by hallucinations, parkinsonian 17. Coping, compromised family features (resting tremor, bradykinesia, cog- wheeling), and extrapyramidal symptoms; • Biochemical interventions (APA, 2007; Flood & caused by Lewy inclusion bodies in cerebral Buckwalter, 2009; Keltner et al., 2007; Stahl, 2008, cortex; attention rather than memory deficits 2009) evident early in illness; markedly adverse ef- 1. After verifying a diagnosis of Dementia, blood fects with antipsychotics. pressure management at the higher end of the

5. Dementia Due to B12 Deficiency (reversible)— normal range is recommended for improving Pernicious anemia is the most common cause cognitive function in Vascular Dementia (ACE

of B12 deficiency. Dementias caused by this inhibitors and diuretics do not amplify cogni- deficiency are rare—characterized by parethe- tive impairment). sias of lower, then upper extremities resulting 2. Initial interventions depend on the etiologic from neuronal demyelinization. Other clinical factor causing the dementia and to treat the manifestation of this dementia can include: underlying cause of the disturbance (e.g., treat mood and behavior changes, psychosis, and diabetes with insulin, hypothyroidism with reflex changes (hypo- and hyper-reflexive). thyroid replacement, thiamine deficiency

Biological intervention is Vitamin B12 replace- with replacement, and iatrogenic disorders by ment therapy. eliminating the causative drug). 6. Dementia Due to Normal Pressure Hydroceph- 3. In patients with Dementia, benzodiazepines alus (NPH) (reversible with early treatment)— may be used for anxiety; antidepressants for NPH results when the flow of cerebrospinal depressive symptoms, and antipsychotics fluid between the brain and spinal column is for psychosis. Exercise caution when treating impaired. Clinical symptoms of NPH include older patients. Avoid the use of pharmacologic urinary incontinence, gait apraxia, and de- agents with high anticholinergic actions. mentia. The dementia associated with NPH a. “Sundowner syndrome” occurs when effects one’s ability to manage activities of older patients are overly sedated—and daily living, and may result in personality dull- in Dementia patients experiencing an ing, lack of motivation, and limited judgment/ adverse reaction to a psychoactive drug insight. Memory loss occurs in later stages of or with deprivation of external cues such the process and is followed by a progressive as light and orienting cues (e.g., interper- decline in cognitive functioning. Treatment sonal contact, clock). This syndrome is involves surgical placement of a ventricular characterized by drowsiness, confusion, shunt in the brain and is most successful in ataxia, and accidental falls (Sadock & reversing dementia in the early stages (Keltner Sadock, 2007) et al., 2007). b. If biochemical intervention is indicated for control of agitation or hallucination Information Common to all Dementias (unless associated with Dementia, drug treatment stated otherwise) should be used cautiously (particularly in • Nursing diagnoses—several of the 2009–2011 older patients), beginning with the low- NANDA International (2009) nursing diagnoses est possible dose and tapering upward as can be applied to dementia, including: needed. Haloperidol is the drug of choice 1. Behavior, risk-prone health for controlling agitation in dementias 2. Coping, ineffective due to lower anticholinergic effects. Low 3. Self-Care Deficit, bathing dosage of 0.25 mg should be initiated. 4. Self-Care Deficit, dressing Side effects include dystonias (rigidity in 5. Self-Care Deficit, toileting joints and torticollis) and excessive saliva- 6. Confusion, acute tion. Orthostatic blood pressures should 7. Confusion, risk for acute be monitored and the client and his/her 8. Confusion, chronic caregiver(s) should be taught the side 9. Memory, impaired effects. 10. Social Interaction, impaired c. In treating depression associated with, 11. Caregiver Role Strain, risk for SSRIs are preferred over TCAs (due to the 12. Insomnia high anticholinergic and antiadrenergic 194 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

properties of TCAs), and MAOIs (due to agents showing some promise are lithium, and potential for serious interactions). beta amyloid antagonists. d. Atypical antipsychotics have been used successfully in treating associated hal- • Psychosocial approaches lucinations and delusions, but recent 1. Base on careful nursing assessment of the evidence suggests a connection with inpatient. creased risk of cardiovascular events and 2. Goal of nursing care regardless of the setting is mortality in this population, as well as in- to help the client maintain the highest possible creased risk in the development of meta- level of independence. Skill training can assist bolic syndrome, thus very cautious use is the client to reach his/her potential (Tappen, advised. 1994). 4. Thus far, the FDA has approved five medica- 3. Use warm, caring, respectful approach. tions (cholinesterase inhibitors) for treating 4. Use clear, simple, and direct communication. Dementia of the Alzheimer’s Type (other de- 5. Keep tasks within the client’s abilities, using mentias are not listed).(See Table 9-1) sequencing and cuing (i.e., laying out the cli- 5. Other treatment options include unproven in- ent’s clothing in the order in which he/she terventions such as selegiline, statins, ginko bi- needs to put it on) loba, folate preparations, and Vitamin E, which 6. Avoid over- or under-stimulation. have limited support for their efficacy thus far; 7. Provide for adequate rest and nutrition.

Table 9-1 Cholinesterase Inhibitors Used in Treating Dementia*

Generic Approved (Trade Name) Dementia Level Usual Dose Dosing Information Comments Donepezil Mild, Moderate & 5 to 10 mg PO in Start at 5 mg; may First-line option; (Aricept) Severe evening increase to 10 mg in 4 also available in to 6 weeks disintegrating tablet form Galantamine Mild to Moderate 16 to 24 mg PO daily Immediate release: Second-line option; (Razadyne) Initially 8 mg twice available in once-daily daily; may increase to extended release form 16 mg twice daily after 4 weeks; maximum 24-hr dose 32 mg Rivastigmine Mild to Moderate 6 to 12 mg PO in two Initially 1.5 mg PO Second-line option; (Exelon) divided doses twice daily; increase by also available in 3 mg every 2 weeks; transdermal form— maximum 24-hr dose dose: initially 4.6 12 mg mg/day; in 4 weeks increase to maximum dose of 9.5 mg/day Tacrine (Cognex) Mild to Moderate 20 to 40 mg PO four Initially 10 mg PO 4 1st drug approved times daily times daily (qid) for 4 by FDA for treating weeks; may increase by Alzheimer’s dementia; 10 mg qid increments rarely used due to risk every 4 weeks as of reversible hepatic needed; maximum toxicity 24-hr dose 160 mg Memantine Moderate to 10 mg PO twice daily Initially 5 mg PO daily; Second-line option; (Namenda) Severe may increase by 5 mg recommended to each week; maximum divide doses over 5 mg, 24-hr dose 20 mg usually twice daily

*FDA Approval for Dementia of the Alzheimer’s Type (APA, 2007; Stahl, 2008, 2009) Cognitive Disorders 195

8. If the dementia is vascular, provide informa- depression or who have one of the previously tion to the client regarding managing risk mentioned disorders. factors associated with cardiovascular disease 3. Educational groups seek to inform and em- (diet, exercise, decreasing stress, medication, phasize learning and discussion instead of signs of impending stroke, etc.). therapy (Neese & Abraham, 1992). For elders who have mild cognitive impairment and • Family dynamics/Family therapy their families, educational groups addressing 1. Family needs to be included in the assessment the various types of dementias are an excel- as well as the intervention phase of treatment lent method to help alleviate the isolation that with cognitively impaired clients since they clients and families feel when faced with a can provide much useful information regard- chronic disorder. ing how to best care for their loved one. 4. Validation groups developed by Feil (1989) 2. Family members are often the hidden victims are designed to benefit even severely im- of the illness, especially when the dementia is paired clients. The goals of validation are to chronic rather than reversible. stimulate communication in order to prevent 3. Family interventions always include provid- withdrawal inward, to restore well-being, to ing support and education, and in some cases, facilitate the resolution of unresolved issues such as when the dementia is due to sub- to prepare for death, and to reduce caregiver stance abuse, counseling or therapy may be burnout by teaching empathy skills (Bleathe- indicated. man & Morton, 1996; Fine & Rouse-Bane, 4. Family interventions also include assisting 1995). the family for anticipatory grief, which usu- 5. Activity, movement, and sensory stimulation ally is a deep sadness that occurs before the groups also enhance functioning in cognitively anticipated future loss. Symptoms of anticipa- impaired older adults (Arno & Frank, 1994). tory grief are depression, an increased preoccupation with the affected family member, an • Milieu interventions—are a critical factor in the analysis of all the possible problems that may treatment of both acute and chronic dementias, occur during the course of the disease, and an- whether the client is at home or in an institution. ticipation how each family member will need 1. Provide safety, structure, and support. to readjust to care for the affected family mem- 2. Provide consistency of routine. ber (Barry, 1996). In addition to anticipatory 3. Provide orientation and environmental cues. grief, family members also may experience the 4. Explain procedures in clear, direct language to bereavement stages proposed by Kubler-Ross enhance understanding and allay anxiety. (1969): denial, anger, bargaining, depression, 5. Provide for adequate rest, nutrition, and and acceptance. elimination. 6. Disruptive behavior in demented clients of- • Group approaches—In selecting elder group par- ten occurs in response to an environmental ticipants, as with young adults, extreme paranoia trigger. Therefore, it is important to assess and severe cognitive impairment is usually con- and modify the environment (Whall, 1995). traindicated for effective group work. Therefore, Disruptive behavior often occurs in response elders who are experiencing the latter stages of to perceived pain, need for control, need to Alzheimer’s disease or other dementias, tend not feel safe, need for stimulation, and need to de- to benefit significantly from most of the following crease stress. groups while those with mild cognitive impairment can and do benefit from group therapy: • Community resources 1. Reminiscence groups aim to increase self- 1. Potential resources for clients and caregivers esteem through positive affiliations and in- can be extensive depending on the etiology, teractions with others (Ashton, 1993). These duration, and level of cognitive and functional groups may be helpful for elders and indi- impairment associated with the dementia. viduals with mild cognitive disorders and 2. Organizations related to organic factors caus- depression. ing the disorder would include Alcoholics 2. Cognitive-behavioral groups assist clients in Anonymous, The American Cancer Society, correcting negative thoughts and attitudes, American Diabetes Association, American as well as maladaptive ways in which clients Lung Association, and the Alzheimer’s Disease process information (Hitch, 1994). This type of and Related Disorders Foundation. group can be helpful to elders who suffer from 3. A wide array of community services are mild cognitive impairment with superimposed available to maintain the client and family, 196 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

including home health agencies, social ser- abilities/capacity for independent living vices, outreach programs, homebound meals, (nutrition, dressing, grooming, toileting, church support, day care, respite care, hospice, etc.) nursing homes, and others. b. Increased suicide risk is related to loneliness, helplessness, hopelessness—spe- Geropsychiatric Nursing cifically ask if the client is experiencing thoughts of suicide. • Overview (Kolanowski & Piven, 2006; Sadock & c. Assess disturbances in cognition—incor- Sadock, 2007)—Old age is a natural phase of the porate use of MMSE, Mini-cog or other life cycle, not a disease. A continuum of health assessment tools (See discussion earlier in in aging exists; ranging from those described as this chapter) well-old to those described as sick-old. Well older individuals are maintaining daily functions and • Mental disorders & associated findings in old age enjoying a time of integrity rather than despair (Keltner, Schwecke, & Bostrom, 2007; Kolanowski & (Eric Erikson—See Chapter 3). Conversely, the Piven, 2006; Sadock & Sadock, 2007) sick-old experience a variety of physical and men- 1. Dementia disorders (See earlier sections of this tal disorders or combinations thereof. Within the chapter)—antipsychotic use contraindicated— next 20 years, the demands and opportunities for related to increased risk of mortality due to geropsychiatric nursing, in caring for well and sick cardiovascular or infectious events. older persons, will expand and grow exponentially. 2. Substance-related disorders Issues regarding health maintenance, healthy a. Long-term alcohol abuse can lead to in- lifestyle promotion, comorbid disorders (psycho- firmities such as cirrhosis, Wernicke’s en- logical and physical), long-term consequences of cephalopathy and Korsakoff’s syndrome, substance abuse and/or military conflict, cultural malnutrition, effects of exposure (gan- considerations and the effects of globalization/ grene) and falls. migration each contribute to future health care b. Sudden onset of delirium in older persons needs. hospitalized for medical conditions is the most frequently recorded cause of alcohol • Psychiatric examination of the older patient withdrawal. (Keltner, Schwecke, & Bostrom, 2007; Kolanowski & 3. Anxiety disorders—some anxiety disorders can Piven, 2006; Sadock & Sadock, 2007) occur for the first time after age 60. 1. Nurses encountering older adults in any set- 4. Schizophrenia—rarely diagnosed after age 65. ting need to consider their physical, emo- 5. Depressive disorders tional, and social needs. a. Depressive disorders occur in about 15% 2. In assessing older persons in a psychiatric set- of community-dwelling elders (home and ting, follow the same format as that used for nursing home residents). younger adults. b. Useful assessment instruments include 3. If evidence of cognitive impairment is pre- the Geriatric Depression Scale (GDS). sented, additional collateral information from c. Cognitive impairment with depression is family/caretaker is needed. referred to as pseudodementia (dementia 4. In an approach with older clients, keep in syndrome of depression)—occurs in about mind the continuum of aging—taking into 15% of depressed older patients. account whether the person is a well 75-year- d. Antidepressant use by adults older than 65 old who volunteers at a local agency, or a frail years increases risk of suicide. As with all 75-year-old residing in a nursing home. patients, monitor closely for changes that 5. Psychiatric history should include: indicate increased suicidality. a. Childhood/adolescent history and e. Increased suicide risk exists for persons milestones older than 65 years—loneliness is the lead- b. Family history ing cause for suicide ideation. c. Marital/Civil union history 6. Other mental disorders d. Sexual history—many well elders are sexu- a. Sleep disorders—advanced age is a ally active well into advanced age primary factor contributing to sleep e. Abuse history and vulnerability for elder disorders. abuse b. Pain disorders 6. Mental status variations (1) Comorbidity of medical and psychi- a. Patients older than 65 should be assessed atric conditions make pain a special for functional limitations that affect condition among older adults. Questions 197

(2) Pain is associated with increased rates a. Reminiscence—characterized by review of of depression, anxiety, delayed wound meaningful and/or conflictual memories healing, reduced mobility, poor sleep of past experiences and nutrition, reduced activity. b. Life review therapy capitalizes on reminiscence behaviors through a conscious, • Biochemical interventions (Keltner, Schwecke, & deliberate process. Bostrom, 2007; Kolanowski & Piven, 2006; Sadock (1) Therapist may guide process by en- & Sadock, 2007) couraging written/tape-recorded 1. A pretreatment medical evaluation is war- biographies/histories review of special ranted, including electrocardiogram (ECG) events/milestones. a. Age-related changes affect drug absorp- (2) Techniques include reunions with sig- tion, distribution, metabolism, and nificant others, review of photos and elimination. other memorabilia. (1) Delayed absorption of oral agents is (3) Useful in resolving conflicts, guilt/fear more common in older adults. (unfinished business), reducing de- (2) Multiple drugs competing for pression, enhancing self-esteem, in- same enzyme can reduce hepatic creasing socialization, and acceptance metabolism. of present reality. (3) Creatinine clearance can be reduced despite normal serum creatinine Questions levels. (4) Reduced renal clearance might reduce Select the best answer dose requirements. b. Include assessment of all medications 1. Ms. S, age 50, has been hospitalized for a used, as well as all over-the-counter and cholecystectomy. Two days postoperatively she herbal compounds—25% of all prescribed develops pneumonia. The nurse notes that drugs are written for individuals age 65 Ms. S. does not know where she is and that she is and older. picking at the bedclothes. What is the most likely 2. Most psychotropics should be given in equally diagnosis? divided doses over a 24-hour period; once- a. Hemorrhage daily dosing can cause intolerably rapid rise in b. Sensory deprivation drug blood levels. c. Delirium a. Initial dosage is usually lower and adjust- d. Urinary tract infection ments made over time (“start low and go slow”) 2. Ms. S. is likely to be oriented to which of the b. First-line options for treating major men- following? tal disorders in younger adults are gener- a. The time of day ally well tolerated at older age but in lower b. The day of the week and more frequent doses, as previously c. Her daughter described) d. The name of her medication

• Psychotherapeutic interventions (Sadock & 3. Which of the following is the hallmark indication Sadock, 2007; Stevens & Kaas, 2008) of delirium? 1. The standard psychotherapies (individual, a. Fluctuation of sensorium and limited atten- family & group) discussed in this text are effi- tion span cacious for older adults as well. b. Global cognitive impairment 2. Psychotherapies with empirical support for c. Severe agitation use among older clients include cognitive- d. Dysphona behavioral therapy (CBT), interpersonal therapy (IPT), psychodynamic psychotherapy 4. What level of consciousness is Ms. S. likely to (PDP), and life review therapy—CBT, IPT, and exhibit during delirium? PDP have been addressed elsewhere in this a. Alert and oriented text (See Chapter 3 & specific disorders chap- b. Hypervigilant ters for more details) c. Fluctuating 3. Life review therapy d. Comatose 198 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

5. Ms. S. is likely to NOT exhibit what type of per- 13. Ms. S. was diagnosed with Delirium. What inter- ceptual disturbance? vention is most critical? a. Poorly organized delusions a. Symptom management b. Hallucinations b. Treating the underlying cause c. Illusions c. Administering medication d. Well organized delusions d. Education of the patient 6. The onset of delirium is characterized by: 14. Which intervention would be the second most important? a. Onset occurring over several days b. Abrupt onset a. Symptom management c. Occurrence within two days of exposure to a b. Treating the underlying cause causative factor c. Administering medication d. Fluctuating onset d. Education of the patient 7. Ms. S. has an EEG. The findings are likely to show 15. Which of the following drugs would be least which feature? likely to further complicate Ms. S.’s delirium? a. Diffusely abnormal slowing a. Antibiotics b. Normal b. Antihistamines c. Focal points c. Antihypertensives

d. Lower range of normal d. Vitamin B12 8. Ms. S.’s nurse needs to write a care plan. Which is 16. Mr. D. is a 65-year-old widowed white male. He the major nursing diagnosis she would use? is brought to the emergency room by his family because he has become agitated, disoriented, a. Self-care Deficit and has been hallucinating. Family reports that b. Confusion, acute Mr. D. takes ranitadine for ulcer disease. What is c. High Risk for Violence the most likely cause of his symptoms? d. Alteration in Role Performance a. His age 9. One of the ways in which delirium is differenti- b. His ulcer disease ated from dementia is that delirium is: c. His medication a. Characterized by sundowning d. An undetected organic factor b. A progressive deteriorating disease 17. The most important initial nursing intervention c. Characterized by fluctuating level of for Mr. D. is to: consciousness d. Chronic a. Interview Mr. D. without his family present b. Use chemical restraints to protect Mr. D 10. Which of the following is NOT a risk factor for c. Provide the family with a list of support delirium? groups a. Use of narcotics d. Institute measures to clear the medication b. Family dynamics from Mr. D’s body c. Systemic illness 18. Which of the following medications could the d. Presence of dementia nurse anticipate for Mr. D.? 11. Delirium is most common in which age group? a. Chlordiazepoxide 25 mg po a. Age 10–20 b. Physostigmine 2mg IV b. Age 20–40 c. Chlorpromazine 100 mg IV c. Age 40–60 d. Diazepam 10 mg IV d. Age 60–80 19. In administering physostigmine, the nurse would 12. Which of the following physical disorders is least be concerned about which of the following likely to cause delirium? classes of medications potentiating the drug? a. Hypertension a. Antiemetics b. Substance abuse and withdrawal b. Antianxiety c. Metabolic disorders c. Antidepressants d. Systemic infections d. Anticonvulsants Questions 199

20. If Mr. D. continues to be agitated, what other 27. Ms. T.’s nurse notes that she has short-term pharmacological agent is the physician likely to memory loss. An example would be: order? a. Inability to remember what happened a. Haloperidol yesterday b. Chlorpromazine b. Inability to remember current president c. Thioridazine c. Inability to remember three objects after five d. Lithium minutes d. Inability to remember an anniversary 21. The nurse would NOT anticipate which of the following side effects of haloperidol? 28. A disorder of language is also noted. What would it be called? a. Cogwheel rigidity b. Excessive salivation a. Agnosia c. Dystonia b. Anhedonia d. Orthostatic hypertension c. Apraxia d. Aphasia 22. Which individual intervention would the nurse NOT use in caring for Mr. D.? 29. Ms. B., a 68-year-old African American, has a B/P of 220/110. She has had several episodes of diz- a. Reorienting Mr. D. to day, place, situation ziness and temporary loss of consciousness. Her b. Being attentive to Mr. D.’s fears family notes that she has had difficulty remem- c. Telling Mr. D. that he needs to eat to get bering in the past few months. The most likely better diagnosis would be: d. Offering fluids every 2 hours a. Dementia of the Alzheimer’s type 23. Which of the following would NOT be an appro- b. Delirium priate environmental intervention? c. Vascular Dementia a. Limiting family visits as these may be d. Mood Disorder due to General Medical overstimulating Condition b. Providing orientation devices (clocks, calen- 30. Mr. A. is an 82-year-old white married male. dars) in Mr. D.’s room He has been diagnosed as having probable c. Keeping a low light on at night Dementia of the Alzheimer’s type. He has with- d. Having Mr. D. wear his glasses during the drawn from his activities at the senior center day but continues to perform his ADLs. The level of 24. Which of the following interventions is NOT indi- severity of his dementia could be characterized cated for Mr. D. at this time? as: a. Individual a. Mild b. Group b. Moderate c. Family c. Severe d. Milieu d. Nonexistent 25. Which of the following is NOT a cognitive mental 31. Which one of the following is NOT needed to disorder? make a diagnosis of Dementia? a. Affective disorders a. Impairment in short-term memory b. Dementia of the Alzheimer’s Type b. Transient confusion c. Vascular Dementia c. Impairment in long-term memory d. Delirium d. Significant changes in social relationships 26. Ms. T., who is 85, is unable to perform several 32. Which nursing diagnosis would be used for Mr. of her ADLs due to her inability to conceptu- A.’s condition? alize and complete tasks. Her level of dementia a. Self-care deficit is: b. Social isolation a. Mild c. Sensory/perceptual alterations b. Moderate d. Memory, impaired c. Severe d. Fluctuating 200 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

33. Various types of dementias will NOT have symp- 38. Of the following, which would NOT inform selec- toms similar to which of the following? tion of nursing diagnoses for Ms. C.? a. Acute psychotic episode a. Altered thought processes b. Delirium b. Fear related to persecutory delusions c. Major depressive episode c. Risk for violence d. Adjustment disorder d. Need for additional knowledge 34. Which one of the following etiologic factors is 39. Which is always associated with dementia? NOT a factor in dementia? a. Ataxic gait a. Heredity and degenerative neurologic b. Impaired memory and judgment disease c. Delusions b. Cerebral vascular disease and normal pres- d. Affective disturbances sure hydrocephalus 40. Alzheimer’s disease is primarily characterized by: c. Lack of education, social isolation d. Toxins and metabolic disturbances a. Progressive memory decline b. Emotional distress 35. Mr. W. is a 68-year-old widowed white male c. Dysphoria with a history of alcohol abuse. On interview he d. Hallucinations is able to remember in detail an incident that occurred 20 years ago but cannot remember 41. Assessment of Alzheimer’s disease is best done by 3 objects after 5 minutes on the mental status a: exam. He has no change in personality and his a. Physician judgment is good. Mr. W.’s condition is probably b. Nurse caused by: c. Multidisciplinary team a. A deficiency of thiamine d. Psychologist b. Heredity 42. Senile onset refers to: c. Situational stress d. A tumor a. The development of the disease before age 65 36. Ms. C. is a 70-year-old widowed female. Recently b. The development of the disease after the she has become very suspicious about her person is determined to be senile neighbor, whom she believes is an FBI agent. On c. The disease occuring after age 65 a recent CT scan a right cerebral lesion was dis- d. The development of the disease before the covered. Her suspiciousness is most likely related person is determined to be senile to: 43. Mr. Y., an 80-year-old married male, has been a. Her neighborhood diagnosed with Dementia of the Alzheimer’s b. Her family relationships Type and placed on haloperidol, 10 mg at night, c. Her cerebral tumor which is his only medication. He has become d. A grief reaction more agitated in the past week. His agitation is 37. Ms. C. is brought to the emergency room by the probably due to: police after locking herself in her apartment a. His illness and making threatening phone calls to her b. A change in his environment neighbor. The best initial nursing response to c. His medication her is: d. A urinary tract infection a. Tell her not to worry, her neighbor is not an 44. Mr. Y.’s wife, to whom he has been married FBI agent for 50 years, dies 2 years after he is first diag- b. Take measures to allay her anxiety and nosed with Dementia. Several months later he protect her from harm experiences weight loss, crying spells, and sleep c. Agree that the FBI does intrude into our lives disturbance. The most likely diagnosis would be: d. Conduct a complete nursing assessment including physical examination a. Dementia of the Alzheimer’s Type with delusions Questions 201

b. Dementia of the Alzheimer’s Type with 52. Which of the following are not causes of depression delirium? c. Dementia of the Alzheimer’s Type with a. Medications delirium b. Metabolic and endocrine imbalances d. Dementia of the Alzheimer’s Type with c. Sensory deprivation paranoia d. Infectious diseases 45. Which affect would you NOT expect Mr. Y. to 53. Which of the following is the most prevalent have? form of dementia? a. Sadness a. AIDS Dementia Complex b. Hopelessness b. Amnestic Disorder Due to a General Medical c. Euphoria Condition d. Helplessness c. Dementia of the Alzheimer’s type 46. Which type of hallucination would you NOT d. Vascular Dementia expect Mr. Y. to have? 54. The second most prevalent dementia is: a. Tactile a. AIDS Dementia Complex b. Visual b. Amnestic Disorder Due to a General Medical c. Auditory Condition d. Olfactory c. Dementia of the Alzheimer’s type 47. Mr. Y. develops praxis. This includes: d. Vascular Dementia a. Simple delusions 55. Ms. T. has dementia and resides in a nursing b. Confusion home. Which of the following individual inter- c. Inability to write ventions is not indicated to enhance her care? d. Short attention span a. Provide balance between stimulation and 48. Which of the following medications would NOT rest. be used to treat Mr. Y.’s depression? b. Provide structure and support. c. Provide clear and direct communication. a. Prozac d. Provide intensive group therapy. b. Zoloft c. Trazodone 56. Which of the following should be avoided in pro- d. Haldol viding care to Ms. T.? 49. Which of the following is classified as a selective a. The use of chemical and physical restraints serotonin reuptake inhibitor (SSRI)? b. Having family members visit c. Reminiscence groups, as they would be too a. Trazodone stimulating b. Desipramine d. Orientation measures c. Fluoxetine d. Lithium 57. The nurse is considering starting a group for residents of Ms. T.’s nursing home who have 50. Alzheimer’s disease is considered to result from: mild cognitive impairment. Which type of group a. Aluminum intoxication would be indicated? b. Alcohol abuse a. Reminiscence c. Tumors b. Jungian d. Causes that are still unknown c. Psychoanalytic 51. Vascular Dementia is characterized by which of d. Gestalt the following: 58. The primary purpose of cognitive-behavioral a. Stepwise and patchy deterioration in intel- group interventions is to: lectual functioning a. Increase self-esteem through positive affilia- b. Global cognitive impairments tions with others c. Retrograde amnesia b. Correct negative thoughts and attitudes d. Headaches and fainting spells c. Provide information d. Explore unconscious motivations of behavior 202 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

59. Mr. B., two days postadmission for esophageal Answers varices, develops delirium tremens. This state is most associated with which of the following 1. c 34. c conditions? 2. c 35. a a. Cocaine withdrawal 3. a 36. c b. Parkinson’s disease 4. c 37. b c. Alcohol withdrawal 5. d 38. d d. Hypoxia 6. b 39. b 7. a 40. a 60. Which of the following community resources would be most helpful to Mr. B.’s family? 8. b 41. c 9. c 42. c a. Alanon 10. b 43. c b. Alzheimer’s Disease and Related Disorders 11. d 44. b Foundation 12. a 45. c c. American Heart Association 13. b 46. a d. Mental Health Association 14. a 47. c 61. Validation is a method to: 15. d 48. d a. Limit communication 16. c 49. c b. Restore well-being 17. d 50. d c. Facilitate avoidance of unresolved issues 18. b 51. a d. Teach sympathy skills 19. c 52. c 62. Dementia Due to HIV Disease is NOT called which 20. a 53. c of the following? 21. d 54. d 22. c 55. d a. AIDS Dementia Complex 23. a 56. a b. HIV Vascular Dementia 24. b 57. a c. HIV Encephalopathy 25. a 58. b d. HIV Subcortical Dementia 26. c 59. c 63. In treating geropsychiatric patients, most 27. c 60. a psychotropics: 28. d 61. b a. Are best divided into equal doses over 24 29. c 62. b hours 30. a 63. a b. Are best in once-daily doses to reduce the 31. b 64. b incidence of medication errors 32. d 65. d c. Are prescribed no differently than for 33. d younger adults d. Are contraindicated due to effects of Bibliography dementia 64. For patients older than 70 years, assessment of Abraham, I. L., Holroyd, S., Snustad, D. G., Manning, sexual activity is: C. A., Brashear, H. R., Diamond, P., & Thompson- Heisterman, A. A. (1994). Multidisciplinary assess- a. Unimportant because few older than 70 are ment of Alzheimer’s disease. Nursing Clinics of North sexually active America, 29(1), 113–128. b. Important because sexual activity continues Abraham, I. L., Niles, S. A., Thiel, B. P., Siarkowski, K. I., well into advanced age & Cowling, W. R. (1991). Therapeutic group work with c. Irrelevant for persons in long-term care depressed elderly. Nursing Clinics of North America, d. Both a and c are correct 26(3), 635–650. 65. During the next 20 years, demands for expertise Abramowiez, M. (1993). Drugs that cause psychiatric in geropsychiatric nursing is expected to: symptoms. The Medical Letter on Drugs and Thera- peutics, 35(901), 65–70. a. Decline Alzheimer’s Disease Education & Referral (ADEAR) b. Remain the same Center. (2008). Alzheimer’s disease genetics: Fact c. Grow slightly sheet. (NIH publication No. 08-6424). Bethesda, MD: d. Grow substantially Author. Bibliography 203

American Psychiatric Association. (2006). Practice Fine, I. L., & Rouse-Bane, D. (1995). Using validation guideline for the treatment of patients with Alzheim- techniques to improve communication with cogni- er’s disease & other dementias (2nd ed.). Arlington, tively impaired older adults. Journal of Gerontologi- VA: American Psychiatric Publishing. Retrieved cal Nursing, 21(6), 39–45. from http://www.psychiatryonline.com/pracGuide/ Flood, M., & Buckwalter, K. C. (2009). Recommenda- pracGuideTopic_3.aspx tions for mental health care of older adults: Part American Psychiatric Association. (2000). Diagnostic 2––An overview of dementia, delirium, & substance and statistical manual of mental disorders (4th ed., abuse. Journal of Gerontological Nursing, 35(2), text revision). Washington, DC: Author. 35–47. Arno, S., & Frank, D. L. (1994). A group for “wander- Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). ing” institutionalized clients with primary degenera- “Mini-Mental State.” Journal of Psychiatric Research, tive dementia. Perspectives in Psychiatric Care, 30(3), 12, 189–198. 13–16. Francis, J. (1992). Delirium in older patients. Journal of Ashton, D. (1993). Therapeutic use of reminiscence with the American Geriatrics Society, 40, 829–838. the elderly. British Journal of Nursing, 2(18), 894–898. Gorbien, M. J., Bishop, J., Beers, M. H., Norman, D., Barry, P. D. (1996). The physical cause of cognitive men- Osterweil, D., & Rubenstein, L. Z. (1992). Iatrogenic tal disorders. In P. D. Barry (Ed.), Psychosocial nursing: illness in hospitalized elderly people. Journal of the Care of the physically ill patients and families (3rd ed. American Geriatric Society, 40, 1031–1042. pp. 195–219). Philadelphia, PA: J. B. Lippincott. Griepp, A., Landau-Stanton, J., & Clementis, C. D. Bergeron, N., Dubois, M. J., Dumont, M., Dial, S., & (1993). The neuropsychiatric aspects of HIV infection Skrobik, Y. (2001). Intensive Care Delirium Screening and patient care. In J. Landau-Stanton & C. D. Clem- Checklist: Evaluation of a new screening tool. Inten- ents (Eds.), AIDS health and mental health: A primary sive Care Medicine, 27(5), 859–864. source book (pp. 192–213). New York, NY: Brunner/ Bleathman, C., & Morton, I. (1996). Validation therapy: Mazel. A review of its contribution to dementia care. British Hitch, S. (1994). Cognitive therapy as a tool for caring Journal of Nursing, 5(4), 866–868. for the elderly confused person. Journal of Clinical Boehm, S., Whall, A. L., Cosgrove, K. L., Locke, J. D., & Nursing, 3(1), 49–55. Schlenic, E. A. (1995). Behavioral analysis and nurs- Hollander, H., & Katz, M. H. (1997). HIV infection. In ing interventions for reducing disruptive behaviors L. M. Tierney, S. J. McPhee, & M. A. Papadakis (Eds.), of patients with dementia. Applied Nursing Research, Current medical diagnosis & treatment (36th ed., pp. 8(3), 118–122. 1178–1202). Stamford, CT: Appleton & Lange. Bor, R., Miller, R., & Goldman, E. (1992). Theory and Inaba-Roland, K. E., & Maricle, R. A. (1992). Assessing practice of HIV counseling: A systematic approach. delirium in acute care setting. Heart and Lung, 21(1), New York, NY: Brunner/Mazel. 48–55. Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dok- Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). mak, A. (2000). The Mini-Cog: A cognitive “vital signs” Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. measure for dementia screening in multi-lingual el- Kolanowski, A., & Piven, M. L. (2006). Geropsychiatric derly. International Journal of Geriatric Psychiatry, nursing: The state of the science. Journal of the Amer- 15, 1021–1027. ican Psychiatric Nurses Association, 12(2), 75–99. Breitner, J. C., & Welsh, K. A. (1995). Diagnosis and Kubler-Ross, E. (1969). On death and dying. New York, management of memory loss and cognitive disorders NY: Macmillian. among elderly persons. Psychiatric Services, 46(1), Lipowski, Z. J. (1992). Update on delirium. Psychiatric 29–35. Clinics of North America, 15(2), 335–346. Canadian Medical Association (CNA). (1993). CMA pol- Meagher, D., & Leonard, M. (2008). The active manage- icy summary: Medication use and the elderly. Cana- ment of delirium: Improving detection & treatment. dian Medical Association, 149(8), 1152A–1152B. Advances in Psychiatric Treatment, 14, 292–301. Coccaro, E. F., Kramer, E., Zemishlany, Z., Thorne, A., NANDA International. (2009). Nursing diagnoses: Defi- Rice, C. M., Giordani, B., Duvvi, K., Bhupendra, M. P., nitions & classifications, 2009–2011. West Sussex, UK: Torres, J., Nora, R., Neufeld, R., Mohs, R. C., & Davis, Wiley & Sons. K. L. (1990). Pharmacologic treatment of noncogni- National Institute on Aging. (2009, March 17). Scientists tive behavioral disturbances in elderly demented report important step in biomarker testing for Al- patients. American Journal of Psychiatry, 147(12), zheimer’s disease. News. Retrieved June 4, 2009, from 1640–1645. http://www.nia.nih.gov/Alzheimers/ResearchInfor- Feil, N. (1989). Validation: An empathetic approach to mation/NewsReleases/PR20090317biomarkers.htm the care of dementia. Clinical Gerontologist, 8, 89–94. Neese, J. B. (1991). Depression in the general hospital. Ferrini, A. F., & Ferrini, R. L. (1992). Health in the later Nursing Clinics of North America, 26(3), 613–622. years (2nd ed.). Madison, WI: Brown & Benchmark. 204 Chapter 9 Cognitive Mental Disorders and Geropsychiatric Nursing

Neese, J. B., & Abraham, I. L. (1992). Group interven- Tappen, R. M. (1994). The effect of skill training on tions with the elderly. In K. C. Buckwalter (Ed.), Ge- functional abilities of nursing home residents with riatric mental health nursing: Current and future dementia. Research in Nursing and Health, 17(3), challenges (pp. 75–83). Thorofare, NJ: Slack. 159–165. North American Nursing Diagnosis Association. (1994). Thompson-Heisterman, A. A., Smullen, D. E., & Abra- NANDA nursing diagnoses: Definition & classifica- ham, I. L. (1992). Psychogeriatric nursing assessment. tion. St. Louis, MO: Mosby. In K. C. Buckwalter (Ed.), Geriatric mental health Rawlins, R. P., Williams, S. R., & Beck, C. K. (1993). Men- nursing: Current and future challenges (pp. 17–26). tal health-psychiatric nursing: A holistic life-cycle ap- Thorofare, NJ: Slack. proach (3rd ed., pp. 649–670). St. Louis, MO: Mosby. Trzepacz, P. T., Baker, R. W., & Greenhouse, J. (1988). A Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sa- symptom rating scale for delirium. Psychiatry Re- dock’s synopsis of psychiatry (10th ed.). Philadelphia, search, 23(1), 89–97. PA: Lippincott. Tune, L., Carr, S., Hoag, E., & Cooper, T. (1992). Anticho- Schor, J. D., Levoff, S. E., Lipsitz, L. A., Reily, C. H., linergic effects of drugs commonly prescribed for the Cleary, P. D., Rowe, J. W., & Evans, D. A. (1992). Risk elderly: Potential means for assessing risk of delirium. factors for delirium in hospitalized elderly. JAMA, American Journal of Psychiatry, 149(10), 1393–1394. 267(6), 827–831. Tune, L., & Ross, C. (1994). Delirium. In C. E. Coffey & Shulman, K. I., Shedletsky, R., & Silver, I. (1986). The J. L. Cummings (Eds.), Textbook of geriatric neuro- challenge of time: Clock drawing and cognitive func- psychiatry (pp. 352–365). Washington, DC: American tion in the elderly. International Journal of Geriatric Psychiatric Press. Psychiatry, 1, 135–140. Videbeck, S. L. (2006). Psychiatric mental health nurs- Stahl, S. M. (2008). Stahl’s essential psychopharmacol- ing (3rd ed.). Philadelphia, PA: Lippincott, Williams & ogy: Neuroscientific basis & practical applications (3rd Watkins. ed.). New York, NY: Cambridge University Press. Whall, A. L. (1995). Disruptive behavior in late stage Stahl, S. M. (2009). Stahl’s essential psychopharmacol- dementia: Using natural environments to decrease ogy: The prescriber’s guide (3rd ed.). New York, NY: distress. Journal of Gerontological Nursing, 21(10), Cambridge University Press. 56–57. Stevens, G. L., & Kaas, M. J. (2008). Psychotherapy with Yi, E. S., Abraham, I. L., & Holroyd, S. (1994). Alzheim- older adults. In K. Wheeler, Psychotherapy for the er’s disease and nursing: New scientific and clini- advanced practice psychiatric nurse. St. Louis, MO: cal insights. Nursing Clinics of North America, 29(1), Mosby. 85–99. St. Pierre, J. (1996). Delirium in hospitalized elderly patients: Off track. Critical Care Nursing Clinics of North America, 8(1), 53–60. 10 Behavioral and Emotional Disorders of Childhood and Adolescence

Child and Adolescent than other youth to initiate alcohol and Psychiatric Mental Health other substance use. Nursing c. Among children ages 10–14, homicide and suicide were the third and fourth leading • Professional standards—Specialists in this area causes of death. hold a master’s or doctoral degree addressing d. About 4.5 million children 3–17 years of specific issues in child and adolescent psychiatric age (7%) had Attention Deficit Hyperactiv- nursing and are certified as clinical nursing spe- ity Disorder (ADHD), with a 2:1 ratio for cialists in child and adolescent psychiatric nurs- boys vs girls. ing or family psychiatric and mental health nurse e. Attention-Deficit Disorder and Attention- practitioners (FPMHNP) by the American Nurses Deficit/Hyperactivity Disorder (30%), and Credentialing Center. They are recognized by their depression, anxiety, or other emotional peers as Advanced Practice Registered Nurses. problems (21%) were among the most frequently reported health conditions in • Epidemiology children with special healthcare needs 1. Prevalence rates of mental disorders among (younger than 17 years). children and adolescents (Bloom, & Cohen, f. Alcohol is the most common psychoactive 2009; Federal Interagency Forum on Child and substance used during adolescence. Family Statistics, 2009; Keltner, Schwecke, & (1) 8% of both male and female 8th-grade Bostrom, 2007)—20% of school-age children students reported heavy drinking. suffer significant mental health problems (2) 17% of 10th-grade males and 15% of (8–12 million children and adolescents); of females reported heavy drinking. these, only 20% are receiving mental health (3) 20% of 12th-grade males reported services. heavy drinking, compared with 21% of 2. Reports of child and adolescent health surveys 12th-grade females. from 2006 to 2008 (Bloom, & Cohen, 2009; Fed- g. Illicit drug use (marijuana, cocaine, etc.) eral Interagency Forum on Child and Family within the past 30 days was reported by: Statistics, 2009) include the following facts: (1) 8% of 8th-grade students. a. The incidence of adolescent depression is (2) 16% of 10th-grade students. 8.2% (highest incidence was among girls (3) 22% of 12th-grade students. and those aged 16–17 years). b. Youth who have had a major depressive • Cultural and ethnic considerations episode (MDE) in the past year are at 1. Cultural weaknesses greater risk for suicide and are more likely

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a. Lack of acculturation means children 3. Being abused physically or sexually of immigrants (and their parents) are at 4. Being of minority ethnic status (associated greater risk for depression and suicide with poverty) (Hovey & King, 1996, Sadock & Sadock, 5. Having teenage parents 2007). 6. Being in families with marital discord, parental b. Some folk medicine practices and child conflict, divorce, instability in family environ- rearing practices may be perceived as ment; being in foster care abusive by Western cultural standards. 7. Having a chronic illness or disability The nurse needs to observe and educate 8. Living with prolonged parent-child separation, parents about certain practices (Zimmer- multiple separations, frequent changes in pri- man, 1997), but needs to be aware of other mary caretaker cultural beliefs before imposing Western 9. Homelessness (families with children are practices. the fastest growing segment of the homeless 2. Cultural strengths population) a. Strong loyalty to family, family cohesive- 10. Being a Native-American child from certain ness, and family ownership of children’s tribes whose suicide rates are 2–3 times that of problems is prevalent in Native-American, the rest of the US population for the same age African-American, and Asian families. b. Strong supportive extended family link- • Genetic/Biologic origins ages and sharing in child-care tasks by 1. Low birth weight family, friends, and neighbors is prevalent 2. Developmental delay in families of color. 3. Brain damage c. Cultural emphasis on discipline, obedi- 4. Epilepsy ence to rules, and respect for elders who 5. Addiction as a result of maternal substance are sources of advice for child rearing is abuse prevalent in Asian families. 6. Early difficulties in adjustment between infant d. Having bicultural competence preserves and primary caretaker temperament styles cultural identity while the child negotiates 7. Mental retardation the dominant culture. 8. Genetic loading—there is an increased risk e. Humor as a means of coping with adver- for developing a mental disorder for children sity is a strength. with a first-degree relative afflicted with the f. Independence for children is prevalent disorder (specifically genetic links have been in Native-American families; interdepen- found among: mood and anxiety disorders, dence of siblings in Hispanic families. substance-related disorders, tic disorders, and g. Strong religious values, customs, rituals, ADHD) (Keltner et al., 2007) and institutions that provide spiritual sup- 9. Physical illness and impairments port and reinforce strong, ethical values a. Illness often interferes with the acquisition for life decisions, and give meaning to life of skills and negotiation of developmental are prevalent; churches provide group milestones. socialization activities and supplementary b. Children have fears and anxieties re- child care. lated to their developmental age, and the h. Value placed on education of children, younger the child, the fewer the coping who are seen as hope for the future by strategies. African-American and Asian families. c. Regression occurs in the face of illness or i. Strong ethnic community representatives disability. and organizations exist that help people d. Chronic illness may pose greater risk for of color to bargain, negotiate, and obtain psychological disturbance. resources from larger societal systems e. Children with AIDS are at particularly high (Gaudin,1993). risk due to (1) Family dysfunction—extreme poverty, • Risk factors for mental and emotional disorders are drug abuse, social isolation, and/or increased in the following situations: homelessness 1. Living in poverty and in crowded, inner city (2) Parental ill health or social environments (poverty increases intensity of stigmatization all other risk factors) 10. Circumstances that may decrease risk include: 2. Having mentally ill and substance abusing parents Child and Adolescent Psychiatric Mental Health Nursing 207

a. Presence of primary attachment fig- a. Parental discord prior to a separation and ure during the child’s illness and or/ divorce hospitalization b. Continuous discord regarding custody, b. Family’s functionality—stress manage- visitation, child support, and each parent’s ment, coping, competence, and ability to activities and friends support child appropriately c. Children exposed to parental separation c. Community support and respite care for before school entry may show increased family risk of later conduct or oppositional and d. Partnership of family and providers mood disorders. in assisting child to adapt to illness or d. Children exposed to parental separation impairment after 10 years of age show increased risk of e. Attention to psychological and social substance abuse. needs along with physical and medical e. Children and adolescents in therapy may issues within the context of the child’s de- focus on parent’s separation as a major velopmental stage event in their lives. f. Assistance in achieving developmental 4. Blended families milestones, realistic academic goals, a. Children must adjust to stepparents, step- self-esteem, mastery, and social support siblings and step-grandparents. (Johnson, 1995) b. Visitation schedules often disrupt family g. Parents or caretakers who create an envi- routines; children often feel resentment, ronment with nonthreatening language, anger, and a sense of abandonment. descriptive praise, play and related activ- c. Loyalty conflicts and attachment prob- ity, mediated learning experiences, and lems are common and relate to child’s de- positive self-talk (Johnson, 1995) velopmental stages. h. Child factors that may contribute to re- 5. Alternative lifestyles duced risk include: a. Children sense they are different or are (1) Problem-solving ability teased. (2) Social skills b. Adolescent peer pressure and develop- (3) Warm, caring relationship with a sup- mental needs propel the youngster to fit in portive, consistent adult with the peer culture. (4) Compensatory experiences outside 6. Foster families—Number of children in foster the home care has recently decreased from record highs (5) Personality characteristics, such as reported early this decade: 783,000 children perceived competence and social served by the system in 2007, of which over acceptance 496,000 lived in foster care; 75% placed due (6) Normal intellectual development to maltreatment or inadequate care (Trends (7) Social support from family, peers, and in Foster Care report from the Administra- teachers (Johnson, 1997; Krauss, 1993) tion for Children & Families: http://www.acf. hhs.gov/programs/cb/stats_research/afcars/ • Family constellations and stressors—child’s func- trends.htm). tioning and well-being are dependent on the family and school setting in which he or she lives and • Access to health care studies (JAACAP, 1997a). 1. Services for children are inadequate, inappro- 1. Nuclear families priate, or unavailable. a. Economic pressures on both parents to 2. Over 12 million US children lack health work insurance. b. Lack of adequate day care and the low pri- 3. Cutbacks in funding of mental health services ority given to child care have affected psychiatric care of children and c. Poor parenting skills adolescents. 2. Adoptive families 4. Inadequate residential care is available. a. Recent court rulings returning children to 5. In order to obtain services for their children, birth families many parents must give custody to the state. b. Adopted children at higher risk for emo- 6. Inadequate numbers of mental health pro- tional mental disorders for a variety of fessionals are trained to provide the needed complex reasons mental health services for children and 3. Separation and divorce adolescents. 208 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

7. Cost containment measures by managed care 4. Profound Mental Retardation—IQ level below impact services. 20 or 25 a. 1 to 2% of people with MR • Community background factors b. Minimal capacity for sensorimotor 1. Cultural context functioning 2. How family relates to neighborhood c. Motor development, self-care and com- 3. Religious and ethnic orientation munication skills may improve if appro- 4. Neighborhood resources and adverse priate training provided circumstances d. May live in group homes, intermediate a. Poverty care facilities or with families b. Poor housing e. Need day programs or sheltered workshop c. Crime or urban violence (JAACAP, 1997a) • Associated disorders Mental Disorders Diagnosed 1. The more severe the retardation, the greater in Children & Adolescents the likelihood of other abnormalities being present in one or more systems. Mental Retardation (MR)—coded on Axis 2. In Down syndrome, social skills are much II in the DSM-IV-TR multiaxial system higher than could be expected for the level of (American Psychiatric Association [APA], retardation. 2000; Sadock & Sadock, 2007) 3. Prevalence of mental disorders at least three or four times higher than in the general • Levels population. 1. Mild Mental Retardation—IQ level 50–55 to 4. Common associated disorders approximately 70 a. Pervasive Developmental Disorders a. Can develop social and communication b. ADHD skills c. Stereotypic Movement Disorder b. Acquisition of academic skills to sixth- grade level • Mental status variations—need to be adjusted to c. Acquire skills for minimum self-support level of retardation d. Can live in the community 1. Passivity e. May need guidance and support during 2. Dependency stress 3. Low self-esteem 2. Moderate Mental Retardation—IQ level 35–40 4. Low frustration tolerance to 50–55 5. Aggressiveness a. 10% of the population with MR 6. Poor impulse control b. Can talk and communicate 7. Stereotyped self-stimulating and self-injurious c. Can profit from vocational training, but behavior unlikely to progress beyond second grade level • Nursing diagnoses (NANDA, 2009) d. May have difficulties with social 1. Powerlessness conventions 2. Self-Care Deficit, bathing e. Can live in supervised group homes 3. Self-Care Deficit, dressing f. Need supervision and guidance under 4. Self-Care Deficit, feeding stress 5. Self-Care Deficit, toileting 3. Severe Mental Retardation—IQ level 20–25 to 6. Communication, impaired verbal 35–40 7. Role Performance, ineffective a. 3 to 4% of people with MR b. Little or no communicative speech dur- • Genetic/Biologic origins (Sadock & Sadock, 2007) ing preschool, may learn speech during 1. Hereditary factors in 5% of cases school-age years 2. Inborn metabolism errors (Tay-Sachs disease; c. Can be taught limited hygiene skills phenylketonuria) d. Can “sight-read” some survival words, 3. Single gene abnormalities (Tuberous sclerosis) such as “EXIT” “STOP” “MEN” “WOMEN” 4. Chromosomal aberrations (translocation e. May perform simple tasks under close Down syndrome, Fragile X syndrome) supervision 5. Early alterations of embryonic development f. May live in the community in group (30%) homes or with families, in the absence of an associated handicap Mental Disorders Diagnosed in Children & Adolescents 209

a. Maternal alcohol consumption causing • Milieu interventions prenatal damage due to toxins 1. Mental retardation, per se, is no longer gener- b. Pregnancy and perinatal problems (10%) ally considered a criterion for admission to a c. Fetal malnutrition, prematurity, or psychiatric inpatient setting. hypoxia 2. Day-care settings or sheltered workshops pro- d. Maternal trauma—pregnant women more vide milieu. at higher risk for injury due to family vio- 3. Community meetings can be helpful in group lence than nonpregnant women home, day-care settings or workshop settings. 6. Physical disorders acquired in childhood 4. Designed to address specific problematic behaviors • Biochemical interventions—are diagnostic and 5. Aggressive behaviors are in response to over- symptom specific; include symptomatic treatment whelming lack of power experienced by these of associated features/behaviors children, so child needs help in coping with teasing, and protection from harm by others. • Intrapersonal origins/Psychotherapeutic interventions • Community resources 1. Origins include: psychosocial deprivation, lack 1. Numerous resources exist in larger metropoli- of stimulation, and complications of other tan areas. mental disorders. 2. Rural areas have extremely limited resources. 2. Behavior modification specific for acting-out 3. Steady decline in services has occurred in last can be effective. 20 years. 3. Supportive treatment that raises self-esteem 4. Retarded adults with supervision are reliable may be helpful for the higher functioning and effective workers for routine tasks. patient. 5. Federation for Children with Special Needs 4. Treatment interventions are based on the 6. National Information Center for Handicapped social, educational, psychiatric, and environ- Children and Youth mental needs of the patient. Learning Disorders • Family dynamics/Family therapy 1. Dysfunctional family processes, such as abu- • Definition—Learning disorders, also called learn- sive and chemically dependent families may ing disabilities, occur in 4 to 6% of school-age contribute. children. There is controversy over the inclusion of 2. Families who undernurture and understimu- these as mental disorders. Often there is no sign of late may contribute. psychopathology. Detection and treatment gener- 3. Therapy is geared to correcting dysfunctional ally occurs within the school system. processes without pathologizing family; promote rewarding, praising. Reading Disorder (APA, 2000; Keltner et al, 2007) 4. Deficits of mentally retarded child create se- • Definition—Also called dyslexia, Reading Disorder vere stress for family; pattern of overprotection involves lower achievement in reading skills than and overcompensation may develop. would be suggested by aptitude or intellectual 5. Families need both respite care and help in abilities. Treatment involves remediation strategies focusing on the child’s strengths as well as re- to improve reading skills. alistic expectations. 6. Psychoeducational approaches can be used to Mathematics Disorder (APA, 2000; engender family cooperation with programs. Keltner et al, 2007) • Definition—Mathematics Disorder involves • Group approaches lower achievement in math skills than would be 1. Traditional, insight-oriented group is not suggested by aptitude or intellectual abilities. indicated. Treatment involves problem-solving strategies to 2. Behavior modification, educational group may improve math skills. be helpful. 3. Multiple family group therapy decreases fam- Disorder of Written Expression (APA, 2000; ily’s sense of isolation and stress, and provides Keltner et al, 2007) a forum for sharing effective management • Definition—Involves lower achievement in writing strategies. skills than would be suggested by aptitude or intel- 4. Socialization groups can be useful. lectual abilities. Treatment involves direct practice 5. Skills building can be useful. to improve writing skills. 210 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

Motor Skills Disorder/Developmental • Family dynamics/Family therapy—families may Coordination Disorder (APA, 2000; Sadock & need assistance in parent management strategies Sadock, 2007) and psychoeducational approaches may be in • Definition & signs and symptoms—Deficits occur order. in coordination and ability to perform gross and/or fine motor skills associated with activities of daily • Group approaches—may be helpful in self- living. Children with this disorder frequently esteem issues and to help overcome feelings of struggle to perform activities including jump- differentness. ing, hopping, running, and may perform poorly academically due to clumsiness and poor writing • Community resources—educational intervention skills. About 5% of all school-age children meet the depends upon degree of impairment. criteria for Developmental Coordination Disorder. 1. National Learning Disabilities Association A diagnosis is informed by standardized testing. 2. Federation for Children with Special Needs

• Differential diagnosis Communication Disorders 1. Mental retardation 2. Neurological disorders • Definition—Communication disorders involve 3. Pervasive Developmental Disorders deficits in speaking or language (the formulation 4. ADHD and comprehension of verbal exchange between 5. Elective mutism people), and affect about 5% of preschool and 3% 6. Inadequate schooling of school-age children. A diagnosis is informed 7. Impaired vision or hearing by standardized testing (APA, 2000; Keltner et al., 8. PTSD-induced regression and loss of recently 2007; Sadock & Sadock, 2007). acquired skills Expressive Language Disorder (APA, 2000; Sadock & Sadock, 2007) • Mental status variations 1. Determined by history, observation • Definition & signs and symptoms—Children with 2. Teacher report/checklists essential this disorder tend to function below their intellectual abilities in terms of correct tense usage, • Nursing diagnoses (NANDA, 2009) complex sentence structure, vocabulary, and word 1. Behavior, risk-prone health recall. 2. Coping, ineffective 3. Communication, impaired verbal • Therapeutic interventions may involve practice 4. Knowledge, deficient (specify) and possibly a speech specialist; other therapeutic 5. Development, risk for delayed options include psychotherapy to address self- esteem. • Genetic/Biologic origins/Biochemical Mixed Receptive-Expressive Language Disorder interventions (APA, 2000; Sadock & Sadock, 2007) 1. Perinatal injury of various kinds may be a causative factor. • Signs and symptoms (APA, 1994, p. 60–61)—in- 2. No information on sex ratio for the arithmetic clude those for Expressive Language Disorder as and coordination disorders; the others are well as difficulty understanding words, sentences, from two to four times more common in males or specific types of words, such as spatial terms. than females. Phonological Disorder (APA, 2000; Sadock & 3. Some research shows history in first-degree Sadock, 2007) biologic relatives. 4. No evidence that medication directly benefits • Signs and symptoms—failure to use developmen- children with these disorders; may be used for tally expected speech sounds that are appropriate associated conditions. for age and dialect (e.g., errors in sound production, use, representation, or organization such as, • Individual psychotherapy but not limited to, substitutions of one sound for 1. May be helpful with issues of low self-esteem another [use of /t/ for target /k/ sound] or omis- and school failure. sions of sounds such as final consonants) 2. Collaboration with school guidance counselor Stuttering (APA, 2000; Sadock & Sadock, 2007) and school counseling may be helpful. 3. Use of visual, auditory, and tactile materials • Signs and symptoms—disturbance in the nor- have been successful in skill building. mal fluency and time patterning of speech Mental Disorders Diagnosed in Children & Adolescents 211

(inappropriate for the individual’s age), character- 3. May have generalized neurological soft signs. ized by one or more of the following behaviors: 4. No factors have been shown to be clearly asso- 1. Repetition of sounds or syllables ciated with recovery. 2. Sound prolongations 5. Approximately 80% recover before 16 years of 3. Interjections age. 4. Pauses within a word 6. Females more commonly recover than males. 5. Filled or unfilled pauses in speech 6. Word substitutions to avoid problematic words • Psychotherapeutic and behavioral interventions (circumlocutions) 1. Therapy should focus on overcoming associ- 7. Words produced with an excess of physical ated anxiety and frustration. tension 2. Relaxation training, positive self-talk and 8. Monosyllabic whole-word repetitions stress management may help provide a sense (e.g., “I-I-I see him”) of mastery and self-control. 3. Teach self-control strategies. Information Common to All Communication Disorders • Family therapy • Differential diagnosis 1. Family may help raise child’s self-esteem. 1. Hearing impairment or other sensory deficit 2. Assist parents to understand and be empa- 2. Speech-motor deficit thetic with patient. 3. Normal dysfluencies that occur in young 3. Contributory family dysfunctional patterns children need to be addressed; confront interactions 4. Severe environmental deprivation (for Pho- that maintain dysfunction. nological Disorder and Expressive Language 4. Challenge denial surrounding deficit in order Disorder) to support actual interventions. 5. Neurological deficit 5. Promote realistic expectations, e.g., filling in 6. Mental retardation with learning disabilities pauses (Jongsma et al., 1996). 7. Autistic disorder (for Expressive Language Disorder) • Group approaches—overcome low self-esteem and 8. Mental retardation (for Expressive Language impairment of social functioning. Disorder) 9. Acquired aphasia due to general medical con- • Community resources dition (for Expressive Language Disorder) 1. Speech and hearing therapy services—usually 10. Spastic dysphonia not covered by third-party payers. 11. Anxiety disorder 2. School systems may have special education services. • Mental status variations 1. Often causes the speaker great anxiety and Pervasive Developmental Disorders fearfulness of speaking. (PDD) 2. Speech rate may be altered. 3. Motor movements frequently accompany stut- Autistic Disorder (APA, 2000; Keltner et al., 2007; tering, such as eye blinks, tics, tremors of the Sadock & Sadock, 2007) face and head, fist clenching. • Definition & signs and symptoms—Autism is a 4. Severity of symptoms may increase under PDD characterized by symptoms involving impair- pressure to communicate, such as during ment in social interaction, communication, and interview. restrictive repetitive and stereotyped patterns of behavior/interests. Autism disorder can be dif- • Nursing diagnoses (NANDA, 2009) ferentiated from other PDD due to early age of 1. Communication, impaired verbal onset for autism (younger than 30 months); severe 2. Anxiety deficits in social relating, communication, and development (e.g., Rett syndrome involves a rapid • Genetic/Biologic origins decline in previously acquired skills); occurs in 1. Familial pattern is noted. about 0.08% of children. 2. Stuttering—research supports genetic evidence for origin of stuttering. • Associated features (the younger the child and the a. Male-to-female ratio is 3 to 1. more severe the impairment, the higher the num- b. 50% of first degree biologic relatives ber of associated features) affected. 212 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

1. Abnormal development of cognitive skills with Asperger’s disorder often have normal intel- 2. Abnormal posture and motor behavior ligence (compared to the high incidence of men- 3. Odd response to sensory input such as obliv- tal retardation among those with autism); verbal ion to pain or cold, but hypersensitivity to be- abilities/intellect are frequently higher than per- nign sounds, such as birds chirping; may have formance abilities/intellect; have a tendency to a fascination for some sensations of touch, interpret language cues concretely; and possess such as velvet pillow social skills deficits that are evidenced by difficul- 4. Abnormalities in eating, drinking, or sleeping ties in reading social cues. Additional character- 5. Abnormalities of mood istics include clumsiness, difficulty managing 6. Mental retardation transitions, and a preoccupation with areas of their 7. Temporal lobe deficit own interest. The disorder is more common among 8. Prenatal complications boys. 9. Self-injurious behavior, such as head-banging, finger-biting, gouging skin • Therapeutic interventions for Pervasive Develop- mental Disorders • Differential diagnosis 1. Behavioral therapy to target behaviors that will 1. Mental retardation—even seriously impaired, improve abilities to assimilate into school and can socialize and communicate in some way social relationships; and increase the likeli- 2. Schizophrenia—rare in childhood hood of future independent living 3. Hearing impairments and specific develop- 2. Symptomatic treatment of associated psychi- mental language and speech disorders atric conditions 4. Tic disorders and Stereotypic Movement Disorder Attention-Deficit and Disruptive 5. Other PDD Behavior Disorders 6. Schizotypal or Schizoid Personality Disorder • Definition—Behaviors that are disturbing to oth- • Genetic/Biologic origins—linkage studies have ers and often socially disruptive. The behaviors identified candidate genes associated with autism are referred to as “externalizing” symptoms. They on chromosomes 7, 2, 4, 15, and 19. interfere with the child’s social functioning and learning. Rett’s Disorder • Definition & signs and symptoms (APA, 2000; Kelt- Attention-Deficit/Hyperactivity Disorder (ADHD) ner et al., 2007; Sadock & Sadock, 2007)—a rare • Definition & signs and symptoms (American Acad- PDD that involves a significant decline in function- emy of Child & Adolescent Psychiatry, 2007a; APA, ing following normal development of at least 2000; Keltner et al., 2007; Sadock & Sadock, 2007)— 6 months ADHD is among the most common of childhood psychiatric conditions; characterized by symptoms • Differential diagnosis of inattention, impulsivity, and overactivity that 1. Autistic Disorder occur in at least two different settings (i.e., home 2. Childhood Disintegrative Disorder and school) with significant impairment in func- 3. Mental Retardation tioning (socially, academically, occupationally). ADHD is divided into the following three subtypes Childhood Disintegrative Disorder that specify the dominant associated behaviors: • Definition & signs and symptoms (APA, 2000; Kelt- 1. Hyperactive-impulsive type ner et al., 2007; Sadock & Sadock, 2007)—a marked 2. Inattentive type regression in multiple areas of functioning after a 3. Combined (hyperactive-impulsive and inat- period of normal development for at least the first tentive) type 2 years after birth as characterized by significant deterioration of age-appropriate verbal and non- • Associated features verbal communication, social relationships, play, 1. Child may become alienated from peers due and adaptive behavior to inability to cooperate with others or follow game rules; excessive talking is common. • Differential diagnosis—another PDD or 2. Child may engage in dangerous activities with- Schizophrenia out considering consequences. 3. Symptoms may not be evidenced when child Asperger’s Disorder is in a highly structured, novel, or one-to-one • Definition & signs and symptoms (APA, 2000; Kelt- situation, or when watching TV or playing ner et al., 2007; Sadock & Sadock, 2007)—Children video games. Mental Disorders Diagnosed in Children & Adolescents 213

4. Age of onset is generally before 7 years of age 2. Age-appropriate overactivity is evaluated by (almost half before 4 years of age). quality of activity; ADHD child has difficulty 5. Disorder is often diagnosed at entry into regulating his or her activity level to demands school. of the environment. 6. Low self-esteem, labile mood, and temper tan- 3. Observe for symptoms of ADHD oppositional trums are often present. behavior, aggressive behavior.

• Differential diagnosis • Nursing diagnoses (NANDA, 2009) 1. Considerations: 1. Coping, ineffective a. It is sometimes impossible to differenti- 2. Social Interaction, impaired ate this diagnosis from response to a 3. Communication, impaired verbal chaotic environment, including parenting 4. Role Performance, ineffective problems. b. Teacher reports are somewhat more valid • Genetic/Biologic origins/Biochemical than those from family since the family interventions may either normalize or be unaware of 1. Genetic link—evidence of higher concordance what degree of compliance to expect from rates has been shown among monozygotic children at various ages. twins. 2. Rule out: 2. Increased incidence of ADHD among first- a. Specific learning disabilities degree relatives (although subtypes may differ) b. Acute situational reactions could be a factor. c. Adjustment disorders 3. May be sex-linked—more males than females d. Conduct Disorder and Oppositional Defi- are diagnoses with ADHD. ant Disorder 4. Fathers may be alcoholic or have Antisocial e. Mental Retardation Personality Disorder. f. Pervasive Developmental Disorders 5. Children with ADHD have higher risk of devel- g. Mood disorders, fear or anxiety oping Conduct Disorder, SUD, and Antisocial h. Impaired vision or learning Personality Disorder than general population. i. Seizures or sequelae of head trauma 6. Conduct Disorder and specific developmental j. Acute or chronic medical illness disorders are more frequent in relatives. k. Poor nutrition 7. Predisposing factors l. Insufficient sleep a. CNS abnormalities m. Various drugs that interfere with attention b. Disorganized, chaotic environments (1) Phenobarbital c. Noradrenergic, dopaminergic, and sero- (2) Carbamazepine tonergic abnormalities (3) Alcohol d. Family history of ADHD (4) Illicit drugs 8. Diagnostic studies—hyper/hypothyroid may (5) Theophylline be contributing factor; although no specific n. Early onset mania or bipolar illness laboratory tests aid in the diagnosis of ADHD. o. Undifferentiated Attention-Deficit Disor- 9. Psychopharmacology (AACAP, 2007a; Sadock & der—no impulsiveness or hyperactivity Sadock, 2007; Stahl, 2008, 2009) 3. Utilize psychological evaluation and parent- a. Between 70% and 80% of children with teacher checklists such as: ADHD respond to medication. a. Child Behavior Checklist (CBCL) b. First-line agents are slow-dose (sustained- b. Teacher Report Form release) stimulants; second-line agents c. ADHD Rating Scale-IV are the immediate-release stimulants; and d. Conner’s Revised Parent and Teacher rat- third-line options include antidepressants ing scales (CPRS-R & CTRS-R) with noradrenergic properties, such as bu- e. Parent interviews including family history propion (See Table 10-1) of ADD/ADHD, other disorders, family (1) In 2006, the FDA required labeling conflict changes for all stimulants to warn about the effects of sudden death • Mental status examination associated with stimulants used at 1. Observation in a free space situation, such unusual doses in children and adoles- as the playroom, is critical because the nov- cents with heart problems including elty of interview situation may encourage structural cardiac abnormalities or concentration. other serious cardiac condition. 214 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

Table 10-1 Medications Used in Treating ADHD

Drug Class Generic Name Trade Name Usual Dose Stimulants Methylphenidate Ritalin 0.3 to 2 mg/kg bid or tid; up to 60 mg (Schedule II) Ritalin-SR 20 mg/day or bid Ritalin LA 20 to 40 mg/day—am Metadate ER 10 to 20 mg/day or bid—am Metadate CD 20 to 60 mg/day—-am Concerta 18 to 54 mg/day—am (extended release) Methylphenidate Daytrana 10 mg/9 hour patch (off 15 hours); up to transdermal 30 mg/9 hour patch (off 15 hours) Dexmethylphenidate Focalin 2.5 to 10 mg bid; up to 20 mg Focalin XR 10 to 20 mg/ day—am Dextroamphetamine Generic/Dexedrine 0.15 to 0.5 mg/kg bid; up to 40 mg/day ProCentra 2.5 to 40 mg/day—in 1 to 3 doses/day Dextroamphetamine & Adderall 2.5 to 5 mg in divided doses; up to 40 mg/day amphetamine salt Adderall XR 10 to 20 mg/day—am Lisdexamfetamine Vyvanse 30 mg/day; up to 70 mg/day Nonstimulants Atomoxetine Strattera 0.5 to 1.2 mg/kg/day; up to 70 mg/day Bupropion Wellbutrin 1.4 to 6 mg/kg/day in divided doses; up to 300 mg/day Wellbutrin SR Adult dose: 100 to 200 mg/day; not approved for children Wellbutrin XL Adult dose: 150 to 450 mg/day; not approved for children Venlafaxine Effexor Adult dose: 25–150 mg/day; use bid; not approved for children Effexor XR Adult dose: 37.5 to 150 mg/day; not approved for children Clonidine Catapres 3 to 10 µg/kg/day—divided tid; up to 0.1 mg tid Guanfacine Tenex, Intuniv 0.05 to 0.12 mg/kg/day; up to 4 mg/day

(Sadock & Sadock, 2007; Stahl, 2008, 2009)

(2) In addition, there is an increased risk • Intrapersonal origins/Psychotherapetic of abuse and dependency for stimu- interventions lant class medications. 1. Origins (3) For adults with ADHD, first-line a. Retarded ego development agents include nonstimulants (atom- b. Low self-esteem oxetine, guanfacine ER, and possibly 2. Psychotherapeutic interventions modafinil), and sustained-release a. Provide careful environmental control— stimulants. tasks and chores broken down into short, c. Pemoline and dextroamphetamine sulfate manageable components; homework are also used. done in short periods with opportunities d. Bupropion—contraindicated in children/ for breaks. adolescents with seizure disorders. b. Convey unconditional positive regard since these children often have low • Treatment approach for ADHD should be multi- self-esteem and respond to positive modal, incorporating pharmacotherapy with other reinforcement. indicated interventions including behavioral and c. Provide social skills training. family therapies. d. Provide problem-solving strategies/CBT. Mental Disorders Diagnosed in Children & Adolescents 215

e. Assist with organization and planning, Conduct Disorder (CD) (APA, 2000; Keltner et al., particularly related to study skills. 2007; Sadock & Sadock, 2007) f. Approach child with firmness, consistency • Definition & signs and symptoms—Children with and limit-setting as well as patience. conduct disorder engage in repeated acts of antisocial behavior including aggression that endanger • Family dynamics/Family therapy themselves and others. Conduct disordered behav- 1. Dysfunctional family system iors include: multiple violations of rules (truancy), 2. Sociopathic, alcoholic, conduct disordered aggression to persons or animals, destruction of relatives property, theft, deceitfulness, and all of which may 3. Chaotic environment—promote consistency violate the rights of others. The disorder occurs in and schedules about 5% of the general population. 4. Family therapy and parenting classes—teach negotiation, problem solving and contingency • Associated features contracting, parenting skills training 1. Early use of tobacco, alcohol, nonprescribed 6. Behavioral reinforcement from family drugs therapist 2. Lack of empathy, guilt or remorse; often blam- 7. “Time out” vs physical punishment ing others 3. Low self-esteem covered by bravado with • Group approaches/Self-help low frustration tolerance, irritability, and 1. Promote and encourage parent support group. recklessness 2. Refer to parenting classes. 4. Poor academic achievement 3. Parents need information on structuring and 5. Other conditions including anxiety and de- planning the child’s milieu at home (See also pression; specific developmental disorder; Milieu interventions—next section). ADHD a common comorbid finding 4. Provide skills building for anger management, 6. Adolescent chemical dependency has a high decreasing impulsivity and rules compliance degree of comorbidity (Bloomquist, 1996). 7. Adult Axis II disorder of Antisocial Personality may be given by 18 years of age. • Milieu interventions—children with a primary diagnosis of ADHD usually do not meet criteria for • Differential diagnosis hospitalization unless they have other diagnoses 1. Not diagnosed by single acts of antisocial be- such as Major Depression and Posttraumatic Stress havior, but by persistent and repetitive pattern Disorder. 2. Different from Oppositional Defiant Disorder 1. Limit-setting in that the rights of others are violated as well 2. Point system as major age-appropriate social norms 3. Behavioral charts and schedules 3. Bipolar disorder usually representing brief 4. Decrease in external stimuli manic episodes 5. Providing for large muscle activity to discharge 4. ADHD motor activity 5. Substance abuse 6. Limit setting on disruptive behavior 6. PTSD 7. Clear explanation of expectations 7. BPD 8. Encouraging positive peer activities 8. Adjustment Disorder 9. Multidisciplinary coordination involving 9. Narcissistic Personality Disorder child’s teachers 10. Schizophrenia (JAACAP, 1997e) 10. Opportunities and incentives for success 11. Academic skills training • Mental status examination 12. Social skills training and problem solving 1. May present as angry or superficially friendly; 13. Therapeutic recreation self-centered, lacks empathy or concern for others. • Community resources 2. Major defenses include denial, projection; 1. Support groups such as Attention Deficit Dis- blames or implicates others. order Association (ADDA), Attention Deficit 3. Has poor insight. Information Network (AD-IN), and Children 4. May attempt to bully examiner and behave in with ADD (CHADD) coercive or threatening ways. 2. Parenting classes—Systematic Training for Ef- fective Parenting (STEP) and Parent Effective- • Nursing diagnoses (NANDA, 2009) ness Training (PET) classes 1. Coping, ineffective 216 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

2. Violence, [actual/] risk for other-directed 5. Paternal absence, alcoholism, and parental 3. Violence, [actual/] risk for self-directed mental illness 4. Anxiety 6. Large family size 5. Role Performance, ineffective 7. Early institutional living 6. Social Interaction, impaired 8. Association with delinquent subgroup 9. Isolation of self in family • Genetic/Biologic origins/Biochemical 10. Court involvement/Child Protective Services; interventions often known to multiple agencies 1. Conduct Disorder is common in children with 11. Family therapy aimed at intervening in dys- antisocial and alcoholic parents. functional dynamics and training in new 2. Low levels of 5-H1AA (associated with aggres- approaches. sion and violence) may be present. a. Work with strengths. 3. Associated conditions, such as ADHD, depres- b. Train parents to be consistent and de- sion or Posttraumatic Stress Disorder may be crease both overly permissive and overly treated pharmacologically. harsh responses. 4. Atypical antipsychotics have been useful in c. Foster self-responsibility, differen- managing aggressive behaviors. tiation of self and decrease blaming 5. Drug screens to identify drug use and abuse communication. are indicated. d. Allow for expression of grief and tenderness. • Intrapersonal origins/Psychotherapeutic e. Multiple family therapy approaches may interventions be beneficial. 1. Origins f. Conduct family stress management. a. Fixed in separation-individuation phase b. Retarded ego development; id driven • Group approaches c. Child maltreatment and associated paren- 1. Allow for confrontation. tal substance abuse and psychiatric illness 2. Test new ways of relating, including practicing d. Poverty, psychosocial toxicity, lack of sup- empathy. portive community structure (JAACAP, 3. Model effective coping. 1997e) 4. Form healthy relationships with non-CD 2. Psychotherapy (the earlier the intervention peers; promote appropriate peer network. occurs, the better the outcome) 5. Utilize exercises designed to deal with feelings, a. Multimodal therapy—incorporate behav- facilitate trust and develop healthy coping ioral interventions that promote prosocial, skills. nonaggressive behavior. 6. Conduct psychosocial skills building. b. Security and trust provide climate for 7. Refer to Alateen or Children of Alcoholics growth. (COA) group. c. Self-esteem can be enhanced by behav- 8. Provide chemical dependency assessment ioral change and increased autonomy. and referral to appropriate 12-step program or d. Understand dynamics of anger to es- adolescent intensive outpatient program. tablish locus of control; incorporate 9. Provide anger management training. skills building in anger management 10. Encourage alternatives to sexual promiscuity; (Bloomquist, 1996). sex education program (Jongsma, et al., 1996). e. Recognize and express feelings to eliminate dysfunctional defenses. • Milieu interventions f. Provide for processing grief and loss. 1. Crisis shelters when indicated, and resi- g. Computer-assisted self-evaluation and dential treatment or group homes may be provision of alternatives are helpful appropriate. due to massive use of denial to cover 2. Provide for physical safety of patient and vulnerability. others. 3. Promote regulation of impulse control. • Family dynamics/Family therapy 4. Promote positive problem-solving abilities. 1. Multiple moves or schools 5. Promote healthy expression of anger, such as 2. Inconsistent management; harsh discipline; providing safe place, e.g., gymnasiums, etc. poor parenting 6. Provide structured mechanisms for learning 3. History of parental rejection trust. 4. Shifting of parent figures Mental Disorders Diagnosed in Children & Adolescents 217

7. Disseminate accurate information about staff • Nursing diagnoses (NANDA, 2009) changes, turnover, etc. since changes may re- 1. Coping, ineffective awaken old abandonment issues. 2. Anxiety 8. Provide job and independent living skills 3. Role Performance, ineffective training. 4. Social Interaction, impaired 9. Primary nursing promotes bonding with adult. • Genetic/Biologic origins/Biochemical • Community resources interventions 1. Appropriate 12-step program 1. No information on familial pattern 2. Big Brother, Big Sister programs 2. Age at onset by 8 years old, no later than early 3. CASA (Court Appointed Special Advocates) adolescence 4. Promoting sports, fitness activities 3. Medication for associated ADHD 5. Outward Bound therapeutic programs; boot 4. Antidepressants for associated depression camps a. SSRI 6. Parents Involved Network b. Bupropion 7. Federation of Families for Children’s Mental Health • Intrapersonal origins/Psychotherapeutic 8. Case management is essential due to multiple interventions agency involvement and family tendency to 1. Treatment is focused on building behavioral seek help only in times of crisis. management skills for the child and parent/ 9. Coordination with school and appropriate caregiver. other community systems, such as juvenile 2. May be related to physical or sexual abuse, or probation and parole both. 3. Play therapy may be used to encourage aware- Oppositional-Defiant Disorder (AACAP, 2007b; ness of feelings, facilitate disclosure of issues, APA, 2000; Keltner et al., 2007; Sadock & Sadock, learn new ways of effective coping. For prever- 2007) bal children, play is the child’s language and • Definition & signs and symptoms—Occurs in 16– the toys are their words. How the toys are used 20% of school-age children and is characterized by in play themes (nurturing, power/control, pro- persistent patterns of disobedience, negativity, and tection, etc.) provides insight into the child’s hostility toward authority figures; failure to take emotional world. responsibility for mistakes and placing blame on a. Board games others. These behaviors are evidenced by frequent b. Talking, Feeling, Doing Game arguments with parents and other adults, annoy- c. The Ungame ance with others, and a generally angry and resent- d. Therapeutic stories ful demeanor. There is an absence of aggression e. Role playing and destructive behavior characteristic of Conduct 4. Conduct art therapy—drawing, modeling, clay, Disorder. sand tray to process unconscious issues. Pro- mote self-esteem and self-worth. • Differential diagnosis—diagnosis only made if be- 5. Promote skill building in interpersonal re- havior is more common than that of other children lationships, anger management, increasing of the same age; usually defiance is only seen with compliance and effective problem solving adults and peers the child knows well, and is justi- (Bloomquist, 1996). fied by the child. 6. Provide social skills training. 1. Conduct Disorder 2. Passive Aggressive Personality Disorder • Family dynamics/Family therapy 3. Chemical dependency 1. Utilize family therapy to promote healthy 4. ADHD family interaction and decrease tendency to pathologize child. • Mental status examination 2. Support parental hierarchy. 1. Few signs of disorder are seen on mental status 3. Explore alternate ways of coping, especially examination. assisting parents to avoid playing into opposi- 2. When confronted with behavior, client often tional tendencies. utilizes projection and blames others. 3. Associated features include labile mood, bad • Group approaches temper, and low frustration tolerance. 1. Encourage verbalization of feelings and de- 4. History, including teacher reports, is essential. velop positive social support mechanisms. 218 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

2. Learn alternate ways of coping. regurgitation behavior (arching of back to initiate 3. Psychodrama encourages trying out new regurgitation of stomach content); the rumination behaviors. is a self-soothing or self-stimulating behavior. Par- 4. Provide positive reinforcement. tially digested food is brought up into the mouth 5. Social skills groups can be useful. without nausea, retching, disgust. The food is 6. Promote positive peer relationships. ejected, or chewed and reswallowed. The condition is potentially fatal. With an onset after 3 months of • Milieu interventions age, children with this disorder usually have inad- 1. Children with this diagnosis are rarely admit- equate emotional interaction; rumination disorder ted to inpatient settings, although they may may lead to failure to thrive. have a dual diagnosis with a major mental health problem such as depression or Bipolar • Differential diagnosis Disorder. 1. Congenital anomalies (e.g., pyloric stenosis) 2. Environmental activities and group process 2. GI infections are necessary, as well as those mentioned under Conduct Disorder. • Nursing diagnoses (NANDA, 2009) 1. Feeding Pattern, ineffective infant • Community resources 2. Attachment, risk for impaired 1. Parenting classes, such as STEP and PET 3. Parenting, impaired 2. Sports and team activities 4. Parenting, readiness for enhanced 3. Wilderness and Outward Bound type 5. Knowledge, deficient (specify) programs 4. Camps, YMCA, YWCA programs • Genetic/Biologic origins—no information; sponta- 5. Big Brother, Big Sister neous remissions are common. 6. See also resources in Conduct Disorder • Family dynamics/Family therapy Feeding and Eating Disorders of Infancy 1. Treatment is focused on education of caregiver or Early Childhood and behavioral techniques. 2. Parents may become alienated from the infant Pica due to their frustration and his/her failure to • Signs and symptoms (APA, 2000; Keltner et al., respond. 2007; Sadock & Sadock, 2007)—Pica is character- 3. Noxious odor of the regurgitate may cause par- ized by the eating of non-nutritive substances for ent to avoid holding the infant. a period of at least one month. More common 4. Health teaching regarding nature of illness and among the very young and among those with men- suggestions for coping are essential. tal retardation (up to 15% in MR population). • Community resources—Public health nursing • Treatment interventions 1. Determine etiology of eating of substances Anorexia and Bulimia such as zinc or iron deficiency. 2. Remove or eliminate access to toxic sub- • Definitions—Eating disorders are a risk for adoles- stances such as lead. cents. Anorexia has a mortality rate of 10 to 15%. 3. Therapeutic intervention focus—psychologi- Hallmarks of these disorders are secretiveness, cal, environmental, behavioral strategies, and denial of the problem, and resistance to therapy or family education and guidance any treatment that will lead to weight gain (Mohr, 1998; Hartman & Burgess, 1998). • Community resources 1. Public health nurses • Signs and symptoms (APA, 2000; Keltner et al., 2. Well-child clinics 2007; Sadock & Sadock, 2007) 3. Lead poisoning prevention programs 1. Classic DSM-IV criteria may not be applicable. 4. Social services 2. Begins in late school age (10 to 12 years old); onset most common between 12 and 18 years Rumination Disorder of Infancy of age. • Signs and symptoms (APA, 2000; Keltner et al., 3. Child does not have to lose the percentage of 2007; Sadock & Sadock, 2007)—A rare feeding dis- weight applicable for an adult with an eating order of rumination, meaning “to chew a cud,” as disorder. evidenced by rhythmic sucking of the tongue and Mental Disorders Diagnosed in Children & Adolescents 219

a. Prepubertal children have lower percent- 3. Complex Motor Tics—facial gestures, groom- age of body fat, and thin children may being behaviors, touching come unhealthy quickly. 4. Complex Vocal Tics b. Boys and girls present with childhood a. Repeating words and phrases out of anorexia. context c. Affects 1 in 200 adolescent females. b. Coprolalia—use of socially unacceptable words • Intrapersonal origins/Psychotherapeutic c. Palilalia—repeating one’s own sounds or interventions words 1. Origins d. Echolalia—repeating the last heard sound a. Adolescent anorexia or word (1) Consider issues relative to puberty e. Echokinesis—repeating someone else’s (2) Separation dynamics and increased movements independence from family (3) Increased autonomy in problem Tourette’s Disorder solving • Definition & signs and symptoms (APA, 2000; Kelt- (4) Peer pressure, including sexuality ner et al., 2007; Sadock & Sadock, 2007)—Tourette’s (5) Difficulty with interpersonal intimacy is characterized by multiple motor tics and at least and closeness one vocal tic that are not caused by a substance or (6) May have a history of sexual trauma medical condition—with onset prior to 18 years b. Adolescent bulimia of age (average age at onset is 7 years old); and is (1) Generally not common in children; 3 times more likely in boys than in girls. Tourette’s begins between ages 13 and 18 is associated with ADHD and OCD in clinical (2) Initiation into process of major life populations. choices 2. Psychotherapeutic interventions • Differential diagnosis a. Close coordination with medical care 1. Abnormal motor movements associated with (1) Establish minimum daily caloric neurologic disorders intake. 2. Organic mental disorders (2) Initiate food journal. 3. Schizophrenia (3) Monitor vomiting, binging, exercise, and laxative abuse. • Mental status examination b. Implement within the context of the ado- 1. The definitive manifestations of these disor- lescent’s developmental, social, and aca- ders may be present on assessment, or the demic needs. caretaker may describe the salient features. c. Individual therapy 2. There may be associated anxiety due to social d. Group approaches situation embarrassment. e. Family therapy—major component; need 3. Depressed mood is common. to understand dynamics of the family as a system (Antai-Otong, 1995). • Nursing diagnoses (NANDA, 2009) f. Bibliotherapy 1. Social Interaction, impaired 2. Social Isolation Tic Disorders (APA, 2000; Keltner et al., 3. Communication, impaired verbal 2007; Sadock & Sadock, 2007) 4. Powerlessness 5. Anxiety (related to unexpected manifestation • Definition—Tics are defined as sudden, rapid, of tics) recurrent, nonrhythmic, motor movements, vocal- 6. Coping, ineffective izations, repetitive movements, gestures, or utter- 7. Self-Esteem, chronic low ances that mimic some aspect of normal behavior. 8. Sensory Perception, disturbed/kinesthetic Tics cannot be controlled, but can be suppressed for varying lengths of time. They are worsened by • Genetic/Biologic origins stress and diminished during sleep. Types include: 1. Age-dependent expression of symptoms 1. Simple Motor Tics—eye blinking, facial 2. Familial patterns reported for all cases of tic grimacing disorders—more common in first degree bio- 2. Simple Vocal Tics—coughing, throat clearing, logic relatives of people with Tourette’s sniffing, snorting, barking 220 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

3. OCD more common in first degree biologic 1. Parents need guidance in understanding bio- relatives of those with Tourette’s than those logic determinants of this disorder and in rec- with other tic disorders ognizing compulsive nature of behavior. 4. At least three times more common in males 2. Punishment may reinforce symptoms. than females 3. Efforts to help child overcome socialization 5. Controversy over association with: problems should be emphasized. a. Exposure to phenothiazines b. Head trauma • Group approaches c. Administration of CNS stimulants 1. May benefit from inclusion in a diverse group d. Intrauterine environment with opportunity to receive support from other (1) Maternal life stress members. (2) Complications of pregnancy 2. Self-help is an important aspect of care, and (3) First trimester nausea support groups are available in larger cities. 6. EEG abnormalities in 50% of patients • Milieu interventions • Biochemical interventions 1. Rarely admitted to inpatient unit unless asso- 1. Haloperidol (Haldol) has been effective in ciated with depression or ADHD. chronic tic disorders and Tourette’s 2. Provide opportunity to process feelings of dif- a. Children 3 to 12 years old—initial dose: ferentness in the milieu as an extension of nor- 0.025 to 0.05 mg/kg/day in divided doses, mal adolescent growth and development. with gradual increase to 0.5 mg/kg in 5 to 7 days to bring symptoms under control • Community resources—Gilles de la Tourette b. Children older than 12 years—initial dose: Foundation 0.5 to 5 mg two or three times daily; dosage increased by 0.5 to 1 mg increments to Chronic Motor or Vocal Tic Disorder maximum dose of 100 mg/day • Definition & signs and symptoms (APA, 2000; c. Side effects Keltner et al., 2007; Sadock & Sadock, 2007)—char- (1) Similar to piperazine phenothiazines acterized by the presence of either motor or vocal (a) Low incidence of sedation and tics, but not both. autonomic effects (b) High incidence of extrapyramidal Transient Tic Disorder reactions • Signs and symptoms (APA, 2000; Keltner et al., (2) Food and Drug Agency Pregnancy 2007; Sadock & Sadock, 2007)—characterized by Category C the presence of single or multiple motor or vocal 2. Pimozide (Orap)—strongly antidopaminergic tics or both. like haloperidol (Haldol) 3. Other pharmacologic options include: • Differential diagnosis for all tic disorders except a. Clonidine (Catapres) Tourette’s (1) Not as effective as Orap or Haldol 1. Other movement disturbances (2) No tardive dyskinesthesia risk 2. Neurological conditions b. SSRIs (used alone or with antipsychotics) 3. Medication reaction have been successful in treating Tourette’s. • Biochemical interventions—medication only used • Intrapersonal origins/Psychotherapeutic in very severe cases of Chronic Motor or Vocal Tic interventions Disorder 1. Behavioral therapy can be effective in symptom modulation. Elimination Disorders 2. Symptoms may be exacerbated by stress; autogenic relaxation and stress management may Enuresis help the patient to self-regulate. • Definition & signs and symptoms (APA, 2000; Kelt- 3. Massed practice behavioral technique where ner et al., 2007; Sadock & Sadock, 2007)—Enuresis patient practices intentionally the undesired is a persistent, repeating pattern (intentional or behavior can be effective. unintentional) of voiding of urine into clothes or 4. Acceptance by therapist is a key in treatment. bedding after the age of 5 years; occurring at least twice weekly for 3 or more months (or causing • Family dynamics/Family therapy significant social or academic distress/impair- Mental Disorders Diagnosed in Children & Adolescents 221

ment to the child); and is not a result of a physical bination of Pavlovian conditioning, avoid- condition. ance learning, and placebo effect) b. Intermittent reinforcement and overlearn- • Differential diagnosis ing to reduce relapse 1. Medical conditions c. Retention control training 2. Urinary tract infection d. Training in rapid awakening 3. Anxiety disorders, e.g., phobias related to e. Reinforcement for daytime micturition toileting f. Avoiding negative social consequences g. Encouraging active participation • Mental status examination h. Encouraging patient responsibility 1. Child may have low self-esteem due to care- i. Challenging/confronting noncompliance taker rejection or social ostracism by peers. (Jongsma et al., 1996) 2. Incidence of associated major mental illness is greater among those with functional Enuresis Encopresis than in the general population. • Signs and symptoms (APA, 2000; Keltner et al., 2007; Sadock & Sadock, 2007)—Defecating in in- • Associated features appropriate places (such as in clothing or other 1. Functional Encopresis, Sleepwalking Disorder, places) at least one a month for 3 consecutive Sleep Terror months, after the age of 4 years; and the passing of 2. Associated with other behavioral disorders and feces is not caused by a physical condition. Usually psychopathology, however, associated disor- resolves by 16 years of age. May be related to psy- ders may stem from Enuresis chogenic megacolon—with bowel retention leading to constipation and eventually to chronic rectal • Nursing diagnosis (NANDA, 2009)—Urinary Incon- distention—and desensitization to rectal pressure tinence, functional with deficient signaling of the urge to defecate. This condition can lead to overflow encopresis • Biologic origins/Biochemical interventions where leaking of small amounts of soft or loose 1. Low functional bladder volume bowel content can occur. 2. More males than females 3. 75% have first-degree biologic relative with • Nursing diagnoses (NANDA, 2009) disorder 1. Bowel Incontinence 4. Imipramine 2. Constipation a. 1.5 mg/kg/day to no more than 5 mg/kg/ 3. Constipation, perceived day 4. Constipation, risk for b. Side effects include: (1) Dry mouth • Genetic/Biologic origins/Biochemical (2) Constipation interventions (3) Tachycardia 1. 15% of fathers of encopretics were encopretic. (4) Drowsiness 2. Ratio of male-to-female encopretics ranges (5) Postural hypotension from 66% to 88% of samples. (6) Cardiac conduction slowing 3. Common with mental retardation but poorly c. ECG monitoring essential with baseline defined. 4. Can originate from inadequate physiological • Intrapersonal origins/Psychotherapeutic functioning of defecation. interventions 1. Secondary enuretics have same rate of emo- • Intrapersonal origins/Psychotherapeutic tional or behavioral problems as primary interventions enuretics. 1. Social learning theory attributes disordered 2. Psychotherapy alone is not effective treatment, learning or insufficient learning. but may be helpful with associated psychiatric 2. Secondary encopresis involves learned conditions. avoidant behavior, reinforced by delay of pain- 3. Hypnotherapy may be effective, although du- ful defecation. ration of recovery has not been substantiated. 3. Psychogenic theories formulated by Freud— 4. Behavioral techniques (conditioning) compliance vs opposition in “anal period.” a. Mowrer apparatus (bell and pad awaken 4. Treatment determined by thorough child when he wets and work by a com- assessment. 222 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

a. Toilet training needed if appropriate train- • Differential diagnosis ing has not taken place. 1. Conduct Disorder and Oppositional-Defiant b. Provide positive behavioral reinforcement Disorder of appropriate toileting behavior. 2. School phobias c. Secondary encopresis related to more seri- 3. Learning problems ous psychopathology—need to treat high 4. Attention-deficit disorders levels of anxiety, anger, or depression. 5. Chemical dependency d. If encopresis in response to severe en- 6. Anxiety disorders vironmental stress, modifying stressor 7. Specific developmental disorders brings relief. 8. Chronic illness 9. Grief and loss/bereavement • Family therapy for Enuriesis and Encopresis 1. Orient family counseling to supporting behav- • Family dynamics—experiences of abuse and vio- ioral techniques. lence, runaways, family chemical dependency, and 2. Treat family psychopathology if present; some having one or both parents with a mood disorder theorists postulate issues of paternal distance increases the risk. and maternal anxiety, as well as parental absence. • Suicide 3. Support and management alternatives lessen 1. Adolescent depression is positively associated parental pressure on child, enabling learning with suicidal behavior. to take place; parental management training 2. Suicide incidence is rising among adolescents (PMT) can be effective. with mood disorders. 4. Explore rigidity in toilet training. 3. Suicide attempts in children younger than 12 5. Confront and challenge hostile and critical years of age are relatively rare (Johnson, 1997). behavior. 4. Suicide attempts rise sharply at ages 13 to 14 6. Interrupt cycle of hostile dependent angry years. interactions. 5. Suicide is third leading cause of death for 7. Identify and defuse secondary gains (Jongsma, youth ages 15 to 24 years. et al., 1996). a. Highest rates occur in white males. b. Next highest rates occur in nonwhite • Milieu interventions—behavioral techniques as males. outlined should be incorporated in care plan. 6. Risk factors for suicide include: a. Affective illness—depression or mania • Community resources—parenting classes b. Parental divorce c. Use of firearms Mood Disorders in Children and d. Antisocial or aggressive behavior Adolescents e. Family history of suicidal behavior 7. Signs of suicide possibility include: Depression a. Change in grades • Prevalence of depression is extremely low until 9 b. Giving away possessions years of age, but rises sharply from 9 to 19, espe- c. Decreased interest in after-school cially in females (Federal Interagency Forum on activities Child and Family Statistics, 2009; Lewisohn, Clarke, d. Few friends Seeley & Rhode, 1994). e. Breakup with girlfriend or boyfriend f. Pressure by family to stop dating one • Signs and symptoms person 1. Same diagnostic criteria are utilized for chil- g. Wearing black dren and adolescents as for adults. Depressed h. Listening to morose or violent music mood in children and adolescents may be ex- i. Drug and/or alcohol use pressed as irritability. j. Discussing suicide 2. The criteria for weight change or appetite k. Self-mutilation (Botz & Bidwell-Cerone, disturbance in children is failure to achieve 1997) expected gain, or greater than 5% loss of body 8. Cluster suicides may be preceded by exposure weight in 1 month. to fictional suicide in media, completed sui- 3. Declining academic performance cide in a school system, and friendship with 4. Isolation and refusal to communicate someone who has completed suicide. Mental Disorders Diagnosed in Children & Adolescents 223

9. Reducing suicide contagion 4. Severe behavioral deterioration is present. a. Avoid simplistic explanations for suicide. 5. Screening/psychological testing may be uti- b. Do not engage in repetitive discussion of lized in diagnostic evaluation. the recent suicide event. a. Children’s Depression Inventory (CDI) c. Do not provide graphic descriptions of b. School-Age Depression Listed Inventory suicide. (SADLI) d. Do not glorify suicide or persons who c. Bellevue Index of Depression (BID) commit it. d. Children’s Depression Rating e. Focus on deceased’s nonsuicidal charac- Scale—Revised teristics (Botz & Bidwell Cerone, 1997). e. Mania Rating Scale 10. Nursing interventions include: a. Monitoring potential for harm to self or • Differential diagnosis other 1. Effects of drug/medication use, e.g., cortico- b. Focusing on the motivations of the sui- steroids, sympathomimetics, isoniazid, antide- cidal youngster pressants, stimulants c. Coordinating the support system 2. Abusive substances, e.g., amphetamines, d. Working with school-based crisis teams cocaine, inhalants, phencyclidine (JAACAP, e. Reinforcing patient’s open expression of 1997d) underlying feelings 3. Endocrine disorders, such as hyperthyroidism 11. Psychotherapeutic interventions—efficacy of 4. Neurologic conditions, such as head trauma, CBT, interpersonal therapy, behavior problem temporal lobe seizures, tumors, HIV, multiple solving, brief solution-focused therapy have sclerosis been reported (American Academy of Child 5. Infections—encephalitis, influenza, syphilis and Adolescent Psychiatry [AACAP], 2007c). 6. The following psychiatric conditions: a. Childhood disruptive disorders • Biochemical interventions (AACAP, 2007c; Sadock b. PTSD & Sadock, 2007; Stahl, 2008, 2009) c. Substance abuse 1. SSRIs (e.g., sertraline, fluoxetine, fluvoxamine, d. Schizophrenia paroxetine, citalopram, escitalopram), SNRIs e. Schizoaffective Disorder (e.g., venlafaxine, desvenlafaxine), and NDRIs f. Borderline Personality Disorder (e.g., bupropion) are first-line antidepressants. g. Agitated depression Caution: increased suicide risk—use with caution in children and adolescents, particularly • Mental status examination—presentation similar in first months of treatment—monitor depres- to adults sive symptoms and suicide ideation. 1. Adolescents may have psychotic symptoms. 2. Tricyclics are second-line treatment options 2. Markedly labile and erratic symptoms and also carry increased risk for suicide among 3. Severe behavioral deterioration children and adolescents. a. Tricyclic antidepressant (TCA)—seizures • Nursing diagnoses—same as for adult bipolar occur more frequently in children than in disorders adults. b. Rapid clearance may mean that therapeu- • Genetic/Biologic origins (See also Mood Disorders tic response takes longer in children than chapter) in adults. 1. Affects both sexes equally 2. Males more affected in early onset cases Bipolar Disorders (often not diagnosed or misdiagnosed in children and adolescents) • Biochemical interventions (AACAP, 2007d) • Signs and symptoms 1. Medication management addresses manic or 1. Adolescents—resemble the adult course of ill- mixed symptoms, depressive symptoms, and ness; 20% of all cases present prior to 19 years prevention of relapses. of age (AACAP, 2007d). 2. Lithium is the only agent with FDA approval 2. Children younger than 9 years of age are more for Bipolar Disorder in youth (approved for likely to present with irritability and affective children 12 years of age and older) lability (Johnson, 1995). a. Renal clearance of lithium is higher in 3. Older children present with labile moods, children than in adults; children and ado- paranoia, grandiose delusions, and other psy- lescents may require higher dosages to chotic symptoms. 224 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

achieve therapeutic blood levels (Antai- • Group approaches Otong, 1995). 1. Self-esteem group b. Complete physical examinations and 2. “Time out” provided to protect other group baseline laboratory studies must be done members prior to initiating drug therapy. 3. Addressing associated psychological problems c. Children and adolescents often tolerate 4. Anger management lithium better than adults. d. Dosage ranges from 600 mg daily for a • Milieu interventions weight of 15 to 25 kg given in divided 1. Same as adults, but modified for developmen- doses to 1500 mg per day for a weight tal level range of 50 to 60 kg given in divided doses. 2. Must provide safe environment for other 3. Anticonvulsant mood stabilizers and atypical patients antipsychotic agents approved for adult treatment of manic symptoms have also been used Anxiety Disorders in Children and in treating children and adolescents. Adolescents a. Anticonvulsant mood stabilizers (1) Carbamazepine (Tegretol) is given in • Definition—Powerlessness, increased dependency, doses of 15 to 30 mg/kg/day impaired self-esteem, and poor social skills are (2) Valproic acid (Depakene) given in common manifestations of anxiety disorders in nonresponse to lithium or Tegretol— children. Child and adolescent anxiety disorders dose is 25 to 60 mg/kg/day, with a are on a continuum with, and may become adult blood level of 50 to 120 mEq/L anxiety disorders. Retrospective studies of adults b. Atypical antipsychotics (e.g., aripipra- with anxiety disorders indicated that 65% had two zole, olanzapine, quetiapine, risperidone, or more anxiety disorders as children. Insecurely ziprasidone) or ambivalently attached infants develop more 4. Benzodiazepines are a possible adjunct for anxiety diagnoses in childhood and adolescence. acute mania and SSRIs for management of as- Behavioral inhibition is a risk factor in the develop- sociated depression. ment of anxiety disorders in young children. Anxi- 5. Neuroleptics ety disorders in children do not appear in isolation. 6. Antimania agents They are part of an array of other symptoms and 7. ECT traits.

• Intrapersonal origins/Psychotherapeutic Separation Anxiety Disorder interventions • Definition & signs and symptoms (AACAP, 2007e; 1. Mania is common among families—it is APA, 2000; Keltner et al., 2007; Sadock & Sadock, thought that bipolar parents may exercise in- 2007)—Separation anxiety disorder (commonly adequate parenting techniques. termed stranger anxiety) is one of two anxiety dis- 2. Cohort effect indicates increased incidence of orders found in the child and adolescent section bipolar illness in individuals born after 1940. of the DSM-IV-TR. This disorder is characterized 3. Hospitalization is frequently indicated. by persistent fear, shyness, and social withdrawal 4. Age-specific psychotherapy/play therapy— when confronting unfamiliar people and settings; CBT and/or interpersonal therapy may be use- the disorder is diagnosed when upon separating ful to address skill building, and monitoring of from a major attachment figure, the child exhibits symptoms/progress. intense, excessive, and developmentally inappropriate fear/anxiety. The anxiety must be present • Family dynamics/Family therapy for at least 1 month and produce significant im- 1. Psychoeducational approaches essential for pairment in functioning at home, school, or with patient and family. friends. The fear/anxiety is manifested by reluc- 2. Psychotherapeutic interventions include: tance or refusal to separate from the attachment a. Support and empathy figure and nightmares about separation; occurs b. Academic and occupational functioning in about 15% of all children and 4% of school-age c. Social and family functioning children. d. Relapse prevention 3. Biologic origins of this disorder must be taken • Differential diagnosis into account (therapist may be dealing with 1. Somatic complaints several bipolar persons in family). 2. Developmentally appropriate separation anxiety Mental Disorders Diagnosed in Children & Adolescents 225

3. Overanxious disorder 2. Decrease conflict and increase problem- 4. Panic Disorder with Agoraphobia solving. 5. PDD or Schizophrenia 3. Clarify communication. 4. Increase individual autonomy and decrease • Mental status examination fusion. 1. May refuse to separate from parent. 5. Take focus off child as symptom-bearer. 2. May cling or cry and fuss if parent tries to 6. Educate parents re: developmentally normal leave; if separated, checks frequently in spite anxiety. of reassurances and knowledge that parent is 7. Educate parents to decrease their own anxiety close by. and overprotection.

• Nursing diagnoses (NANDA, 2009) • Group approaches 1. Anxiety—mild, moderate, severe 1. Self-esteem group 2. Coping, ineffective 2. Play therapy group 3. Powerlessness 3. Theraplay 4. Self-Esteem, situational, low 4. Organized and informal play/sports 5. Social Interaction, impaired opportunities 6. Social Isolation 7. Fear • Milieu interventions 1. Highly unusual to admit these children to an • Genetic/Biologic origins/Biochemical inpatient setting; treated as outpatients interventions 2. Organization and predictability helpful, while 1. Specific developmental disorders involving gradually fostering child’s independence and language and speech may predispose to this self-reliance condition. 2. Mothers with anxiety disorders more common • Community resources in this population according to some studies. 1. Educational programs for parents 3. More common in females than males. 2. Church and sports activities

• Interpersonal origins/Psychotherapeutic Selective Mutism (Elective Mutism) interventions • Definition & signs and symptoms (APA, 2000; 1. Moderate to catastrophic stressor as defined Sadock & Sadock, 2007)—Although fully capable on Axis IV may contribute. of speaking competently, children with selective 2. More research needed on genetic vs environ- mutism remain completely silent or whisper nearly mental transmission. inaudible one-syllable words when experiencing a 3. Brief, symptom-focused therapy approaches socially anxiety-producing situation, most typically include: at school. Selective mutism is one of two anxiety a. Psychodrama disorders found in the child and adolescent section b. Art work of the DSM-IV-TR. The disorder has been associ- c. Play therapy utilizing role play, doll house, ated with Social Phobia, and may be a subtype of sand box, puppets to explore anxieties, social anxiety/social phobia. Familial factors con- fears, and worries tributing to selective mutism (and other anxiety d. Therapeutic games, storytelling to expand conditions) include maternal anxiety, depression, awareness and heightened dependency needs. e. Emphasis on symptom reduction, empowerment, mastery and control • Differential diagnosis f. Goal to decrease symptoms quickly to 1. Severe or Profound Mental Retardation, Perva- enhance functioning, avoid permanent sive Developmental Disorder, Developmental dysfunction Expressive Language Disorder g. Relaxation training—diversion, deep 2. Children of families who have recently emi- breathing; muscle relaxation (Jongsma grated to a country of a different language et al., 1996) 3. Organic factors/medical problems

• Family dynamics/Family therapy • Mental status examination 1. Decrease anxiety and rigidity in parental 1. Attempts to engage the patient in conversation system. are futile, although the presence of adequate receptive language is apparent. 226 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

2. May communicate by gestures, nodding a. Confront family denial so parents cooper- or shaking head, or by short monotone ate with treatment plan. utterances. b. Assist in developing realistic expectations. c. Teach effective communication skills to • Nursing diagnoses (NANDA, 2009) family. 1. Anxiety [specify level] d. Utilize parent-training models to enhance 2. Coping, ineffective child and family coping (Elder, 1997). 3. Fear 4. Powerlessness • Group approaches—not indicated—although pre- 5. Self-Esteem, chronic low school children may benefit from a therapeutic 6. Social Interaction, impaired nursery/preschool setting. 7. Communication, impaired verbal • Milieu intervention—provide reinforcement for • Biologic origins/Biochemical interventions verbal responses. (Sadock & Sadock, 2007) 1. May be related to neorobiologic precursor of • Community resources Anxiety Disorder, specifically Social Phobia 1. Parenting classes 2. A multimodal approach to treatment, in- 2. Socialization and sports activities corporating Cognitive-Behavior therapy, Anxiety Disorders Not in Child and Adolescent psychoeducation, and medication (SSRI), is Section of DSM-IV-TR recommended. 3. SSRIs shown to decrease anxiety in selective Social Phobia (See also Anxiety and Stress Related mutism include: Disorders chapter) a. Fluoxetine—20 to 60 mg/day for children older than 8 years • Definition & signs and symptoms (AACAP, 2007e; b. Sertraline—25 to 200 mg/day for children APA, 2000; Keltner et al., 2007; Sadock & Sadock, older than 6 years 2007)—Avoidant behaviors in children and ado- c. Paroxetine—10 to 50 mg/day for children lescents are manifested as persistent or extremely older than 7 years constricted social interaction with unfamiliar people. There is fear of acting in a humiliating or • Intrapersonal origins/Psychotherapeutic embarrassing manner. interventions 1. Associated with shyness and other opposi- • Differential diagnosis for anxiety disorders tional behavioral problems. 1. Physical conditions 2. Case histories report symptoms developed fol- a. Hypoglycemic episode lowing reprimand for verbalization. b. Hyperthyroidism 3. Challenging to treat since these patients don’t c. Cardiac arrhythmias talk to therapist and often passively refuse d. Caffeinism nonverbal communication. e. Pheochromocytoma 4. Psychoanalysis reportedly is beneficial. f. Seizure disorders 5. Behavior therapy may be beneficial. g. Migraine 6. Resolve core conflict contributing to mutism h. CNS disorders so patient speaks consistently in all social 2. Medication reactions situations. a. Antihistamines b. Anti-asthmatics • Family dynamics/Family therapy c. Sympathomimetics 1. Maternal overprotection d. Antipsychotics 2. Major personality or psychiatric conflict or a e. Nonprescription drugs, e.g., diet pills, cold combination of both medicine (JAACAP, 1997b) 3. Families seen as vulnerable to a hostile world 3. Mood disorders 4. Symptom seen as an expression of family 4. ADHD conflict 5. Adjustment Disorder 5. Silence used as manipulation 6. Substance-Use Disorder 6. Increased rate of psychiatrically ill/abnormal family dynamics • Etiology 7. Family therapy and school counseling 1. Modeling of shy aloof behaviors by primary essential caregivers Other Disorders of Infancy, Childhood, or Adolescence 227

2. Child abuse 2. Tricyclic antidepressants (imipramine, clo- 3. Early traumatic childhood losses mipramine) have been successful in treating 4. Chronic medical problems school phobia—use customary TCA protocol 5. Impaired social skills including baseline vital signs, ECG, and serum levels. • If continued into adulthood, becomes Avoidant 3. Buspirone (Bernstein, Borchadt, & Perwein, Personality Disorder 1996; AACAP, 2007e) 4. Other medications such as antispasmodics Generalized Anxiety Disorder (includes Overanxious and antihistamines Disorder of childhood) (See also Anxiety and Stress 5. Benzodiazepines have not shown efficacy in Related Disorders chapter) child/adolescent anxiety disorders. • Children with this disorder are extremely sensitive. • Psychotherapeutic interventions 1. Objectives • Overanxious behavior is exaggerated during times a. Overcoming fear of threat of stress. b. Differentiating and understanding various feelings • Overly concerned about social performance and c. Elevating self-esteem and feelings of competency. security Obsessive-Compulsive Disorder (See also Anxiety d. Understanding the link between feelings, and Stress Related Disorders chapter) thoughts, and behaviors e. Understanding that arousal is a symptom • Thought to be rare in children until recently. of fear f. Enhancing problem-solving skills • Symptoms in children include obsessive thoughts, g. Gaining a sense of mastery rituals, such as washing, checking, and repeatedly h. Developing adaptive coping skills rewriting letters or numbers until perfect. i. Resolving core conflicts j. Eliminating anxiety • Adults realize the behaviors are unreasonable; chil- 2. Psychotherapy dren may not. a. Systematic desensitization b. Exposure and response prevention Panic Disorder—uncommon before the prepubertal c. Cognitive-Behavioral Therapy period; peak age of onset is 15–19 years of age Posttraumatic Stress Disorder (See Anxiety and • Family therapy—psychoeducation for parents to Stress Related Disorders chapter) help reinforce healthy parenting skills 1. Support child’s increasing autonomy and Treatment Measures—should be a multimodal competence. approach incorporating behavioral/CBT, 2. Modify family functioning. psychodynamic, family therapies as well as pharmacotherapy. Other Disorders of Infancy, • Biochemical interventions (AACAP, 2007e; Sadock Childhood, or Adolescence & Sadock, 2007; Stahl, 2008, 2009) 1. SSRIs have emerged as the medications of Reactive Attachment Disorder (RAD) of choice for treating childhood anxiety disorders Infancy or Early Childhood (monitor for increased risk of suicidality)— complete routine screening for Bipolar Disor- • Definition & signs and symptoms (American Acad- der prior to initiating treatment with SSRIs. emy of Child & Adolescent Psychiatry, 2005; APA, a. Fluoxetine (20 to 60 mg/day)—OCD, panic 2000; Sadock & Sadock, 2007)—RAD involves ab- disorder normal social behaviors in young children as a re- b. Fluvoxamine (50 to 200 mg/day sult of an environment of maltreatment (involving divided)—OCD sensory deprivation and neglect) that interfered c. Escitalopram (10 mg/day)—GAD with the development of normal attachment be- d. Paroxetine (10 to 60 mg/day)—GAD, OCD, haviors. RAD is characterized by a lack of a clearly Panic Disorder, PTSD, Social Anxiety identified attachment figure, nonresponsiveness, Disorder excessive inhibition, hypervigilance, indiscrimi- e. Sertraline (25 to 50 mg/day)—OCD, Panic nant socialization, or disorganized attachment Disorder, PTSD behaviors. RAD is divided into two subtypes: 228 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

1. Inhibited type—emotionally withdrawn—fail- a. First, engage principle caregiver (then ing to initiate or respond, in a developmentally other relevant family members) in appropriate manner, to most social interac- treatment. tions; experiencing hyper-arousal, difficulty (1) Therapist can act as coach for care- in regulation of emotion (irritability, anger/ giver to promote child’s healthy at- aggression in response to efforts to comfort) tachment behaviors. 2. Disinhibited type—indiscriminant sociabil- (2) Alternatively, therapist can model ity—little, if any, fear of strangers; seeking and attachment-promoting behaviors in accepting comfort from unfamiliar adults; dyadic work with caregiver in joint sometimes considered to be emotionally shal- therapy with child. low, attention seeking, and interpersonally b. Identify family stresses. superficial c. Assess family resources. d. Assess and intervene in dysfunctional • Differential diagnosis conflicts affecting child’s well-being. 1. Physical examination to determine/treat fac- e. Supervise care. tors contributing to disturbance in rates of f. Recommend out-of-home placement if growth and development necessary. 2. Mental Retardation or Pervasive Developmen- tal Disorder, such as Autistic Disorder • Milieu interventions 3. Children with severe neurological abnormali- 1. Does not meet criteria for psychiatric ties, including deafness, blindness, profound hospitalization. multisensory defects, major central nervous 2. Patient may be placed in infant home or pe- system disease, or severe chronic physical diatric unit to treat other conditions while illness awaiting placement; cuddling and stimulation essential; staff may model appropriate behav- • Mental status examination ior for parents. 1. Lack of developmentally appropriate social responsiveness • Community resources 2. Apathy and lack of interest in environment 1. Community mental health parent support 3. Child may stare, have weak cry and poor mus- groups cle tone, as well as low motility. 2. Parenting classes 4. Home visit often required to investigate ne- 3. Public health nursing glect or abuse since caregiver reports not 4. Pediatric/family-centered outpatient program reliable. 5. Child protective services 6. Child abuse prevention services • Nursing diagnoses (NANDA, 2009) 7. Multidisciplinary team approach—case man- 1. Parenting, risk for impaired agement and coordination of care essential 2. Role Performance, ineffective 3. Social Interaction, impaired Stereotypic Movement (Formerly 4. Caregiver Role Strain, risk for Stereotypy/Habit) Disorder 5. Attachment, risk for impaired 6. Growth and Development, delayed • Signs and symptoms (APA, 2000; Keltner et al., 2007; Sadock & Sadock, 2007)—characterized by • Intrapersonal origins/Psychotherapeutic interven- repeated voluntary, often rhythmic movements tions—response to neglect/provision of adequate (head banging, hand/arm biting, hand flapping, caretaking rocking); more frequently occurs in PDD and Men- tal Retardation. • Family dynamics/Family therapy 1. Parents—severe character pathology • Differential diagnosis 2. Severe depression, isolation, and lack of sup- 1. Normal rocking and thumb-sucking are com- port systems mon in infants and young children. 3. Lack of bonding in first weeks of life 2. Pervasive Developmental Disorder, Tic Disor- 4. Transgenerational pattern of dysfunctional der, and Obsessive-Compulsive Disorder parenting, abuse, neglect, and mental illness 5. Overwhelming psychosocial stresses in par- • Mental status examination—behavior appears ents with emotional deficits compulsive and involuntary. 6. Family therapy Other Disorders of Infancy, Childhood, or Adolescence 229

• Nursing diagnoses (NANDA, 2009) 2. Associated with mood, anxiety, and disruptive 1. Injury, risk for behavior disorders. 2. Behavior, risk-prone health 3. Adolescent drug and alcohol abuse is major health problem and precedes later drug and • Biologic origins alcohol dependency. 1. Common in Mental Retardation 4. Disrupts adolescent’s ability to meet develop- 2. Associated with congenital deafness and mental tasks. blindness 5. Associated with: 3. Associated with degenerative and CNS a. Accidents, suicides, and psychiatric illness disorders b. Dual diagnosis, especially depression, 4. Temporal-lobe epilepsy and severe ADHD, and Conduct Disorder Schizophrenia c. Teenage pregnancy, infant morbidity and 5. May be induced by certain psychoactive sub- mortality, high-risk sexual behavior and stances such as amphetamine, in which case STDs the diagnosis of Psychoactive Substance- (1) Children of cocaine-addicted mothers Induced Organic Mental Disorder should also may experience difficulty in bonding; be made at risk for multiple problems, including low birth weight. • Treatment measures (2) Cocaine interferes with parental 1. Promote safety and reduced episodes of self- bonding and empathy. injury. (3) Infants born to alcohol-dependent/ 2. Behavioral techniques (habit reversal differen- alcohol-addicted mothers are at risk tial reinforcement of alternative behavior) and for fetal alcohol syndrome; infants are pharmacological interventions have yielded difficult to soothe, are at high risk for successful results. later developmental abnormalities, 3. Dopamine agonists, specifically phenothi- disruptive behavior disorders, and azines, such as haloperidol, chlorpromazine mental retardation. (Thorazine) have been the most frequently d. Parental substance use used medications for treating stereotypic e. Emotional distance between parent and movement/injurious behaviors adolescent and lack of involvement in 4. Haloperidol—Children older than 3 years— adolescent’s life initial dose: 0.05 to 0.15 mg/kg/day in divided f. Lack of supervision and discipline doses, with gradual increase to 0.5 mg/kg in g. Low self-esteem, high population density, 5 to 7 days to bring symptoms under control; high crime (JAACAP, 1997g) maximum dose of 100 mg/day. Side effects 6. Developmental issues are often delayed, dis- include sedation, headache, extrapyramidal rupted, or arrested when adolescents become symptoms, tardive dyskinesia, neuroleptic substance abusers. malignant syndrome, orthostatic hypotension, 7. Strong evidence exists to support a genetic or photosensitivity, anorexia, constipation, para- constitutional risk for SUD. lytic ileus, impaired liver function, hypersali- 8. Diagnostic/Screening instruments include vation, agranulocytosis, anemia, leucopenia, the Teen Addiction Severity Index (T-ASI) and cough reflex suppression, laryngeal edema, Adolescent Drug and Alcohol Diagnostic As- brochospasm, diaphoresis sessment (ADAD). 5. The efficacy of opiate antagonists in reducing 9. Treatment programs use interventions similar self-injury is presently under study. to adult programs (12-step programs, family involvement, reliance on group confrontation) • Family dynamics/Family therapy—provide fam- a. Treatment is designed to prevent ily support and information re: management and substance-use behaviors and provide pharmacology. education for patient and family. b. Address coexisting behavioral and psy- Substance-Use Disorders (SUD) in chiatric problems; family functioning, Childhood & Adolescence (Sadock & academic functioning, and peer relations Sadock, 2007)—See also Substance- (JAACAP, 1997g). Related Disorders chapter c. Substance abuse is often a way of dealing with chronic stress and family dysfunc- 1. Prevalence rate among adolescents is 32%; tion, so entire family must be targeted for higher among those at high risk for social intervention. impairment. 230 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

10. Level of treatment service decisions can be • Nursing diagnoses—same as adults determined using the Child and Adolescent Levels of Care Utilization Services (CALOCUS) • Biologic origins: instrument (levels range from 0 to 6; 0 = basic 1. Neurodevelopmental models suppose a fixed preventative services, whereas 6 = secure/ lesion in interaction with a combination of ge- locked inpatient setting with intensive 24-hour netic or nongenetic factors such as early viral care). CNS infection, autoimmune mechanisms, or pregnancy/birth complication. Early-Onset Schizophrenia (EOS)/ 2. Association of Asperger’s with psychotic phe- Childhood-Onset Schizophrenia (COS) nomena in children has been found. 3. Children with EOS may come from families • Definition & signs and symptoms: (APA, 2000; with greater prevalence of disorder. Sadock & Sadock, 2007) 4. Chromosomal abnormalities/prenatal insult is 1. Onset of psychotic symptoms before 12 years possible. of age (prepuberty) for COS; after for EOS; on- 5. Eye-tracking abnormalities reported in adoles- set before 6 years of age very rare. cents at risk for Schizophrenia; smooth pursuit 2. Similarity of cognitive, neurologic, and lin- abnormalities, or the inability to track a mov- guistic deficits suggests the same disorder as ing object with the eyes, specific for vulner- adults, with greater severity and chronicity. ability to Schizophrenia. 3. Same criteria used as for adults, but difficulties 6. Information processing deficits could underlie in applying criteria to children. illogical thinking and loose associations. 7. Position Emission Tomography (PET) evalu- • Differential diagnosis ation shows striking right posterior parietal 1. Autism and other pervasive developmental hypometabolism. disorders 2. Neurological disorders • Mental status examination 3. Multidimensionally impaired (MDI) 1. Prodromal illness, exaggeration of that seen in a. Mood lability and social ineptness present adults but not social withdrawal 2. Motor clumsiness b. Most meet criteria for ADHD 3. Speech and language problems c. Fleeting hallucinations 4. Delay in language acquisition d. Odd thinking, often in conjunction with 5. Early diagnosis of disruptive or avoidant language disorder behaviors 4. Affective disorder—psychosis associated 6. Positive and negative symptoms with Bipolar Disorder often misdiagnosed as 7. Auditory hallucinations most frequent, so- Schizophrenia matic and visual, less frequent 5. Medical conditions and pharmacological 8. Higher baseline levels of thought disturbance agents (stimulants) 9. Loose associations and illogical thinking not 6. Substance abuse typically seen in normal children after 7 years 7. Dissociative states of age 8. Trauma-related symptoms 9. Associated with Borderline Personality Disor- • Biochemical interventions der (Volkmar, 1996; (JAACAP), 1997f) 1. Similar medications used with both adults and 10. Easier to diagnose in adolescents (EOS) than children. children (COS) 2. Atypical antipsychotics, such as risperidone a. Inability of preschool children to use rules and clozapine useful due to limited extrapyra- of logic or notions of reality makes it dif- midal side (EPS) effects; side effects of clozap- ficult to establish delusions or thought ine include agranulocytosis, and need close disorder. monitoring. b. Focus on disorganized speech makes it 3. Comorbid depression may guide choice of difficult to evaluate a child with a language agents in polypharmacy. disorder. 4. Since onset of therapeutic effect not apparent c. Hallucinations difficult to distinguish from until some time after treatment started, rapid sleep-related and other developmental switching of agents is not helpful. phenomena. 5. Stimulant use contraindicated due to capac- d. Need accurate information about premor- ity to induce psychotic symptoms (Volkmar, bid functioning. 1996). Treatment Modalities for Mental Disorders in Childhood and Adolescence 231

• Psychotherapeutic interventions • Nursing research agenda 1. Individual therapy based on the following 1. Outcome studies of treatment models that factors: best facilitate patient functioning a. Developmental stage 2. Impact of illness on siblings b. Degree of active thought disorder c. Ability to tolerate intimacy, and assess- Personality Disorders ment of the degree of importance of the relationship to the child • Although personality disorders are not generally d. Encouragement of focus on reality of out- included in the disorders of infancy, childhood, side world and adolescence, the presentation, defenses and e. Refocusing disordered thinking symptomatology of these disorders are presaged f. Setting limits on inappropriate behavior by the childhood disruptive behavior disorders. (Jongsma, Peterson & McInnis, 1996) According to DSM IV-TR (APA, 2000), one may see 2. Supportive therapy based on whether expres- the following personality disorders or the initial sion or suppression of affect is desired signs in older children or adolescents: 3. Expressive therapy 1. Antisocial 4. Social skills training 2. Avoidant 5. Special educational interventions 3. Borderline

• Family dynamics/Family therapy • Signs and symptoms—See Behavioral Syndromes 1. Parents often report children appeared normal and Disorders of Adult Personality chapter at birth. 2. Families experience profound sadness, guilt, • Biologic/Intrapersonal origins and self-blame; older theories of “schizophre- 1. Faulty ego functioning may be related to de- nogenic mothers” and cold, rejecting par- velopmental arrests in childhood as well as ents may still be held by some mental health genetic predisposition and trauma (See Be- professionals. havioral Syndromes and Disorders of Adult 3. Parents may view themselves as victims of Personality chapter) child’s disorder. 2. Primitive defenses of personality disorders 4. Lack of respite care and services places addi- may be triggered by experiences of poor par- tional burdens on family. enting, family dysfunction, and inadequate 5. Family therapy with psychoeducational ap- caretaking. proaches fosters clear communication. 3. Children reared in unstable environments have low self-esteem, lack trust, and have poor • Group approaches—enhance socialization skills social skills. 4. Early trauma, including physical abuse and • Milieu interventions sexual abuse. 1. Facilitate child’s highest level of functioning. 2. Facilitate age appropriate skills. • Family dynamics/Family therapy 3. Consistency and predictability essential. 1. Parents lack empathy and affection; often re- 4. Use isolation sparingly to facilitate child’s inte- jecting and chaos ridden. gration into unit (Johnson, 1995). 2. Family substance abuse, mental illness, abuse, 5. Staff needs education and help with child’s un- and violence may be present. even developmental presentation and variety 3. Review family and environmental dynamics in functioning. for Conduct Disorder. 6. Expectations must be realistic. Treatment Modalities • Community resources for Mental Disorders in 1. Support groups for parents Childhood and Adolescence 2. National Association for the Mentally Ill (NAMI) • Individual psychotherapy—current treatment of 3. Case management services to coordinate di- child and adolescent mental disorders involves a verse services multimodal approach (Keltner et al., 2007; Sadock 4. Federation of Families for Children’s Mental & Sadock, 2007). Health 1. Supportive therapy 5. Parents of Schizophrenics 2. Play therapy—historically, the most commonly used modality with children; play therapy is 232 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

an intervention defined as the purposeful use • Family dynamics/Family therapy of toys and other equipment to assist the child 1. Helps family achieve healthy coping and inter- in communicating his or her perception of rupts behaviors that maintain child or adoles- the world and to help him or her master en- cents symptoms vironment (Zimmerman, 1997); play therapy 2. Usually a mandatory component of a child’s has not received the empirical support that therapeutic environment; parental involve- other therapies (CBT, interpersonal therapy) ment is strong predictor of positive outcomes have experienced. Behavioral play (practice/ for child rehearsal exercises) can help child learn and 3. Problems treated: experience new ways of behaving. a. Communication and expression of feel- 3. Behavioral modification—behavior therapists ings among family members actively direct treatment. b. Limit-setting skills a. Most useful when implemented in home, c. Rules, consequences, and rewards classroom, and with individual child. d. Dealing with separation dynamics b. Parents taught behavioral management strategies. • Milieu interventions c. Children and adolescents learn self- 1. Physical setting control and relaxation techniques. a. Age-appropriate furniture that is mobile d. Treatment goals are mutually set with for arranging small conversation area child, therapist, and parents. b. Games, puzzles, books and toys geared to e. Compatible with solution focused, short developmental level of residents term approaches. (Zimmerman, 1997). c. Provision for safety 4. Cognitive therapy is beneficial for children d. Sociopetal structure with all client rooms aged 9 to 10 and older; cognitive therapy en- entering a central family room to foster ables child and adolescent to utilize coping interaction and support safety self-statements and to overcome dysfunctional e. Warm, home-like ambience with pictures, cognitive distortions. plants, padded furniture 5. Skills training has as its goal helping children f. Provision for privacy in sleeping, dress- achieve competence in mastering developing, and bathing while allowing necessary mental tasks and to make use of environmen- monitoring and supervision tal and personal resources to achieve a good g. Respect for children’s and adolescents’ outcome (Bloomquist, 1996) need for own “space” for possessions, school work, writing, etc. • Group approaches h. Provision of active orientation to 1. Childhood treatment a. Social skills groups (1) Bulletin boards with calendars, sched- b. Emotional expression ules, staff names c. Behavioral expression (2) Patient names, assignments, primary d. Protection from unsafe environment therapist and staff member, privilege e. Coping with divorce, separation, and level and point system blended families 2. Structured treatment programs f. Recovery groups for children of substance a. Philosophy—child and adolescent pro- abusing parents grams often based on a family systems g. Art therapy groups for identification and model with developmental perspective expression of feeling (1) Inpatient unit becomes a family that 2. Adolescence provides for expression of feelings, a. Peer relationships effective communication between b. Substance abuse recovery/12-step group members, development of cop- c. Communication with parents ing skills, and positive recreational d. Coping with divorce, separation, and experiences. blended families (2) Family life simulated with meal e. Critical incident debriefing preparation and other routine activi- f. Decreasing impulsive and high-risk ties; birthdays and celebrations are behavior planned and implemented. b. Rules, limit setting, and consequences (1) Unit rule books Treatment Modalities for Mental Disorders in Childhood and Adolescence 233

(2) Consistency in application of rules 4. Final dose may be higher than in adults be- and consequences cause of metabolic and organ differences. (3) Peer or buddy system for older chil- 5. Clinical observations of effects are essential dren and adolescents because of absence of carefully controlled (4) Positive reinforcement rather than studies of pharmacotherapy in children. punishment 6. Variation in dosing between adults and chil- (5) Point system for privileges with higher dren considers difference in size, metabolism, points indicating a higher level with and desired action. more privileges 7. Combined pharmacotherapy is being used (6) Recognition in community meeting safely in children; same considerations in (7) Limit setting on a continuum with introducing multiple medicines apply to chil- positive social interaction at one end dren as to adults. and time out on the other 8. Antihistamines lower seizure threshold and (a) Positive social interaction such as cause delirium and worsening of tic disorders. smiles, nods, and encouragement 9. Lithium is cleared rapidly by children, so they (b) Extinction is used for mildly in- may require higher doses to stabilize a mood appropriate behaviors by with- disorder. holding positive reinforcements 10. Valproate (Depakote) may be hepatotoxic in or ignoring behavior; inappropri- children younger than age 10. ate behavior usually escalates 11. MAOIs are contraindicated in pediatric popu- after period of ignoring prior to lation due to dietary and other risks. extinguishing 12. Children both metabolize neuroleptics more (c) Providing direction rapidly and are more sensitive to their main (d) Verbal reprimand or specific effects. statements that point out conse- 13. Stimulants are first line of treatment for atten- quences if inappropriate behavior tion deficit hyperactivity disorder (ADHD), and continues this practice is generally continued through (e) Privilege removal that is natural adolescence into adulthood. consequence to the behavior 14. SSRIs are generally considered safe and ef- (f) Time out to child to reflect and re- fective for treatment of depression and some gain control and equating to one anxiety disorders in children; however, an minute per year of development increased risk for suicide among children, ado- (Johnson,1995; Antai-Otong, lescents, and young adults exists for this class. 1995) 15. Buspirone (BuSpar) may be helpful in manag- c. Treatment level system—organized, con- ing aggression and agitation in children with crete way to show child’s progress through Mental Retardation or a Pervasive Develop- treatment ment Disorder (PDD) (Zimmerman, 1997) (1) Expectations and privileges increase with advance to next treatment level • Medication management for adolescents or phase. 1. Establishment of trust is essential because of (2) Child or adolescent may earn a set developmental issues regarding control by number of points each day; increased authority. privileges are attached to higher 2. Adolescents are more susceptible to extrapyra- levels. midal side effects. d. School program must be provided as part 3. Teens have poor fluid intake, which makes of inpatient, partial, or residential pro- them susceptible to constipation, dry mouth, grams for children and adolescents. and urinary retention. 4. Vital signs need monitoring for potential • Medication management considerations for hypotension. children 5. Drowsiness may interfere with school. 1. Children differ in response to medication’s 6. Abuse of medications, including selling medi- main and side effects. cations at school, especially anti-anxiety or 2. Children may metabolize and eliminate medi- sympathomimetic agents is a risk factor. cations more rapidly. 7. Adolescent, family, and school professionals 3. When medicating children, start slow, titrate should understand indications, responses, in- carefully, use lowest effective dose. teractions and compliance issues to facilitate proper adjustment of medication dosage. 234 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

8. Adolescent, family, school, and other psychiat- overnight; or is 14 years old or younger and ric professionals must have reasonable expec- voluntarily chooses not to come home when tations of medications. expected; or child older than 15 years stays 9. Monitor for potential overdose when patient away for more than two nights. is experiencing suicidal thoughts (Botz & 2. 500,000 to 2 million youngsters (mainly ado- Bidwell-Cerone, 1997). lescents) run away from home each year and another 900,000 have no home (Mohr, 1998)— Adolescent Behavioral Issues 68% of all runaways are older adolescents (aged 15–17) • Violence (Federal Interagency Forum on Child and a. Situational runaways—largest subgroup; Family Statistics, 2009) circumstances include: 1. Adolescent acting-out behaviors continue, but (1) Eldest daughters seeking relief from the juvenile crime rate has declined from an major household responsibilities (del- all-time high rate in 1993 (26% of all violent egating family dynamics) crimes); juvenile crime rate decreased in 2007 (2) Adolescents used as pawns in parental to 17% (all such victimizations reportedly in- conflicts volved a juvenile offender); 56% of all violent (3) Parents trying to obstruct normal ado- crimes committed by a juvenile involved mul- lescent separation process (binding tiple perpetrators. family dynamics) 2. Rate of victimization of teens (ages 12–17) is (4) Reunion fantasy causing adolescents twice that of the general population. to run away as a ploy to pull parents 3. Girls 14 to 15 years of age have highest risk of together any age group of being raped (Johnson, 1997). b. Departure runaways—depressed and an- 4. Violence by juveniles usually acted out on gry about treatment at home and hungry other juveniles; nearly one million juveniles for affection and a sense of belonging; es- between 12 and 19 years of age are raped, cape is a genuine survival tactic robbed, or assaulted, twice that of the general c. Throwaways—youth who are asked to population. leave home (expelling family dynamics); 5. Lethality of teenage violence is increasing; usually endure lifestyles similar to depar- teenage violent death rate rose 13% between ture runaways; approximately 200,000 to 1985 and 1991. 600,000 have been thrown out, agree to 6. 12% to 31% of the general adolescent popula- leave, or are removed by authorities (Ham- tion have elevated depressive symptomatology mer, Finkelhor, & Sedlak, 2002; Mohr, placing them at risk for Major Depression and 1998). suicide. 3. Circumstances associated with departure run- 7. Positive correlation between juvenile violent aways and throwaways include the following: behavior and adult violent behavior. a. Parental criminal activity, violence, alcoholism, and addiction • Youth gangs and violence b. Overall chaotic home environment 1. Results from a National Youth Gang Center c. Physical, emotional, and sexual abuse and (NYGC) survey in 2007 (Egley & O’Donnell, neglect 2009) indicate that gang activity among youth d. Conflicts over same-sex orientation has begun to rise (2007 prevalence rate of 4. Population of children and adolescents with 35%), following a low in 2001(24%). no social service support 2. Antisocial behavior in adolescence is positively a. Become homeless street people and often associated with depression. turn to prostitution, drug dealing, stealing 3. Conduct disorder is associated with involve- and panhandling to survive; most can- ment with a delinquent peer group. not return home due to high degree of 4. Victims of teen violence are being killed rather dysfunction. than injured (Johnson, 1997); increasingly, b. Are vulnerable to exploitation; group at firearms are involved in adolescent homicide highest possible risk for rape, assault, and suicide; teenage homicide rate has dou- homicide, depression, suicide, drug over- bled since 1985. dosing, pregnancies, poor nutrition, poor hygiene, sleep deprivation, and STDs • Runaways (Hammer, Finkelhor, & Sedlak, 2002) including HIV/AIDS and communicable 1. Definition—A runaway child is one who leaves diseases (Botz & Bidwell-Cerone, 1997; home without permission and stays away Haber, 1997; Mohr, 1998). Treatment Modalities for Mental Disorders in Childhood and Adolescence 235

Child Maltreatment d. Have a history of inadequate care themselves. • Incidence (US Department of Health and Human 6. Emotional availability of parents includes: Services, Administration on Children, Youth and a. Parental sensitivity Families, 2009) b. Child responsiveness 1. 794,000 children were victims of child abuse c. Parental nonintrusiveness and neglect, and 1,760 children died as a result d. Involvement of parent with child of abuse/neglect, during 2007. Of the fatalities, 75.7% were younger than 4 years of age. In- • Medical neglect fants (age birth to 1 year) had the highest rate 1. Caregivers’ failure to provide prescribed medi- of victimization (2.2%); more than half were cal treatment for their children, e.g., immuni- female (51.5%) and nearly half were white zations, prescribed medication, recommended (46.1%), although boys were more likely to die surgery as a result of the abuse/neglect. 2. May involve clash between parents’ religious 2. The most common form of maltreatment is beliefs and recommendations of medical neglect (56.0%); followed by physical abuse community (10.8%); sexual abuse (7.6%); and psychological maltreatment (4.2%). • Mental health neglect—caregivers’ refusal to com- 3. Perpetrators of the child maltreatment were ply with recommended corrective or therapeutic parents (79.9%) or relatives of the victim procedures (6.6%); female (56.5%), and under the age of 40 years (74.8%). Of the perpetrators who were • Educational neglect—failure to comply with state child daycare providers, nearly 24 percent regulations for school attendance (Erickson & (23.9%) committed sexual abuse. Egelund, 1996)

Neglect—may be impossible to estimate actual Physical Abuse (measures of incidence and scope because neglect is easily overlooked. prevalence rates can vary based on restrictiveness • Physical neglect—most widely recognized and of definition) commonly identified form of neglect; includes fail- • Child characteristics related to abuse ure to protect from harm or danger and provide for 1. Early health problems increase risk, including: child’s basic physical needs (shelter, food, clothing) a. Medical b. Intellectual • Emotional neglect—more difficult to document or c. Developmental aberrations substantiate, often beginning when children are 2. Temperament/behavior too young to communicate or know they are not a. Difficult temperament (impulsivity, receiving appropriate care crying) 1. Extreme form of neglect leads to nonorganic b. Conduct problems failure to thrive. c. High activity 2. American Humane Association describes emo- d. Limited sociability tional neglect as passive or passive/aggressive inattention to child’s emotional needs, nurtur- • Parental characteristics related to abuse ing, or emotional well-being (Erickson & 1. Heightened levels of distress or dysfunction Egelund, 1996). a. Depression 3. “Psychologically unavailable” parents overlook b. Physical symptoms infants’ cues and signals, especially cries and c. Substance abuse pleas for warmth and comfort. d. Posttraumatic Stress Disorder (PTSD) 4. Has serious long term consequences for child; 2. Early physical punishment of parent emotionally neglected children expect their a. Adults who experience or witness abuse needs will not be met, and do not even try to during childhood are exposed to aversive solicit care and warmth; they expect failure, models and use aggressive discipline with therefore lack motivation. children. 5. Neglectful parents: b. Violence becomes transgenerational a. Lack an understanding of children’s be- and multiplied; victims may reenact the havior and parent-child relationship. trauma by identifying with the aggressor b. Experience a great deal of stress. and acting out on others. c. Are socially isolated or unsupported. c. 30% of those abused as children abuse their own children. 236 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

3. Personality disturbances 4. Sexual exploitation a. Hostile personality 5. Child pornography b. Parental explosiveness 6. Child prostitution c. Irritability and use of threats 4. Cognitive style • Social conditions increasing risk of sexual abuse a. Negative cognitive attributional style— 1. Separated from both biologic parents or perceive children in negative light runaway b. Belief in strict physical discipline 2. Raised in poverty c. Have high expectations of children in re- 3. Child handicapped lation to age-appropriate behaviors and 4. Alcoholic family member cognitive skills 5. Drug abusing family member 5. Behavioral functioning 6. Prostitution at home a. Inconsistent child-rearing practices re- 7. Transient adults living in home flecting critical, hostile, or aggressive man- 8. Mentally ill caretaker agement styles 9. AIDS related disability of caretaker (Montele- b. Poor problem-solving ability; less atten- one, Glaze, & Bey, 1994) tion-directing verbal and physical strategies, less mutual interaction in free play • Impact of sexual abuse on child and problem-solving situations 1. Traumatic sexualization 6. Biologic factors—hyperarousal to stressful 2. Stigmatization child as measured by autonomic arousal 3. Betrayal 7. Family system characteristics 4. Powerlessness a. Coercive parent-child interactions 5. Traumatic amnesia—may interfere with pro- b. Poor family relationships/family context cessing event and placing it in past memory of hostility (Whitfield, 1998) 8. Experiences of abuse and violence are related to development of personality disorders, de- Assessment of Child Maltreatment—conducted pressive, anxiety, and dissociative disorders. within the context of the environment • Issues to be considered Sexual Abuse 1. Ethnicity and socioeconomic status • Definition—occurs between a child and adult, or 2. Social desirability and reporting bias older child; is defined as sexual contact or interac- 3. Professional roles affecting outcomes of as- tion for purpose of sexual stimulation/gratification sessment (interviewer bias, lack of training, of adult or older child (Monteleone, Glaze & Bly, leading questions) 1994) 4. Use of standardized measures 5. Multi-axial assessment • Sexual acts range from least severe to most severe 6. Information from children and intrusive a. Behavioral report and/or observation 1. Noncontact acts—making sexual comments to b. Casual observations child, exposure, voyeurism, pornographic ma- c. Mental status examination terial viewing, inducing child to undress d. Projective assessments and drawings 2. Sexual contact e. Projective storytelling/apperception tests a. Offender touching child’s breasts, but- f. Rorschach tocks, genitals or asking child to touch his/ g. Cognitive assessments her genitals h. Bayley scales of infant development b. Frottage—rubbing genitals against victim’s (BSID) body or clothing for pleasure i. Wechsler series of intelligence tests for c. Digital or object penetration children d. Oral sex—offender to child or child forced j. Kaufman assessment battery for children to perform on offender (K-ABC) e. Penile penetration—vaginal or anal k. Clinical interviews f. Intercourse with animals l. Nondirective play sessions m. Structured psychiatric diagnostic • Circumstances of sexual abuse interviews 1. Dyadic 7. Information from parents 2. Group sex a. Child Behavior Checklist (CBCL) 3. Sex rings b. Vineland Adaptive Behavior Scales (VABS) Treatment Modalities for Mental Disorders in Childhood and Adolescence 237

8. Family assessment 2. Structured and semistructured interview pro- a. Standardized measures of family tocols (e.g., Cognitive Interview, Step-Wise assessment Interview) have been established to increase b. Clinical interviews accuracy of information obtained, and to 9. Supplemental information minimize mistaken or false information from a. Teachers/school personnel children who become confused, frightened, b. CBCL Teacher Report overwhelmed, or intimidated with the inter- c. Caseworkers view process (Sadock & Sadock, 2007). d. Foster parents/supplemental caretakers 3. Recommended that role of evaluator and ther- 10. Risk assessment of harm to self and/or others apist be kept separate (American Professional a. Suicide Society on the Abuse of Children [APSAC], b. Self-destructive behavior 1997). c. Danger to others 4. Sexual acts are considered abusive when the d. Risk of revictimization following are present: a. Power differential Maltreated Children and Therapy b. Knowledge differential • Reasons most children are brought to therapy c. Gratification differential 1. Child is showing symptoms of abuse or 5. History is most difficult phase of evaluation neglect. and most important. 2. Parents are concerned about how child is af- 6. Both physical and behavioral assessments are fected by abuse or neglect. necessary in establishing likelihood of abuse, however, majority of sexually abused children • Child factors that affect progress in therapy have no physical evidence. 1. Willingness to participate in therapy a. Child Sexual Behavior Inventory-3—valid 2. Ability to acknowledge experience of abuse or instrument for assessing sexually abused neglect children aged 2 to 12 (Friedrich, Berliner, 3. Capacity to use therapy Butler, Cohen, Damon, Shafram, 1996) a. Genetic make-up b. Sexualized behavior continues to be one b. Level of functioning of the most valid markers of sexual abuse c. Phase of development in children (children who demonstrate d. Content and intensity of the event sexual behavior), including: e. Accumulated life events and history of (1) Sexual play prior trauma (2) Sexual talk 4. Child needs reassurance to know that his/her (3) Sexual actions, e.g., compulsive mas- needs will be addressed in therapy. turbation or attempts to engage others in sexual activity • Essentials components of successful therapy (4) Touching others’ genitals 1. Trust—physical and emotional (5) Asking others to touch them 2. Needs assessment (Friedrich, et al., 1996) 3. History taking (essential) 4. Family genogram (essential) • Sexual abuse treatment 5. Strong alliance with parent or caretaker 1. Goals a. Deal with effects of sexual abuse • Stages of therapy in treating sexual assault (Hart- b. Decrease risk for future abuse man & Burgess, 1998) 2. Treatment issues for victim 1. Management of defensive patterns a. Trust 2. Anchoring for safety b. Emotional reactions to sexual abuse 3. Psychoeducation regarding complex trauma c. Responsibility for act response d. Altered sense of self 4. Strengthening personal resources e. Anxiety and fear 5. Surfacing trauma information f. Behavioral reactions to sexual abuse 6. Processing the trauma (1) Sexualized behavior 7. Future and transformation (2) Aggression (3) Runaway • Assessment of sexual abuse (4) Self-harm 1. Specialized skill—should be performed by pro- (5) Criminal activity fessionals who have been trained and super- (6) Substance abuse vised in this modality. (7) Suicidal behavior 238 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

(8) Hyperactivity • Implications for therapy with ritual abuse (9) Sleep problems 1. Higher incidence of PTSD (10) Eating problems 2. Higher incidence of dissociative disorder (11) Toileting problems 3. Greater symptom severity 4. Vicarious traumatization of the therapist be- • Therapeutic questions cause of greater impact on victim 1. What happened? 2. What thoughts/beliefs did you experience dur- Confidentiality ing the (incident) . . . and since then? • Applies regardless of patient’s age. 3. What will you do if something like this happens again? • Information cannot be disclosed to outsiders without parental consent. • Modalities 1. Group approaches • Decision to reveal information to parents is relative a. Treatment of choice for sexual abuse ex- to child or adolescent’s developmental age. cept for patients who are too disturbed or 1. May be developmentally inappropriate to seek disruptive child’s “consent” for disclosure to parents of b. Screen members information revealed during therapy. c. Six-to eight-members; three to six with 2. May be developmentally and therapeutically younger children appropriate to safeguard an adolescent’s dis- d. Minimum of 16 to 20 sessions closures, even from parents. e. Long-term, open-ended treatment helpful 3. Nurse should set ground rules for confidential- for adolescents ity during assessment/evaluation. f. Include several well socialized children • If parent has abused or neglected a child, disclo- (Friedrich, et al., 1996) sure of confidential information to maltreating g. Skills building for problem solving parent may be contraindicated regardless of the (Bloomquist, 1996) child’s age. 2. Individual psychotherapy (including play therapy)—also appropriate with an emphasis • Nurse should be familiar with legal concept of on alliance building privilege. 3. Dyadic treatment—used to repair relationship between victim and nonoffending adult • Written records, notes, videotapes, drawings, and 4. Family therapy—if reunification is in victim’s photographs may be subpoenaed. best interest 1. Attorney issuing subpoena cannot require/ 5. Use of multiple therapists indicated force professional to produce records. a. Range of services 2. Subpoena does not override confidentiality b. Shared responsibility for multiproblem requirement. families; one therapist can be over- 3. Patient should be consulted when subpoena whelmed with demands of highly needy for records is received. families with multiple problems and multiple agency involvement Legal Issues in Child Abuse and Neglect c. Therapist support • First child abuse reporting laws enacted in 1963, d. Cotherapy demonstrates a variety of roles following societal awareness of need for child to the patient protection. e. Shared decision making (Faller, 1993) 1. C. Henry Kempe published the seminal article 6. Cognitive reactions to sexual abuse—child on Battered Child Syndrome in 1962. must be able to make sense of the abuse 2. All professionals who work with children are before it becomes suppressed, denied, or mandated to report suspected abuse or ne- repressed and not resolved (Friedrich, et al., glect to designated child protection or law en- 1996) forcement authorities. 7. Protection from future victimization a. This includes both the generalist and spe- 8. Pharmacotherapy to alleviate target symp- cialist in psychiatric nursing. toms, such as anxiety, depression, or indica- b. Reporting laws override ethical duty to tions of posttraumatic stress protect confidential information (Myers, 9. Therapy performed as part of a larger context 1992). in which safety, stability, and support are pro- c. Reporting requirement is triggered vided (Friedrich, et al., 1996) when there is evidence that would lead a Treatment Modalities for Mental Disorders in Childhood and Adolescence 239

competent professional to believe abuse 1. Evaluating children suspected of abuse or neglect is reasonably likely. 2. Providing therapy for abused children and for d. No requirement to prove abuse or neglect children experiencing legal proceedings rein order to file a report. lated to abuse e. Professionals protected from retaliation 3. Serving as expert witness in child abuse cases for an unfounded or unsubstantiated re- 4. Political action on behalf of children port if report was made in good faith. 5. Case management on behalf of children f. Misdemeanor charge for intentional failure to report. • Nurses must be familiar with the following: 1. Roles and responsibilities of various systems • Congress enacted Child Abuse Prevention and involved in child protection, including child Treatment Act in 1974 protective services, police, and court system 1. This established the National Center on Child 2. Emergency protective custody—all states pro- Abuse and Neglect (NCCAN) vide mechanism to protect children in emer- 2. States must comply with federal guidelines to gencies; police officers and in some states, receive federal funding, but have some choice child protective services’ professionals and how services are provided. physicians have authority to take children into temporary protection custody; these laws have • States have three kinds of laws (Pence & Wilson, strict time limits 1992; Feller, 1992; Depanfilis & Salus, 1992). 3. Guidelines established for evaluation of chil- 1. Reporting laws dren suspected of abuse (APSAC Guidelines, a. Define child abuse and neglect. 1997) b. Specify conditions for state intervention in 4. Laws in some states authorizing professionals family life. to take pictures and x-rays without parental c. Encourage treatment approach rather consent than punitive. d. Encourage coordination/cooperation • Expert witness testimony by advanced practice among services. PMH nurses e. Designate administrative structures for 1. Before a person may testify as an expert wit- handling. ness, they must provide documentation of 2. Juvenile and Family Court laws their expertise. a. Emergency hearings—determine need for a. Educational accomplishments and protection of alleged maltreated child. licensure b. Adjudicatory hearings—determine if child b. Specialized training, including board cer- has been maltreated. tifications and continuing education c. Dispositional hearings—determine action c. Extent of experience with children or to be taken after adjudication. adolescents and direct clinical experience d. Review hearings—review dispositions and (percent of practice time devoted to speci- determine need to continue placement for fied problem) services and/or court intervention. d. Familiarity with relevant professional 3. Criminal laws literature a. Define criminally punishable offenses. e. Membership in professional organizations (1) Law enforcement agencies investigate. f. Publications, presentations, teaching (2) Prosecutor decides if prosecution will g. Honors, awards, professional recognition occur. 2. The forms of expert testimony b. Burden of proof must be beyond a reason- a. Opinion—expert witness is permitted to able doubt (stronger than in Juvenile or offer professional opinions; expert must: Family Court). (1) Be reasonably confident of the c. Defendants have full protection of 4th, 5th opinion. and 6th amendments (jury, cross examina- (2) Employ appropriate methods of as- tion, appointed counsel, and speedy trial). sessment and consider all relevant d. Directed at deterring or rehabilitating de- facts. fendant (probation or incarceration). (3) Understand pertinent clinical and scientific principles. • Role(s) of advanced practice PMH nurse may (4) Be objective include: (5) Provide rationale and information leading to the opinion. 240 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

b. Answer to a hypothetical question 5. Being examined and cross-examined; difficul- (1) Legal strategy whereby an attorney ties for child include: gives an extensive or lengthy, hypo- a. Formality of interview procedures thetical statement and asks the expert b. Unfamiliarity of language to provide an answer to the hypotheti- c. Challenging nature of cross-examination cal scenario d. Time element in serious trials (Goodman (2) Strategy generally falling out of favor & Bottoms, 1993) c. Expert testimony in the form of a dissertation • Forensic nursing (Lynch & Burgess, 1998) (1) Expert provides a lecture on a par- 1. APN-PMH nurse may serve as sexual as- ticular subject, e.g., the dynamics of a sault nurse examiner (SANE) for children and syndrome. adolescents. (2) Testimony assists judge or jury to 2. APN-PMH nurse may have advanced training understand a phenomenon (Myers, in collection of forensic evidence and classifi- 1992). cation of wounds. 3. APN-PMH nurse may review equivocal child • Issues regarding child testimony death cases. 1. Linked to interviewing of children (specialized 4. APN-PMH nurse may provide counseling for training to avoid leading child’s responses) homicide victim’s families. 2. Interviews classified as investigative or therapeutic Questions 3. Interviews conducted for purpose of treatment may be used in investigations Select the best answer 4. Goals for child investigative interviews include: 1. Estimates of children and adolescents experi- a. Minimizing trauma of the investigation encing a mental disorder in the United States b. Maximizing information obtained are: c. Minimizing contaminating effects of inter- a. 7.5 million view on the child’s memory of the event b. 10 million d. Maintaining integrity of the investigative c. 250,000 process (Goodman & Bottoms, 1993) d. 2.5 million 5. Efforts underway to minimize gap between child’s ability to testify and demands of legal 2. Among children and adolescents with psychiatric system disorders about ____ are receiving treatment. a. 90% • Sources of stress in legal proceedings involving b. 50% children c. 20% 1. Long delays before trial which may: d. less than 10% a. Create anxiety for victims. b. Hamper therapeutic interventions. 3. Since the 1960s, the suicide rate for youngsters c. Affect child’s memory (gives support to 15 to 19 years of age has: concept of videotaping early interviews). a. Been unknown 2. Lack of legal knowledge c. Declined a. Preparation or orientation may help di- b. Stayed the same minish child’s anxiety. d. Increased b. Concept of “Court School” for child witnesses has been implemented; specialized 4. Children of immigrants who experience a lack of training is available for child advocates to acculturation may be at greater risk for: help orient children to courtroom proce- a. PTSD dures and stresses. b. PDD 3. Intimidating courtroom environment c. Mental retardation 4. Giving evidence in presence of accused d. Depression a. Videotaped testimony and videolink can alleviate some stress. 5. Risk factors are those that increase the likelihood b. Child’s live testimony may have more im- of developing an emotional mental disorder. pact on jury. Which of the following risk factors increases the c. Possible prejudicing of the defendant intensity of all other risk factors? must be considered. Questions 241

a. Physical and sexual abuse a. Other juveniles b. Adolescent parents b. Younger children c. Divorce, parental conflict, and family c. Middle-aged adults instability d. Elderly people d. Poverty 13. Cults are attractive to alienated adolescents who 6. Biologic or genetic factors that negatively impact have not internalized social norms. Cults are a child’s mental health include: usually led by: a. Personality characteristics a. Adults who provide substitute parenting to b. Low birth weight the adolescent c. Problem-solving ability b. Same sexed peers with organizational skills d. Normal intellectual development c. Charismatic authority figures who claim to possess certain powers 7. Life in a blended family may increase the risk of d. Peers who have dabbled in Satanism developing inadequate coping skills due to: 14. Runaways are a population of children and ado- a. Child support issues lescents who are at high risk for emotional and b. Step-siblings replacing peers physical health problems. Family forces that con- c. Visitation schedules disrupting family tribute to runaway behavior include delegating routines dynamics. Which of the following is an example d. Economic pressures for all parents to work of delegating dynamics? 8. Children in foster care are at very high risk for a. Preventing the adolescent from after school developing psychiatric disorders. One reason for activities this may be due to: b. Telling the adolescent to move out when he a. Cutbacks in funding finishes high school b. Poorly selected foster families c. A single father using the adolescent girl as a c. Lack of turnover in placement maternal figure for the younger siblings d. Lack of permanency preventing development d. Physical abuse of the adolescent of significant interpersonal relationships 15. A 15-year-old girl’s parents divorced and pro- 9. A major factor in lack of access to health care for ceeded to continue to argue with each other children in the United States is the lack of health around issues of child support and visitation. The insurance and: girl was interrogated about life at each parent’s home by the other, and the mother prevented a. Inadequate numbers of prepared mental visitation when the child support check was late. health professionals to provide needed In addition, the mother became angry when services the youngster came back from visitation and b. Poor follow-through by foster parents reported having a good time. The girl ran away c. Inadequate primary prevention by school and stayed with different friends for 10 days. nurses This is an example of which type of runaway? d. Poor psychiatric skills among primary care providers a. Departure b. Situational 10. Teens are victimized at a rate that is_____ that of c. Throwaway the general population. d. Emotional survival a. Twice 16. Harry, age 16, ran away from home because his b. Three times parents were both abusive alcoholics. There was c. Four times little structure or predictability in the home envi- d. Five times ronment, with people often moving in or out. 11. Which group has the highest risk of being raped? Harry became a “street person.” Harry is at high risk for: a. Girls 16–18 b. Boys 11–14 a. Victimization and exploitation c. Boys 6–8 b. Having a reunion fantasy d. Girls 14–15 c. Developing a gender identity disorder d. Having difficulty with time management 12. Violence by juveniles is most often inflicted on which population? 242 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

17. Amy, age 19, is addicted to crack cocaine and a. Less than most children since her parents will becomes pregnant. She continues drug use while want to protect her pregnant. A serious problem that may occur due b. No different from any other child, as children to her addiction is low birth weight. Another do not bring on abusive behavior serious problem may be: c. Slightly higher than other children d. Higher than other children due to the fact a. Pervasive Developmental Disorder that early health and medical problems b. Failure to thrive increase risk of abuse c. Failure to bond d. High utilization of health services 24. Jeffrey is a 6-year-old who has ADHD and difficulty attending to social cues. He is always on 18. Adolescent substance abuse affects what per- the go and is noted to have behavior problems centage of the adolescent population? in school. What, if any, is Jeffrey’s risk of being a. 12% abused? b. 46% a. No different from other children c. 24% b. Greater than others d. 32% c. Less than others 19. Substance abuse is potentially more serious d. Impossible to predict among adolescents because: 25. Donna Barry, a single mother, brings her daughter a. They are difficult to manage at home Lorraine, age 7, in for an evaluation of “behavior b. There are few 12-step programs for problems.” Ms. Barry speaks about Lorraine in youngsters negative terms. She acknowledges that Lorraine c. There is an interference with developmental does not present a problem at school, and says issues she spanks Lorraine if her room is not cleaned to d. It perpetuates substance abuse throughout Ms. Barry’s satisfaction. Lorraine appears to be the generations anxious and somewhat depressed. An appropriate intervention would be: 20. The incidence of child abuse and neglect includes: a. Counseling aimed at teaching Ms. Barry effective management skills a. An increased risk for children younger than 4 b. Reporting Ms. Barry for child abuse years old c. Referring Lorraine for medication b. An increased risk for adolescents management c. Decreased risk for infants d. Asking Lorraine’s teacher to report any d. Decreased risk for preschool children unusual bruising 21. A 3-year-old boy regularly arrives at the daycare 26. Assessment of child sexual abuse requires spe- center inappropriately dressed for cold weather. cialized skills and training. It is important that He appears undernourished and is often dirty. the interviewer use age-appropriate language, This may be an example of: provide a safe environment, and avoid leading a. Medical neglect questions. An example of a leading question is: b. Emotional neglect a. What happened after you went to bed? c. Physical neglect b. Where did you touch him? d. Passive inattention c. He put his fingers in your bottom, didn’t he? 22. The type of neglect that is difficult to document d. Tell me what happened next. or substantiate is: 27. Most children who have been maltreated are in a. Medical neglect therapy because they are showing symptoms of b. Emotional neglect being abused or neglected and: c. Physical neglect a. Social services requires treatment of the child d. Educational neglect b. Therapy enables the child to be a better 23. Suzanne is a 3-year-old who was born prema- witness turely and spent the first several months of her c. Therapy may be used to gather information life in the hospital. When she was sent home, she to prosecute the perpetrator was on a cardiac monitor. Suzanne was slow to d. The parents are concerned about how the walk, talk, and toilet train. What is her risk for child is affected by the abuse or neglect experiencing abuse? Questions 243

28. Cynthia is a 5-year-old kindergarten child who d. It is probable that someone coached Danny was digitally penetrated by her babysitter’s to say negative information about the teenage son. She is usually eager to come to her stepfather. therapist’s office and has been able to describe 34. Conditions that increase the likelihood of a child what happened to her. Other factors that may being sexually abused are life apart from both impact on her progress in treatment include: biologic parents, poverty, mental illness of a a. The perpetrator’s apology to Cynthia caretaker, and: b. The babysitter’s apology to Cynthia a. Having a grandparent in prison c. The therapist’s alliance with the parent b. Academic failure d. Cynthia’s mother’s abuse history c. Attention Deficit Hyperactivity Disorder 29. A primary focus in the beginning of therapy with d. Alcoholic family member abused children includes establishing trust and 35. The advance practice PMH nurse has developed rapport and: specialized skills in the treatment of sexually a. Integrating the child’s thoughts about abused children. The intervention regarded as herself the treatment of choice for sexually traumatized b. Helping the child to take risks children is: c. Reliving or reexperiencing the abuse a. Conjoint family therapy d. Determining the child’s coping style b. Solution-focused therapy 30. Helping the child to develop ways to cope effec- c. Analytical play therapy tively with symptoms, memories, sensations, d. Group therapy thoughts, and feelings is a focus of which stage 36. Advantages of cotherapists in working with sexu- of therapy? ally abused children include: a. Assessment a. Greater protection from further victimization b. Beginning b. Greater consensus on validation of the abuse c. Middle c. Protection from further victimization d. Termination d. Shared responsibility for multiproblem 31. Sexual acts are abusive clinically when there is a families differential between the victim and the offender 37. Common target symptoms related to child sexual in terms of power, knowledge, and: abuse that may be alleviated by pharmaco- a. Gratification therapy include anxiety, depression and: b. Intellect a. Poor school performance c. Socioeconomic level b. Regressed behavior d. Gender c. Soiling 32. In assessing sexual abuse, current recommen- d. Posttraumatic symptoms dations regarding the role of evaluator and 38. Ritual abuse is defined as the intentional phys- therapist are that they should be: ical, sexual, or psychological abuse of a child a. Kept separate when the abuse is repeated and stylized and b. Integrated typified by acts such as cruelty to animals, threats c. Done in different agencies of harm to the child, other people, or animals. d. Aimed at keeping the child’s story consistent Which of the following is true of ritual abuse? for court purposes a. The impact on the victim is greater than in 33. Danny is a 6-year-old boy who reported to his other forms of abuse, and the children are teacher that his stepfather often fondles him and more symptomatic as assessed by standard- forces him to suck his penis. A physical examina- ized instruments. tion reveals no evidence of sexual abuse. Which b. There is less impact on the victim than in of the following statements is true? other forms of abuse because of a greater tendency on the part of the victim to a. Most sexually abused children show physical dissociate. signs of abuse. c. The ritually abused child’s parents have a b. Most sexually abused children are molested greater sense of control than when their chil- by persons outside the home. dren are victimized in nonritualized ways. c. The majority of children who are sexually d. This type of abuse is well documented and abused have no physical evidence of abuse. thoroughly researched. 244 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

39. The psychiatric and mental health advanced a. Unfamiliarity with legal terminology practice nurse working with children must be b. The judge’s black robes aware of the laws regarding reporting child c. Confronting the accused abuse. Which of the following provides a guide- d. Lack of memory for the events over time line for the nurse? 45. States must comply with federal child abuse and a. All abuse must be thoroughly investigated by neglect guidelines to receive federal funds, yet the APN-PMH nurse before it is reported. have autonomy in deciding how services are b. The reporting requirement does not require provided to abused and neglected children. The proving abuse before reporting. types of laws that are relevant to reporting, c. There is generally a felony charge for inten- intervention, and prevention of child abuse tional failure to report. include reporting laws, criminal laws, and: d. The reporting laws do not override a. Affirmative action laws the ethical duty to protect confidential b. Sexual harassment statutes information. c. Anti-pornography statutes 40. Who decides whether or not the psychiatric and d. Juvenile and Family Court laws mental health advanced practice nurse is quali- 46. Rationale for parents “rooming in” with a sick fied as an expert witness? child are theories of: a. The nurse a. Ego development b. The nurse’s peers b. Attachment c. The attorney issuing a subpoena c. Psychodynamic development d. The judge d. Communication 41. Professionals who qualify as expert witnesses are 47. Marylou is a 4-year-old hospitalized with a severe permitted to offer opinions about which they upper respiratory infection. Her mother notes are confident. In arriving at an opinion, it must that she has begun wetting the bed after being be demonstrated that the expert considered all dry for the last two years. She expresses her relevant facts, employed appropriate methods of concern to the consultation liaison nurse clinical assessment, and: specialist. In helping the mother to understand a. Is advocating for the patient this change in her daughter’s behavior, the nurse b. Has a doctoral degree should teach the mother about which of the c. Interviewed all parties in a dispute following? d. Demonstrates objectivity a. Learning strategies for relaxing 42. Interviews of children may be therapeutic or b. Understanding concepts of regression in investigative. It is important in conducting inves- illness tigative interviews that the interviewer: c. Promoting family functioning d. Retraining toileting a. Makes sure that sufficient evidence is gathered for a prosecution in spite of the impact 48. Children hospitalized with chronic illnesses need on the child of repeated interviews opportunities for stress management, play and b. Minimizes the investigative trauma for the related activities, promoting family functioning, victim and: c. Is qualified as an expert witness a. Learning and academic activities d. Reports all details of the child’s disclosures to b. Learning ways to express hostility by the child’s therapist abreaction 43. Sources of stress for children experiencing legal c. Family therapy proceedings include: d. Continuing relations with their outpatient therapist a. The constitutional right for the offender to have a speedy trial 49. Childhood-Onset Schizophrenia is defined as an b. Lack of familiarity with the courtroom onset of psychotic symptoms at approximately environment which age? c. Going to “court school” a. Before age 16 d. Rapid changes in development b. By age 8 44. The major stressor for children who testify in c. Between 4 and 10 trials of accused abusers is: d. Before age 12 Questions 245

50. Childhood-Onset Schizophrenia is considered: 56. The community mental health case manager in child and adolescent psychiatric nursing may be a. The same disorder as adult Schizophrenia called upon to coordinate care for the schizo- b. A different disorder from adult phrenic child. This may include arranging for Schizophrenia hospitalization if indicated, involving the families c. A Pervasive Developmental Disorder with NAMI, referring to a child study team, and: d. Related primarily to poor prenatal nutrition a. Providing direct services 51. Differential diagnosis of Childhood-Onset Schizo- b. Prescribing medication to a stressed parent phrenia needs to take into consideration that c. Arranging for respite care symptoms may yield the possibility of neurolog- d. Providing inpatient services ical disorders, affective disorders, and: 57. Four-year-old Nicholas screams when he is held, a. Trauma-related symptoms does not go to a caretaker when hurt, plays in b. Reactive Attachment D isolation with the same object for long periods c. Developmental Learning Disorder of time, has numerous rituals, and cannot tol- d. Anxiety Disorder NOS erate the sound of computer keys clicking. A 52. Brain scans of children with Childhood-Onset possible diagnosis to screen for would be: Schizophrenia show: a. Attention Deficit Hyperactivity Disorder a. Left posterior parietal hypometabolism b. Oppositional Defiant Disorder b. Right posterior parietal hypometabolism c. Reactive Attachment Disorder c. Left anterior temporal hypermetabolism d. Pervasive Developmental Disorder d. Right anterior temporal hypermetabolism 58. Andy, age 2, had a history of normal develop- 53. Children with Schizophrenia show loose associa- ment for the first 6 months of life as well as tions and illogical thinking. This type of thought apparently normal prenatal and perinatal devel- disturbance is: opment. After 6 months, his head growth slowed down, he began to wring his hands constantly, a. Typically seen in normal children between showed a decline in social engagement, had a ages 5–11 poorly coordinated gait, and showed impaired b. Unusual before 6 years of age in normal expressive language and psychomotor retarda- subjects tion. The most likely diagnosis would be: c. Not typically seen in normal children after 7 years of age a. Mild Mental Retardation d. Not responsive to medication management b. Childhood Disintegrative Disorder c. Rett’s Disorder 54. Treatment of childhood Schizophrenia involves d. Autistic Disorder the use of medications that are similar to adult medication. Care should be exercised in the use 59. Adult personality disorders may be presaged of which medications that may cause psychotic by which of the following child and adolescent symptoms? disorders? a. Minor tranquilizers a. Reactive Attachment Disorder b. SSRIs b. Dysthymia c. Stimulants c. School Phobia d. Antiparasitical agents d. Oppositional Defiant Disorder 55. An appropriate intervention for the schizo- 60. Which of the following of the personality dis- phrenic child on an inpatient unit would be: orders may be diagnosed in older children or adolescents? a. Tailoring rules and expectations to his or her level of functioning a. Narcissistic b. Using isolation to protect the other children b. Borderline from anxiety about the schizophrenic child’s c. Schizotypal odd behavior d. Phobic c. Facilitation of age-appropriate skills through 61. Depression is unusual up until the age of: having the same rules for everyone d. Having high expectations to promote devel- a. 10 opment of skills b. 13 246 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

c. 7 c. The same as adults d. 9 d. Higher than adults 62. Change in weight or appetite disturbance are 69. Bipolar youngsters are often a diagnostic chal- vegetative signs of depression. This criterion is lenge. Children less than 9 years old who are modified in children to include failure to achieve manic are usually: expected gain or: a. Extremely aggressive a. Greater than 5% loss of body weight in 1 b. Difficult to soothe month c. Good team players b. Greater than 10% loss of body weight in 1 d. Irritable with emotional lability month 70. Which of the following conditions may present c. Loss of 5 pounds in 3 months in a similar way to bipolar illness in children? d. Weight gain of 5% in 6 weeks a. Neurological conditions, such as head trauma 63. Depression in children is comorbid with many b. Munchausen’s Syndrome by Proxy other disorders, including: c. Chromosomal abnormalities a. Childhood-Onset Schizophrenia d. Hepatitis b. Childhood Disintegrative Disorder 71. The age of onset for anorectic youngsters is most c. Anxiety disorders commonly at: d. Rumination Disorder of Infancy a. 10–14 64. The risk of a child having a mood disorder b. 12–18 increases with which of the following? c. 14–19 a. Family chemical dependency d. 9–12 b. Divorce of the child’s parents 72. What is important for the nurse to keep in mind c. Change in schools when evaluating a child who has lost weight due d. Obesity to anorexia? 65. Suicide among adolescents increases markedly at a. The same percentage of body weight lost which age range? applies to children and adults. a. 15–17 b. Three-percent weight loss in children is diag- b. 13–14 nostically certain for anorexia. c. 15–24 c. Anorectic children do not lose weight if d. 17–20 attention is not focused on them. d. Children do not have to lose the percentage 66. The highest suicide rates occur in: of weight applicable for an adult with an a. Black males eating disorder. b. Black females 73. Stephen, age 7, throws up his breakfast every c. White males morning before school. The least likely disorder d. White females is: 67. Two youngsters in a small school successfully a. Separation Anxiety Disorder complete suicide. The psychiatric and mental b. School Phobia health advanced practice nurse is invited to do c. Bulimia Nervosa a crisis debriefing for the school personnel. It is d. Anxiety disorder not otherwise specified important to help the staff to avoid simplistic explanations for the suicide and: 74. Which of the following is essential to include in developing a plan of care for an adolescent with a. Avoid graphic descriptions of the suicides an eating disorder? b. Glorify the deceased c. Focus on the deceased’s nonsuicide a. Art therapy to uncover childhood trauma characteristics b. Music therapy d. Pretend as if nothing had happened c. Psychodynamic approaches to ascertain the underlying motivations for difficulties with 68. Bipolar children and adolescents usually require food dosing that is: d. Family therapy to modify dysfunctional pat- a. Lower than adults terns that maintain the disorder b. Divided in smaller doses Questions 247

75. The peak age of onset of Panic Disorder is: a. Smiling at him because it is important to help him feel welcome a. 10–12 b. Ignoring the behavior b. 15–19 c. Saying “Josh, remember the unit rules we c. 14–16 reviewed earlier today? No running and no d. 10–15 crossing the line. The rules are posted in the 76. Play therapy in which the child tells a story and a dining room if you aren’t sure.” therapist also tells a story in reciprocal fashion is d. “Stop running. If you do that again, you’ll a technique that enables a child to express his or have to go to time out in your room.” her: 82. Which of the following is NOT a medication con- a. Ways of behaving sideration for children? b. Cultural norms a. Children differ in response to a medication’s c. Unconscious feelings main and side effects. d. Autonomy b. When medicating children, start slow, titrate 77. Marcie is a 9-year-old girl with severe Attention carefully, use the lowest effective dose. Deficit Hyperactivity Disorder. Her parents have c. Children may metabolize and eliminate med- developed a chart that tracks Marcie’s ability to ications more rapidly. manage and succeed at her various responsibili- d. Antihistamines are safe over the counter ties and activities. This technique is part of which medications which have no effect on psycho- type of therapy used with children? tropic medications. a. Cognitive therapy 83. Kevin is a 12-year-old boy recently diagnosed b. Family therapy with Bipolar Disorder. In planning medica- c. Behavior therapy tion management for Kevin, it is important to d. Solution-focused therapy remember: 78. Which of the following is a strong predictor of a. Children, adolescents, and adults require the positive outcomes for a child who has a DSM IV same dosing range. diagnosis? b. Lithium is hepatotoxic to children. c. Lithium is cleared rapidly by children, so they a. Intellectual abilities may need higher doses to stabilize a mood b. Positive peer relationships disorder. c. Parental involvement in therapy d. Lithium is only used for augmentation in d. Absence of chemical dependency issues in children. family of origin 84. The psychiatric and mental health advanced 79. Many children and adolescent inpatient settings practice nurse is discussing medication man- are based on which of the following models: agement with a 16-year-old adolescent. It is a. Family systems model important to remember that adolescents are b. Community mental health model often resistant to complying with medication c. Medical model due to: d. Strategic and solution-focused model a. Resistance to perceived control by authority 80. “Time out” is a way for a child to reflect upon b. The success of anti-drug education his or her behavior and regain control. Time in c. Side effects “time out” is generally determined by which of d. A resurgence of interest in “natural the following? medicines” a. Two minutes for each day on the unit 85. Adolescents may abuse medications by giving or b. One minute for each year of development selling them to their friends. Which medications c. Level of care are likely to be abused this way? d. Staffing adequacy a. Major tranquilizers 81. Joshua, a new boy on the unit, runs up to the b. Anti-anxiety agents nurses’ station and crosses over a line meant c. MAO inhibitors to keep the children at some distance from the d. SSRIs staff. This is the first time you have seen him 86. Skills training as a therapeutic intervention has do this. Which would be the most appropriate as its goal: response? 248 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

a. Career preparation 92. Conditions to be ruled out in establishing a diag- b. Arts and crafts therapy nosis of Attention Deficit Hyperactivity Disorder c. Competence in mastering developmental would include: tasks a. Seizures or sequelae of head trauma d. Activities of daily living training b. Posttraumatic stress disorder 87. Which of the following interventions encourages c. Hypersomnia the child to express feelings or reenact loss or d. Selective mutism trauma? 93. Which of the following is contraindicated for the a. Structured play treatment of Attention Deficit Disorder if there is b. Supportive therapy a coexisting seizure disorder? c. Behavioral play a. Tricyclic antidepressants d. Mutual story telling b. SSRIs 88. The child psychiatric nurse clinical specialist pro- c. Mirtazapine vides a sand tray with small figures and objects d. Bupropion to encourage a child to tell a story by setting up 94. Benzodiazepines may be used on a short term a scene. This is known as: basis for children with anxiety disorders. A side a. Structured play therapy effect of clonazepam is: b. Nondirective play therapy a. Behavior inhibition and shyness c. Solution-focused play therapy b. Behavior disinhibition d. Stress management c. Cardiotoxicity 89. One of the most serious outcomes of substance- d. Excessive clinginess abuse disorders (SUD) among adolescents is 95. Which of the following is NOT true of adoles- which of the following? cents with an eating disorder? a. Lack of social mobility a. The adolescent is a high risk patient. b. Interruption of developmental tasks b. Adolescents with eating disorders tend to be c. Poor social skills training extremely secretive about their illness. d. Conflict with parents c. The mortality rate is 10 to 15%. 90. Adolescent substance abuse would be more d. They are extremely compliant with likely in which of the following families? treatment. a. Rural farming family 96. The latest consensus regarding selective mutism b. Emotionally detached parents with lack of is that: involvement in youth’s life a. It is a form of social phobia c. Dual career parents b. Medicine is ineffective in the treatment of d. Parents who are not involved with commu- this condition nity issues c. These patients have highly controlling 91. Seven-year-old Danielle was sexually assaulted parents by the babysitter’s adolescent son. She has no d. Most of these children have associated memory of the event, and has been diagnosed hearing problems as having traumatic amnesia. Which of the fol- 97. Which ADHD medication is NOT a controlled lowing is a probable outcome of the experience substance? of amnesia? a. Methylphenidate a. Traumatic amnesia interferes with the pro- b. Amphetamine cessing of the event and placing it in past c. Atomoxetine memory. d. All are controlled substances b. The child is protected from the effects of the abuse. c. She will likely recall the event when she is ready. d. She will recall the event in traumatic dreams. Bibliography 249

Answers American Academy of Child & Adolescent Psychiatry (AACAP). (2007c). Practice parameter for the assess- 1. b 34. d 67. a ment & treatment of children & adolescents with de- 2. c 35. d 68. d pressive disorder. Journal of the American Academy of 3. d 36. d 69. d Child & Adolescent Psychiatry, 46(11), 1503–1526. American Academy of Child & Adolescent Psychiatry 4. d 37. d 70. a (AACAP). (2007d). Practice parameter for the assess- 5. d 38. a 71. b ment & treatment of children & adolescents with bi- 6. b 39. b 72. d polar disorder. Journal of the American Academy of 7. c 40. d 73. c Child & Adolescent Psychiatry, 46(1), 107–125. 8. d 41. d 74. d American Academy of Child & Adolescent Psychiatry 9. a 42. b 75. b (AACAP). (2007e). Practice parameter for the assess- 10. a 43. b 76. c ment & treatment of children & adolescents with 11. d 44. c 77. c anxiety disorders. Journal of the American Academy 12. a 45. d 78. c of Child & Adolescent Psychiatry, 46(2), 267–283. American Academy of Child & Adolescent Psychiatry 13. c 46. b 79. a (AACAP). (2005). Practice parameter for the assess- 14. c 47. b 80. b ment & treatment of children & adolescents with 15. b 48. a 81. c reactive attachment disorder of infancy & early child- 16. a 49. d 82. d hood. Journal of the American Academy of Child & 17. c 50. a 83. c Adolescent Psychiatry, 44(11), 1206–1219. 18. d 51. a 84. a American Nurses Association, American Psychiatric 19. c 52. b 85. b Nurses Association, & International Society of Psy- 20. a 53. c 86. c chiatric-Mental Health Nurses. (2007). Psychiatric- mental health nursing: Scope and standards of prac- 21. c 54. c 87. d tice. Silver Springs, MD: Author. 22. b 55. a 88. a American Professional Society on the Abuse of Chil- 23. d 56. c 89. b dren. (1997). Guidelines for psychosocial evaluation 24. b 57. d 90. b of suspected sexual abuse in children. Chicago, IL: 25. a 58. c 91. a APSAC. 26. c 59. d 92. a American Psychiatric Association. (2000). Diagnostic 27. d 60. b 93. d and statistical manual of mental disorders (4th ed., 28. c 61. d 94. a text revision). Washington, DC: Author. 29. d 62. a 95. d Antai-Otong, D. (Ed.). (1995). Psychiatric nursing: Bio- logical and behavioral concepts. Philadelphia, PA: 30. c 63. c 96. a W. B. Saunders. 31. a 64. a 97. c Assessment and treatment of children and adolescents 32. a 65. b with anxiety disorders. (1997b). Journal of the Ameri- 33. c 66. c can Academy of Child & Adolescent Psychiatry, 36(10), Supplement, 69s–84s. Assessment and treatment of children, adolescents, and Bibliography adults with attention-deficit/hyperactivity disorder. (1997c). Journal of the American Academy of Child & American Academy of Child & Adolescent Psychiatry Adolescent Psychiatry, 36(10), Supplement, 85s–121s. (AACAP). (2007a). Practice parameter for the assess- Assessment and treatment of children and adolescents ment & treatment of children & adolescents with with bipolar disorder. (1997d). Journal of the Ameri- attention-deficit/hyperactivity disorder. Journal of can Academy of Child & Adolescent Psychiatry, 36(10), the American Academy of Child & Adolescent Psychia- Supplement, 157s–176s. try, 46(7), 894–921. Assessment and treatment of children and adolescents American Academy of Child & Adolescent Psychiatry with conduct disorder. (1997e). Journal of the Ameri- (AACAP). (2007b). Practice parameter for the assess- can Academy of Child & Adolescent Psychiatry, 36(10), ment & treatment of children & adolescents with Supplement, 122s–139s. oppositional defiant disorder. Journal of the Ameri- Assessment and treatment of children and adolescents can Academy of Child & Adolescent Psychiatry, 46(1), with schizophrenia. (1997f). Journal of the American 126–141. Academy of Child & Adolescent Psychiatry, 36(10), Supplement, 177s–193s. 250 Chapter 10 Behavioral and Emotional Disorders of Childhood and Adolescence

Assessment and treatment of children and adolescents Federal Interagency Forum on Child and Family Sta- with substance use disorders. (1997g). Journal of the tistics. (2009). America’s children: Key national in- American Academy of Child & Adolescent Psychiatry, dicators of well-being, 2009. Washington, DC: US 36(10), 140s–156s. Government Printing Office. Bernstein, G. A., Borchardt, C. M., & Perwein, A. (1996). Feller, J. (1992). Working with the courts in child pro- Anxiety disorders in children and adolescents: A re- tection. Washington, DC: National Center on Child view of the past 10 years. Journal of the American Abuse and Neglect. Academy of Child & Adolescent Psychiatry, 35(9), Friedrich, W. Berliner, L., Butler, J., Cohen, J., Damon, L., 1110–1119. & Shafram, C. (1996). Child sexual behavior: An up- Biederman, J., Faraone, S. V., Milberger, S., Jettonl, date with the CSBI-3. The APSAC Advisor, 9(4), 13–14. J. G., Chen, L., Mick, E., Greene, R. W., & Russell, R. L. Gaudin, J. 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11 The Larger Mental Health Environment

Mental HealthCare a. Deinstitutionalization, which began in the Delivery System 1970s, has reduced the census of the public mental hospitals established by state • The number and variety of psychiatric-mental governments. health delivery care settings have both greatly in- b. Over the last 40 years, public mental hos- creased since the 1970s. pital census has declined, while the number of admissions has risen. • In the United States, the major focus has been in c. Public mental hospitals have seen an in- treatment of mental disorders, not the prevention crease in admission rates of younger, vio- of mental disorders. lent patients. d. The goals of deinstitutionalization are: • Types of settings (1) To save clients from debilitating ef- 1. Acute care inpatient settings, either psychiat- fects of lengthy, restrictive periods of ric units in general hospitals or in psychiatric hospitalization. hospitals (2) To return the client to home and a. Often psychiatric units specialize in community as soon as possible after adults, children, adolescents, alcohol, sub- hospitalization. stance abuse or geriatrics. (3) To maintain the client in the commu- b. In recent years, changing reimbursement nity for as long as possible. of inpatient stays has resulted in shorter e. In general, the public mental hospital pa- psychiatric lengths of stays. tient population decreased by returning c. From this decline in hospitalization days, the patients to their families, transferring many psychiatric units offer an array of them to nursing homes, and by shifting services including partial hospitalization, them into the community, where unfor- outpatient, and home care. tunately some became homeless street d. Today, most patients that are admitted people because community support did to the hospital are in crisis with the treat- not work. ment goal of stabilization. 3. Ambulatory settings e. Inpatient treatment is focused on pre- a. Community Mental Health Centers venting harm to oneself or others and the (CMHC) need for multidisciplinary assessment and (1) The CMHC Act passed by Congress in stabilization. 1963 supported mental health centers 2. Public mental hospital settings and deinstitutionalization in all 50 states.

253 254 Chapter 11 The Larger Mental Health Environment

(2) This legislation represented a shift face-to-face evaluations of patients 24 from the focus of the mentally ill in hours a day. public mental hospitals to flexible, (a) Most of these programs are com- community care. munity-based with some operat- (3) A principle in the development of ing in conjunction with a general CMHC was that people with mental hospital emergency department. illness have a right to treatment in the (b) Emergency services were origi- least restrictive environment. nally targeted for suicide preven- (4) In 1965, the five essential services for tion and outpatient treatment of a federally funded CMHC were in- acute psychosis. patient services, outpatient services, (c) Crisis programs provide care partial hospitalization, and consulta- for the acutely decompensated tion and education. chronically mentally ill patient (5) The legislation provided federal fund- living in the community ing to local communities for construc- (11) Psychiatric emergency services have tion and staffing of CMHC, with the continued to evolve in the community understanding that funding would over the last 20 years as most urban eventually shift to state and local settings have centralized emergency resources. services in one or a few sites. (6) In 1975, seven other essential ser- (a) Many rural areas are coordinating vices were added including children’s networks of emergency services at services, geriatric services, aftercare, a limited number of sites, usually state hospital prescreening, drug in a general hospital. abuse treatment, alcohol abuse treat- (b) Many emergency services have ment, and transitional housing. expanded roles so that patients (7) After deinstitutionalization, the pa- can stay for several days. tients were discharged from public (c) Some programs offer community mental health hospitals to a CMHC outreach programs whereby staff system so that the CMHC staff could go into the community to work provide adequate follow-up. with patients. (8) CMHC experienced the following (d) Many emergency services start problems working with discharged long-term medication regimes public mental health hospital such as antidepressants. patients: (12) The current state of mobile crisis ser- (a) Many discharged patients found it vices by a 50-state survey: difficult to adjust to independent (a) By 1995, 73% of the states had community living because pa- mobile emergency services and tients needed a slow, gradual in- provided services in private troduction to independent living. homes, hospital emergency (b) Patients had difficulty keeping ap- rooms, residential programs, shel- pointments and complying with ters, correctional facilities, bus medication schedules. and train stations, and general (c) Many patients became involved in hospital medical units. a revolving door syndrome or had (b) Mobile crisis units were reported many, short hospital admissions. to provide for patients and (d) Some discharged patients did families: earlier interventions, not receive the anticipated ser- improved access to care, support vices due to homelessness or for families, minimizing patient’s incarceration. trauma (Geller et al, 1995). (9) CMHC are successful in working (c) A 2009 Agency for Healthcare with chronic patients by using crisis Research & Quality (AHRQ) intervention, extensive community report described reduced in- outreach programs, supportive living patient hospitalization, shorter arrangements, and work programs. stays if hospitalized, and a sig- (10) Psychiatric emergency crisis/walk-in nificant reduction in healthcare programs are centralized community costs for children in crisis who mental health programs that offer were managed by a mobile Mental Healthcare Delivery System 255

multidisciplinary crisis team in groups over the continuum of care, from Milwaukee, WI—report available an inpatient setting to community-based at: http://www.innovations.ahrq. care such as an outpatient clinic or home. gov/content.aspx?id=1719 c. Case management, a standard of PMH 4. Day treatment programs and partial hospi- nursing care (ANA, APNA, ISPN, 2007), is talization programs (PHP) are ambulatory a clinical system that focuses on the ac- treatment programs that include the major, countability of an identified individual or diagnostic, medical, psychiatric, and prevo- group by: cational treatment modalities designed for (1) Coordinating patient or group patient patients with serious mental disorders who care across an illness episode or con- require coordinated, intensive, and multidis- tinuum of care (for example, clinic to ciplinary treatment not provided in the usual hospital to home) outpatient setting. The length of these pro- (2) Ensuring and facilitating achievement grams varies from 4-to-8 hours per day and of quality and clinical cost outcomes from 1-to-5 days a week, and programming (3) Negotiating, obtaining, and coordi- can occur at nearly any time of the day (day- nating services and resources needed time, evening, or night) (Keltner, Schwecke, by patients/families & Bostrom, 2007; Rosie, Azim, Piper, & Joyce, (4) Intervening at key points for individ- 1995). ual patients (for example, using criti- a. The four functions of partial hospitaliza- cal pathways) tion include: (5) Addressing and resolving patient pat- (1) Treatment of acutely ill patients who terns that cause poor quality-cost out- would be inpatients comes within collaborative teams (2) Rehabilitation of patients who are in (6) Creating opportunities and systems transition from acute inpatient to out- of health care to enhance patient patient care outcomes (Easterling, Avie, Wesley & (3) Intensive treatment of patients who Chimner, 1995) do not require inpatient care but who d. Community mental health nurses assist may benefit from more intensive care patients with a range of psychological than it is possible to provide on an problems and are concerned with the pa- outpatient basis tient’s stress, coping and adaptation. (4) Long-term maintenance of chronic e. Community mental health nurses assist psychiatric patients individuals and families to anticipate the b. For maximum treatment effectiveness, course of events in the mental healthcare partial hospitals should match the func- system. tional level of patients with treatment f. Psychiatric mental health nursing in home intensity. health (a) An intensive group-oriented (1) In recent years, there has been an in- psychotherapy program may creased need for psychiatric nurses in lead to deterioration of acutely ill the home. patients. (2) A criterion for providing home health (b) If low functioning patients are is usually that the patients are home- treated with patients needing bound or their illnesses result in them intensive group-oriented psycho- not being able to leave their home. therapy, the intensity of the pro- (3) Three groups of common homebound gram may be diluted. patients include: 5. Other community settings (a) People living alone especially the a. There are many psychiatric nurse roles, elderly including case managers, psychiatric (b) People with medical illnesses, es- home health nurses, psychiatric commu- pecially chronic illnesses nity outreach nurses, psychiatric nurses (c) Chronically mentally ill people who practice in vocational and rehabilita- (4) The psychiatric nurse may provide: tion centers, and psychiatric nurses who (a) Direct caregiving, such as as- work in a variety of collaborative practice sisting a depressed patient to settings. perform his/her activities of daily b. A psychiatric nurse who is a case man- living ager can work with patients, families, and 256 Chapter 11 The Larger Mental Health Environment

(b) Counseling, such as assisting a c. Nurses can practice alone or with other depressed patient to modify nega- healthcare professionals. tive thinking d. Nurses’ private practice can include a vari- (c) Education, such as teaching a ety of functions, including individual and depressed patient about his/her family assessment; individual, group, and antidepressant medication side family psychotherapy; and prescriptive effects authority for psychotropic medication, de- (d) Referral, such as scheduling an pending applicable restrictions of practice appointment when the patient as defined by the state nursing practice needs medication adjustment act, as well as rules for reimbursement. (e) Health promotion for patients e. In general, barriers to Certified Psychiatric and family, such as guiding the Clinical Nurse Specialists include difficulty families in preparing balanced in obtaining third-party reimbursement, nutritional meals limited autonomy in organized practice (5) A community mental health nurse settings, and low salaries (Merwin, Fox & who provides psychotherapy for in- Bell, 1996; Puskar & Bernardo, 2002). dividuals, families, or groups should f. The following are important consider- possess a graduate degree and be na- ations in working in private practice. The tionally certified. private practitioner: 6. Outpatient & private practice (1) Has the client as the primary a. Since the 1960s, psychiatric nurses have obligation. engaged in private practice, especially (2) Determines who the client will be. clinical specialists who hold national (3) Determines the techniques to be used certification, e.g., American Nurses Cre- in service to this client. dentialing Center (ANCC) Certification in (4) Determines practice professionally, Advanced Practice (Peplau, 1990). not bureaucratically. (1) ANCC certification exams for psy- (5) Receives a payment directly from or chiatric nursing include specialty on behalf of the client. certification in psychiatric and (6) Is educated in a graduate program. mental health (PMH) nursing for (7) Is sufficiently experienced as an ad- RNs, and several advanced practice vanced practice nurse. certifications: (8) Adheres to advanced practice nursing (a) Adult PMH clinical nurse values, standards, and ethics and is specialist professionally responsible. (b) Child/Adolescent PMH clinical (9) Is licensed and certified where appli- nurse specialist cable to engage in private practice. (c) Adult PMH nurse practitioner g. Disadvantages of private practice include: (d) Family PMH nurse practitioner (1) Economic uncertainties and possible (2) Building concerns about the potential financial difficulties fragmentation of advanced practice (2) Professional isolation, loneliness, and PMH nursing suggested by multiple lack of advancement certification titles prompted an analy- (3) Malpractice suits sis of the job skills associated with the (4) Total responsibility for professional various areas of advanced practice accountability and professional PMH nursing. competence b. Findings from a collaborative study in- h. Guidelines for establishing a viable private volving the ANCC and American Psychi- practice atric Nurses Association (APNA) found (1) Evaluate whether solo or group prac- artificial divisions and considerable over- tice is desirable. lap among the advanced practice roles (of (2) Create a financial management the 335 PMH advanced practice tasks, 332 system. were deemed essential for both CNS & NP (3) Obtain malpractice and office liability practitioners) (Rice, Moller, DePascale, insurance. & Skinner, 2007). The findings prompted (4) Establish criteria for hiring employees recommendation for development of one and using consultants. exam for advance practice nurses certify- (5) Ensure that private practice is geo- ing as PMH CNS or NP. graphically accessible. Types of Healthcare Insurance Plans 257

(6) Implement successful marketing • Organizational changes needed in managed care strategies, including specialization include: and courteous attention to referrals. 1. Promotion of team-based care or creating a seamless organization Managed Care—An Internal 2. Aggressive promotion of self-care Force of Change Within the 3. Case management for high-cost, high-use Mental Health Delivery members System 4. Continuous improvement emphasis

• Managed care is a healthcare strategy designed to • Impact of managed care on hospital nurses (Buer- achieve the positive outcomes that can result from haus, 1994) adopting price competition while controlling for 1. Decreasing patient length of stay, which results unfavorable effects. in more staff layoffs, buyouts, retirement, and termination • For competitive low prices, there must be a variety 2. Downsizing of hospitals including contracting of healthcare providers such as hospitals, physi- (outsourcing) some services cians, and Health Maintenance Organizations 3. Tracking specific patient hospital and nursing (HMOs). costs, resulting in more administrative tasks 4. Substituting of lower skill workers for higher • For competitive low prices, healthcare providers skill workers to lower labor costs must keep their costs low by, for example, using cost containment strategies. • Ethical dilemmas in managed care 1. Early patient discharge because of financial • Along with low prices, healthcare providers must incentives provide a quality service. 2. Providers limiting and denying patient treatments and options because of financial incen- • Healthcare changes as the result of managed care tives, which may result in denial of care in the following ways: 3. Providers monitoring and controlling patient 1. Change of provider incentives, change from treatments and resources fee-for-service reimbursement to capitation (See changes resulting with Mental Health & • Impact of managed care on advanced practice Addiction Equity Act of 2008—capitation is nurses (Buerhaus, 1994) prohibited with this law) 1. Substituting advanced practice nurses for a. Fee-for-service reimbursement is the tra- physicians ditional method of paying healthcare pro- 2. Professional conflicts among different provid- viders, where providers determine what ers who provide similar services healthcare services the patient needs, and 3. Increasing responsibility of advanced practice the insurer passively pays for each service nurses to lower costs and monitor patients’ received by the patient according to the source consumption reasonable charge in a given geographical area. Reimbursement for Mental b. Capitation is a preset amount of money Health Services allocated to provide set services for a population over a stated period of time, • Sources of reimbursement include: regardless of service used. Typically, an 1. Government payers—Medicaid & Medicare employer or third-party payor will con- 2. Private insurers—HMOs and other private in- tract with a behavioral managed care demnity organizations company or a provider organization to 3. Private pay—patients paying their own bills provide comprehensive mental health “out of pocket” care for a lump sum payment. The man- 4. Contracts—with business, other agencies, etc. aged care company and/or the provider (Buppert, 2008) organization then decides what care the patient needs. In capitation, the managed Types of HealthCare care company and/or the provider organi- Insurance Plans zation incurs more risk if healthcare costs for a group of people exceed the capitated • Health Maintenance Organizations (HMOs) are payment. organizations that receive money from consumers 258 Chapter 11 The Larger Mental Health Environment

in exchange for a promise to provide all health care (c) Nursing roles with other health- required during a defined period of time. Consum- care disciplines ers have restricted choice of healthcare providers, 2. Power no cost for services beyond insurance payment, a. Definition—the potential of an individual restricted choice to hospitals, reduced cost to em- or a group to influence the behavior of ployers who buy the insurance (Cleverley, 1997). another b. Types of power (Marquis & Huston, 1994) • Preferred Provider Organizations (PPO) are pro- (1) Legitimate power—power gained by a grams that contract with healthcare providers to title or official position provide healthcare services to consumers, usu- (2) Expert power—power gained through ally at a discounted rate. Consumers have some knowledge and expertise restricted choice by using contracted healthcare (3) Reward power—power obtained by providers, copay for services, access to contracted the ability to grant favors or to reward hospitals, some reduced cost to employers who others with what they value buy the insurance (Cleverley, 1997). (4) Coercive power—power obtained on fear of punishment • Traditional fee-for-service insurance plan— (5) Referent power—power obtained by Consumers have freedom of choice of healthcare an individual because of an associa- providers, usually pay a deductible and 20% of tion with others outpatient charges, unlimited access to choice of c. Strategies for acquiring and using power hospitals. Employers usually pay a higher cost but in communities and organizations (Mar- employees have freedom of choice. quis & Huston, 1994) (1) Present a powerful image and assume • Combinations and variations of HMOs, PPOs and authority in your interactions. traditional fee-for-service types can be available. (2) Learn to speak the community’s or organization’s language. External Forces Interacting (3) Acquaint yourself with who is power- with the Mental Health System ful and network. (4) Seek experts’ advice and build a • Social issues knowledge base. 1. Role behavior (5) Increase visibility and use the politi- a. Stereotyping behavior is useful in examin- cians’ priorities to speak your needs. ing roles such as men and women, nurse (6) Empower others by sharing knowl- and physician, and female patient and edge and increasing team building. male therapist, male patient and female therapist. • Political issues b. In general, there are distinct beliefs about 1. Current healthcare legislative issues include the characteristics of men and women, concerns about: including: a. Healthcare coverage for the uninsured and (1) Male characteristics reflect competen- other vulnerable populations such as chil- cies such as competitiveness, inde- dren, women, and the chronically ill pendence, and objectivity. b. Developing and implementing a national (2) Females are perceived as being oppo- healthcare plan to assure adequate health site of these characteristics and there- care, including mental health care, for all fore dependent, noncompetitive, and citizens subjective. 2. The care of people with mental health disor- (3) Men are perceived as being blunt and ders is challenged by their vulnerability and unable to express feelings. lack of voice in the political process. (4) Women are seen as having tact, 3. Key past mental health legislation awareness of other’s feelings, and an a. In 1935, the Social Security Act influenced ability to express their feelings. mental health care because of the shift (5) These sex role stereotypes can impact from state to the federal government in many areas of a person’s life including: the care of ill people. (a) A person’s self-esteem and pre- b. In 1955, the Mental Health Study Act cre- scribed role in society ated the Joint Commission on Mental Ill- (b) The nurse-client therapeutic ness and Health that recommended shift relationship of patient populations from state hospital External Forces Interacting with the Mental Health System 259

systems to community mental health b. The use of seclusion and restraints should systems. occur only after all other therapeutic inter- c. In 1963, the Community Mental Health ventions have been exhausted. All patients Centers Act created community mental have the right to be free from any form of health centers and led to deinstitutional- restraint (physical or chemical) (2009 up- ization. Federal funds were to match state date of the CMS document retrieved from: funds in creating CMHC. http://www.cms.hhs.gov/manuals/ d. In 1975, the Developmental Disabilities Downloads/som107ap_a_hospitals.pdf). Act focused on the rights and treatment 5. National healthcare agenda, under the Public of people with developmental disabilities Health Service, Healthy People 2010 (US De- and provided a foundation for individuals partment and Health and Human Services, with mental disorders. 2000) creates a national focus on promoting e. In 1977, the President’s Commission on health and preventing disease. The following Mental Health supported community are areas related to mental health and mental mental health centers, protection of hu- disorders: man rights, and insurance for mentally ill a. Reduce suicide, especially among children people. and adolescents and in jails. f. In 1986, the Protection and Advocacy for b. Reduce mental disorders among children, Mentally Ill Individuals Act provided advo- adults, and elderly. cacy programs for mentally ill people. c. Among those with serious mental ill- g. In 1990, the Americans with Disabilities ness, reduce homelessness, increase Act promoted employment opportuni- employment. ties and prohibited discrimination for all d. Reduce relapse among those with eating people with disabilities including mental disorders. disorders. e. Increase the numbers receiving screening h. In 1998, the Mental Health Parity Act of for mental disorders when receiving care 1996 prohibited lifetime or annual limita- in primary healthcare setting. tions on mental health coverage for cer- f. Increase treatment for people with depres- tain insured employees. sive disorders, anxiety, schizophrenia, sub- g. In 2008, the Paul Wellstone & Pete Do- stance abuse and co-occurring substance menici Mental Health Parity & Addiction abuse and mental disorders. Equity Act of 2008 (P.L. 110-343) amended g. Increase access to care for people with the 1996 Mental Health Parity Act (to take personal and emotional problems. effect January 2010). The law does not h. Increase cultural competence of providers. require health insurance plans to provide i. Among recipients, increase satisfaction mental health and substance abuse ben- with mental healthcare services efits, but prohibits employer healthcare 6. Strategies for psychiatric-mental health nurses plans from imposing caps or limitations to serve as change agents for addressing men- on mental health treatment or substance- tal health issues include: use disorder benefits that aren’t applied to a. Write and verbalize concerns and solu- nonpsychiatric benefits (Retrieved from: tions to legislative bodies and the media. http://www.cms.hhs.gov/healthins b. Seek membership on community commit- reformforconsume/04_thementalhealth tees that recommend or formulate policy. parityact.asp) c. Be familiar with the legislative process, ob- 4. Use of seclusion/restraints—within the Patient taining copies of bills and making presen- Rights Document, the Centers for Medicare & tations at local, state, and federal hearings. Medicaid Services (CMS) has published strict rules for the use of seclusion and restraints. • Financial issues a. Seclusion and restraint are defined as 1. The United States finances health care by both follows: public and private monies. (1) Restraint—the physical control of a 2. With the passage of Medicare and Medicaid patient to prevent injury to patient, legislation in 1965, the federal government staff, and others embarked upon a significant subsidy to health (2) Seclusion—the involuntary con- care, greatly increasing access to care finement of a patient to a specially (McCloskey & Grace, 1994). designed room for their own safety 3. Expenditures for mental health treatment grew (O’Brien, Kennedy & Ballard, 2008) from $33 billion in 1986 to $100 billion in 2003 (Mark et al., 2007). 260 Chapter 11 The Larger Mental Health Environment

4. Since 1986, more mental health care is being insurer provider panels, requests provided in the outpatient setting with an infor the following information are creased use of psychotropics. usually included in the credential- 5. Reimbursement for advanced practice nursing ing application: a. With the Budget Reconciliation Act in 1997 i. Advance practice PMH (the legislation included the Primary Care nurse’s identifying informa- Health Practitioner Incentive Act), Con- tion (name, address, birth gress authorized direct Medicare reim- date, social security number, bursement for all advance practice nurses military service, etc.) (at 85% of physician fee rate), regardless of ii. Licensure information (RN, geographic practice area (Buppert, 2008; state advance practice autho- Frakes & Evans, 2006). rization, specialty area) b. Types of reimbursements (McCloskey & iii. National provider identifier Grace, 1994) (NPI) number (1) Fee-for-service reimbursement— iv. DEA license number (if pre- current trends throughout the country scriptive authority includes indicate that probably less than 20% controlled substances) of mental health care will be delivered v. Professional liability coverage through the traditional fee-for-service vi. National certification in area model. of specialty (2) Medicare reimburses health care for vii. Any professional sanctions the elderly and some disabilities by viii. Practice type and location this federal program. Hospitals are e. Billing for private practice (Billings, 1993) now reimbursed a flat amount based (1) Not all clients have or want to work (Diagnostic Related Group) upon with insurance; some will pay for ser- the patient’s medical diagnosis, age, vices themselves. surgical procedure, and comorbidity (2) Give new clients a handout so the fi- (existence of other medical condi- nancial arrangement will be clear. tions). Home care, including psychi- (3) Before the first visit, have the client atric home care, is reimbursed under check with their insurance to see what Medicare. services are covered or whether visit (3) Medicaid is a federally assisted and needs to be preauthorized. state-administered program for the (4) On the first visit, use an initial data indigent. form to obtain all necessary infor- c. Contract payment and services mation, such as date of birth, social (1) Nurses can develop contracts to pro- security number, and insurance vide specific services independently information. for patient subgroups being served by (5) If the client is filing for his/her own HMOs or other healthcare providers. reimbursement, provide the necessary (2) Many times, these providers are in- information. terested in the cost of the service and (6) If the client requests your assistance, who can legally and safely provide approach the insurer with the as- that service. sumption that you will be reimbursed. (3) Service contracting is a matter of de- (7) If need be, apply to become an autho- fining a required service for a group of rized provider. clients that is difficult to provide with (8) One way to increase referrals is to de- existing staff. velop a relationship with the referral (4) Reasons for promoting contractual li- source. aisons (Marshall, 1994) include: defin- f. Questions that assist in determining pri- ing a particular population, increasing vate practice charges include: profitability for selected healthcare (1) How much do other advanced prac- professionals, and lowering the cost tice nurses providing a similar service for third-party payers and facilities. in the area charge? d. Obtaining third-party reimbursement (2) How much do other similar helping (Buppert, 2008) professionals in the area charge? (a) When making an application (3) What is your level of experience and to managed care organization/ education? Leadership and Management 261

(4) What do third-party payers say are behavior; leaders explain deci- “reasonable and customary charges” sions and provide opportunity for for professionals in your area? clarification (5) What is the most attractive rate for the (3) Participating—for followers who are clientele that you hope to attract? more mature and need low task struc- g. Private practice in managed care (God- ture and high relationship behavior; schalx, 1996)—In fee-for-service reim- leaders share ideas and facilitate deci- bursement, the nurse must evaluate the sion making client to obtain a diagnosis and to match (4) Delegating—for followers who are the client to available services. Reimburse- mature and need low task structure ment is based upon the diagnosis. and low relationship behavior; leaders turn over responsibility for decisions Leadership and Management and implementation

• Leadership theory and roles • Management theory and roles—classical man- 1. Leadership is the process of influencing others agement theory describes the functions of man- toward goal setting. agement as planning, directing, organizing, and 2. Gardner identifies the tasks of leaders as: en- evaluating. visioning goals, affirming values, motivating, 1. Planning managing, achieving workable unity, explain- a. Using epidemiology for planning priorities ing, serving as a symbol, representing the (1) Epidemiology is the study of disease group, and renewing their energy (Swansburg, in human populations. 1996). (2) Epidemiologists are concerned with 3. Early leadership studies focused on identifying patterns of disease such as commu- leadership traits in individuals, such as intel- nicable, congenital, and chronic ill- ligence, personality, and abilities. nesses within a population. 4. Studies of leadership styles in the 1930s by (3) Epidemiology focuses on character- Lewin and colleagues examined the decision- izing health outcomes in terms of making styles of leaders: what, who, where, when, and why. For a. Autocratic—leaders make decisions alone. example, what is the disease? Who is b. Democratic—leaders involve followers in affected by the disease? When do dis- the decision making process. ease related events occur? Why did the c. Laissez-faire—leaders are permissive disease related events occur? and allow followers to have complete (4) Epidemiological research has shown autonomy. a positive relationship between physi- 5. Hersey and Blanchard’s Life-Cycle of Situ- cal and psychiatric disorders, and that ational Leadership (Swansburg, 1996) the strength of this relationship varies a. Assumes that the type of leadership de- among different populations. pends on the situation. (5) Epidemiological findings assist re- b. The three main factors to consider in the searchers and funding agencies to leadership process are: the leader, the situ- establish priorities to guide future ation, and level of maturity (readiness) of research. the followers. (6) Epidemiology has been useful in c. As a follower becomes more mature, the examining mental illness caused by follower needs less structure (task struc- poisoning, chemicals, drug usage, ture) and more focus on building relation- nutritional deficiencies, biological ships in the group (relationship behavior). agents, and electrolyte imbalances d. Leadership strategies vary depending on (Stuart & Sundeen, 1996). the follower and include: (7) The following epidemiological triangle (1) Telling—for followers who are im- is useful to explain the presence or mature and need high task structure absence of illness: and low relationship behavior; lead- (a) Host or population characteristics ers provide specific instructions and in the occurrence, nonoccur- closely supervise performance rence, or prognosis of an illness— (2) Selling—for followers who are a includes factors such as age, little less immature and need high gender, marital status, ethnicity, task structure and high relationship 262 Chapter 11 The Larger Mental Health Environment

race, religion, national origin, ge- (5) The systems model focuses on devel- netics, life-style behaviors oping a comprehensive system of care (b) Agent or cause—includes infec- and coordinating mental health ser- tious agents (bacteria, viruses, vices. Interventions include creating fungi, parasites), physical agents community support services, service (radiation, heat, cold, machinery), coordination, and case management or chemical agents (heavy metals, (Worley, 1996). toxic chemicals, pesticides) c. Planning community interventions (c) Environment or surround- (1) Primary prevention is an intervention ings—includes factors such as to reduce the incidence of disease by population density, education, promoting and preventing disease occupation, income, housing, processes. social support, rainfall, habitat, (2) Secondary prevention is an interven- levels of stress, satisfaction, noise, tion such as depression screening that resources, access to care, and detects disease in early stages. temperature. (3) Tertiary prevention is an intervention (8) The identification of risk factors is im- that attempts to reduce the severity of portant for planning for populations a clinically apparent disease. most likely to suffer illness or injury. d. Planning children’s health issues (a) Psychosocial risk factors include (1) Children compose one third of our developmental or situational population. events that occur at a certain time (2) Major health problems include inju- that can create a vulnerable point ries and acute illness. for an individual. An example is (3) Behavioral problems include eat- suicide. Adolescents have a high ing disorders, attentional problems, suicide rate. substance abuse, conduct disorders (b) Workers who lose their jobs are and delinquency, sleep disorders, and especially vulnerable to depres- school maladaptation. sion, illness, and family conflicts. (4) A child’s coping mechanisms are b. Incorporating community assessment into influenced by the individual develop- planning ment level, temperament, previous (1) Community needs assessment in- stress experiences, role models, and cludes assessing social indicators or support of parents and peers. examining community characteristics (5) Healthy People 2010 supports pro- such as income, race, population den- grams for decreasing smoking, re- sity, and crime. ducing gun violence, and promoting (2) More information on community playground safety. needs can be obtained from key in- e. Planning women’s health formants in the community or people (1) Programs need to focus on women’s who work in the community such as psychosocial and physiological well- clergy, social service, and healthcare being. providers. (2) Women are more likely to suffer from (3) Community forums can provide com- major depression and phobias (Jones munity members an opportunity to & Trabeaux, 1996). express their needs. Important in (a) Women have twice the rate of community assessment is viewing the depression than men have, even community as a partner so that inter- when income level, education, ventions can be community-focused. and occupation are controlled. (4) One community assessment wheel (b) Women 18–44 years old have the (Anderson & McFarlane, 1995) as- highest rates of depression. sesses the areas of physical envi- (c) Factors that contribute to depres- ronment, education, safety and sion in women include: unhappy transportation, health and social intimate relationships, history services, communication, econom- of sexual and physical abuse, ics, politics and government, and reproductive events, multiple recreation. roles, ethnic minority status, Leadership and Management 263

low self-esteem, poverty and (3) Operational planning is everyday unemployment. work management, develops shorter (3) Three major causes of mortality in term goals from both long-range and women are heart disease, cancer, and short-range plans. cerebrovascular disease. i. Steps in preparing a planning project pro- f. Planning men’s health posal, for example, starting an adolescent (1) Men are physiologically more vulner- therapy group for an outpatient practice able, evidenced by more male infant setting include: deaths and shorter predicted lifespan. (1) Describe the current business or the Many reasons account for this differ- current outpatient practice. ence including genetics, risk-taking (2) Analyze the strengths and weakness behaviors, and ignoring warning within the outpatient setting of start- signals. ing the proposed adolescent group. (2) Males have more significant death (3) Analyze the opportunities and threats rates in AIDS, suicides, homicides, outside of the setting of starting the and accidents. proposed adolescent group; for exam- (3) Male suicide rate is four times higher ple, are other outpatient settings also than females and the eighth leading conducting the same group? cause of death overall. (4) Describe the product or group ther- (a) Men are more likely to make a apy, including all staff, facility, and serious attempt to kill themselves financial resources. rather than use it as a cry for help. (5) Describe how the program will be (b) Suicide risk factors for men in- marketed. clude: over 65 years of age, un- (6) Describe how the program fits into the married, unemployed, previous organizational chart. attempt, positive family history, (7) Show a projected time line or the and suffering from terminal ill- steps and dates when the project or ness or other medical condition. group therapy will begin. (4) Alcohol disorders remain high for (8) Describe how much the program will men—chronic liver disease and cir- cost, and how much revenue the pro- rhosis are health diseases affecting gram will produce. men. 2. Directing (5) Men have a higher incidence of anti- a. Definition—coordinating or activating social behavior. work g. Planning for the homeless b. The manager directs work activities (1) Homelessness and criminalization such as issuing assignments, orders, and are concerns for many people with instructions that permit the worker to chronic mental illness. understand what is expected as well as (2) It is believed between 25–33% of the contribute to the attainment of organiza- homeless population is chronically tional goals. mentally ill. c. The manager needs to establish work (3) The new “revolving door” is not within guidelines, manage time efficiently, re- the state hospital but has been now solve conflict, facilitate collaboration, and described as inside the county jail, negotiate for needed resources. with the criminal justice system be- d. The manager needs to create a motivating described as the newest mental ing climate for staff by using motivation hospital. theories. h. Three types of planning (1) Reinforcement Theory—B. F. Skinner’s (1) Strategic planning is a continuous, Behavior Modification. To motivate systematic process of making risk- staff, managers need to: taking decisions today with the great- (a) Create a consistent, visible reward est possible knowledge of their impact system. on the future, usually done for the (b) Reward positive staff behav- next 5-year period. iors or the behaviors will be (2) Functional planning is a specialty ser- extinguished. vice planning, such as planning for a staff development department. 264 Chapter 11 The Larger Mental Health Environment

(2) Herzberg’s Two Factor Motivation (e) What is the power and work struc- Theory (Swansburg, 1996). Assump- ture of the parties? tions are: (f) How involved are third parties? (a) People want to work and do that (g) How do the parties perceive the work well. progress of the conflict? (b) Workers can be motivated by (4) Conflict resolution strategies work itself. (a) Avoidance or keeping the conflict (c) It is possible to separate personal quiet motivators from job dissatifiers. i. Ignoring the conflict—when (d) Job motivators (satisfiers) pres- issue is trivial or symptom- ent in work itself and encourage atic of a more basic issue workers to do the work well— ii. Imposing a solution—when include achievement, recognition, a quick decision is needed the work itself, responsibility, ad- or when an unpopular deci- vancement, possibility for growth, sion is going to be made and status, company policy. the group can not reach a (e) Maintenance factors (hygiene decision factors) keep workers from being (b) Defusion or cooling the emotions dissatisfied but do not motivate— of the parties involved include salary, supervision, job i. Smoothing—playing down its security, positive working condi- importance and magnitude, tions, personal life, interpersonal giving people time to cool relations/peers. down and gain perspective; e. The role of the manager in creating a mo- used when conflict is with tivating climate (Marquis & Huston, 1994) issues not related to work (1) Communicate clear expectations to ii. Appealing to superordinate staff. goals—when there are im- (2) Develop the idea of working as a team. portant goals that both par- (3) Request staff input for decisions that ties cannot meet without the affect staff. other’s help (4) Give positive reinforcement. (c) Containment allows some conflict (5) Be fair and consistent with all to come out into the open, but in employees. tightly controlled manner. (6) Allow employees to make as many au- i. Bargaining—when two par- tonomous decisions as possible. ties have relatively equal (7) Integrate the uniqueness of each in- power dividual into meeting organizational ii. Structuring the interaction— goals. when a third party is needed (8) Explain your own and organizational so that the conflict does not decisions to staff. escalate f. Resolving conflicts (d) Confrontation is openly discuss- (1) Conflicts are inevitable outcomes of ing all areas of conflict with the social interactions. end result of finding a solution to (2) Levels of conflict include: intra- conflict. personal, intragroup, intraterrito- i. Integrated problem solving— rial, interpersonal, intergroup, and when there is limited trust interterritorial. among parties and unlimited (3) Questions for diagnosing the conflict time to problem solve (Swansburg, 1996) ii. Redesigning the organi- (a) What is the issue in question? zation—when sources of (b) What is the magnitude of the conflict come from work stakes? processes and the work can (c) How interdependent are the be divided into more self- parties? contained work groups (d) Are the parties in a continuing 3. Organizing relationship? a. Open systems theory Leadership and Management 265

(1) An organization is greater than the have use over a year’s time, such sum of its parts. as hospital beds or desks. (2) Permeable boundaries exist between (2) Stages of the budget include: the organization and its environment. (a) Planning the budget, usually 6 (3) The input, throughput, and output months to a year processes are goal-oriented, focused (b) Reviewing and justifying the final on accomplishing organizational budget work. (c) Implementing the budget (4) The components of the throughput (d) Monitoring and reviewing the (work) process are the workers, the budget work itself, the formal support pro- d. Organizing nurse and client cesses, and the informal support empowerment processes. (1) Empowerment is a process that (5) The organization is dependent on the changes the distribution of power and environment for resources to do the enables others to recognize and use work and to accept its work. their talents and contributions so that (6) The organization is constantly they experience their own personal adapting. power. (7) Over time, the organization will be- (2) Nursing empowerment is creating an come larger and will become increas- empowering climate for nurses and ingly complex and specialized. staff (Gunden & Crissman, 1994). Em- b. Organizing patient care delivery powerment is created by: (1) Many nursing units organize patient (a) Fostering trust—manager needs care based on the existing delivery to demonstrate constancy, con- system or by the latest trend. gruity, reliability, and integrity. (2) Patient care delivery systems include (b) Feedback—manager needs to re- case management, primary nursing, ceive and give realistic feedback team nursing, functional nursing, and including fostering opportunities any variation of these. for staff to make decisions, and by (3) Factors to be considered in the deci- providing inspiration. sion of selecting the optimal patient (c) Communication—manager needs care delivery system include (Marquis to encourage openness in organi- & Huston, 1994): zational communication. (a) Quality of care and cost- (d) Goal setting—manager needs to effectiveness work with staff to set goals for (b) Patient and family satisfaction their work and for their profes- (c) Nursing and other discipline sional development. satisfaction (e) Positivity—manager needs to cre- (d) Consistency with organizational ate a positive climate so that the philosophy and goals staff can accomplish their goals. (e) The nature of work that needs to (3) Client empowerment creates an em- be accomplished powering climate for patients. c. Organizing the budget (a) Nurses should assist all vulner- (1) Managers are concerned with follow- able groups to achieve a greater ing types of budgets: sense of empowerment. (a) Personnel budgets reflecting the (b) Clients who are empowered have amount of money spent on staff- a greater sense of hope and are ing, including full-time personnel, more able to make autonomous part-time personnel, and person- decisions about health care that nel hired as needed. may increase their level of health. (b) Operating budgets reflect ex- (c) Nursing interventions for assist- penses that fluctuate up or down ing clients to feel more empow- when services are provided, such ered include: active listening, as electricity, supplies, rent, and letting clients know their rights, repairs. initially acting as an advocate for (c) Capital expenditure budgets re- them if needed, reassuring them flect large purchase items that that fears are normal, mutually 266 Chapter 11 The Larger Mental Health Environment

setting reasonable goals, helping x. Basing quality improvement them identify their strengths, be- of mental health services on ing culturally sensitive, and teach- outcome measures designed ing health promotion and disease by survivors and consumers prevention. 4. Evaluating (d) The empowerment model of a. Evaluation is the systematic attempt to as- recovery is a health promotion sess worth and value for decision-making model in which individuals de- purposes. fine their own needs and are ac- b. Program management and evaluation tive collaborators with a variety (1) For program improvement, use of people in their own healing formative evaluation or receive in- (Fisher, 1994). termittent feedback throughout the (e) The empowerment model of re- program’s performance. covery is based on experiences of (2) For program judgment at the end of consumers in recovery and on the program, use summative evaluation. independent living movement, c. Types of measurement in evaluation which is a grass-roots movement (1) Resources for program—structure of for social justice and civil rights people, equipment, and setting led by people with disabilities. (2) Judgments of process performance (f) Nurses can apply the principles (3) Concerns and issues of all stakehold- of the empowerment model of ers or those having an interest in the recovery by using the following program methods (Fisher, 1994): (4) Goals and objectives of program and i. Facilitating recovery through whether goals and objectives were education and instilling hope met ii. Developing alternatives to (5) Intended and unintended program hospitalization outcomes iii. Providing state funding for d. Methods of measurement. involuntary admissions un- (1) Empirical research designs with statis- der the public safety budget tical analysis rather than the healthcare (2) Questionnaires and surveys of stake- budget holders for attitudes, satisfaction, and iv. Maximizing consumer in- goal attainment volvement in all aspects (3) Comparison to other similar programs of treatment; establishing (4) Review of documents, policies, and self-help and consumer-run procedure manuals services (5) Cost analysis for effectiveness, ben- v. Ensuring that consumers are efits, feasibility genuinely and effectively in- (6) Interviews of individuals or focus volved in activities to protect groups human rights and improve (7) On-site observation of process and the quality of services structure vi. Favoring the role of personal e. Quality in health care care attendants rather than (1) Continuous quality improvement case managers (who are too (CQI) is a philosophy for evaluating controlling) and managing the quality of health- vii. Viewing the life experience of care services. recovery from a serious psy- (2) To successfully integrate a philosophy chiatric disability as an asset of quality into a mental health setting, in hiring, not a liability staff must understand the philosophy viii. Promoting consumer control and processes of improving quality and choice in housing and in a collaborative, multidisciplinary financial, educational, voca- setting. tional, and social services (3) Total Quality Management is a man- ix. Providing staff training based agement philosophy that incorporates on the needs of consumers the concept of continuous quality improvement by involving all levels Leadership and Management 267

of personnel within an organization g. Self-evaluation to actively participate in decision (1) Nurses should be continually involved making. in self-evaluation or identifying their (4) The definition of “quality” has broad- own strengths and weaknesses in a ened from a property of the product to professional role. Nurses are account- being defined by the customer, which able to the public and profession. focuses mental health care on the (2) Self-evaluation has been found to customer. be threatening if an employee must (5) Deming (1986) wrote that to increase discuss findings in a group of other quality, management should: employees. (a) Create an organizational culture (3) Advanced practice nurse self- that embraces opportunities to evaluates practice based on client improve services. outcomes (ANA, 1996). (b) Eliminate quotas, slogans, and h. Evaluation of care and legal issues (Fon- awarding contracts based on price taine & Fletcher, 1995; Stuart & Sundeen, alone. 1996) (c) Promote self-improvement of (1) Nurses’ ability to provide safe care is workers and management. enhanced by knowledge of the law, (6) To be effective over time, quality im- particularly legislative decisions af- provement involves: fecting the state’s nurse practice act, (a) Staff working together to improve ANA Code of Ethics for Nurses, and the work process. Employees can Standards of Psychiatric Practice. only be as productive as their (2) An important concept in psychiatric work process is organized. nursing is understanding the legal (b) All staff using a continuous, ratio- framework for the delivery of mental nal approach for problem solv- health care in the state in which the ing over time. It involves every nurse practices. employee on every level working (3) State law may also vary regarding ad- together. missions, discharges, patient rights, (c) Feedback mechanisms built into and informed consent. work processes so that work can (4) Types of admissions to psychiatric be monitored and improved. units When quality is improved, mis- (a) Voluntary admission—signed takes occur less often, resulting in standard admission form indicat- less cost. ing patient voluntarily seeks help. (d) A plan systematically attacking (b) Involuntary admission or com- problems identified by staff and mitment—patient did not request patients. hospitalization and admission f. Peer evaluation was initiated by hospital or court. (1) Peer evaluation has been shown to be (c) Emergency involuntary admission a valuable part of a total performance i. State laws differ as to pro- evaluation plan and can include mul- cedures for petitioning for tiple ratings of different peers. admission, psychiatric evalu- (2) Peer evaluation identifies strengths ation of the client, treatment and weaknesses of an employee, available, and length of de- identifies competency, increases self- tainment (usually 2–3 days). awareness, improves and evaluates ii. Clients are restricted from the enactment of professional roles. leaving and may be forced (3) The three phases of peer review to take psychotropic (a) Employees become familiar with medication. peer review. iii. Clients’ right to consult with (b) Objectives are defined; employees attorney to prepare for hear- try different peer review tech- ing must be enforced. niques; objectives are further (d) Indefinite involuntary admission refined. i. Civil hearing is convened to (c) Peer evaluation becomes fully determine need for continu- operational. ing involuntary treatment. 268 Chapter 11 The Larger Mental Health Environment

ii. “Clear and convincing evi- ability to carry out the threat immedi- dence” of “mentally ill and ately (words alone are not enough). dangerous to self and others” (9) Negligence is an act or an omission to must be demonstrated. act that breaches the duty of due care (5) Clients do not lose their legal rights and results in or is responsible for a because they are admitted to a psychi- person’s injuries. atric facility. (10) For psychiatric mental health nurses, (6) Malpractice is the failure of profes- the most common causes of negli- sionals to provide the proper and gence are implementation of suicide competent care resulting in harm to precautions and assisting in electro- the patients, judged by national stan- convulsive therapy. dards of care by other members of (12) Informed consent is the client’s right their profession. to receive enough information to (a) Nurses should be familiar with make a decision about treatment the following resources that help and to communicate the decision to define standards of care: others. i. Code of Ethics for Nurses (a) In an absence of consent, a with Interpretive Statements healthcare provider can be held ii. Scope and Standards of Psy- liable in a civil lawsuit for bat- chiatric Nursing Practice tery, assault, and professional iii. Nurse practice statutes of the negligence. state (b) In the case of an emergency situa- iv. Evidence-based practice/ tion, consent may not be obtained treatment guidelines because a delay would endanger v. Documents published by the client’s health and/or safety, the Joint Commission on Ac- and the client may be treated creditation of Health Care without legal liability. Organizations (JCAHO) (c) To give informed consent, the vi. Federal Agency Guidelines patient should be told the diagno- (USPHS) (AHCPR) sis, differential diagnosis, nature vii. Statements from the Ameri- of diagnostic and therapeutic can Hospital Association procedures to be performed, viii. Policies and Procedures of the prospect of success from the the employing agency treatment, prognosis or expecta- (b) If standards are not clear in a par- tions, and alternative courses of ticular instance, a lawyer should treatment if available. be consulted. (13) Clients must be informed of the po- (c) Malpractice suits usually come tential risks of medications and have from angry patients who have had the right to refuse medications. If the poor results from treatment. physician or nurse believes the pa- (d) Malpractice lawsuits involving tient needs the refused medication, nurses usually include adminis- the physician can take the decision tration of medications or treat- to the courts to rule whether client is ment, communications, and incompetent. supervision of patients. (14) Competency is a legal determination (e) Most malpractice suits are filed that a client can make reasonable under the law of tort, which is a decisions about treatment and other private civil wrong committed by areas of his/her personal life. one individual against another for (15) Communication, both written and which money damages are col- oral, is a legal responsibility. Specific lected by the injured party from charting, e.g. on suicide precautions, the wrongdoer. documents the nurse’s actions. (7) Battery is a harmful or offensive (16) There are federal rules regarding touching of another’s person. chemical dependence confidential- (8) Assault is a threat to use force without ity so that staff members cannot actual bodily contact, although the disclose any admission or discharge person must have the opportunity and information. Leadership and Management 269

(17) All 50 states have enacted child abuse centered consultation—See next section) reporting statutes that generally in- (ANA et al., 2007). clude a definition of child abuse, a list 2. In the community mental health model, Ca- of persons required or encouraged to plan (1970) defines consultation as a specific report, and the governmental agency professional process between two systems. designated to receive and investigate The consultee system has a problem and re- the reports. quests assistance. The consultant system gives (18) Some states have enacted adult abuse the assistance. laws. 3. Role characteristics include collaborative pro- (19) Duty to warn or disclose (Tarasoff v. fessional relationships, not supervisory rela- The Regents of University of Califor- tionships, where the users/consultees choose nia, 1976) ruled that a psychotherapist whether or not to accept professional advice. had the duty to warn his or her client’s 4. The psychiatric liaison nursing role pro- potential victim of potential harm. In vides and coordinates psychiatric care and 1983, the court stated that the duty to maintains a therapeutic environment for warn was composed of two elements: clients admitted with a physical symptom or (1) the duty to diagnose and predict dysfunction. the client’s danger of violence, (2) the 5. Psychiatric liaison nurses, as members of the duty to take appropriate action to pro- healthcare team, provide direct care, including tect the identified victim. The duty to psychotherapy, health teaching, anticipatory warn supercedes the client’s right to guidance, and somatic therapy to individuals, confidentiality. groups, and families. (20) Some general areas of healthcare 6. Psychiatric consultation liaison nurses may litigation in multidisciplinary psychi- provide indirect care such as consultation, atric/mental health private practice— education, maintenance of a therapeutic envi- informed consent, faulty diagnosing ronment, systems evaluation, and program de- resulting in wrong treatment, physical velopment for work unit and/or organizational restraint and bodily harm, confiden- issues. tiality and defamation, failure to warn 7. The consultation liaison nurse provides sup- those threatened by clients, limita- port and guidance in assisting the user/ tion of ability to perform a needed consultee to solve the problem and gain more service and failure to refer to another understanding of the issues. professional, misuse of therapy, and 8. Consultation liaison nurses may fill roles in a inappropriate termination and aban- variety of settings—independent private prac- donment of client. titioners who are self-employed, nurses who are contracting out services to an organization • The consultative liaison role based on a fee-for-service arrangement, 1. This advanced practice nursing role evolved and/or staff members of an organization. from consultative roles and requires the ability 9. In general, the nurse consultant will deal with to integrate expert psychiatric-mental health the following three problem areas: knowledge into all healthcare settings (ANA, a. A problem with a specific patient APNA, & ISPN, 2007). b. A specific service program problem a. PMH consultant-liaison activities occur c. An organizational problem in nonpsychiatric care settings such as 10. Phases of the interactive consultative liaison hospitals, outpatient clinics, rehabilitation process (Lehmann, 1996) settings, and extended care facilities in a. Orientation phase which the advanced practice PMH nurse (1) Identifying the overt and covert expec- provides specialized consultation or direct tations of the consultee care. (2) Clearly defining the problem so that b. A variety of services can be provided by the staff have realistic expectations for the PMH consultant-liaison nurse includ- the consultation ing client-centered consultation (to treat (3) Communicating confidentiality or advise treatments for identified men- (4) Writing a written contract tal health needs) and providing nurses (a) Represents an exchange between and other care providers information, the consultee and consultant. support, and training about identified (b) Clearly writes services expected mental health issues/concerns (consultee- and method of payment signed 270 Chapter 11 The Larger Mental Health Environment

by each party. It is not so much c. Admissions of younger, violent patients have a legal document but an agree- declined. ment between two professional d. Inpatient census has increased by 50%; systems. admissions have decreased. (c) Contains a brief description of 4. In 1963, a fundamental change in the mental problem, expected outcomes or health delivery system occurred because of the goals, estimated time to be de- following mental health legislation: voted to project, amount of compensation for consultant’s time, a. Omnibus Reconciliation Act key department and personnel b. Community Mental Health Center Act related to consultant, and name c. Social Security Act of contact person from consultee d. Americans with Disabilities Act agency. 5. In general, discharged public mental health b. Working phase patients had the following problem most fre- (1) After contract is formalized, further quently in working with community mental assessing the problem. health centers: (2) Selecting interventions for the problem. At this point, the nurse a. Had difficulty working in family therapy consultant may have completed the b. Wanted to immediately live independently in consultation depending upon the the community terms of the contract. c. Had difficulty keeping appointments c. Termination phase d. Became involved in a revolving door with (1) Writing a formal summary written long jail times report 6. In working with discharged public mental health (2) Including in the written report— patients, the community mental health program purpose, dates, time, and activities of that was most essential was: consultation; statement of identified problem; assessment and diagnoses a. An inpatient unit of problem; proposed interventions b. Geriatric services for problem resolution; alternative c. Drug abuse treatment problem-solving approach; and evalu- d. 24-hour crisis intervention ation criteria and findings, if available 7. Mobile crisis services, including services in private homes, hospital emergency rooms, and residen- Questions tial programs, help provide: Select the best answer a. Group therapy b. Improved access to care 1. Today, the goal of most inpatient hospitaliza- c. Family psychotherapy tions is: d. Long-term rehabilitation of chronic patients a. Assessment 8. One important function of a partial hospitaliza- b. Rehabilitation tion program is to: c. Psychotherapy d. Crisis stabilization a. Stabilize the patient in an inpatient setting b. Transition patients from the inpatient to out- 2. The main difference between inpatient and outpatient setting patient treatment is: c. Provide 24-hour 7-day-a-week crisis a. Therapeutic milieu intervention b. Caregiving activities d. Provide mobile crisis services at the patient’s c. Integrating and coordinating care home d. Evaluating outcomes 9. For maximum treatment effectiveness, partial 3. In the last 30 years, public mental hospital hospitalization nurses should consider the fol- settings’: lowing group therapy issue: a. Inpatient census and admissions have a. Acutely ill patients need an intensive group- increased over 75%. orientated psychotherapy. b. Inpatient census has declined over 75%; b. Low-level and high-level patients have the admissions have doubled. same group needs. Questions 271

c. High-level patients may dilute intensive a. Referent group-orientated psychotherapy for low- b. Expert level patients. c. Legitimate d. Low-level patients may dilute intensive d. Coercive group-orientated psychotherapy for high- 16. A nurse can use which of the following strategies level patients. for acquiring power in an organization? 10. Managed care has created the following health- a. Increase visibility. care change: b. Inform patients about their rights. a. Separating treatment plans for inpatient and c. Write letters to the media about the outpatient providers organization. b. Shifting from capitated to fee-for-service d. Complain about management to other staff reimbursement members. c. Evaluating quality and patient outcomes 17. The most effective strategy for psychiatric- d. Longer and more intense psychiatric inpa- mental health nurses to use as change agents in tient stays mental health policy is to: 11. Which of the following is NOT a goal of a. Serve on a legislative committee deinstitutionalization? b. Write the media about mental health issues a. To save clients from debilitating effects of c. Advocate for patients in the hospital long, restrictive hospitalization d. Notify the patient of his/her rights b. To return the client to community after 18. A continuing mental health coverage issue discharge involves: c. To maintain the client in the community for as long as possible a. Giving parity of insurance coverage to d. To increase revenue resulting from revolving- mental health clients door/multiple hospitalizations b. Creating Medicaid coverage to include wrap- around services 12. The most prevalent ethical dilemma in managed c. Restricting hospital reimbursement care is that managed care providers: d. Caring for the elderly a. Prolong inpatient stays 19. The most influential legislation to give patients b. Limit patient treatments and options access to health care was the: c. Prescribe too many patient treatments given by too many providers a. Omnibus Reconciliation Act d. Prolong life-saving measures in intensive care b. Community Mental Health Center Act units c. Social Security Act d. Americans with Disabilities Act 13. For an advanced practice nurse to work com- petitively in a managed care setting, the nurse 20. Healthy People 2010 focuses the United States on should: the following mental health promotion: a. Provide cost effective care a. Decreasing polypharmacy in mental health b. Focus exclusively on self-care care c. Expect referrals from providers providing b. Reducing child and adolescent suicide similar services c. Promoting deinstitutionalization d. Focus on decreasing case load d. Increasing social supports for the indigent 14. In therapy, the nurse should be aware of gender 21. The most significant barrier for advance practice role stereotypes. Which of the following is least psychiatric-mental health nurses in practicing influenced by gender role stereotypes? within healthcare organizations is: a. A person’s self-esteem and prescribed role in a. Preferred Provider Organizations’ (PPOs) society restrictive hiring policies b. The nurse-client therapy relationship b. Lack of clients c. Nursing roles with other disciplines c. Limited autonomy in organized practice d. Lateral peer nursing roles settings d. Limited liaison roles 15. When a staff nurse assumes a nurse manager’s position, the nurse assumes the following type of power: 272 Chapter 11 The Larger Mental Health Environment

22. Of the following, which action does NOT demon- 28. The strongest predictor of private practice strate the nurse as change agent? charges for psychiatric-mental health clinical specialist is: a. Voicing concerns and solutions to legislative bodies and the media a. Charges of a private practice psychologist b. Seeking membership on community commit- who has comparable experience tees that formulate policy b. The price just above what your clientele is c. Voting for a candidate who supports mental willing to pay health legislation c. Chareges of a private practice social worker d. Familiarity with the legislative process and who has equal education requirements making presentations about pending legisla- d. The charges that third-party payers are tion at scheduled hearings saying are “reasonable and customary” 23. Paying a set amount of money for mental health 29. In mental health care, parity: services for a defined group of people is referred a. Encourages capitation of services to help to as: reduce healthcare costs a. Fee-for-service reimbursement b. Restricts legislators from adding unrelated b. Capitation legislation to bills; paring them down c. Prospective payment reimbursement c. Levels/equalizes mental health benefits as d. Sliding scale reimbursement compared to nonpsychiatric benefits d. Pairs mental disorders that are common dual 24. Which role should be performed by an advanced disorders for the purpose of billing practice nurse with a graduate degree? 30. Which of the following are NOT leaders’ tasks? a. Case management a. Renewing b. Consultation b. Distracting members from goals c. Budgeting c. Envisioning goals d. Coordinator of patient care d. Serving as a symbol 25. Which nursing activity demonstrates an indirect 31. According to Hersey and Blanchard’s Leadership nursing care function? Theory, leadership strategies are based upon: a. Teaching patients a. The ability of the leader b. Supervising staff b. The level of readiness of the follower c. Crisis intervention c. The leader’s charisma d. Group therapy d. The organization’s goals and objectives 26. To consider beginning a solo private practice, 32. The four classical functions of managers are: what factor would be most important? a. Planning, organizing, leading, and a. Experience as an advanced practice nurse evaluating b. Survival with the economic uncertainties of b. Visioning, planning, leading, and supervising private practice c. Planning, directing, organizing, and c. An intensive personal support system evaluating d. Total responsibility for professional d. Changing, visioning, bargaining, and accountability supervising 27. Which of the following are key factors in estab- 33. Epidemiology is useful in mental health care lishing a viable private practice? because it: a. Adapting a financial management system, a. Shows that the relationship between physical obtaining insurance, marketing successfully and psychiatric disorders does not vary in dif- b. Creating support groups, establishing criteria ferent populations for using consultants, successful marketing b. Allows attention to be focused on identi- c. Establishing criteria for using consultants and fying causes of mental illnesses employees, adapting a financial manage- c. Allows attention to be focused on giving dif- ment system ferent populations different levels of social d. Creating professional support groups, paying support courteous attention to referrals d. Shows that the relationship between patterns of diseases varies in human beings and animals Questions 273

34. An example of developmental risk is: c. Need for treatment and homebound status of patient a. Age d. Patient’s ability to pay and need for b. Ethnicity treatment c. Population density d. Social support 42. Which population is at high risk because 35. An example of a situational risk is: members ignore warning signals and engage in risk-taking behaviors? a. Family history b. Age a. Children c. Genetics b. Women d. Unemployment c. Men d. Elderly 36. An example of an environmental risk is: 43. The following is important to consider in plan- a. Religion ning women’s issues and mental health? b. Bacteria c. Housing a. Women are more likely to make a serious d. Ethnicity attempt to kill themselves than cry for help b. Women have a depression rate twice that of 37. Which combination gives the most complete men. community assessment? c. Major health problems include accidents and a. Community’s educational level, safety, and acute illness. social support d. Women’s suicide rate is four times higher b. Community’s politics, recreation, and safety than men. c. Community’s physical environment, social 44. The “new” revolving door with mental health support, and economics patients is: d. Community’s transportation, safety, and communication channels a. Community mental health centers 38. Nurses who screen workers for depression are b. The public mental hospital using which type of intervention? c. The acute care inpatient unit d. The jail a. Primary intervention b. Secondary intervention 45. The following type of planning is 3–5-year long c. Tertiary intervention range planning: d. Quality intervention a. Strategic 39. Nurses are creating and implementing a plan b. Operational to assist nursing home residents in dealing with c. Functional homesickness. They are using which type of d. Capital intervention? 46. The following type of planning addresses a. Primary intervention everyday work management: b. Secondary intervention a. Strategic c. Tertiary intervention b. Operational d. Quality intervention c. Functional 40. Which of the following populations is often in d. Capital need of mental health services, but is neglected 47. In preparing a proposed plan for a new program, because of lack of programs? the most important factor the nurse should con- a. Geriatric population sider is: b. Adolescents and children a. The evaluation plan containing both quality c. Substance abusers and patient outcomes measures d. Mentally ill in jail b. The need for the program 41. Two criteria for home visits by psychiatric nurses c. Marketing strategies for the program are: d. The fit of the program into the organiza- a. Need for treatment and geographical loca- tional chart tion of patient b. Type of diagnosis and family services resources available 274 Chapter 11 The Larger Mental Health Environment

48. The nurse manager knows that positive rein- 53. When choosing an optimal patient care delivery forcements for productive staff behaviors are system, desired outcomes include: important in the workplace. Which theory most a. Short length of stay, physician satisfaction, supports this statement? and least expensive nursing care a. Maslow’s Need Theory b. Cost effective nursing care and administra- b. Skinner’s Behavior Modification Theory tion satisfaction c. Herzberg’s Two Factor Theory c. Patient, administration, and managed care d. Hersey and Blanchard’s Life-Cycle Theory satisfaction d. Patient satisfaction, quality nursing care, and 49. Based on Herzberg’s Motivation Theory, which cost-effective nursing care is most important for the nurse manager in creating a motivating work environment for the 54. The clinic needs a new computer. This expense staff? will come out of what type of budget? a. Physiology needs are lower level needs and a. Technology are being met. b. Capital b. Consistent, clear rules guide the staff in pro- c. Personnel ducing the work. d. Operating c. The work itself should be interesting to the 55. For the nurse manager, the second stage of a worker. budget is: d. Staff must understand the mission of the work. a. Monitoring and reviewing the budget b. Implementing the budget 50. A nurse manager wants to create a motivating c. Planning the budget climate for staff. Which strategy best accom- d. Reviewing and justifying the budget plishes this goal? 56. The purpose of evaluating programs is to: a. Allow staff to create the budget for the department. a. Assess cost effectiveness b. Allow staff input into decisions which affect b. Assess community needs and desires their work. c. Assess stakeholders’ involvement for decision c. Give all staff a 10% raise. making purposes d. Allow staff more sick time. d. Assess worth and value for decision-making purposes 51. Two staff members approach you and state that they are arguing over the upcoming political 57. In evaluating a program, an essential component election. The best strategy for the nurse manager to measure is whether: is: a. Goals and objectives of program are met a. Bargaining, so that the argument will not b. Cost containment strategies are finished escalate c. Formative evaluation is used b. Confrontation, so the issue can be resolved d. Employees are motivated expeditiously 58. Continuous quality improvement (CQI) can be c. Redesigning the organization, because the defined as a philosophy for: work group needs to be more self-contained d. Smoothing, because the issue is trivial and a. Checking quality at set intervals not related to work b. Evaluating and managing quality c. Providing quality at the lowest possible cost 52. The evening charge nurse complains repeatedly d. Determining quality over time to you, the nurse manager, that day shift personnel do not complete admitting new patients 59. Which of these nursing interventions most exem- who enter the unit late on day shift. What is the plifies the CQI process: best conflict management approach? a. Interdisciplinary teams work together to a. Redesigning the organization, because the solve patient discharge problems. conflict is within the work process b. The nurse manager creates a plan to b. Avoidance, because the issue is trivial decrease costs over time. c. Smoothing, because it gives people time to c. Nursing administrators decide to give all calm down staff raises. d. Structuring, because an objective third party d. The nurse management team collaborates to is needed monitor sick-time usage. Questions 275

60. PMH consultation-liaison nursing services occur: 67. On an inpatient unit, the patient commits suicide because an intensive suicide watch was not con- a. Exclusively in the emergency department tinued throughout the shift. The nurse breached b. In any psychiatric setting which legal concept? c. In any nonpsychiatric setting d. Exclusively in outpatient settings a. Informed consent b. Negligence 61. Psychiatric mental health nursing practice c. Battery may vary from state to state because of laws d. False imprisonment governing: 68. A therapist has a duty to warn. This involves a. Child abuse reporting informing: b. Informed consent c. Nurse practice acts a. A patient about possible side effects of d. The ANA Code for Nurses medications b. A patient about tardive dyskinesia 62. When a patient is an involuntary admission to c. A patient about their right to refuse the psychiatric unit, the nurse knows that the treatment patient: d. A potential victim of potential harm a. Requested hospitalization 69. A nurse manager gives the staff the ability to b. Can sign out against medical advice create their own work schedules. This is an c. Has his/her legal rights taken away example of: d. Has restricted freedom a. Risk management 63. Malpractice can be shown if the nurse: b. Goal setting a. Gives a reasonable standard of care c. Self-realization b. Does not harm the patient d. Empowerment c. Fails to give competent care 70. Nursing interventions that enable client empow- d. Gives quality care but the patient has a poor erment include: outcome a. Suggesting hospitalization if client does not 64. Which patient right can be suspended with justi- comply with medication regime fied documentation? b. Assisting patients in not disclosing their psy- a. Right to treatment in least restrictive chiatric hospitalizations environment c. Promoting consumer choice in treatment b. Right to freedom from restraints and d. Promoting family therapy seclusion 71. A consultation liaison nurse’s role includes: c. Right to warn others of danger d. Right to access courts and attorneys a. Supervision of staff b. Support and guidance 65. In most states, the amount of time that a person c. Organization of patient care delivery can be under an emergency commitment is: d. Monitoring the CQI process a. 12 to 24 hours 72. A characteristic of a liaison contract is: b. 24 to 36 hours c. 48 to 72 hours a. A legally binding contract between two pro- d. 3 to 5 days fessional systems b. Set-up for a 5-year period 66. A healthcare worker telephones a substance c. A permanent document that can only be abuse unit and asks the nurse if Mr. A. Smith is modified by the court a patient there and can he talk with him. The d. An agreement between two professional nurse replies: systems a. “Here is Mr. Smith’s telephone number, 73. The nurse manager wants to empower the staff please call him.” and uses the following strategy: b. “Mr. Smith is in a group and cannot talk with you now.” a. Creating staff committees with authority to c. “No information can be given.” resolve departmental problems d. “Please talk to Mr. Smith’s caseworker.” b. Creating staff committees to develop goals for other departments 276 Chapter 11 The Larger Mental Health Environment

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Pages followed by t or f denote tables or figures respectively.

A African Americans, 206 Anorexia Nervosa (AN), 165–166, 218–219 AASECT (American Association of Sex Aggression-turned-inward hypothesis, Antiandrogenics, 169 Educators, Counselors, and mood disorders, 153 Antianxiety agents, 84t Therapists), 171 Agnosia, 190–191 Anticholinergics, 120, 121, 122t ABCs memory aid, 2–3 Agoraphobia, 83–84, 93 Anticonvulsants, 147, 224 Abstinence from addictive substances, Aguilera, Donna, 51 Antidepressants. See also specific categories agents to treat, 70 Akathisia, 121 such as SSRIs Abuse level, Substance-Use Disorder, 64 Alcohol abuse. See also Substance-related anxiety disorders, 84t, 87, 92, 94 Access to health care, childhood and disorders Bulimia Nervosa, 167 adolescence disorders, 207–208 biochemical interventions, 69, 70 Dementia, 193 Acetylcholine, 50t fetal alcohol syndrome, 66, 229 DID/MPD, 102 Acronyms as memory aids, 2 genetics of, 69 and elderly patients, 196 Acrostics as memory aids, 2 manifestations and treatment, 66t mood disorders, 144–145t, 145, 223 Active listening, 14 testing for, 64 neurotransmitter effects, 50t Acute care inpatient settings, 253 Alcoholics Anonymous, 176 Pain Disorder, 98, 196–197 Acute dystonia, 120 Alzheimer’s Disease (AD), 191–192, 194t as substance abuse treatment, 70 Acute Stress Disorder (ASD), 87 Ambulatory settings, 253–255 Antihistamines, 122t, 172, 233 AD (Alzheimer’s Disease), 191–192, 194t American Association of Sex Educators, Antimanic medications, 145, 147, 149t, 224 Adaptation Model (Roy), 38 Counselors, and Therapists Antipsychotics ADHD (Attention-Deficit/Hyperactivity (AASECT), 171 Conduct Disorder, 216 Disorder), 212–215 American Nurses Credentialing Center Delirium, 189 Adjustment Disorder, 104–105, 138t (ANCC), 256 Dementia, 193, 194t Adler, Alfred, 41–42 Americans with Disabilities Act (1990), 259 mood disorders in children and Admissions to psychiatric inpatient Amino acids (glutamate), 50t, 119 adolescents, 224 facilities, types of, 267–268 Amitriptyline, 146t personality disorders, 175 Adolescents. See also Childhood and Amoxapine, 146t psychotic disorders, 119–125, 230 adolescence disorders Amphetamine abuse, 67t. See also Antisocial Personality Disorder, 175–176 behavioral issues particular to, 234 Substance-related disorders Anxiety disorders eating disorders, 165–168, 218–219 AN (Anorexia Nervosa), 165–166, 218–219 children and adolescents, 224–227 Substance-Use Disorder, 229–230 Analysis thinking process, 1, 3 coping types, 83 and violence/gang activity, 234 ANCC (American Nurses Credentialing GAD, 84, 89–91 Adult learners, guidelines for teaching, 21 Center), 256 and geropsychiatric nursing, 196 Advocacy, client, 17 Anhedonia, 139 levels of anxiety, 83

279 280 Index

Anxiety disorders (continued) Behavior Therapy (Skinner), 45, 263 geropsychiatric nursing, 197 medications, 84–85t, 92, 94 Behavioral syndromes impulse control disorders, 173 OCD, 84, 93–95, 227 childhood and adolescence, 212–218, mood disorders overview, 83 234 additional considerations, 147, 148t, Panic Disorder, 84, 91–93 eating disorders, 165–168, 218–219 152 phobias, 83–86 Gender Identity Disorder, 169–170 antidepressants, 144–145t, 145, 223 PTSD, 84, 86–89 impulse control disorders, 173–174 children and adolescents, 223–224 and substance abuse, 63 sexual disorders, 168–169, 170–171 dietary restrictions, 148t theoretical considerations, 42 sleep disorders, 171–173 mood stabilizers, 145, 146–147t, 147, Anxiolytics, 50t, 85t Behavioral therapies 149–151t Aphasia, 190 Adjustment Disorder, 105 personality disorders, 175, 177, 178, 179 Appearance as nonverbal communication, anxiety disorders, 85, 90, 92, 94 psychotic disorders, 119–125, 230 14 childhood and adolescence disorders, sexual disorders, 169, 171 Application thinking type, 1, 3 211, 212, 221, 229, 232 sleep disorders, 172 Apraxia, 190 Dementia, 195 somatoform disorders, 96, 98 Archer, Richard L., 52 eating disorders, 167–168 substance-related disorders, 69–70 Aripiprazole, 123t, 125, 149t mood disorders, 154 Biologic origins. See Genetic/biologic ASD (Acute Stress Disorder), 87 personality disorders, 170, 177 origins Asian heritage, 69, 206 sexual disorders, 169, 171 Bipolar Disorder Asperger’s Disorder, 212 substance-related disorders, 72t biochemical interventions, 149–151t Assault, legal definition, 268 theoretical considerations, 44–49, 263 children and adolescents, 223–224 Assessment. See also Diagnostic studies/ Beneficence, 24 epidemiology, 137, 139 tests; Mental status variations/ Benzodiazepines features, 138t examination; Signs and symptoms anxiety disorders, 84–85t, 90, 92 types I and II, 140–141 of child maltreatment, 236–237 Delirium, 189 Bipolar I Disorder, 140 community, 262 Dementia, 193 Bipolar II Disorder, 140–141 cultural, 16 mood disorders in children and Blood alcohol concentration (BAC), 64 as part of nursing process, 12 adolescents, 224 Blood alcohol level (BAL) test, 64 substance-related disorders, 65 neurotransmitter effects, 50t Borderline Personality Disorder, 176–177 Atomoxetine, 214t sleep disorders, 172 Bowen, Murray, 48 Attention-deficit and disruptive behavior substance-related disorders, 68t, 69 Brain stimulation interventions, 152–153 disorders, 212–218 Berne, Eric, 47 Breathalyzer, 64 Attention-Deficit/Hyperactivity Disorder Beta-adrenergic antagonists, 84 Breathing-related Sleep Disorder, 173 (ADHD), 212–215 Billing for private practice, 260–261 Brief Psychotic Disorder, 117 Attribution theory, 154 Binge-eating/purging type of Anorexia Budget, organizing, 265 Atypical antipsychotics Nervosa, 165 Bulimia Nervosa, 166, 218–219 Conduct Disorder, 216 Biochemical interventions. See also specific Buprenorphine, 69, 70 Delirium, 189 medications Bupropion, 214t Dementia, 194t anxiety disorders Buprotrion, 145t EOS/COS, 230 childhood and adolescence, 225, 226, Buspirone, 90, 227, 233 mood disorders in children and 227 Butyrophenones, 120t adolescents, 224 GAD, 90 psychotic disorders, 122–125 OCD, 94 C Autistic Disorder, 211–212 Panic Disorder, 92 Caffeine abuse, 67t Autocratic leadership style, 261 phobias, 84 CALOCUS (Child and Adolescent Levels of Autonomy, respect for, 23–24 PTSD, 87 Care Utilization Services), 230 Avoidant Personality Disorder, 178, 179 children and adolescents Cannabis abuse, 67t Azapirone, 85t anxiety disorders, 225, 226, 227 Capitation, 257 attention-deficit and disruptive Carbamazepine, 69, 149t, 224 B behavior disorders, 213, 216, Case management, 17–18, 255 B12 Deficiency, Dementia Due to, 193 217 Case study research, 36 BAC (blood alcohol concentration), 64 elimination disorders, 221 Catatonic Schizophrenia, 116 BAL (blood alcohol level) test, 64 EOS/COS, 230 CBT (Cognitive-Behavioral Therapy) Bandler, Richard, 46–47 learning disorders, 210 (Meichenbaum), 46, 72t, 195 Bandura, Albert, 46, 71 medication management, 233–234 CD (Conduct Disorder), 215–217 Barbiturate abuse, 68t Mental Retardation, 209 Centers for Medicare & Medicaid Services Basic Anxiety, Theory of (Horney), 42 mood disorders, 223–224 (CMS), 259 Battered Child Syndrome, 238 tic disorders, 220 Cerebrovascular disease and Dementia, 192 Battered Women’s Shelter for Domestic Delirium, 189 Certified Psychiatric Clinical Nurse (Spouse) Abuse, 89 Dementia, 193–194, 194t Specialists, 256 Battery, legal definition, 268 dissociative disorders, 99, 100, 101, 102 Challenge, healthy approach to, 11 Beck, Aaron, 45–46 eating disorders, 167 Change, mental process of, 11–12 Index 281

Chemical dependence, confidentiality Cluster C personality disorders, 174, feeding and eating disorders, 218 issue, 268. See also Substance- 178–179 learning disorders, 210 related disorders Cluster suicides, 222–223 Mental Retardation, 209 Child Abuse Prevention and Treatment Act CMHC (Community Mental Health RAD, 228 (1974), 239 Centers), 253–255 tic disorders, 220 Child and Adolescent Levels of Care CMS (Centers for Medicare & Medicaid Delirium, 190 Utilization Services (CALOCUS), Services), 259 Dementia, 195–196 230 Cocaine/crack, 70, 229. See also Substance- dissociative disorders, 101 Child maltreatment (abuse), 235–240, 269 related disorders eating disorders, 168, 218 Child testimony in child maltreatment Cognitive Behavior Modification impulse control disorders, 174 cases, 240 (Meichenbaum), 46 mood disorders, 155–156 Childhood and adolescence disorders Cognitive Development, Theory of (Piaget), personality disorders, 176, 177, 179 access to health care, 207–208 42–43 psychotic disorders, 129 adolescent behavioral issues, 234 Cognitive disorders, 187–196 sexual disorders, 171 anxiety disorders, 224–227 Cognitive theories, 42–43, 45–46 sleep disorders, 173 attention-deficit and disruptive behavior Cognitive therapies somatoform disorders, 98 disorders, 212–218 Adjustment Disorder, 105 substance-related disorders, 75 and child maltreatment (abuse), anxiety disorders, 87, 90, 92, 93, 94 Comorbidity (dual diagnosis), 63, 69 235–240 childhood and adolescence disorders, Companion Peer (COM-PEER), 129 communication disorders, 210–211 232 Competency, mental, 268 cultural and ethnic considerations, eating disorders, 167–168 Complex Motor Tics, 219 205–206 mood disorders, 153–154 Complex Vocal Tics, 219 elimination disorders, 220–222 personality disorders, 179 Comprehension thinking, 1 EOS/COS, 230–231 sexual disorders, 171 Computerized tests, considerations for, 8 epidemiology, 205 sleep disorders, 172 Conduct Disorder (CD), 215–217 family dynamics/family therapy, 207 Cognitive Therapy (Beck), 45–46 Confidentiality, 238, 268 feeding and eating disorders, 218–219 Cognitive-Behavioral Therapy (CBT) Conflict resolution strategies, 264 genetic/biologic origins, 206–207 (Meichenbaum), 46, 72t, 195 Consultative liaison role, 269–270 learning disorders, 209–210 Collaborative practice settings, 255 Consumption decrease agents, 70 Mental Retardation, 208–209 Commitment, 11 Content knowledge for test taking, 3–6 PDDs, 211–212 Communication Contingency Management Interventions/ personality disorders, 231 culturally derived attitudes about, 16 Motivational Incentives, 72t professional standards for nurses, 205 principles, 13–15 Continuous quality improvement (CQI), RAD, 227–228 right to outside, 24 266–267 Stereotypic Movement Disorder, theories, 46–47 Contract payment and services, 260 228–229 Communication disorders, 210–211 Control, personal, 11 Substance-Use Disorder, 229–230 Community assessment, 262 Controlled substances overview, 20–21, 20t tic disorders, 219–220 Community background factors, childhood Conversion Disorder, 95 Childhood Disintegrative Disorder, 212 and adolescence disorders, 208 Conway, M. E., 52 Childhood-Onset Schizophrenia (COS), Community Mental Health Centers Coping theory (Monat and Lazarus), 52 230–231 (CMHC), 253–255 Coprolalia, 219 Children. See also Childhood and Community Mental Health Centers Act COS (Childhood-Onset Schizophrenia), adolescence disorders (1963), 259 230–231 communication techniques, 15 Community Reinforcement Approach Countertransference, 13, 23 health issue planning, 262 (CRA) Plus Vouchers, 72t CQI (continuous quality improvement), Children of alcoholics, 69 Community resources 266–267 Chlorpromazine, 120 Adjustment Disorder, 105 CRA (Community Reinforcement Cholinesterase inhibitors, 50t, 194t anxiety disorders Approach) Plus Vouchers, 72t Chronic or Vocal Tic Disorder, 220 children and adolescents, 225, 226 Cramming (studying), 5–6 Circadian rhythm hypothesis, mood GAD, 91 Craving, agents to decrease, 70 disorders, 142–143 OCD, 94 Crisis Intervention theory (Aguilera), 51, Circadian Rhythm Sleep Disorder, 173 Panic Disorder, 93 105 Citalopram, 144t phobias, 86 Critical Pathways, 18 Client Centered Therapy (Rogers), 43–44 PTSD, 89 Cultural and ethnic factors Clinical supervision, defined, 13 children and adolescents Asian response to alcohol, 69 Clomipramine, 146t anxiety disorders, 225 childhood and adolescence disorders, Clonazepam, 179 attention-deficit and disruptive 205–206 Clonidine, 69, 214t, 220 behavior disorders, 215, and communication, 14 Clozapine, 122–123, 122t 216–217, 218 overview, 15–16 Cluster A personality disorders, 174–175 communication disorders, 211 Cultural Assessment, 16 Cluster B personality disorders, 174, elimination disorders, 222 Cultural relativism, defined, 15 175–178 EOS/COS, 231 Culture, defined, 15 282 Index

Culture Care Diversity and Universality, mood disorders, 143 Disulfiram, 70 Theory of (Leininger), 38 substance-related disorders, 64, 229 DMST (dexamethasone suppression test), Cyclothymic Disorder, 138t, 141 Dialectic Behavior Therapy (DBT) 143 (Linehan), 46, 177 Domestic violence, phases of, 89 D Dibenzoxazepines, 120t Donepezil, 194t DA (dopamine), 50t, 119 DID (Dissociative Identity Disorder), Dopamine (DA), 50t, 119 Day treatment programs, 255 102–104 Dopamine agonists, 121, 122t, 229 DBT (Dialectic Behavior Therapy) Diet therapy, 17 Double Depression, 138t (Linehan), 46 Dietary restrictions for MAOIs, 148t Doxepin, 146t De Shazer, S., 51 Differential diagnosis Droperidol, 189 Deep brain stimulation, 153 Adjustment Disorder, 104 DS (Discontinuation Syndrome), 152 Defense mechanisms, psychoanalytic, 41t anxiety disorders Dual diagnosis (comorbidity), 63, 69 Deinstitutionalization, 253, 254 children and adolescents, 224–225, Duloxetine, 145t Delegating leadership strategy, 261 226 Duty to warn or disclose (for threats of Delirium, 187–190 GAD, 91 violence from clients), 269 Delusional Disorder, 116–117 Panic Disorder, 93 Dyspareunia, 171 Delusions in mood disorders, 137. See also phobias, 84, 86 Dysthymic Disorder, 137, 138t, 140 Psychotic disorders PTSD, 89 Dementia, 190–196 children and adolescents E Dementia Due to B12 Deficiency, 193 anxiety disorders, 224–225, 226 Early-Onset Schizophrenia (EOS), 230–231 Dementia Due to General Medical attention-deficit and disruptive Eating disorders, 165–168, 218–219 Condition, 192–193 behavior disorders, 213, 215, EBP (evidence-based practice), 35–36, 71, Dementia Due to HIV Disease, 192 217 72t Dementia Due to Lewy Body Disease, 193 communication disorders, 211 Echokinesis, 219 Dementia Due to Normal Pressure elimination disorders, 221 Echolalia, 190, 219 Hydrocephalus (NPH), 193 EOS/COS, 230 Ecstasy abuse, 67t Dementia Due to Pick’s Disease, 192 feeding and eating disorders, 218 Education, mental health, 12, 21, 22, 88 Dementia Due to Traumatic Brain Injury, learning disorders, 210 Educational groups for Dementia, 195 192–193 mood disorders, 222, 223 Educational neglect of child, 235 Dementia of the Alzheimer’s Type, 191–192, PDDs, 212 Egoism ethical perspective, 23 194t RAD, 228 Elderly patients, 190–197 Deming, W. E., 267 Stereotypic Movement Disorder, 228 Elective Mutism, 225–226 Democratic leadership style, 261 tic disorders, 219 Electroconvulsive therapy, 152–153 Deontology/formalism ethical perspective, Delirium, 187 Elimination disorders, 220–222 23 Dementia, 191, 192 Ellis, Albert, 44–45 Departure runaways, 234 dissociative disorders, 99–100, 101, 102 EMDR (Eye Movement Desensitization and Dependence level, Substance-Use Disorder, eating disorders, 166–167, 218 Reprocessing), 88 63–64 factitious disorders, 99 Emergency involuntary admission/ Dependent Personality Disorder, 178, 179 Gender Identity Disorder, 170 commitment, 267 Depersonalization Disorder, 101–102 impulse control disorders, 173 Emergency services, psychiatric, 254 Depressive disorders (unipolar), 138t, mood disorders, 139, 140, 141, 222, 223 Emotional neglect of child, 235 139–140, 179, 196. See also Major personality disorders, 174–175, 176, 177, Emotions Anonymous, 176 Depression 178 Employment, right to, 24 Depressive Personality Disorder, 138t, 179 psychotic disorders, 116, 117, 118 Empowerment, client and nursing, Desipramine, 146t sexual disorders, 169, 171 265–266 Detoxification agents, 69 sleep disorders, 171–172 Empowerment model of recovery, 266 Developmental Coordination Disorder, 210 somatoform disorders, 95, 96, 97 Encopresis, 221–222 Developmental Disabilities Act (1975), 259 substance-related disorders, 64 Endocrine cascades, 50t Dexamethasone suppression test (DMST), Dihydroindolones, 120t Enuresis, 220–221 143 Directing function of management, Environment, therapeutic. See Milieu Dexmethylphenidate, 214t 263–264 interventions Dextroamphetamine, 214t Discontinuation Syndrome (DS), 152 EOS (Early-Onset Schizophrenia), 230–231 Diagnosis, as part of nursing process, Disease model for substance-related Epidemiology 12. See also Differential diagnosis; disorders, 73 childhood and adolescence disorders, Mental status variations/ Disinhibited type of RAD, 228 205 examination; Nursing diagnoses; Disorder of Written Expression, 209 in management planning, 261–262 Signs and symptoms Disorganized Schizophrenia, 116 mood disorders, 137, 138t, 139 Diagnostic studies/tests Dissociative Amnesia, 99–100 PTSD, 87 Cluster B personality disorders, 176 Dissociative disorders, 99–104 Schizophrenia, 115 Delirium, 187–188 Dissociative Fugue, 100–101 substance-related disorders, 63 Dementia, 191 Dissociative Identity Disorder (DID), Erikson, Erik Homburger, 42 eating disorders, 165 102–104 Erotomanic delusions, 117 Index 283

Escitalopram, 144t, 227 mood disorders, 155, 222, 224 attention-deficit and disruptive Eszopiclone, 172 overview, 21–22 behavior disorders, 213, 216, Ethical considerations, 23–24 personality disorders, 175, 176, 177, 179, 217 Ethnicity and mental health nursing, 15, 16 231 communication disorders, 211 Ethnocentrism, defined, 15 psychotic disorders, 128–129 elimination disorders, 221 Ethnohistory, 39 and runaways, 234 EOS/COS, 230 Evaluating function of management, sexual disorders, 171 learning disorders, 210 266–267 somatoform disorders, 95, 96, 97, 98 Mental Retardation, 208–209 Evaluation of client responses, 12 substance-related disorders, 71, 73 mood disorders, 223 Evidence-based practice (EBP), 35–36, 71, Family history, 21 PDDs, 212 72t Family Systems Theory (Bowen), 48 personality disorders, 231 Executive functioning problems, Dementia, Family theories (natural system theory), Stereotypic Movement Disorder, 229 191 48–49 tic disorders, 219–220 Exhibitionism, 168 FAS (fetal alcohol syndrome), 66, 229 Delirium, 188 Existential/humanistic theories, 43–45 Feeding and eating disorders of infancy and Dementia, 192 Experimental research, 36 early childhood, 218 dissociative disorders, 100, 101, 102 Expert witness testimony by nurses for Fee-for-service reimbursement, 257, 258, eating disorders, 167 child maltreatment cases, 239–240 260 Gender Identity Disorder, 170 Exposure therapy, 87–88 Female Sexual Arousal Disorder, 170–171 impulse control disorders, 173 Expressive Language Disorder, 210 Fetal alcohol syndrome (FAS), 66, 229 mood disorders, 142–143, 223 Expressive therapies, 17, 88 Fetishism, 168 neurobiologic theories and models, 49, Extrapyramidal symptoms of Financial issues in mental health care, 50t, 118–119, 142 antipsychotics, 120, 121, 122 259–261 personality disorders, 175, 176, 177, Eye Movement Desensitization and Fluoxetine, 144t, 149t, 226, 227 178–179, 231 Reprocessing (EMDR), 88 Fluoxetine and olanzapine combination, psychotic disorders, 118–119 149t sexual disorders, 169, 171 F Fluphenazine, 119–120 sleep disorders, 172 Family dynamics/family therapy Fluvoxamine, 144t, 227 somatoform disorders, 95, 96, 97, 98 Adjustment Disorder, 105 Folie à deux, 117 substance-related disorders, 69 anxiety disorders Forensic nursing, 240 Geropsychiatric nursing, 196–197 children and adolescents, 225 Forming stage of group development, 23 Gestalt therapy (Perls), 44 GAD, 90–91 Freud, Sigmund, 39–40, 41t Gilligan, Carol, 43 OCD, 94 Frotteurism, 168 Glasser, William, 45 Panic Disorder, 93 Functional planning, 263 Glutamate (amino acids), 50t, 119 phobias, 86 Goal Attainment, Theory of (King), 37 PTSD, 88 G Grandiose delusions, 117 children and adolescents, 207, 232 GAD (Generalized Anxiety Disorder), 84, Grinder, John, 46–47 anxiety disorders, 225, 226, 227 89–91, 227 Group approaches attention-deficit and disruptive Galantamine, 194t Adjustment Disorder, 105 behavior disorders, 215, 216, Gamma-aminobutyric acid (GABA), 50t, anxiety disorders 217 90, 119 children and adolescents, 225 communication disorders, 211 Gangs, 234 GAD, 91 elimination disorders, 222 GAS (General Adaptation Syndrome), 52 OCD, 94 EOS/COS, 231 Gender Identity Disorder, 169–170 phobias, 86 feeding and eating disorders, 218, Gender role stereotypes, 258 PTSD, 88 219 General Adaptation Syndrome (GAS), 52 children and adolescents, 232 learning disorders, 210 General Medical Condition anxiety disorders, 225 Mental Retardation, 209 Dementia Due to, 192–193 attention-deficit and disruptive mood disorders, 222, 224 Mood Disorder Due to, 137, 138t, 141 behavior disorders, 215, 216, personality disorders, 231 Psychotic Disorder Due to, 117 217–218 RAD, 228 Generalized Anxiety Disorder (GAD), 84, and child maltreatment, 238 Stereotypic Movement Disorder, 89–91, 227 communication disorders, 211 229 Genetic/biologic origins EOS/COS, 231 tic disorders, 220 Adjustment Disorder, 104 learning disorders, 210 Delirium, 189 anxiety disorders Mental Retardation, 209 Dementia, 195 GAD, 89–90 mood disorders, 224 dissociative disorders, 100, 101–102, OCD, 94 tic disorders, 220 103 Panic Disorder, 92 Dementia, 195 eating disorders, 168, 218, 219 phobias, 84 dissociative disorders, 100, 101, 102 factitious disorders, 99 PTSD, 87 eating disorders, 168 Gender Identity Disorder, 170 children and adolescents, 206–207 impulse control disorders, 174 impulse control disorders, 174 anxiety disorders, 225, 226 mood disorders, 155, 224 284 Index

Group approaches (continued) Hypothalamic-pituitary adrenal axis (HPA), mood disorders, 153, 224 overview, 22–23 50t personality disorders personality disorders, 175, 176, 179 Hypothalamic-pituitary gonadal axis Antisocial Personality Disorder, 176 psychotic disorders, 129 (HPGA), 50t Borderline Personality Disorder, sexual disorders, 171 Hypothalamic-pituitary thyroid axis 177 sleep disorders, 172 (HPTA), 50t children and adolescents, 231 somatoform disorders, 95, 96, 97, 98 Cluster A disorders, 175 substance-related disorders, 73–74 I Cluster C disorders, 179 Group behavior theories, 47–49 Imipramine, 146t, 221 Histrionic Personality Disorder, 178 Growth and development theories, 42–43 Immunologic/risk factor models, psychotic psychotic disorders, 125 Guanfacine, 214t disorders, 119 sexual disorders, 169, 171 Impaired nurses (substance-related sleep disorders, 172 H disorders), 75 somatoform disorders, 95, 96, 97, 98 Habeas corpus, right to, 24 Impulse control disorders, 173–174 substance-related disorders, 70–71 Haley, J., 49 Indefinite involuntary admission, 267–268 Intrapersonal psychotherapeutic Hallucinations, 137, 187–190. See also Independent psychiatric exam, right to, 24 interventions Psychotic disorders Individual Psychology, Theory of (Adler), Adjustment Disorder, 105 Hallucinogen abuse, 67t 41–42 anxiety disorders Haloperidol, 120, 189, 193, 220, 229 Individual/personal factors in mental children and adolescents, 225, 226, Hardiness, mental, 11 health, 11 227 Hardy, M. E., 52 Informed consent, right to, 24, 268 GAD, 90 Hashish abuse, 67t Inhalant abuse, 68t OCD, 94 Hattie, John, 51–52 Inhibited type of RAD, 228 Panic Disorder, 92 HE (hypomanic episode), 138t, 140 Inpatient settings, 253 phobias, 85 Health education, 12, 21, 22, 88 Insomnia, 171–173, 189 PTSD, 87 Health Management Organizations Interdisciplinary Treatment Plans (ITPs), 18 children and adolescents, 231–232 (HMOs), 257 Interdisciplinary treatment team, 16–17 anxiety disorders, 225, 226, 227 Health Promotion Model (HPM) (Pender), Intermittent Explosive Disorder, 173–174 attention-deficit and disruptive 39 Interpersonal Development, Theory of behavior disorders, 214–215, Healthcare insurance plan types, 257–258 (Sullivan), 43 216, 217 Healthy People 2010 (2009), 259 Interpersonal interventions, mood and child maltreatment, 237–238 Hersey and Blanchard’s Life-Cycle of disorders, 153 communication disorders, 211 Situational Leadership, 261 Interpersonal/relationship factors in eating disorders, 219 Herzberg’s Two Factor Motivation Theory, mental health, 11. See also Family elimination disorders, 221 264 dynamics/family therapy EOS/COS, 231 Hispanic heritage, 206 Intervention overview, 12. See also specific feeding and eating disorders, 219 Histrionic Personality Disorder, 177 interventions learning disorders, 210 HIV Disease, Dementia Due to, 192 Intrapersonal origins Mental Retardation, 209 HMOs (Health Management Adjustment Disorder, 105 mood disorders, 223, 224 Organizations), 257 anxiety disorders PDDs, 212 Home health setting, 255–256 children and adolescents, 225, 226 RAD, 228 Homeless people, 253, 263 GAD, 90 Stereotypic Movement Disorder, Homeodynamics, 38 OCD, 94 229 Hopelessness theory of depression, 154 Panic Disorder, 92 substance-related disorders, Horney, Karen, 42 phobias, 84–85 229–230 HPA (hypothalamic-pituitary adrenal axis), PTSD, 87 tic disorders, 220 50t attention-deficit and disruptive behavior dissociative disorders, 100, 101, 103 HPGA (hypothalamic-pituitary gonadal disorders, 214–215, 216, 217 eating disorders, 167–168, 219 axis), 50t children and adolescents factitious disorders, 99 HPM (Health Promotion Model) (Pender), anxiety disorders, 225, 226 Gender Identity Disorder, 170 39 elimination disorders, 221 and geropsychiatric nursing, 197 HPTA (hypothalamic-pituitary thyroid feeding and eating disorders, 219 impulse control disorders, 174 axis), 50t Mental Retardation, 209 mood disorders, 141, 153–154, 223, 224 Human subjects, protection of in research, mood disorders, 224 overview, 12, 13 37 personality disorders, 231 personality disorders, 175, 176, 177, 178, Humanistic/Holistic theory (Maslow), 44 RAD, 228 179 Hypertension and mood disorder tic disorders, 220 psychotic disorders, 125–128 medications, 147t dissociative disorders, 100–101, 103 sexual disorders, 169, 171 Hypnosis, 85, 103, 171 eating disorders, 167–168, 219 sleep disorders, 172 Hypoactive Sexual Desire Disorder, 171 factitious disorders, 99 somatoform disorders, 95, 96, 97, 98 Hypochondriasis, 95–96 Gender Identity Disorder, 170 substance-related disorders, 71, 72–73t, Hypomanic episode (HE), 138t, 140 impulse control disorders, 174 229–230 Index 285

Involuntary admission/commitment, with melancholic features, 139 healthcare insurance plan types, 267–268 postpartum onset, 139–140 257–258 Isocarboxazid, 146t SAD, 139 leadership theory and roles, 261 ITPs (Interdisciplinary Treatment Plans), 18 signs and symptoms, 139 managed care, 257 Major depressive episode (MDE), 138t, 139, management theory and roles, J 140 261–269 Jealousy delusions, 117 Male Erectile Disorder, 170 political issues, 258–259 Joining technique in family therapy, 21 Malpractice lawsuits, 268–269 reimbursement for mental health Joint Commission, 258–259 Managed care, 257, 261 services, 257–258, 260 Jung, Carl, 40 Management theory and roles, 261–269 social issues, 258 Justice, defined, 24 Manic episode (ME), 138t, 140, 152, 153 types of settings, 253–257 MAOIs (monoamine oxidase inhibitors) Mental Retardation, 208–209 K anxiety disorders, 87 Mental status variations/examination Kempe, C. Henry, 238 children and adolescents, 233 Adjustment Disorder, 104 Kinesics, 14 dietary restrictions, 148t anxiety disorders King, Imogene, 37 mood disorders, 145, 146t, 147t children and adolescents, 225–226 Kleptomania, 174 personality disorders, 175 GAD, 89 Kohlberg, Lawrence, 43 Marijuana abuse, 67t OCD, 93–94 Maslow, Abraham, 44 Panic Disorder, 91–92 L Masochism, sexual, 168 phobias, 84 Laissez-faire leadership style, 261 Mathematics Disorder, 209 PTSD, 87 Lamotrigine, 149t Matrix Model, substance-related disorders, children and adolescents Lazarus, R. S., 52 72t anxiety disorders, 225–226 Leadership theory and roles, 261 MCQs (multiple-choice questions), attention-deficit and disruptive Learned helplessness, 154 preparing for, 6–7 behavior disorders, 215, 217 Learning disorders, 209–210 MDD (Major Depressive Disorder). See communication disorders, 211 Least restrictive setting for treatment, right Major Depression elimination disorders, 221 to, 24 MDE (major depressive episode), 138t, 139, EOS/COS, 230 Legal issues 140 learning disorders, 210 in child abuse and neglect, 238–239 MDMA abuse, 67t Mental Retardation, 208 in evaluation of health care, 267–269 ME (manic episode), 138t, 140, 152, 153 mood disorders, 223 mental health legislation history, Medicaid, 259, 260 RAD, 228 258–259 Medical Condition, General Stereotypic Movement Disorder, Leininger, Madeleine, 38–39 Dementia Due to, 192–193 228–229 Lewy Body Disease, Dementia Due to, 193 Mood Disorder Due to, 137, 138t, 141 tic disorders, 219 LFTs (liver function tests), 64 Psychotic Disorder Due to, 117 Delirium, 188 Liaison nursing, 18 Medical neglect of child, 235 Dementia, 192, 196 Life review therapy, 197 Medicare, 259, 260 dissociative disorders, 100, 101, 102 Life-Cycle of Situational Leadership (Hersey Medications, as cause of Delirium, 188–189. eating disorders, 166 and Blanchard), 261 See also Biochemical interventions; factitious disorders, 99 Linehan, M. M., 46 specific medications Gender Identity Disorder, 170 Links as memory aid, 3 Meichenbaum’s Cognitive Behavior impulse control disorders, 173 Lisdexamfetamine, 214t Modification, 46 mood disorders, 223 Lithium Melancholic features, MDD with, 139 personality disorders, 176–177 children and adolescents, 223–224, Memantine, 194t sexual disorders, 169, 171 233 Memory sleep disorders, 172 mood disorders, 145, 147, 149t, aids for test taking preparation, 2–3 somatoform disorders, 95, 96, 97, 98 150–151t, 223–224 contribution to thinking, 1 substance-related disorders, 66–68t side effects and toxicity, 150–151t impairment of in Delirium and Mesoridazine, 120 Liver function tests (LFTs), 64 Dementia, 188, 190–196 MET (Motivational Enhancement Therapy), Loxapine, 120 Men and women, gender role stereotypes, 73t LSD abuse, 67t 258 Methodone, 69, 70 Men’s health issues, management planning, Methylphenidate, 214t M 263 Mild Mental Retardation, 208 Madanes, C., 49 Mental health definition and factors, 11, Milieu interventions Major Depression (Major Depressive 213 Adjustment Disorder, 105 Disorder [MDD]) Mental health neglect of child, 235 anxiety disorders children and adolescents, 222–223 Mental Health Parity Act (1996), 259 children and adolescents, 225, 226 differential diagnosis, 139 Mental Health Study Act (1955), 258–259 GAD, 91 electroconvulsive therapy, 152 Mental healthcare delivery system OCD, 94 epidemiology, 137, 139 consultative liaison role, 269–270 phobias, 86 features of, 138t financial issues, 259–261 PTSD, 88 286 Index

Milieu interventions (continued) nursing diagnoses, 143–144 NE (norepinephrine), 50t, 119 children and adolescents, 232–233 overview, 137–139 Nefazodone, 145t anxiety disorders, 225, 226 with psychotic features, 137 Neglect, child, 235 attention-deficit and disruptive screening instruments, 143–144 Negligence, medical, 268 behavior disorders, 215, severity levels, 137 Neuroanatomic models, psychotic 216–217, 218 signs and symptoms, 139, 140, 141, 222, disorders, 118 elimination disorders, 222 223 Neurobiologic theories, 49, 50t, 118–119, EOS/COS, 231 Substance-Induced Mood Disorder, 63, 142 Mental Retardation, 209 141 Neuroendocrinology, 49 RAD, 228 suicide, 141–142 Neuroleptic Malignant Syndrome (NMS), tic disorders, 220 Mood stabilizers (antimanics), 145, 147, 121–122 defined, 18 149t, 224 Neuroleptic-induced pseudoparkinsonism, Delirium, 190 Mood-congruent mood disorders with 120–121, 122 Dementia, 195 psychotic features, 137 Neuroleptics, 224, 233 dissociative disorders, 100, 101, 102, 104 Mood-incongruent mood disorders with Neurolinguistic Programming (NLP) eating disorders, 168 psychotic features, 137 (Bandler and Grinder), 46–47 factitious disorders, 99 Moral development, theories of (Kohlberg Neurophysiologic models, psychotic impulse control disorders, 174 and Gilligan), 43 disorders, 119 mood disorders, 155 Moral imperatives (ethical considerations), Neurotransmitters overview, 12, 18–19 23–24 chemical imbalance and self- personality disorders, 177 Moreno, J. L., 48 medication, 69 psychotic disorders, 129 Motivating climate, creating, 264 mood disorders, model for, 142 sexual disorders, 169, 171 Motivation, test taking, 8–9 in neurobiologic theories, 49, 50t sleep disorders, 172–173 Motivational Enhancement Therapy (MET), psychotic disorders, model for, somatoform disorders, 95, 96, 97, 98 73t 118–119 substance-related disorders, 74–75 Motor Skills Disorder, 210 Nicotine abuse, 68t. See also Substance- Ministry role in interdisciplinary team, 17 Mourning stage of group development, 23 related disorders Minuchin, Salvador, 48–49 Mowrer apparatus for Enuresis, 221 NLP (Neurolinguistic Programming) Mixed Receptive-Expressive Language Multi-Infarct Dementia, 192, 195 (Bandler and Grinder), 46–47 Disorder, 210 Multiple family group, 22 NMS (Neuroleptic Malignant Syndrome), Mixed-type delusions, 117 Multiple Personality Disorder (MPD), 121–122 Mobile crisis services, 254–255 102–104 Nodal events, mood disorders, 155 Moderate Mental Retardation, 208 Multiple-choice questions (MCQs), Nonexperimental research, 36 Molindone, 120 preparing for, 6–7 Nonmaleficence, 24 Monat, A., 52 Music as memory aid, 3 Nonverbal communication, 13–14 Monoamine oxidase inhibitors (MAOIs). Norepinephrine (NE), 50t, 119 See MAOIs (monoamine oxidase N Normal Pressure Hydrocephalus (NPH), inhibitors) Naltrexone, 70 Dementia Due to, 193 Mood disorders. See also Major Depression NAMI (National Alliance for the Mentally Norming stage of group development, 23 biochemical interventions, 144–152, Ill), 129 Nortriptyline, 146t 223–224 Narcissistic Personality Disorder, 177–178 Nurse–client relationship, 12–13 Bipolar Disorder, 140–141 Narcolepsy, 173 Nursing Care Plans, 18 children and adolescents, 222–224 Narcotics Anonymous, 176 Nursing diagnoses community resources, 155–156 Narcotics/opioids, 68t, 69, 70. See also Adjustment Disorder, 104 depressive disorders (unipolar), 138t, Substance-related disorders anxiety disorders 139–140, 179, 196 National Alliance for the Mentally Ill children and adolescents, 225, 226 diagnostic studies/tests, 143 (NAMI), 129 GAD, 89 differential diagnosis, 139, 140, 141, 222, National Center on Child Abuse and OCD, 94 223 Neglect (NCCAN), 239 Panic Disorder, 92 electroconvulsive therapy, 152–153 National Organization for Victim phobias, 84 epidemiology, 137, 138t, 139 Assistance, 89 PTSD, 87 family dynamics/family therapy, 155, Native Americans, 206 children and adolescents 222, 224 Natural system theory (family theories), anxiety disorders, 225, 226 genetic/biologic origins, 142–143, 223 48–49. See also Family dynamics/ attention-deficit and disruptive group approaches, 155, 224 family therapy behavior disorders, 213, intrapersonal origins, 153, 224 Nature, culturally derived attitudes about, 215–216, 217 intrapersonal psychotherapeutic 16 communication disorders, 211 interventions, 153–154 Navane, 175 eating disorders, 218 mental status variations, 223 NCCAN (National Center on Child Abuse elimination disorders, 221 milieu interventions, 155 and Neglect), 239 feeding and eating disorders, 218 Mood Disorder Due to General Medical NDRIs (norepinephrine dopamine learning disorders, 210 Condition, 137, 138t, 141 reuptake inhibitors), 144, 145t, 223 Mental Retardation, 208 Index 287

RAD, 228 Passive-Aggressive Personality Disorder, PMH (psychiatric and mental health) Stereotypic Movement Disorder, 179 nursing. See Psychiatric and mental 229 Pathological Gambling, 174 health (PMH) nursing tic disorders, 219 Patient care delivery, organizing, 265 Political issues in mental health Delirium, 188 Patient Rights Document, 259 environment, 258–259 Dementia, 193 Paul Wellstone & Pete Dominici Mental Positive thinking for testing motivation, 8–9 dissociative disorders, 100, 101, 102 Health Parity & Addiction Equity Act Postpartum depression, 139–140 eating disorders, 167, 218 (2008), 259 Posttraumatic Stress Disorder (PTSD), 84, factitious disorders, 99 Pedophilia, 168 86–89 impulse control disorders, 173–174 Peer evaluation, 267 Power relationships and mental health mood disorders, 143–144 Peer support group, 22 environment, 258 personality disorders, 175, 177, 179 Pender, Nola, 39 PPOs (Preferred Provider Organizations), psychotic disorders, 118 Peplau, H., 43 258 sexual disorders, 171 Performing stage of group development, Practice tests, 3, 7 sleep disorders, 172 23 Pregnancy categories, FDA, 20t somatoform disorders, 95, 96, 97, 98 Perls, Frederick (Fritz), 44 Premature Ejaculation, 171 substance-related disorders, 69 Perphenazine, 120 Prescriptive authority and principles, 12, Nursing process, 12 Persecutory/paranoid delusions, 117 19–21 Nursing theories, 37–39 Personality disorders President’s Commission on Mental Health Nutritional supplements, 69, 189 Antisocial Personality Disorder, 175–176 (1977), 259 Avoidant Personality Disorder, 178, 179 Prevention as community intervention, 262 O Borderline Personality Disorder, 176–177 Primary Hypersomnia, 173 Obesity, proposal as eating disorder, 165 children and adolescents, 231 Primary Insomnia, 171–173 Object loss hypothesis, mood disorders, Cluster A, 174–175 Privacy issue, 16, 24 153 Cluster B, 174, 175–178 Private practice, 256–257, 260–261 Obsessive-Compulsive Disorder (OCD), 84, Cluster C, 174, 178–179 Profound Mental Retardation, 208 93–95, 227 Dependent Personality Disorder, 178, Propanolol, 69 Obsessive-Compulsive Personality Disorder 179 Protection and Advocacy for Mentally Ill (OCPD), 178, 179 Depressive Personality Disorder, 179 Individuals Act (1986), 259 Occupational therapy, 17 Histrionic Personality Disorder, 177 Proxemics, 14 Olanzapine, 123t, 124–125, 149t Narcissistic Personality Disorder, Pseudodementia, 196 Olanzapine and fluoxetine combination, 177–178 Pseudoparkinsonism, 120–121, 122 149t OCPD, 178, 179 Psychiatric and mental health (PMH) One-letter memory aid, 3 Paranoid Personality Disorder, 175 nursing Open systems theory, 264–265 Passive-Aggressive Personality Disorder, case management, 17–18 Operational planning, 263 179 change, defined, 11–12 Opioids/narcotics, 68t, 69, 70. See also Schizoid Personality Disorder, 174–175 childhood and adolescence certification, Substance-related disorders Shizotypal Personality Disorder, 175 205 Oppositional-Defiant Disorder, 217–218 Personality theories, 39–42 client advocacy, 17 Orem, Dorothea, 37 Pharmacodynamics, 19 communication, 13–15 Organizing function of management, Pharmacogenetic research, 19 consultative liaison role, 18, 269–270 264–265 Pharmacokinetics, 19 ethical considerations, 23–24 Orgasmic Disorder, 171 Pharmacology, defined, 19. See also expert testimony role in child Outpatient settings, 256–257 Biochemical interventions maltreatment cases, 239–240 Outside communication, right to, 24 Phase delay hypothesis, mood disorders, family therapy, 21–22 Oxcarbazepine, 149t 143 group therapy and dynamics, 22–23 Phenelzine, 146t interdisciplinary treatment team, 16–17 P Phenothiazines, 120t leadership theory and roles, 261 Pain Disorder, 97–98, 196–197 Phobias, 83–86 managed care, 257 Palilalia, 219 Phonological Disorder, 210 management theory and roles, 261–269 Paliperidone, 123t, 125 PHPs (partial hospitalization programs), mental health education, 21, 22 Panic Disorder, 84, 91–93 255 mental health factors, 11 Paradoxical prescription in family therapy, Physical abuse of child, 235–236 milieu therapy, 18–19 22 Physical attending, 14 nurse–client relationship, 12–13 Paralanguage, 14 Physical neglect of child, 235 nursing process, 12 Paranoid Personality Disorder, 175 Piaget, Jean, 42–43 prescriptive authority and principles, 12, Paranoid Schizophrenia, 116 Pica, 218 19–21 Paraphilias, 168–169 Pick’s Disease, Dementia Due to, 192 reimbursement for mental health Paroxetine, 144t, 226, 227 Pimozide, 220 services, 257–258 Partial hospitalization programs (PHPs), Planning function of management, sociopolitical factors, 15–16, 258–261 255 261–263 types of care settings for, 253–257 Participating leadership strategy, 261 Play therapy, 217, 232 Psychiatric emergency services, 254 288 Index

Psychodrama (Moreno), 48 PTSD (Posttraumatic Stress Disorder), 84, community resources, 129 Psychodynamic/psychoanalytic 86–89 definition, 115 approaches Public mental hospital settings, 253 electroconvulsive therapy, 152 Adjustment Disorder, 105 Pyromania, 174 epidemiology, 115 anxiety disorders family dynamics/family therapy, 128–129 GAD, 90 Q genetic/biologic theories, 118–119 OCD, 94 Qualitative research, 36 and geropsychiatric nursing, 196 Panic Disorder, 92 Quality in health care, 266–267 group approaches, 129 phobias, 84–85 Quasi-experimental research, 36 intrapersonal origins, 125 PTSD, 87 Quetiapine, 123t, 149t intrapersonal psychotherapeutic Dissociative Amnesia, 100 interventions, 125–128 Freudian theory, 39–40, 41t R milieu interventions, 129 Gender Identity Disorder, 170 Ramelteon, 172 nursing diagnoses, 118 Jungian psychoanalysis, 40 Rational Emotive Behavior Therapy (Ellis), and Schizoaffective Disorder, 117 mood disorders, 153 44–45 signs and symptoms, 115–116 sexual disorders, 169, 171 Reactive Attachment Disorder (RAD) of and substance abuse, 63 substance-related disorders, 70–71 Infancy or Early Childhood, 227–228 subtypes, 116 Psychoeducation, 22, 88 Reading Disorder, 209 theory of two types, 119 Psychosocial approaches for Delirium and Reality Therapy (Glasser), 45 Schizophreniform Disorder, 116 Dementia, 189, 194t, 195 Reciprocal Inhibition (Wolpe), 45 Screening instruments Psychosocial Development, Theory of Reconstructive psychotherapy, 13 Dementia, 191 (Erikson), 42 Recreational therapy, 17 eating disorders, 166 Psychosurgery, 153 Re-educative psychotherapy, 13 mood disorders, 143–144 Psychotherapeutic drugs. See Biochemical Refusal of treatment right, 24, 268 substance-related disorders, 64 interventions Rehabilitative case management, 17 Seasonal Affective Disorder (SAD), 139, Psychotherapeutic interventions. See Reimbursement for mental health services, 143 Family dynamics/family therapy; 257–258, 260 Seclusion and restraints, patient rights Group approaches; Intrapersonal Reinforcement theory (Skinner), 263 concerning, 259 psychotherapeutic interventions Relational-collectivist attitudes, 15–16 Sedative hypnotic abuse, 68t. See also Psychotic Disorder Due to a General REM latency measurement, 143 Substance-related disorders Medical Condition, 117 Reminiscence groups, 195, 197 Selective Mutism, 225–226 Psychotic Disorder Not Otherwise Research and theory, 35, 36–37 Selective serotonin reuptake inhibitors Specified, 118 Research-Based Practice Protocols, 18 (SSRIs). See SSRIs (selective Psychotic disorders. See also Schizophrenia Residual Schizophrenia, 116 serotonin reuptake inhibitors) biochemical interventions, 119–125, Resistance, 13 Selegiline, 146t 230 Restraints and seclusion, patient rights Self-Care, Theory of (Orem), 37 Brief Psychotic Disorder, 117 concerning, 259 Self-care activities, 12 community resources, 129 Restricting type of Anorexia Nervosa, 165 Self-Concept, Theory of (Hattie), 51–52 Delusional Disorder, 116–117 Rett’s Disorder, 212 Self-Disclosure, Theory of (Archer), 52 differential diagnosis, 116, 117, 118 Rhymes as memory aid, 3 Self-evaluation, 267 family dynamics/family therapy, 128–129 Rights of client, 24 Self-help approaches. See Group genetic/biologic origins, 118–119 Risperidone, 123t, 124 approaches group approaches, 129 Rivastigmine, 194t Selling leadership strategy, 261 intrapersonal origins, 125 Rogers, Carl, 43–44 Selye, Hans, 52 intrapersonal psychotherapeutic Rogers, Martha, 38 Separation Anxiety Disorder, 224–225 interventions, 125–128 Role Theory (Hardy and Conway), 52 Serotonin (5-HT), 50t, 119 milieu interventions, 129 Roy, Sister Callista, 38 Serotonin norepinephrine reuptake nursing diagnoses, 118 Rumination Disorder of Infancy, 218 inhibitors (SNRIs). See SNRIs Psychotic Disorder Due to a General Runaways, 234 (serotonin norepinephrine reuptake Medical Condition, 117 inhibitors) Psychotic Disorder Not Otherwise S Serotonin Syndrome (SS), 147, 152 Specified, 118 SAD (Seasonal Affective Disorder), 139, 143 Sertraline, 144t, 226, 227 Schizoaffective Disorder, 117, 125 Sadism, sexual, 169 Severe Mental Retardation, 208 Schizophreniform Disorder, 116, 119 SANE (sexual assault nurse examiner), 240 Sex Addicts Anonymous, 171 Shared Psychotic Disorder (Folie à deux), Scapegoating behavior in families, 21 Sexual abuse of child, 236, 237–238 117 Schedule of Controlled Substances, 20t Sexual assault nurse examiner (SANE), 240 signs and symptoms, 115–117 Schizoaffective Disorder, 117, 125, 138t Sexual Aversion Disorder, 171 Substance-Induced Psychotic Disorder, Schizoid Personality Disorder, 174–175 Sexual disorders and dysfunctions, 117–118 Schizophrenia 168–169, 170–171 Psychotic features, mood disorder with, biochemical interventions, 119–125 Sexual masochism, 168 137 childhood or early-onset versions, Sexual sadism, 169 Psychotropic medications, 19 230–231 Shared Psychotic Disorder, 117 Index 289

Shizotypal Personality Disorder, 175 Social Security Act (1935), 258 disease model, 73 Signs and symptoms Social work, 17 dual diagnosis (comorbidity), 69 Adjustment Disorder, 104 Social/interpersonal theories, 43 epidemiology, 63 anxiety disorders Sociocultural theories, substance-related family dynamics/family therapy, 71, 73 children and adolescents, 224, 225, disorders, 73 genetic/biologic origins, 69 226 Solution Focused Therapy (de Shazer and and geropsychiatric nursing, 196 GAD, 89 O’Hanlon), 51, 90 group interventions, 73–74 OCD, 93 Somatic delusions, 117 impaired nurses, 75 Panic Disorder, 91 Somatic therapies for ECT clients, 12 intrapersonal origins, 70–71 phobias, 83–84 Somatization Disorder, 96–97 intrapersonal psychotherapeutic PTSD, 86 Somatoform disorders, 95–98 interventions, 71, 72–73t, children and adolescents SS (Serotonin Syndrome), 147, 152 229–230 anxiety disorders, 224, 225, 226 SSRIs (selective serotonin reuptake mental status variations, 66–68t attention-deficit and disruptive inhibitors) milieu interventions, 74–75 behavior disorders, 212–213, anxiety disorders, 84–85t, 87, 90, 92, 94, nursing diagnoses, 69 215, 217 226, 227 signs and symptoms, 63–64 communication disorders, 210–211 for children and adolescents, 220, 226, sociocultural theories, 73 eating disorders, 218–219 227, 233 Substance-Use vs Substance-Induced elimination disorders, 220, 221 Dementia, 193–194t Disorder, 63 EOS/COS, 230 mood disorders, 144, 144t, 223 Success, culturally derived attitudes about, feeding and eating disorders, sexual disorders, 169 15 218–219 Tourette’s Disorder, 220 Suicide, 139, 141–142, 153, 196, 222–223 learning disorders, 209–210 Standards of care, 268 Sullivan, Harry Stack, 43 Mental Retardation, 208 State laws “Sundowner Syndrome,” 193 mood disorders, 222, 223 on admission to inpatient facilities, 267 Supportive case management, 17 PDDs, 211–212 on child abuse and neglect, 239 Supportive psychotherapy, 13 RAD, 227–228 Statistical data analysis, 36–37 Supportive/therapeutic group, 22 Stereotypic Movement Disorder, 228 Stereotypic Movement (formerly Systematic Reviews in EBP, 36 tic disorders, 219, 220 Stereotypy/Habit) Disorder, 228–229 Systems Theory (Bertalanffy), 47–48 Delirium, 187 Stereotyping, 15 Dementia, 190–191, 192 Stimulants for ADHD, 213–214, 214t, 233 T dissociative disorders, 99, 100, 101, 102 Storming stage of group development, 23 Tacrine, 194t eating disorders, 165, 166, 218–219 Stranger anxiety, 224–225 Tardive dyskinesia (TD), 121 factitious disorders, 98–99 Strategic Family Therapy (Madanes and Task group, 22 Gender Identity Disorder, 169–170 Haley), 49 TCAs (tricyclic antidepressants) mood disorders, 139, 140, 141, 222, 223 Strategic planning, 263 anxiety disorders, 87, 94, 227 personality disorders, 175–176 Stress Theory (Selye), 52 mood disorders, 145, 146t, 223 psychotic disorders, 115–117 Stress-related disorders. See also Anxiety Teaching group, 22 somatoform disorders, 95, 96–97 disorders Telling leadership strategy, 261 substance-related disorders, 63–64 Adjustment Disorder, 104–105 Test taking strategies/techniques Simple Motor Tics, 219 dissociative disorders, 99–104 approach to test questions, 6–7 Simple Vocal Tics, 219 factitious disorders, 98–99 content knowledge, 3–6 Situational runaways, 234 somatoform disorders, 95–98 knowing self, 1 Skills training for childhood and Structural Family Therapy (Minuchin), motivating self, 8–9 adolescence disorders, 232 48–49 rules for test taking, 7–8 Skinner, Burrhas Frederic (B. F.), 45, 263 Studying process and tips, 4–6 thinking skill development, 1–3 Sleep disorders, 171–173, 188, 189, 196 Stuttering, 210–211 Testing behaviors by client, defined, 13 Sleep EEG, 143 Substance-Induced Mood Disorder, 138t, Theoretical frameworks Sleep patterns and mood disorders, 143 141 attribution theory, 154 Sleep Terror Disorder, 173 Substance-Induced Psychotic Disorder, behavioral theories, 44–49, 263 Sleep-Wake Schedule Disorder, 173 117–118 cognitive theories, 42–43, 45–46 Sleepwalking Disorder, 173 Substance-related disorders communication theories, 46–47 Smoking and Schizophrenia, 63 and Antisocial Personality Disorder, 176 Coping, 52 SNRIs (serotonin norepinephrine reuptake assessment elements, 65 Crisis Intervention, 51, 105 inhibitors) biochemical interventions, 69–70 evidence-based practice (EBP), 35–36 anxiety disorders, 84–85t, 87, 90, 92, 94 children and adolescents, 229–230 existential/humanistic theories, 43–45 mood disorders, 144, 145t, 223 community resources, 75 group behavior theories, 47–49 Social communication, 14 complications from, 65–66 growth and development theories, Social issues in mental health environment, definition, 63 42–43 11, 258, 262 and Delirium, 188, 189 Herzberg’s Two Factor Motivation Social Learning Theory (Bandura), 46, 71 diagnostic studies/tests, 64, 229 Theory, 264 Social Phobia, 83, 84, 226–227 differential diagnosis, 64 hopelessness theory of depression, 154 290 Index

Theoretical frameworks (continued) Tolerance for substance indicating Urine drug screening (UDS), 64 leadership, 261 dependence, 64 Utilitarianism ethical perspective, 23 management, 261–269 Total Quality Management (TQM), neurobiologic theories, 49, 50t, 118–119, 266–267 V 142 Tourette’s Disorder, 219–220 Vagal nerve stimulation, 153 nursing theories, 37–39 Transactional Analysis (Berne), 47 Vaginismus, 171 open systems theory, 264–265 Transcranial magnetic stimulation, 153 Validation groups for Dementia, 195 personality theories, 39–42 Transference, 13, 23 Valproate/valproic acid/divalproex sodium, and research, 35, 36–37 Transient Tic Disorder, 220 147, 149t, 224, 233 Role Theory, 52 Transvestic fetishism, 169 Vascular Dementia, 192, 195 social/interpersonal theories, 43, 46, 71 Tranylcypromine, 146t Venlafaxine, 145t, 214t Solution Focused Therapy, 51 Traumatic Brain Injury, Dementia Due to, Verbal communication, 13, 16 Stress Theory, 52 192–193 Violent behavior, 234, 269 theory definition and characteristics, 35 Trazodone, 145t, 172 Voluntary admission, 267 Theory of Self-Concept, 51–52 Treatment, right to, 24 Voluntary agencies, 17 Theory of Self-Disclosure, 52 TRH (thyrotropin releasing hormone) Von Bertalanffy, L. V., 47–48 Theory of Nursing (Rogers), 38 stimulation test, 143 Voyeurism, 169 Therapeutic communication, 14–15 Triangling behavior in families, 21 Therapeutic community, 18 Trichotillomania, 174 W Therapeutic environment. See Milieu Tricyclic antidepressants (TCAs). See TCAs Withdrawal management for substance- interventions (tricyclic antidepressants) related disorders, 74 Thinking skill development for test taking, Trifluoperazine, 120 Withdrawal symptoms for substance 1–3 Trust and rapport, developing, 14–15 indicating dependence, 64 Thioridazine, 120 12-Step Facilitation Therapy, 73t Wolpe, Joseph, 45 Thiothixene, 120 Two Factor Motivation Theory (Herzberg), Women and men, gender role stereotypes, Thioxanthenes, 120t 264 258 Third-party reimbursement, obtaining, Type I Schizophrenia, 119 Women’s health issues, management 260 Type II Schizophrenia, 119 planning, 262–263 Throwaways, 234 Typical antipsychotics, 119–122 Thyrotropin releasing hormone (TRH) Y stimulation test, 143 U Youth gangs, 234 Tic disorders, 219–220 Undifferentiated Schizophrenia, 116 Time, culturally derived attitudes about, Unipolar depressive disorders, 138t, Z 15 139–140, 179, 196. See also Major Zalplon, 172 Tobacco use and Schizophrenia, 63 Depression Ziprasidone, 123t, 125, 149t Token community, 18 Urinary MHPG, 143 Zolpidem, 172