Psychiatric Nursing NCLEX Reviewer

Mental Health and Mental Illness
Mental health and mental illness are difficult to define precisely. The culture of any society strongly influences its beliefs
and values, and this in turn affects how that society defines health and illness.
Mental Health
No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his or her
mental health.
In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying
interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
Factors influencing a person’s mental health can be categorized as: individual, interpersonal, and social/cultural.
 Individual, or personal, factors include a person’s biologic make up, autonomy and independence, self-esteem,
capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging,
reality orientation, and coping or stress management abilities.
 Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a
balance of separateness and connectedness.
 Social/cultural, or environmental, factors include a sense of community, access to adequate resources,
intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet
realistic, view of one’s world.
Mental Illness
The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or
psychological syndrome or pattern that occurs in an individual and is associated with present distress or with a
significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
General criteria to diagnose mental disorders include dissatisfaction with one’s characteristics, abilities, and
accomplishments; ineffective or unsatisfying relationships; dissatisfaction with one’s place in the world; ineffective
coping with life events; and lack of personal growth.
Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/cultural
categories.
 Individual factors include biologic make up, intolerable or unrealistic worries or fears, inability to distinguish
reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of meaning in
one’s life.
 Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from
relationships, no sense of belonging, inadequate social support, and loss of emotional control.
 Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view
of the world, and discrimination.
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) is a taxonomy
published by the APA.
 The DSM-IV-TR describes all mental disorders, outlining specific diagnostic criteria for each based on clinical
experience and research.
The DSM-IV-TR has three purposes:
 To provide a standardized nomenclature and language for all mental health professionals.
 To present defining characteristics or symptoms that differentiate specific diagnoses.
 To assist in identifying the underlying causes of disorders.
The multiaxial classification system that involves assessment on several axes, or domains of information, allows the
practitioner to identify all the factors that relate to a person’s condition.
 Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders.
 Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality
features and defense mechanisms.
 Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the
person’s mental disorder as well as medical conditions that might contribute to understanding the person.
 Axis IV for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and
prognosis of mental disorders.
 Axis V presents a Global Assessment of Functioning, which rates the person’s overall psychological functioning
on a scale of 0 to 100; this represents the clinician’s assessment of the person’s current level of functioning.
Historical Perspectives of the Treatment of Mental Illness
Ancient Times
 People of ancient times believed that any sickness indicated displeasure of the gods and in fact was punishment
for sins and wrongdoing.
 Those with mental disorders were viewed as either divine or demonic, depending on their behavior.
 Later, Aristotle attempted to relate mental disorders to physical disorders and developed his theory that the
amounts of blood, water, and yellow and black bile in the body controlled the emotions.
 These four substances, or humors, corresponded with happiness, calmness, anger, and sadness; imbalances of
the four humors were believed to cause mental disorders, so treatment was aimed at restoring balance through
bloodletting, starving, and purging.
 In early Christian times, all diseases were again blamed on demons, and the mentally ill were viewed as
possessed; priests perform exorcism to to rid evil spirits.
 During the Renaissance, people with mental illness were distinguished from criminals in England; those
considered harmless were allowed to wander the countryside and or live in rural communities, but the more
“dangerous lunatics” were thrown in prison, chained, and starved.
 In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its
kind; by 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the
intimates, who were seen as animals, less than human.
Period of Enlightenment and Creation of Mental Institutions
 In the 1790s, a period of enlightenment concerning persons with mental illness began.
 Phillipe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven
offering protection at institutions where people had been whipped, beaten, or starved just because they were
mentally ill (Gollaher, 1995).
 In the United States, Dorothea Dix (1802-1887) began a crusade to reform the treatment of mental illness after a
visit to Tukes’ institution in England; she was instrumental in opening 32 state hospitals that offered asylum to
the suffering.
Sigmund Freud and Treatment of Mental Disorders
 The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856-1939) and
others, such as Emil Kraeplin (1856-1926) and Eugene Bleuler (1857-1939).
 With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest.
 Freud challenged society to view human beings objectively; he studied the mind, its disorders, and their
treatment as no one had before.
 Kraeplin began classifying mental disorders according to their symptoms, and Bleuler coined the term
schizophrenia.
Development of Psychopharmacology
 A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs,
or drugs used to treat mental illness.
 Chlorpromazine (Thorazine) an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be
developed.
 Over the following 10 years, monoamine oxidase inhibitor antidepressants, haloperidol (Haldol), an
antipsychotic; tricyclic antidepressants; and antianxiety agents, called benzodiazepines, were introduced.
Mental Illness in the 21st Century
 The National Institute of Mental Health (NIMH) estimates that more than 26% of Americans aged 18 years and
older have a diagnosable mental disorder- approximately 57.7 million persons each year (2006).
 Furthermore, mental illness or serious emotional disturbances impair daily activities for an estimated 10 million
adults and 4 million children and adolescents.
 Mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years
of age.
 Homelessness is a major problem in the United States today; the National Resource and Training Center on
Homelessness and Mental Illness (2006) estimates that one-third of adult homeless persons have a serious
mental illness and that more than one half also have substance abuse problems.
 In 1993, the federal government created and funded Access to Community Care and Effective Services and
Support (ACCESS) to begin to address the needs of people with mental illness who were homeless either all or
part of the time.
Psychiatric Nursing Practice
 In 1873, Linda Richards graduated from the New England Hospital for Women and Children in Boston; she went
on to improve nursing care in psychiatric hospitals and organized educational programs in state mental hospitals
in Illinois.
 Richards is called the first American psychiatric nurse; she believed that “the mentally sick should be at least as
well cared for as the physically sick” (Doona, 1984).
 The first training of nurses to work with persons with mental illness was in 1882 at McLean Hospital in Belmont,
Massachusetts.
 The care was primarily custodial and focused on nutrition, hygiene, and activity.
 The role of psychiatric nurses expanded as somatic therapies for the treatment of mental disorders were
developed.
 Treatments such as insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive therapy (1937)
required nurses to use their medical-surgical skills more extensively.
 The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey was published in 1920; in 1913,
John Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum.
 In 1973, the division of psychiatric and mental health practice of the American Nurses Association (ANA)
developed standards of care, which it revised in 1982, 1994, and 2000.
 Standards of care are authoritative statements by professional organizations that describe the responsibilities
for which nurses are accountable.
 The goal of self-awareness is to know oneself so that ones’ values, attitudes, and beliefs are not projected to the
client, interfering with nursing care; self-awareness does not mean having to change one’s values and beliefs
unless one desires to do so.
References
Sources and references for this study guide for mental health and psychiatric nursing, including interesting studies for
your further reading:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American
Psychiatric Pub. [Link]
Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]
Many theories attempt to explain human behavior, health, and mental illness. Each theory suggests how
normal development occurs based on the theorist’s beliefs. assumptions, and view of the world.
 These theories suggest strategies that the clinician can use to work with clients.
 Many theories were not based on empirical or research evidence; rather, they evolved from
individual experiences and might more appropriately be called conceptual models or frameworks.
Types of Psychosocial Theories

The types of psychosocial theories include the following:
 Psychoanalytic. Psychoanalytic theory supports the notion that all human behavior is caused and
can be explained (deterministic theory).
 Developmental. In each stage, the person must complete a life task that is essential to his or her
well-being and mental health.
 Interpersonal. One’s personality involves more than individual characteristics, particularly how one
interacts with others.
 Humanistic. Humanism represents a significant shift away from the psychoanalytic view of the
individual as a neurotic, impulse-driven person with repressed psychic problems and away from the
focus on and examination of the client’s past experiences.
 Behavioral. Behaviorism is a school of psychology that focuses on observable behaviors and what
one can do externally to bring about behavior changes
 Existential. Existential theorists believe that behavioral deviations result when the person is out of
touch with himself or herself or the environment.
1. PSYCHOANALYTIC THEORIES
Psychoanalytic theory supports the notion that all human behavior is caused and can be explained
(deterministic theory).
Sigmund Freud: The Father of Psychoanalysis

 Sigmund Freud (1856-1939) developed psychoanalytic theory in the late 19th and early 20th centuries in Vienna,
where he spent most of his life.
 Freud believed that repressed (driven from conscious awareness) sexual impulses and desires
motivate much human behavior.
 Personality components: id, ego,and superego. Freud conceptualized personality structure as
having three components: id, ego, and superego.
 The id is the part of one’s nature that reflects basic or innate desires such as pleasure seeking
behavior, aggression, and sexual impulses.
 The superego is the part of a person’s nature that reflects moral and ethical concepts, values, and
parental and social expectations, therefore it is in direct opposition to the id.
 The third component, the ego, is the balancing or mediating force between the id and the superego.
 Behavior motivated by subconscious thoughts and feelings. Freud believed that the human
personality functions at three levels of awareness: conscious, preconscious, and subconscious.
 Conscious refers to the perceptions, thoughts, and emotions that exists in a person’s awareness,
such as being aware of happy feelings or thinking about a loved one.
 Preconscious thoughts and emotions are not currently in the person’s awareness, but he or she can
recall them with some effort.
 The unconscious is the realm of thoughts and feelings that motivate a person even though he or
she is totally unaware of them.
Phase Age Focus
Oral Birth to 18 Major site of tension and gratification is the mouth, lips,
months and tongue; includes biting and sucking activities.
Id present at birth.
Ego develops gradually from rudimentary structure

present at birth.
Anal 18 to 36 Anus and surrounding area are major source of interest.

months
Acquisition of voluntary sphincter control (toilet training).
Phallic/oedipal 3 to 5 years Genital focus of interest, stimulation, and excitement.

Penis is organ of interest for both sexes.
Masturbation is common.
Penis envy (wish to possess penis) seen in girls; oedipal

complex (wish to marry opposite-sex parent and be rid of
same-sex parent) seen in boys and girls.
Latency 5-11 or 13 Resolution of oedipal complex.

years
Sexual drive channeled into socially appropriate activities

such as schoolwork and sports.
Formation of the superego.
Final stage of psychosexual development.
Genital 11-13 years Begins with puberty and the biologic capacity for orgasm;
involves the capacity for true intimacy.
2. Developmental Theories
In each stage, the person must complete a life task that is essential to his or her well-being and mental health.
Erik Erikson and Psychosocial Stages of Development

 Erik Erikson was a German born psychoanalyst who extended Freud’s work on personality
development across the life span while focusing on social and psychological development in the life
stages.
 In his view, psychosocial growth occurs in sequential phases, and each stage is dependent on
completion of the previous stage and life task.
Stage Virtue Task
Trust vs. Mistrust (infant) Hope Viewing the world as safe;

relationships as nurturing,
stable, and dependable.
Autonomy vs. Shame and Will Achieving a sense of control

doubt (toodler) and free will.
Initiative vs. Guilt (preschool) Purpose Beginning development of a

conscience; learning to
manage conflict and anxiety.
Industry vs. Inferiority (school Competence Emerging confidence in own

age) abilities; taking pleasure in
accomplishments.
Identity vs. role confusion Fidelity Formulating a sense of self and

(adolscence) belonging.
Intimacy vs. Isolation (young Love Forming adult, loving

adult) relationships and meaningful
attachment to others.
Generativity vs. Stagnation Care Being creative and productive;

(middle adult) establishing the next
generation.
Ego integrity vs. Despair Wisdom Accepting responsibility for

(maturity) one’s self and life.
Jean Piaget and Cognitive Stages of Development

 Jean Piaget explored how intelligence and cognitive functioning develop in children.
 He believed that human intelligence progresses through a series of stages based on age, with the child
at each successive stage demonstrating a higher level of functioning than at previous stages.
Stage Age Focus
Sensorimotor Birth to 2 years The child develops a sense of self as separate

from the environment and the concept of object
permanence; that is, tangible objects do not
cease to exist just because they are out of sight.
He or she begins to form mental images.
Preoperational 2 to 6 years The child develops the ability to express self with
language, understands the meaning of symbolic
gestures, and begins to classify objects.
Concrete 6 to 12 years The child begins to apply logic to thinking,
operations understands spatiality and reversibility, and is
increasingly social and able to apply rules;
however, thinking is still concrete.
Formal 12 to 15 years The child learns to think and reason in abstract
operations and beyond terms, further develops logical thinking and
reasoning, and achieves cognitive maturity.
3. Interpersonal Theories
 One’s personality involves more than individual characteristics, particularly how one interacts with
others.
Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy

 Harry Stack Sullivan was an American psychiatrist who extended the theory of personality development
to include the significance of interpersonal relationships.
 Sullivan established five life stages of development- infancy, childhood, juvenile, preadolescence, and
adolescence, each focusing on various interpersonal relationships.
Stage Ages Focus
Infancy Birth to onset of Primary need for bodily contact and tenderness.
language
Prototaxic mode dominates (no relation between
experiences).
Primary zones are oral and anal.
If needs are met, infant has sense of well-being;
unmet needs lead to dread and anxiety.
Childhood Language to 5 years Parents viewed as source of praise and
acceptance.

Shift to parataxic mode (experiences are
connected in sequence to each other).
Primary zone is anal.
Gratification leads to positive self-esteem.
Moderate anxiety leads to uncertainty and
insecurity; severe anxiety results in self defeating
patterns of behavior.
Juvenile 5-8 years Shift to the syntaxic mode begins (thinking about
self and others based on analysis of experiences
in a variety of situations).

Opportunities for approval and acceptance of
others.
Learn to negotiate own needs.
Severe anxiety may result in a need to control or
in restrictive, prejudicial attitudes.
Preadolescenc 8-12 years Move to genuine intimacy with friend of the same
e sex.

Move away from family as source of satisfaction
in relationships.
Major shift to syntaxic mode.
Capacity for attachment, love, and collaboration
emerges and fails to develop.
Adolescence Puberty to adulthood Lust is added to interpersonal equation.

Need for special sharing relationship shifts to the
opposite sex.
New opportunities for social experimentation
lead to the consolidation of self-esteem or self
ridicule.
If the self-system is intact, areas of concern
expand to include values, ideals, career decisions,
and social concerns.
4. Humanistic Theories
 Humanism represents a significant shift away from the psychoanalytic view of the individual as a
neurotic, impulse-driven person with repressed psychic problems and away from the focus on and
examination of the client’s past experiences.
Abraham Maslow: Hierarchy of Needs
 Abraham Maslow was an American psychologist who studied
the needs or motivations of the individual.
 Maslow (1954) formulated the hierarchy of needs, in which
he used a pyramid to arrange and illustrate the basic drives
or needs that motivate people.
 The most basic needs- the physiologic needs of food, water,
sleep, shelter, sexual expression, and freedom from pain-
must be met first.
 The second level involves safety and security needs, which
include protection, security, and freedom from harm or
threatened deprivation.
 The third level is love and belonging needs, which includes
enduring intimacy, friendship, and acceptance.
 The fourth level involves esteem needs, which include the
need for self-respect and esteem from others.
 The highest level is self-actualization, the need for beauty,
truth, and justice.
Carl Rogers: Client-Centered Therapy

 Carl Rogers was a humanistic American psychologist who focused on the therapeutic relationship and
developed a new method of client-centered therapy.
 Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the
healing process.
 The therapist must promote the client’s self-esteem as much as possible through three central
concepts.
 Unconditional positive regard– a nonjudgmental caring for the client that is not dependent on the
client’s behavior.
 Genuineness– realness or congruence between what the therapist feels and what he or she says to the
client.
 Empathetic understanding– in which the therapist senses the feelings and personal meaning from the
client and communicates this understanding to the client.
5. Behavioral Theories
 Behaviorism is a school of psychology that focuses on observable behaviors and what one can do
externally to bring about behavior changes
Ivan Pavlov: Classical Conditioning

 Laboratory experiments with dogs provided the basis for the development of Ivan Pavlov’s theory of
classical conditioning:Behavior can be changed through conditioning with external or environmental
conditions or stimuli.
B.F. Skinner: Operant Conditioning

 One of the most influential behaviorists was B. F. Skinner, an American psychologist.
 He developed the theory of operant conditioning which says people learn their behavior from their
history or past experiences, particularly those experiences that were repeatedly reinforced.
6. Existential Theories
 Existential theorists believe that behavioral deviations result when the person is out of touch with
himself or herself or the environment.
Cognitive Therapy
 Many existential therapists use cognitive therapy, which focuses on immediate, thought processing-
how a person perceives or interprets his or her experience and determines how he or she feels and
behaves.
 Aaron Beck is credited with pioneering cognitive therapy in persons with depression.
Rational Emotive Therapy
 Albert Ellis, founder of rational emotive therapy, identified 11 “irrational beliefs” that people use to make
themselves happy.
 A cognitive therapy using confrontation of ” irrational beliefs” that prevent the individual from accepting
responsibility for self and behavior.
Logotherapy
 Viktor Frankl based his beliefs on his observations of people in Nazi concentration camps during World
War II.
 A therapy designed to help individuals assume personal responsibility.
 The search for meaning (logos) in life is a central theme.
Gestalt Therapy
 Gestalt therapy, founded by Frederick “Fritz” Perls, emphasizes the person’s feelings and thoughts in
the here and now.
 A therapy focusing on the identification of feelings in the here and now, which leads to self-acceptance.
Reality Therapy
 William Glasser devised an approach called reality therapy that focuses on the person’s behavior and
how that behavior keeps him or her from achieving life goals.
 Therapeutic focus is need for identity through responsible behavior individuals are challenged to
examine ways in which their behavior thwarts their attempts to achieve life goals.
References
Sources and references for this study guide for therapeutic communication, including interesting studies for
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®).
American Psychiatric Pub. [Link]
What are Defense Mechanisms?
 The term defense mechanism refers to a predominantly unconscious self-protective process that seeks
to shield the ego from intense feelings or affect and impulses.
 Additionally, these intrapsychic processes modify, nullify, or convey painful affects or tendencies so
they can be tolerated consciously.
 Defense mechanisms mostly operate at the subconscious level of awareness, so people are not aware
of what they are doing.
Major Defense Mechanisms
 Learning defense mechanism has become an integral component of psychotherapy. Some of the major
defense mechanism that are widely used are the following:
Defense Mechanism Definition Example
Redirection of negative urges or feelings from an original The man who is angry with his boss and returns home and
Displacement
object to a safer or neutral substitute. becomes angry instead with his wife or children.
Refusal to admit to a painful reality, which is treated as if The woman who miscarries denies that she has lost the baby and
Denial
it does not exist. continues to wear maternity clothes.
Use of excessive reasoning rather than reacting or A woman attending Alcoholics Anonymous meeting reports that
Intellectualization
changing. she is a nurse and has conducted many 12-step sessions.
Engulfment or incorporation of specific traits, behaviors A depressed man who incorporates the negative feelings and
Introjection
or qualities into self or ego structure. hatred of his estranged wife, who recently filed for divorce.
Blame of other’s or things for one’s own feelings or

Projection The client experiencing paranoia blames others for disliking him.
thoughts.
An effort to replace or justify acceptable reasons for A woman who overextended credit cards rationalizes that she can
Rationalization
feelings, beliefs, thoughts, or behaviors for real ones. use er savings to pay for a new dress she recently purchased.
Reaction Repression of painful or offensive attitudes or traits with The college student who feels angry and hostile toward her
formation unconscious opposite ones. professor is overtly friendly and agreeable in class.
The 3-year old child who begins wetting his pants after the birth of
Regression Retreat to an earlier developmental stage.
a new sibling.
Unconscious, purposeful forgetting of painful or

The married woman who expresses hostility toward a male co-
Repression dangerous thoughts (the most basic defense
worker to avoid dealing with her sexual attraction to him.
mechanism).
Normal form of dealing with undesirable feelings or The woman who is unable to bear children begins working in a
Sublimation
thoughts by keeping them in an acceptable context. preschool.
Conscious and deliberate forgetfulness of painful or A rape victim attempts to forget the incident and fails to report it to
Suppression
undesirable thoughts and ideas. the proper authorities.
References
Sources and references for this study guide for defense mechanisms:
Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,.
Vaillant, G. E. (1992). Ego mechanisms of defense: a guide for clinicans and researchers. American
Psychiatric Pub.
Videbeck, S. L. (2017). Psychiatric Mental Health Nursing.
Dissociative disorders are mental disorders that involve problems with memory, identity, emotion, perception, behavior,
and sense of self. People who have endured physical, sexual, or emotional abuse during childhood are at a higher risk of
acquiring dissociative disorders. The three major dissociative disorders defined in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) include dissociative identity disorder, dissociative amnesia, and
depersonalization/derealization disorder. Review this study guide and learn more about dissociative disorders, its
nursing care management, interventions, and assessment.
What are Dissociative Disorders?

The essential feature of the dissociative disorders is a disruption in the usually integrated functions of
consciousness, memory, identity, or perception; during periods of intolerable stress, the individual blocks off
part of his or her life from consciousness.
 Dissociative identity disorder. First recognized in DSM-III as “multiple personality disorder,”
dissociative identity disorder is defined in DSM-5 as requiring two or more fully distinct personality
states, which in some cultures may be described as an experience of possession.
 Dissociative amnesia. An inability to recall important personal information, usually of a traumatic or
stressful nature. In DSM-5, two primary forms are listed: localized or selective amnesia for specific
events and generalized amnesia for identity and life history. A major change in DSM-5 is that
dissociative fugue is now a specifier for dissociative amnesia, not a separate diagnosis as in DSM-IV.
 Localized amnesia. Inability to recall all incidents associated with a traumatic event for a specific time
period following the event.
 Selective amnesia. Inability to recall only certain incidents associated with a traumatic event for a
specific period following the event.
 Generalized amnesia. Failure of recall encompassing one’s entire life.
 Continuous amnesia. Inability to recall events subsequent to a specific time up to and including the
present.
 Systematized amnesia. With this type of amnesia, the individual cannot remember events that relate
to a specific category of information, such as one’s family, or to one particular person or event.
 Dissociative fugue. A sudden, unexpected travel away from home or customary work locale with
assumption of new identity and an inability to recall one’s previous identity.
 Depersonalization disorder. Characterized by a temporary change in the quality of self-awareness,
which often takes the form of feelings of unreality, changes in body image, feelings of detachment from
the environment, or a sense of observing oneself from outside the body.
Pathophysiology
 From a psychological perspective, dissociation is a protective activation of altered states of
consciousness in reaction to overwhelming psychological trauma.
 After the patient returns to baseline, access to the dissociative information is diminished.
 Psychiatrists have theorized that the memories are encoded in the mind but are not conscious, i.e.,
they have been repressed.
 In normal memory function, memory traces are laid down in 2 forms, explicit and implicit.
 Explicit memories are available for immediate and conscious recall and include recollection of facts and
experiences of which one is conscious, whereas implicit memories are independent of conscious
memory.
 Further, explicit memory is not well-developed in children, raising the possibility that more memories
become implicit at this age.
 Alterations at this level of brain function in response to trauma may mediate changes in memory
encoding for those events and time periods.
 Dissociation is also a neurologic phenomenon that can occur from various drugs and chemicals that
may cause acute, subchronic, and chronic dissociative episodes.
Statistics and Incidences

Since the 1980s, the concept of dissociative disorders has taken on a new significance.
 Dissociative amnesia occurs in 2-7% of the general population and has a high occurrence in those
involved in wars, in patients with a history of child abuse or sexual abuse, in survivors of concentration
camps, in victims of torture, and in survivors of natural disasters.
 Dissociative identity disorder is observed in 1-3% of the population.
 An estimated of 2.4% of the general population meets the diagnostic criteria of depersonalization
disorder; however, the prevalence is questioned by many clinicians and may be lower
Causes
Predisposing factors to dissociative disorder include:
 Genetics. The DSM-IV-TR suggests that DID is more common in first-degree relative of people with
the disorder than in the general population.
 Neurobiological. Some clinicians have suggested a possible correlation between neurological
alterations and dissociative disorders; although available information is inadequate, it is possible that
dissociative amnesia and dissociative fugue may be related to alterations in certain areas of the brain
that have to do with memory.
 Psychodynamic theory. Freud (1962) believed that dissociative behaviors occurred when individuals
repressed depressing mental health contents from conscious awareness.
 Psychological trauma. A growing body of evidence points to the etiology of DID as a set of traumatic
experiences that overwhelms the individual’s capacity to cope by any means other than dissociation.
Clinical Manifestations
Symptoms of dissociative disorder include:
 Impairment in recall. There is inability to remember specific incidents or inability to recall any of one’s
past life, including one’s identity.
 New identity away from home. Sudden travel away from familiar surroundings; assumption of new
identity, with inability to recall past.
 Multiple identities. Assumption of additional identities within the personality; behavior involves
transition from one identity to another as a method of dealing with stressful situations.
 Feeling of unreality. There is a feeling of unreality or detachment from a stressful situation; may be
accompanied by dizziness, depression, obsessive rumination, somatic concerns, anxiety, fear of going
insane, and a disturbance in the subjective sense of time.
Symptoms of dissociative identity disorder:

 Emotional turmoil
 Behavioral turmoil
 Memory gap
 Incidents of out-of-character behavior
Symptoms of dissociative amnesia:

 Memory loss
 Depression
 Anxiety
 Confusion
Symptoms of depersonalization/derealization disorder:

 Detachment
 Foggy or dreamlike vision
 Emotional disconnection
 Physical numbness
 Distortions in perception of time
 Distortions of distance and the size and shape of objects
Medical Management
Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. The
following are the psychological management for dissociative disorders:
 Encourage healthy coping behaviors. The primary focus is to help patients learn to control and
contain their symptoms; patients must learn to deal with dissociation, flashbacks, and intense effects
such as rage, terror, and despair.
 Logging and monitoring emotions. One way to help patients begin to work with their sense of
unpredictability is to have them keep a log of their emotions.
 Developing a crisis plan. Teaching patients to develop a list that ranges from simple to complex
activities is helpful.
Pharmacologic Management
Medications for a patient with dissociative disorder include:
 Neuroleptics. The atypical neuroleptics, such as aripiprazole, olanzapine, quetiapine, and ziprasidone,
are the accepted mode of treatment for dissociative disorders.
Nursing Management
The nursing management of a patient with dissociative disorder include the following:
Nursing Assessment
Assessment of the client include:
 Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status
with a thorough description of behavior, flow of thought and speech, affect, thought processes and
mental content, sensorium and intellectual resources, cognitive status, insight, and judgement.
Nursing Diagnosis
Nursing diagnosis for patients with dissociative disorders include:
 Ineffective coping related to inadequate coping skills.
 Disturbed thought processes related to childhood trauma or abuse.
 Disturbed personal identity related to severe level of anxiety.
 Disturbed sensory perception (kinesthetic) related to threat to self-concept.
Nursing Care Planning and Goals

The major nursing care plan goals for dissociative disorders are:
 Client will verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial
stress.
 Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation.
 Client will verbalize understanding that loss of memory is related to stressful situation and begin discussing
stressful situation with nurse or therapist.
 Client will recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful
situations.
 Client will verbalize adaptive ways of coping with stress.
Nursing Interventions
The nursing interventions for dissociative disorders are:
 Promote client safety. Reassure client of safety and security by your presence.; dissociative
behaviors may be frightening to the client.
 Assess for stressors. Identify stressor that precipitated severe anxiety; this information is necessary
to the development of an effective plan of client care and problem resolution.
 Explore client’s feelings. Explore feelings that client experienced in response to the stressor; help
client understand that the disequilibrium felt is acceptable-indeed, even expected-in times of severe
stress.
 Encourage methods for coping. Have client identify methods of coping with stress in the past and
determine whether the response was adaptive or maladaptive.
 Enhance client’s self-esteem. Provide positive reinforcement for client’s attempts to change; positive
reinforcement enhances self-esteem and encourages repetition of desired behaviors.
Evaluation
Outcome goals include:
 Client was able to verbalize understanding that he or she is employing dissociative behaviors in times
of psychosocial stress.
 Client was able to verbalize more adaptive ways of coping in stressful situations than resorting to
dissociation.
 Client was able to verbalize understanding that loss of memory is related to stressful situation and
begin discussing stressful situation with nurse or therapist.
 Client was able to recover deficits in memory and develop more adaptive coping mechanisms to deal
with stressful situations.
 Client was able to verbalize adaptive ways of coping with stress.
Documentation Guidelines
Documentation in a patient with dissociative disorder include the following:
 Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of
individual behavior.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.
Disruptive, impulse-control, and conduct disorders involve much more critical and constant behaviors than
typical, temporary episodes of most children and adolescents. They belong to a group of disorders that involve
oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder,
pyromania, and kleptomania. These disorders can cause individuals to behave violently or aggressively toward
others or property. They may have problems controlling and managing their sentiments, emotions, and
behavior and may violate rules or laws. Review this study guide and learn more about disruptive, impulse-
control and conduct disorders, its nursing care management, interventions, and assessment.
Description
In DSM-5, oppositional defiant disorder and conduct disorder are presently classified
with antisocial personality disorder and intermittent explosive disorder, whereby considering emerging
data confirming their clinical and biological commonality along a developmental spectrum.
Antisocial personality disorder concerns violations of the rights of others. Intermittent explosive disorder is
defined by impulsive aggressive and assaultive behaviors that are out of proportion to stressors.
 Oppositional defiant disorder (ODD). A childhood mental health disorder that includes frequent and
persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward a person and other
authority figures.
 Intermittent explosive disorder (IED). A disorder that involves repeated, unforeseen episodes of
impulsive, destructive, violent behavior or angry verbal outbursts in which the person react grossly out
of proportion to the situation.
 Conduct disorder (CD). This disorder is characterized by persistent antisocial behavior in children and
adolescents that significantly impairs their ability to function in social, academic, or occupational areas.
People with conduct disorder have little empathy for others; they have low self-esteem, poor frustration
tolerance, and temper outbursts. Conduct disorder frequently is associated with early onset of sexual
behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors.
 Antisocial personality disorder (ASPD or APD). A mental condition in which a person has a long-
term pattern of manipulating, abusing, or violating the rights of others without any guilt.
 Pyromania. A disorder that is characterized by an impulse to set fires. The definition focused on the
recurrent failure to resist impulses to set fire in persons who were not psychotic, cognitively impaired, or
antisocial.
 Kleptomania. A rare but serious mental health disorder that involves recurrent inability to resist urges
to steal items that the person generally doesn’t really need and that usually have little value.

Conduct disorder occurs between two and 10 percent of the population, with a median prevalence rate of 4
percent. Prevalence rates increase from childhood to adolescence and are higher in males than in females.
Oppositional defiant disorder occurs between one and 11 percent of the population, though the average
prevalence estimate is around 3.3 percent. It may be more prevalent in males, with a ratio of approximately
1.4:1 prior to adolescence. This prevalence does not consistently continue into adolescence or adulthood.
Intermittent explosive disorder occurs in approximately 2.7 percent of the population and is more prevalent
among individuals younger than 35-40 years. The prevalence of kleptomania has been estimated at 0.3%–
0.6% in the general population.
Causes
Researchers generally accept that genetic vulnerability, environmental adversity, and factors such as poor
coping interact to cause the disorder.
 Genetics. There is a genetic risk for conduct disorder, although no specific gene marker has been
identified; the disorder is more common in children who have a sibling with conduct disorder or a parent
with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD.
 Biologic. A lack of reactivity of the autonomic nervous system has been found in children with conduct
disorder; this non-responsiveness is similar to adults with antisocial personality disorder.
 Environmental. Poor family functioning, marital discord, poor parenting, and a family history of
substance abuse and psychiatric problems are all associated with the development pf conduct disorder.
Symptoms of oppositional defiant disorder include:
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as
evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with
at least one individual who is not a sibling.
Angry and irritable mood
 Often loses temper.
 Is often touchy or easily annoyed.
 Is often angry and resentful.
Argumentative and defiant behavior

 Often argues with authority figures or, for children and adolescents, with adults.
 Often actively defies or refuses to comply with requests from authority figures or with rules.
 Often deliberately annoys others.
 Often blames others for his or her mistakes or misbehavior.
Vindictiveness
 Has been spiteful or vindictive at least twice within the past 6 months.
Symptoms of intermittent explosive disorder occurring twice weekly, on average, for a period of 3
months include:
 Verbal aggression
 Temper tantrums
 Tirades
 Verbal arguments or fights
 Physical aggression toward property, animals, or other individuals. The physical aggression does not
result in damage or destruction of property and does not result in physical injury to animals or other
individuals.
 Three behavioral outbursts involving damage or destruction of property and/or physical assault
involving physical injury against animals or other individuals occurring within a 12-month period
Symptoms of conduct disorder include:

 A repetitive and persistent pattern of behavior in which the basic rights of others or major age-
appropriate societal norms or rules are violated, as manifested by the presence of at least three of the
following 15 criteria in the past 12 months from any of the categories below, with at least one criterion
present in the past 6 months.
Aggression to people and animals

 Often bullies, threatens, or intimidates others.
 Often initiates physical fights.
 Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle,
knife, gun).
 Has been physically cruel to people.
 Has been physically cruel to animals.
 Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
 Has forced someone into sexual activity.
Destruction of property
 Has deliberately engaged in fire setting with the intention of causing serious damage.
 Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or theft
 Has broken into someone else’s house, building, or car.
 Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
 Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking
and entering; forgery).
Serious violations of rules

 Often stays out at night despite parental prohibitions, beginning before age 13 years.
 Has run away from home overnight at least twice while living in the parental or parental surrogate
home, or once without returning for a lengthy period.
 Is often truant from school, beginning before age 13 years.
Symptoms of antisocial personality disorder include:

 Pervasive pattern of poor social conformity
 Deceitfulness
 Impulsivity
 Criminality
 Lack of remorse
 Disregard for right and wrong
 Persistent lying
 Being tough, cynical and rude of others
 Using charm or wit to manipulate others for personal gain or personal pleasure
 Arrogance, a sense of superiority and being extremely opinionated
 Recurring problems with the law, including criminal behavior
 Repeatedly violating the rights of others through intimidation and dishonesty
 Hostility, significant irritability, agitation, aggression or violence
 Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others
 Poor or abusive relationships
 Failure to consider the negative consequences of behavior or learn from them
Symptoms of pyromania include:

 Presence of multiple episodes of deliberate and purposeful fire setting and the failure to resist an
impulse to set fires on more than one occasion.
 Persons with pyromania like watching the fire in their communities and enjoy setting off false fire
alarms.
 Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g.,
paraphernalia, uses, consequences).
 Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
 Fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal
criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to
a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder,
intellectual disability [intellectual developmental disorder], substance intoxication).
 Fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality
disorder.
Symptoms of kleptomania include:

 Failure to resist powerful urges to steal items that you don’t need.
 Feeling increased tension, anxiety or arousal leading up to the theft.
 Feeling pleasure, relief or gratification while stealing.
 Feeling terrible guilt, remorse, self-loathing, shame or fear of arrest after the theft.
 Return of the urges and a repetition of the kleptomania cycle.
 Stealing is not committed to express anger or vengeance and is not in response to a delusion or a
hallucination.
 Stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.
Medical Management
Because of the multifaceted nature of conduct problems, particularly related comorbidities, treatment usually
includes medication, teaching parenting skills, family therapy, and consultation with the school.
 Preschool. Preschool programs such as Head Start result in lower rates of delinquent behavior and
conduct disorder through use of parental education about normal growth and development, stimulation
for the child, and parental support during crises.
 School age. For school-aged children with conduct disorder, the child, family, and school environment
are the focus of treatment; techniques include parenting education, social skills training to improve peer
relationships, and attempts to improve academic performance and increase the child’s ability to comply
with demands from authority figures.
 Adolescents. Adolescents rely less on their parents and more on peers, so treatment for this age
group includes individual therapy.
 Pharmacologic Management
 In the short term, stimulant medicine has proven effective in controlling the specific symptoms
of inattention, impulsivity, and hyperactivity.
 Stimulants. The first choice for treatment is stimulants due to their relatively safe side effect profile
however when misuse/diversion is a risk the choice of medications that are less abusable such as
Daytrana (methylphenidate in patch form) or Vyvanse (lis-dexamfetamine -medication is oral however
bound to lysine requiring stomach acid digestion in order to be activated).
 Anticonvulsants. Anticonvulsants are considered to be the second group of medications to be used in
nonspecific aggression.
 Lithium. Lithium and methylphenidate reduced aggressiveness in one set of studies; however, in
subsequent follow-up research, the effectiveness of lithium could not be replicated.
Nursing Management
Nursing care of a client with conduct disorder include the following:
Nursing Assessment
Assessment of a client with conduct disorder includes:
 History. Children with conduct disorder have a history of disturbed relationships with peers, aggression
toward people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.
 General appearance and motor behavior. Appearance, speech, and motor behavior are typically
normal for the age group but may be somewhat extreme.
 Mood and affect. Clients may be quiet and reluctant to talk or openly hostile and angry; their attitude is
likely to be disrespectful toward parents, nurse, or anyone in a position of authority.
 Judgement and insight. Judgement and insight are limited for developmental stage; clients
consistently break rules with no regard for the consequences.
 Roles and relationships. Relationships with other, especially those in authority, are disruptive and
may be violent.
 Nursing Diagnosis
 Nursing diagnosis commonly used for clients with conduct disorders include the following:
 Risk for other-directed violence related to aggression to other people or animals.
 Noncompliance related to resentment of those in authority.
 Ineffective coping related to low self-esteem.
 Impaired social interaction related to hostility towards those in authority.
 Chronic low self esteem related to lack of value to self.

Treatment outcomes for clients with conduct disorders may include the following:
 The client will not hurt others or damage property.
 The client will participate in treatment.
 The client will effective problem solving and coping skills.
 The client will use age-appropriate and acceptable behaviors when interacting with others.
 The client will verbalize positive, age-appropriate statements about self.
Nursing interventions for clients with conduct disorders include the following:
 Decreasing violence and increasing compliance with treatment. The nurse must set limits on
unacceptable behavior at the beginning of treatment; for limit setting to be effective, the consequences
must have meaning for the clients- that is, they must value or desire recreation time.
 Improving coping skills and self-esteem. The nurse must show acceptance of clients as worthwhile
persons even if their behavior is unacceptable; this means that the nurse must be matter-of-fact about
setting limits and must not make judgmental statements about clients.
 Promoting social interaction. The nurse identifies what is not appropriate, such as profanity and
name-calling, and also what is appropriate; positive feedback is essential to let clients know they are
meeting expectations.
 Providing client and family interaction. The nurse can teach parents age-appropriate activities and
expectations for clients such as reasonable curfews, household responsibilities, and acceptable
behavior at home.
Evaluation
Goals are met as evidenced by:
 The client was able to not hurt others or damage property.
 The client was able to participate in treatment.
 The client was able to effective problem solving and coping skills.
 The client was able to use age-appropriate and acceptable behaviors when interacting with others.
 The client was able to verbalize positive, age-appropriate statements about self.
Documentation in a client with conduct disorders include:
 Plan of care.
 Teaching plan.
References
Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams
Nurses and healthcare providers usually present a fundamental role in the management of children with
Attention Deficit Hyperactivity Disorder (ADHD), a disorder that is characterized by a persistent pattern of
inattention and/or hyperactivity/impulsivity that interferes with functioning or development which often persists
into adolescence and adulthood. The diagnosis of ADHD demands thorough history taking, application of
standardized rating scales, and close attention to the patient’s behavior and subjects’ reports. This study guide
gives you an overview of ADHD, its nursing care management, interventions, and assessment.
What is ADHD?
 Attention deficit hyperactivity disorder (ADHD) is a developmental condition of inattention and
distractibility, with or without accompanying hyperactivity.
 ADHD is characterized by inattentiveness, overactivity, and impulsiveness.
 ADHD is a common disorder, especially in boys, and probably accounts for more child mental health
referrals than any other single disorder.
 The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity and impulsivity
more common than generally observed in children of the same age.

 In 2016, an estimated 6.1 million US children aged 2-17 years (9.4%) were diagnosed with ADHD.
 Of these children, 5.4 million currently had ADHD, which was 89.4 % of children ever diagnosed with
ADHD and 8.4% of all US children 2-17 years of age.
 According to a study by CDC researchers, more than 1 in 10 (11%) US school-aged children (4–17
years) had received an ADHD diagnosis by a health care provider by 2011, as reported by parents.
 ADHD prevalence varies by race and ethnicity, with Mexican children having consistently lower
prevalence compared with other racial or ethnic groups.
 In children, ADHD is 3–5 times more common in boys than in girls.
 The percentages in each group are not well established, but at least an estimated 15–20% of children
with ADHD maintain the full diagnosis into adulthood.
Causes
The possible causes of ADHD are:
 Genetics. Parents and siblings of children with ADHD are 2-8 times more likely to develop ADHD than
the general population, suggesting that ADHD is a highly familial disease.
 Environment. According to one study, exposure to second-hand smoke in the home is associated with
a higher frequency of mental disorder among children.
 Personality factors. Although there remains much evidence for the genetic etiology of ADHD, one
study indicated that the contribution of personality aspects in combination with genetics may be
significant.
Criteria
In DSM-5, people with ADHD exhibit a persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development:
1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for
adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6
months, and they are inappropriate for developmental level:
 Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with
other activities.
 Often has trouble holding attention on tasks or play activities.
 Often does not seem to listen when spoken to directly.
 Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (e.g., loses focus, side-tracked).
 Often has trouble organizing tasks and activities.
 Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
(such as schoolwork or homework).
 Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools,
wallets, keys, paperwork, eyeglasses, mobile telephones).
 Is often easily distracted
Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16
years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity
have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s
developmental level:
 Often fidgets with or taps hands or feet, or squirms in seat.
 Often leaves seat in situations when remaining seated is expected.
 Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be
limited to feeling restless).
 Often unable to play or take part in leisure activities quietly.
 Is often “on the go” acting as if “driven by a motor”.
 Often talks excessively.
 Often blurts out an answer before a question has been completed.
 Often has trouble waiting their turn.
 Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:

 Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
 Several symptoms are present in two or more settings, (such as at home, school or work; with friends
or relatives; in other activities).
 There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or
work functioning.
 The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety
disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the
course of schizophrenia or another psychotic disorder.
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
 Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity
were present for the past 6 months
 Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-
impulsivity, were present for the past six months
 Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-
impulsivity, but not inattention, were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.
All criteria must be met for a diagnosis of ADHD in adults:

 Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have
persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively
impacts social and academic/occupational activities.
 Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.
 Several symptoms (inattentive or hyperactive/impulsive) must be present in ≥2 settings (eg, at home,
school, or work; with friends or relatives; in other activities).
 There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or
occupational functioning.
 Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder,
and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder,
dissociative disorder, personality disorder, substance intoxication, or withdrawal).
Assessment and Diagnostic Findings

The diagnosis requires the symptoms of ADHD to be present both in school and at home; furthermore, all
patients must have a full psychiatric evaluation and physical examination.
 Laboratory studies. The diagnosis of attention deficit hyperactivity disorder (ADHD) is based on
clinical evaluation; no laboratory-based medical tests are available to confirm the diagnosis; basic
laboratory studies that may help confirm diagnosis and aid in treatment are serum CBC count with
differential, electrolyte levels, liver function tests, and thyroid function tests.
 Imaging studies. Brain imaging, such as functional MRI or single photon emission computed
tomography (SPECT) scans have been useful for research, but no clinical indication exists for these
procedures because the diagnosis is clinical.
Medical Management
No one treatment has been found to be effective for ADHD; ADHD is chronic, goals of treatment involve
managing symptoms, reducing hyperactivity and impulsivity, and increasing the child’s attention so that he or
she can grow and develop normally.
 Diet. For decades, speculation and folklore have suggested that foods containing preservatives or food
coloring or foods high in simple sugars may exacerbate ADHD.
 Activity. In one study of the effect of physical activity on children’s attention, researchers found that
intense exercise has a beneficial effect on children with ADHD.
Although health care providers, parents, and teachers have hoped for effective therapies and methods that do
not involve medications for children with attention deficit hyperactivity disorder (ADHD), evidence to date
supports that the specific symptoms of ADHD are poorly treated without medication.
 Stimulants. These agents are known to treat ADHD effectively.
 Other psychiatry agents. Selective norepinephrine reuptake inhibitors have been shown to be
effective in the treatment of ADHD.
 Atypical antidepressants. Recent studies support efficacy of venlafaxine and bupropion in ADHD;
they may have a slower onset of action than stimulants but potentially fewer adverse effects.
 Tricyclic antidepressants. Imipramine inhibits the reuptake of norepinephrine or serotonin (5-
hydroxytryptamine, 5-HT) at presynaptic neurons; it may be useful in pediatric ADHD.
 Central-acting alpha 2 agonists. Centrally acting antihypertensives clonidine and guanfacine have
been used to treat children with ADHD; inhibition of norepinephrine release in the brain may be the
mechanism of action.
Nursing Management
Nursing care of a client with ADHD include the following:
Nursing Assessment
During assessment, the nurse gathers information through direct observation and from the child’s parents,
daycare providers (if any), and teachers.
 History. Parents may report that child is fussy and had problems as an infant; or they may have not
noticed the hyperactive behavior until the child was a toddler or entered daycare or school.
 General appearance and motor behavior. The child cannot sit still in a chair and squirms and wiggles
while trying to do so; he or she may dart around the room with little or no apparent purpose; the child
may appear immature or lag behind in developmental milestones.
 Mood and affect. Mood may be labile, even to the point of verbal outbursts or temper tantrums;
anxiety, frustration, and agitation may be common.
 Sensorium and intellectual processes. Ability to pay attention or to concentrate is markedly impaired;
the child’s attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in
milder forms of the disorder.
Nursing Diagnosis
Nursing diagnosis commonly used when working with children with ADHD include the following:
 Risk for injury related to inability to remain still or seated for a short period of time.
 Ineffective role performance related to being intrusive or disruptive with siblings or playmates.
 Impaired social interaction related to inability to perceive the consequences of their actions.
 Compromised family coping related to disruptive or intrusive behavior with siblings, which causes
friction.

Treatment outcomes for clients with ADHD may include the following:
 The client will be free of injury.
 The client will not violate the boundaries of others.
 The client will demonstrate age-appropriate social skills.
 The client will complete tasks.
 The client will follow directions.
Nursing interventions for clients with ADHD include:
 Ensuring safety. Ensuring the child’s safety and that of others; stop unsafe behavior; provide close
supervision; and give clear directions about acceptable and unacceptable behavior.
 Improving role performance. Give positive feedback for meeting expectations; manage the
environment (e.g. provide a quiet place free of distractions for task completion).
 Simplifying instructions. Simplifying instructions/directions; get child’s full attention; break complex
tasks into small steps; and allow breaks.
 Promoting a structured daily routine. Structured daily routine; establish a daily schedule; and
minimize changes.
 Providing client and family education and support. The nurse must listen to parents’ feelings;
including parents in providing and planning care for the child with ADHD is important.
Evaluation
Nursing goals are met as evidenced by:
 The client was able to be free of injury.
 The client was able to not violate the boundaries of others.
 The client was able to demonstrate age-appropriate social skills.
 The client was able to complete tasks.
 The client was able to follow directions.
Documentation in a client with ADHD include the following:
 Plan of care.
 Teaching plan.
References
Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders. [Link]
The American Psychiatric Association (APA, 2000) Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR) identifies two categories of sexual disorders: paraphilias and sexual
dysfunctions. In DSM-5, though, the subject is classified into three chapters, particularly sexual dysfunctions,
gender dysphoria, and paraphilic disorders. Review this study guide and learn more about gender and
sexuality disorders, its nursing care management, interventions, and assessment.
Definition
 Paraphilias are characterized by any intense and persistent sexual interest other than sexual interest
in genital stimulation or preparatory fondling with phenotypically normal, physiologically mature,
consenting human partners.
 Paraphilic disorder with the term ‘disorder’ that was specifically added to DSM-5 to indicate a
paraphilia that is inducing distress or impairment to the person or a paraphilia whereby satisfaction
caused personal harm, or risk of harm, to others.
 Sexual dysfunction disorders can be described as an impairment or disturbance in any of the phases
of the sexual response cycle.
 Gender dysphoria involves a conflict within a person’s physical or assigned gender and the gender
with which he/she/they identify.
 Gender identity disorders are characterized by strong and persistent cross-gender identification
accompanied by persistent discomfort with one’s assigned sex.
Types of Paraphilias
The term “paraphilia” is used to identify repetitive or preferred sexual fantasies or behaviors; types of
paraphilias include the following:
 Exhibitionism. The major symptoms include recurrent, intense sexual urges, behaviors, or sexually
arousing fantasies, of at least 6 months duration, involving the exposure of one’s genitals to an
unsuspecting stranger.
 Fetishism. In DSM-5, fetishism involves recurrent, intense sexual fantasies, of at least 6 months
duration, involving the use of nonliving objects (such as undergarments or high-heeled shoes) or a
highly specific focus on a body part (most often nongenital, such as feet) to attain sexual arousal.
 Frotteurism. This disorder is defined in DSM-5 as the recurrent preoccupation with intense sexual
urges or fantasies, of at least 6 months duration, involving touching or rubbing against a nonconsenting
person and the individual has acted on these sexual urges with a nonconsenting person, or the sexual
urges or fantasies cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
 Pedophilia. The DSM-IV-TR describes the essential feature of pedophilia as recurrent, sexual urges,
behaviors, or sexually arousing fantasies, of at least 6 months duration, involving sexual activity with a
prepubescent child; the age of the molester is 16 or older and is at lest 5 years older than the child.
Pedophilia is termed pedophilic disorder in DSM-5 and the manual specifies it as a paraphilia involving
strong and habitual sexual urges towards and fantasies about prepubescent children that have either
been acted upon or which cause the person with the attraction distress or interpersonal difficulty.
 Sexual masochism. The identifying behavior of this disorder is recurrent, intense sexual urges,
behaviors, or sexually arousing fantasies, of at least 6 months duration, involving the act of being
humiliated, beaten, bound, or otherwise made to suffer (APA, 2000). DSM-5 indicates that a person
may have a masochistic sexual interest but that the diagnosis of sexual masochism disorder would only
pertain to individuals who also report psychosocial distress because of it.
 Sexual sadism. The essential feature of sexual sadism is identified as recurrent, intense sexual urges,
behaviors, or sexually arousing fantasies, of at least 6 months duration, involving acts in which the
psychological or physical suffering (including humiliation) of the victim is sexually exciting.
 Voyeurism. This disorder is identified as recurrent, intense, sexual urges, behaviors, or sexually
arousing fantasies, of at least 6 months duration, involving the act of observing an unsuspecting person
who is naked, in the process of disrobing, or engaging in sexual activity.
Types of Sexual Dysfunctions

 Sexual dysfunctions may occur in any phase of the sexual response cycle; types of sexual
dysfunctions include the following:
 Hypoactive sexual disorder. This disorder is defined by the DSM-5 as persistent or recurrently
deficient sexual or erotic thoughts, fantasies, and desire for sexual activity.
 Sexual aversion disorder. This disorder is characterized by a persistent or recurrent extreme aversion
to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. In the development
from DSM-IV-TR to DSM-5 (APA, 2013), the diagnosis of sexual aversion disorder (SAD) has been
removed.
 Female sexual arousal disorder. This disorder is identified in the DSM-IV-TR (APA, 2000) as a
persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an
adequate lubrication or swelling response of sexual excitement. It is defined in the DSM-5 as lack of, or
significantly reduced, sexual interest/arousal.
 Male erectile disorder. This disorder is defined in the DSM-5 as the recurrent inability to achieve an
erection, the inability to maintain an adequate erection, and/or a noticeable decrease in erectile rigidity
during partnered sexual activity.
 Female orgasmic disorder (anorgasmia). This disorder is defined by the DSM-IV-TR as a persistent
or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. As classified
by the DSM-5, female orgasmic disorder is characterized by difficulty experiencing orgasm and/or
markedly reduced intensity of orgasmic sensations.
 Male orgasmic disorder (retarded ejaculation). With this disorder, the man is unable to ejaculate,
even though he has a firm erection and has had more than adequate stimulation. This disorder is also
known as delayed ejaculation (DE) or delayed orgasm (DO). Delayed ejaculation (DE) is defined in
DSM-5 as a persistent difficulty or inability to achieve orgasm despite the presence of adequate desire,
arousal, and stimulation.
 Premature ejaculation. The DSM-IV-TR describes this disorder as persistent or recurrent ejaculation
with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
In DSM-5, premature ejaculation is defined as a persistent or recurrent pattern of ejaculation occurring
during partnered sexual activity within about one minute following vaginal penetration and before the
individual wishes it.
 Dyspareunia. Dyspareunia is defined as recurrent or persistent genital pain associated with sexual
intercourse, in either a man or a woman, that is not caused by vaginismus,
lack of lubrication, another general medical condition, or the physiological effects of substance use
(APA, 2000).
 Vaginismus. Vaginismus is characterized by an involuntary constriction of the outer third of the vagina,
which prevents penile insertion and intercourse. In DSM-5, the spasm-based definition of vaginismus
was omitted, and vaginismus was combined with dyspareunia, the other “sexual pain disorder,” which
resulted in genito-pelvic pain/penetration disorder (GPPPD).
 Gender identity and sexuality disorders are relatively rare compared to other psychiatric disorders.
 Although there are no large scale epidemiological studies to provide true estimates recent studies
suggest roughly 1:10,000 to 1:30,000.
 Sex ratios of adults with GID (largely based on referrals to clinics) have fluctuated with more males than
females in earlier studies to a more equal ratio in many recent reports.
 Childhood GID is more prevalent in males, roughly 6 to 1; in adolescence, the ratio is more equal
Causes
Predisposing factors to paraphilias include:
 Biological factors. Various studies have implicated several organic factors in the etiology of
paraphilias; destruction of parts of the limbic system in animals has been shown to cause hypersexual
behavior (Becker & Johnson, 2008); temporal lobe diseases, such as psychomotor seizures or
temporal lobe tumors, have been implicated in some individuals with paraphilias; abnormal levels of
androgens also may contribute to inappropriate sexual arousal.
 Psychoanalytic theory. The psychoanalytic approach defines a paraphiliac as one who has failed the
normal developmental process toward heterosexual adjustment (Sadock & Sadock, 2007).
Predisposing factors to sexual dysfunction include:

 Sexual desire disorders. In men, these disorders have been linked to low levels of serum testosterone
and to elevated levels of serum prolactin; evidence also exists that suggests a relationship between
serum testosterone and increased female libido; various medications, such as antihypertensives,
antipsychotics, antidepressants, anxiolytics,
and anticonvulsants, as well as chronic use of drugs such as alcohol and cocaine, have also been
implicated in sexual desire disorders.
 Sexual arousal disorders. These may occur in response to decreased estrogen levels in
postmenopausal women; medications such as antihistamines and cholinergic blockers may produce
similar results; erectile dysfunctions in men may be attributed to arteriosclerosis, diabetes, temporal
lobe epilepsy, multiple sclerosis, some medications (antihypertensives, antidepressants, tranquilizers),
spinal cord injury, pelvic surgery, and chronic use of alcohol.
 Orgasmic disorders. In women these may be attributed to some medical conditions (hypothyroidism,
diabetes, and depression) and certain medications (antihypertensives,
antidepressants); medical conditions that may interfere with male orgasm include genitourinary surgery
(e.g., prostatectomy), Parkinson’s disease, and diabetes.
 Sexual pain disorders. In women these can be caused by disorders of the vaginal entrance, irritation
or damage to the clitoris, vaginal or pelvic infections, endometriosis,
tumors, or cysts. Painful intercourse in men may be attributed to penile infections, phimosis, urinary
tract infections, or prostate problems.
Subjective and objective data of symptoms of paraphilias include the following:
 Exposure of one’s genitals to strangers.
 Sexual arousal in the presence of nonliving objects.
 Touching and rubbing of one’s genitals against an unconsenting person.
 Sexual attraction to, or activity with, a prepubescent child.
 Sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer.
 Sexual arousal by inflicting psychological or physical suffering on another individual.
 Sexual arousal from dressing in the clothes of the opposite sex.
 Sexual arousal from observing unsuspecting people either naked or engaged in sexual activity.
 Masturbation often accompanies the activities described when they are performed solitarily.
 The individual is markedly distressed by these activities.
Subjective and objective data of symptoms of sexual disorders include the following:
 Absence of sexual fantasies and desire for sexual activity.
 Discrepancy between partners’ levels of desire for sexual activity.
 Feelings of disgust, anxiety, or panic responses to genital contact.
 Inability to produce adequate lubrication for sexual activity.
 Absence of a subjective sense of sexual excitement during sexual activity.
 Failure to attain or maintain penile erection until completion of sexual activity.
 Inability to achieve orgasm (in men, to ejaculate) following a period of sexual excitement judged
adequate in intensity and duration to produce such a response.
 Ejaculation occurs with minimal sexual stimulation or before, on, or shortly after penetration and before
the individual wishes it.
 Genital pain occurring before, during, or after sexual intercourse.
 Constriction of the outer third of the vagina prevents penile penetration.
Medical Management
Modalities that may be considered in the treatment of gender dysphoria include pharmacologic therapy,
psychological and other nonpharmacologic therapies, and sexual reassignment surgery (SRS).
 Psychological and speech therapy. Psychological intervention may be beneficial; individual treatment
focuses on understanding and dealing with gender issues; group, marital, and family therapy can
provide a helpful and supportive environment; speech therapy may help male-to-female individuals use
their voice in a more feminine manner.
 Sexual reassignment surgery. Controversy exists regarding whether adolescents should be allowed
to pursue SRS; many countries deny SRS to adolescents; however, early treatment may be beneficial
in adolescents whose secondary sex characteristics (eg, facial hair, lowered voice, and breast
development) have not yet developed fully. In such cases, parental involvement and approval are
essential.
The goal of pharmacotherapy is to inhibit or promote the expression of secondary sex characteristics in males
and females.
 Progestins. These agents may be used to inhibit the secretion of pituitary gonadotropins.
 Gonadotropin-releasing hormone agonists. Gonadotropin-releasing hormone (GnRH) analogs
produce a hypogonadotrophic-hypognadal state by down-regulation of the pituitary gland.
 Aldosterone antagonists, selective. Aldosterone antagonists may block androgen receptors.
 Antineoplastics, antiandrogens. Antiandrogens are another group of agents used as a first-line
therapy for hirsutism.
 Oral contraceptives. Oral contraceptives inhibit ovarian androgen production and are probably the first
choice for young women with hirsutism who do not want to become pregnant.
 Estrogen derivatives. These hormones are used for replacement therapy in hypogonadism associated
with a deficiency or absence of endogenous testosterone or estrogen.
 Androgens. Androgens are used for replacement therapy in hypogonadism associated with a
deficiency or absence of endogenous testosterone.
Nursing Management
Nursing management of a patient with gender and sexual identity disorders include the following:
Nursing Assessment
Nursing assessment include:
Sexual dysfunction. Sexual dysfunction is the person’s experience of change in sexual dysfunction; the
person views this change as unsatisfying, unrewarding, inadequate, or socially inappropriate.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
 Sexual dysfunction related to physical or psychosocial abuse.
 Ineffective sexuality pattern related to conflicts with sexual orientation or variant preferences.
 Disturbed personal identity related parenting patterns that encourage culturally unacceptable
behaviors for assigned gender.
 Impaired social interaction related to socially and culturally unacceptable behavior.
 Low self-esteem related to rejection by peers.

The major nursing care planning goals for sexual dysfunctions, gender dysphoria, and paraphilias are:
 Client will resume sexual activity at level satisfactory to self and partner by (time is individually
determined).
 Client will express satisfaction with own sexuality pattern.
 Client and partner will express satisfaction with sexual relationship.
 Client will demonstrate behaviors that are appropriate and culturally acceptable for assigned gender.
 Client will express personal satisfaction and feelings of being comfortable in assigned gender.
 Client will interact with others using culturally acceptable behaviors.
The nursing interventions are:
 Determine stressors. Help client determine time dimension associated with the onset of the problem
and discuss what was happening in his or her life situation at that time.
 Encourage discussion of disease process. Encourage client to discuss disease process that may be
contributing to sexual dysfunction; ensure that client is aware that alternative methods of achieving
sexual satisfaction exist and can be learned through sex counseling if he or she and partner desire to
do so.
 Identify factors that affect client’s sexuality. Note cultural, social, ethnic, racial, and religious factors
that may contribute to conflicts regarding variant sexual practices.
 Be accepting and nonjudgmental. Sexuality is a very personal and sensitive subject; the client is
more likely to share this information if he or she does not fear being judged by the nurse.
 Provide positive reinforcement. Observe client behaviors and the responses he or she elicits from
others; give social attention (e.g., smile, nod) to desired behaviors.
Evaluation
Nursing goals are met as evidenced by:
 Client was able to resume sexual activity at level satisfactory to self and partner by (time is individually
determined).
 Client was able to express satisfaction with own sexuality pattern.
 Client and partner was able to express satisfaction with sexual relationship.
 Client was able to demonstrate behaviors that are appropriate and culturally acceptable for
 assigned gender.
 Client was able to express personal satisfaction and feelings of being comfortable in assigned gender.
 Client was able to interact with others using culturally acceptable behaviors.
 Documentation in a patient with gender and sexuality disorders include the following:
 Plan of care.
 Teaching plan.
Substance use disorders, also identified as substance abuse, develop when a person’s use of alcohol or another
substance such as drugs leads to health issues, disability, and or not adhering to responsibilities at home, work, or
school. This disorder is also called drug addiction. In the last edition of the DSM, DSM-IV, there were two categories:
substance abuse and substance dependence. DSM-5 merges these two categories into one called “substance use
disorder.”
What is Substance Abuse and substance abuse disorder?

Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite
negative consequences.
 Substance abuse disorders (SAD) are common chronic relapsing illness that are characterized by drug-
seeking and drug-taking behaviors that persist despite negative consequences.
 The DSM-IV-TR distinguishes substance abuse from dependence for purposes of medical diagnosis; substance
abuse denotes problems in social, vocational, or legal areas of the person’s life, whereas substance dependence
also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to
stop using the substance.
 DSM-5 combines substance abuse and substance dependence into one called “substance use disorder.”
It recognizes substance-related disorders resulting from the use of 10 separate classes of drugs: alcohol;
caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other
hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including
amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances.
Criteria
Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria. The
11 DSM-5 criteria for a substance use disorder include:
 Took more extensive amounts/extended time. Using the substance in larger amounts or for longer than it’s
meant to be.
 Repeated efforts to control use or quit. Wanting to cut down or stop using the substance but not succeeding.
 Full time spent using. Consuming a lot of time getting, using, or recovering from use of the substance.
 Craving. Desires and urges to use the substance.
 Disregarded major roles. Not accomplishing what is need to be done at work, home, or school because of
substance use.
 Social or interpersonal dilemmas. Resuming to use even when it causes problems in relationships.
 Missed activities. Giving up significant social, occupational, or recreational activities because of substance use.
 Hazardous use. Using substances again and again even when it places the person in danger.
 Physical or psychological problems. Extending the use even if physical or psychological problems arise.
 Tolerance. Requiring more of the substance to get the effect the person desires.
 Withdrawal. Development of withdrawal symptoms, which can be alleviated by taking more of the substance.
 In order to be diagnosed with a substance use disorder, the person must meet two or more of these criteria
within a 12-month period. A person with a mild substance use disorder possesses two or three of the criteria.
Four to five is considered moderate, and if the person has six or more criteria, he or she has a severe substance
use disorder.
Causes
The exact causes of drug abuse, dependence, and addiction are not known, but various factors are thought to contribute
to the development of substance-related disorders.
 Biologic factors. Children of alcoholic parents are at higher risk for developing alcoholism and drug
dependence than are children of nonalcoholic parents.
 Psychological factors. Children of alcoholics are four times as likely to develop alcoholism compared with
the general population; some theorists believe that inconsistency in the parent’s behavior, poor role modeling,
and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy
relationships, and substance abuse.
 Social and environmental factors. Cultural factors, social attitudes, peer behaviors, laws, cost and
availability all influence initial and continued use of substances.
Types and Symptoms

Each substance use disorder is classified as its own disorder. Here are the most common substance use disorders in the
United States:
 Alcohol. Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream; initially,
the effects are relaxation and loss of inhibition; with intoxication, there is slurred speech, unsteady gait, lack of
coordination, and impaired attention, concentration, memory, and judgment.
 Sedatives, hypnotics, and anxiolytics. This class of drugs includes all central nervous system depressants,
barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines; the effects of the drugs,
symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol.
 Stimulants (amphetamines, cocaine). Stimulants are drugs that stimulate or excite the central nervous
system; intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity,
hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger,
fighting, and impaired judgment.
 Cannabis (marijuana). Cannabis is the most widely used illicit substance in the United States; research has
shown that cannabis has short-term effects of lowering intraocular pressure; symptoms of intoxication include
impaired motor coordination, inappropriate laughter, impaired judgment, and short-term memory, and
distortions of time and perception.
 Opioids. Opioids are popular drugs of abuse because they desensitize the user to both physiologic and
psychological pain and induce a sense of euphoria and well-being; opioid intoxication develops soon after the
initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor
retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory.
 Hallucinogen. Hallucinogens are substances that distort the user’s perception of reality and produce
symptoms similar to psychosis, including hallucinations and depersonalization; hallucinogen intoxication is
marked by several maladaptive behavioral or psychological changes; anxiety, depression, paranoid ideation,
ideas of reference, fear of losing one’s mind, and potentially dangerous behavior such as jumping out the
window in the belief that one could fly.
 Inhalants. Inhalants are a diverse group of drugs that includes anesthetics, nitrates, and organic solvents that
are inhaled for their effects; the most common substances in this category are aliphatic and aromatic
hydrocarbons found in gasoline, glue, paint thinner, and spray paint; inhalant intoxication involves dizziness,
nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision.

The full spectrum of SADs represents one of the nation’s leading health problems.
 In 2007, approximately 22.3 million adults were classified as having substance dependence or abuse disorders.
 Among this population, an estimated 3.2 million were dependent on or abused both alcohol and illicit drugs,
another 3.7 million were dependent on or abused drugs alone, and 15.5 million were dependent on or abused
alcohol alone.
 The rate of abuse and dependence was twice as high for males as it was for females (12.5 vs. 5.7%).
 Illicit drug use among those aged 50 to 54 increased from 3.4% in 2002 to 5.7% in 2007.
 The most popular illicit drugs in the 2007 survey were marijuana (3.9 million), pain relievers (1.7 million), and
cocaine (1.6 million).

Various diagnostic studies may also demonstrate evidence of SADs-related organ dysfunction.
PPD. A positive PPD is a frequent finding among substance abusers living in crowded conditions.
 Hematology. Additional laboratory clues include mild anemia with macrocytosis, folate deficiency,
thrombocytopenia, granulocytopenia, abnormal liver function tests, hyperuricemia, and elevated triglycerides.
 Medical Management
 Clients being treated for intoxication and withdrawal or detoxification are encountered in a wide variety of
medical settings from emergency departments to outpatient clinics.
 Alcoholics Anonymous (AA). Alcoholics Anonymous was founded in the 1930s by alcoholics; this self-help
ground developed the 12-step program model for recovery, which is based on the philosophy that total
abstinence is essential and that alcoholics need the help and support of others to maintain sobriety.
Pharmacologic treatment in substance abuse has two main purposes: to permit safe withdrawal from alcohol,
sedative-hypnotics, and benzodiazepines and to prevent relapse.
 Benzodiazepines. Alcohol withdrawal is usually managed with a benzodiazepine-anxiolytic agent, which is
used to suppress the symptoms of abstinence.
 Disulfiram. Disulfiram (Antabuse) may be prescribed to help deter clients from drinking.
 Acamprosate. Acamprosate (Campral), may be prescribed for clients recovering from alcohol abuse or
dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs
especially in the first few months of recovery.
 Methadone. Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance
programs.
 Levomethadyl. Levomethadyl is a narcotic analgesic whose only purpose is the treatment of opiate
dependence.
 Naltrexone. Naltrexone (ReVia) is an opioid antagonist often used to treat an overdose. It can also be used to
treat alcohol abuse.
Nursing Management
Nursing care of a client with substance abuse disorder include the following:
Nursing Assessment
Assessment of a client with substance abuse disorder include:
 History. Client with a parent or other family members with substance abuse problems may report a chaotic
family life, although this is not always the case.
 Thought process and content. During the assessment of thought process and content, clients are likely to
minimize their substance abuse, blame others for their problems, and rationalize their behavior.
 Sensorium and intellectual process. Clients generally are oriented and alert unless they are experiencing
lingering effects of withdrawal.
 General appearance and motor behavior. Assessment of general appearance and behavior usually reveals
appearance and speech to be normal.
 Self-concept. Clients generally have low self-esteem, which they may express directly or cover with grandiose
behavior.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis for substance abuse are:
 Risk for injury related to substance intoxication or withdrawal.
 Ineffective denial related to underlying fears and anxieties.
 Ineffective coping related to inadequate support system or coping skills.
 Imbalance nutrition: less than body requirements related to drinking alcohol instead of eating
nourishing food.
 Chronic low self-esteem related to retarded ego development

Main Article: Nursing Diagnosis for Substance Abuse: 8 Care Plans
Treatment outcomes for clients with substance use may include the following:
 The client will abstain from alcohol and drug use.
 The client will express feelings openly and directly.
 The client will verbalize acceptance of responsibility for his or her own behavior.
 The client will practice nonchemical alternatives to deal with stress or difficult situations.
 The client will establish an effective after-care plan.
Nursing interventions for a client with substance abuse include:
 Providing health teaching for client and family. Clients and family members need facts about the
substance, its effects, and recovery.
 Addressing family issues. Without support and help to understand and cope, many family members may
develop substance abuse problems of their own, thus perpetuating the dysfunctional circle; treatment and
support groups are available to address issues of family members.
 Promoting coping skills. Nurses can encourage clients to identify problem areas in their lives and to explore
the ways that substance use may have intensified those problems.
Evaluation
 The client was able to abstain from alcohol and drug use.
 The client was able to express feelings openly and directly.
 The client was able to verbalize acceptance of responsibility for his or her own behavior.
 The client was able to practice nonchemical alternatives to deal with stress or difficult situations.
 The client was able to establish an effective after-care plan.
Documentation in a client with substance abuse disorders include:
 Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual
behavior.
 Plan of care.
 Teaching plan.
 Attainment or progress toward the desired outcome
Anxiety disorders involve disorders that contain characteristics of excessive fear and anxiety and linked

behavioral disturbances. There are several types of anxiety disorders including generalized anxiety disorder,
agoraphobia, separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder or social
phobia, panic disorder, substance/medication-induced anxiety disorder, and anxiety disorder due to another
medical condition. Review this study guide and learn more about anxiety disorders, its nursing care
management, interventions, and assessment.
Types of Anxiety Disorders

The characteristic features of this group of disorders are symptoms of anxiety and avoidance
behavior. Anxiety disorders are categorized in the following manner:
 Panic disorder (with or without agoraphobia). Panic disorder is characterized by by recurrent panic
attacks, the onset of which are unpredictable, and manifested by intense apprehension, fear or terror,
often associated with feelings of impending doom, and accompanied by intense physical discomfort.
 Agoraphobia without history of panic disorder. The APA 2000 Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) identifies the essential feature of this
disorder as fear of being in places or situations from which escape might be difficult or in which help
might not be available in the event of suddenly developing a symptoms(s) that could be incapacitating
or extremely embarrassing.
 Social phobia. Social phobia is characterized by a persistent fear of behaving or performing in the
presence of others in a way that will be humiliating or embarrassing to the individual.
 Specific phobia. Formerly called simple phobia, this disorder is characterized by persistent fears of
specific objects or situations.
 Obsessive-compulsive disorder. This disorder is characterized by involuntary recurring thoughts or
images that the individual is unable to ignore and by recurring impulse to perform a seemingly
purposeless activity.
 Posttraumatic stress disorder. Posttraumatic stress disorder is characterized by the development of
physiological and behavioral symptoms following a psychologically traumatic event that is generally
outside the range of usual human experience.
 Acute stress disorder. Acute stress disorder is characterized by the development of physiological and
behavioral symptoms similar to those of PTSD; the major difference in the diagnosis lies in the length of
time the symptoms exist; with acute stress disorder, the symptoms must subside within 4 weeks of
occurrence of the stressor.
 Anxiety disorder due to a general medical condition. The symptoms of this disorder are judged to
be the direct physiological consequence of a general medical condition.
 Substance-induced anxiety disorder. The DSM-IV-TR (APA, 2000) describes the essential features
of this disorder as prominent anxiety symptoms that are judged to be caused by the direct physiological
effects of a substance.
 Obsessive-compulsive disorder (included in the obsessive-compulsive and related disorders),
posttraumatic stress disorder (included in the trauma and stress-related disorders), and acute stress
disorder, are no longer considered anxiety disorders as they were in the previous version of the DSM.
Nonetheless, these disorders are closely linked to anxiety disorders and the sequential order of these
chapters in the DSM-5 reflects this close connection.
Pathophysiology
 The brain circuits and regions associated with anxiety disorders are beginning to be understood with
the development of functional and structural imaging.
 In the central nervous system (CNS) the major mediators of the symptoms of anxiety disorders appear
to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA).
 Other neurotrasmitters and peptides, such as corticotropin-releasing factor, may be involved.
 Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates
many of the symptoms.

 Anxiety disorders are the most common type of psychiatric disorders in the Unites States.
 The lifetime prevalence of anxiety disorders among American adults is 28.8%.
 Social anxiety disorder is the most common anxiety disorder; it has an early age of onset-by age 11
years in about 50%, and by age 20 years in about 80% of individuals that have the diagnosis- and it is a
risk factor for subsequent depressive illness and substance abuse.
 The prevalence of specific anxiety disorders appears to vary between countries and cultures.
 The median prevalence of social anxiety disorder in Europe is 2.3%.
 The female-to-male ratio for any lifetime anxiety disorder is 3:2.
Causes
Predisposing factors to anxiety disorder include the following:
 Biochemical. Increased levels of norepinephrine have been noted in panic and generalized anxiety
disorders; abnormal elevations of blood lactate have also been noted in patients with panic disorder.
 Genetic. Studies suggest that anxiety disorders are prevalent within the general population; it has been
shown that they are more common among first-degree biological relatives of people with the disorders
than among the general population.
 Medical or substance-induced. Anxiety disorders may be caused by a variety of medical conditions or
the ingestion of various substances.
 Psychodynamic theory. The psychodynamic view focuses on the inability of the ego to intervene
when conflict occurs between the superego and the id, producing anxiety.
 Cognitive theory. The main thesis of the cognitive view is that faulty, distorted, or counterproductive
thinking patterns accompany or precede maladaptive behaviors and emotional disorders.
Signs and symptoms of anxiety disorders may include the following:
 Pounding, rapid heart rate.
 Feeling of choking or smothering.
 Difficulty breathing.
 Pain in the chest.
 Feeling dizzy or faint.
 Increased perspiration.
 Feeling of numbness or tingling in the extremities.
 Trembling.
 Fear that one is dying or going crazy.
 Sense of impending doom.
 Feelings of unreality (derealization and/or depersonalization).

For presentations with a higher index of suspicion for other medical causes of anxiety, more detailed
evaluations may be indicated to identify or exclude underlying medical disorders.
 EEG, lumbar puncture, and head/brain imaging. Rule out CNS disorder using EEG, lumbar
puncture, brain computed tomography scan, as indicated by history and associated clinical findings.
 Electrocardiography. Rule out cardiac disorders using electrocardiography or treadmill ECG.
 Tests for infection. Rule out infectious causes using rapid plasma reagent test, lumbar puncture, or
HIV testing.
 Arterial blood gas analysis. Arterial blood gas analysis is useful in confirming hyperventilation and
excluding hypoxemia or metabolic acidosis.
 Chest radiography. Chest radiography is useful in excluding other causes of dyspnea with chest pain.
 Thyroid function. Hyperthyroidism is one of the most common medical causes for anxiety related to a
medical condition.
Medical Management
Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy.
 Cognitive therapy. Cognitive therapy helps patients understand how automatic thoughts and false
beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and can lead to
secondary behavioral consequences.
 Behavioral therapy. Behavioral therapy involves sequentially greater exposure of the patient to
anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience.
 Diet. Caffeine containing products, such as coffee, tea, and colas, should be discontinued.
Antidepressant agents are the drugs of choice in the treatment of anxiety disorders, particularly the newer
agents that have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants.
 Selective serotonin reuptake inhibitors. The SSRIs are first-line agents for long-term management of
anxiety disorders, with control gradually achieved over a 2-to 4-wk course, depending on required
dosage increases.
 Serotonin and norepinephrine reuptake inhibitors. Pharmacologic agents with reuptake inhibition of
serotonin and norepinephrine may be helpful in a variety of mood and anxiety disorders.
 Atypical antidepressants. Antidepressants that are not FDA-approved for the treatment of a given
anxiety disorder still may be beneficial for the treatment of anxiety disorders; mirtazapine acts distinctly
as an alpha-2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while also
blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when
stimulated with serotonin.
 Tricyclic antidepressants. The tricyclic antidepressants are a complex group of drugs that have
central and peripheral anticholinergic effects, as well as sedative effects.
 Benzodiazepines. Benzodiazepines often are used with antidepressants as adjunct treatment; they
are especially useful in the management of acute situational anxiety disorder and adjustment disorder
where the duration of pharmacotherapy is anticipated to be 6 weeks or less and for the rapid control of
anxiety attacks.
 Antianxiety agents. Buspirone is a non-sedating antipsychotic drug unrelated to benzodiazepines,
barbiturates, and other sedative hypnotics; it has fewer cognitive and psychomotor adverse effects,
which makes its use preferable in elderly patients.
 Anticonvulsant. The drug of choice in this category is the gamma-aminobutyric acid derivative
pregabalin (Lyrica).
 Antihypertensive agent. Agents in this class may have a positive effect on the physiological
symptoms of anxiety; beta-blockers may be useful for the circumscribed treatment of
situational/performance anxiety on an as-needed basis.
 Monoamine oxidase inhibitor (MAOI). MAOIs are most commonly prescribed for patients with social
phobia.
 Antipsychotic agent. Atypical and typical antipsychotic medications are generally used more as
augmentation strategies and are second-line treatment options in generalized anxiety disorder.
Nursing Management
Nursing management of a patient with anxiety disorder include the following:
Nursing Assessment
Nursing assessment of a patient with anxiety disorder include:
 History. The client usually seeks treatment for panic disorder after he or she has experienced several
panic attacks; usually, the client cannot identify any trigger for these events.
 General appearance and motor behavior. The client may appear entirely “normal” or may have signs
of anxiety if he or she is apprehensive about having a panic attack in the next few moments.
 Mood and affect. Assessment of mood and affect may reveal that the client is anxious, worried, tense,
depressed, serious, or sad.
 Thought processes and content. During a panic attack, the client is overwhelmed, believing that he
or she is dying, losing control, or “going insane”; the client may even consider suicide.
 Sensorium and intellectual process. During a panic attack, the client may be confused and
disoriented; he or she cannot take in environmental cues and respond appropriately.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis are:
 Anxiety related to unconscious conflict about essential values and goals of life; situational or
maturational crises.
 Fear related to phobic stimulus.
 Ineffective coping related to underdeveloped ego; punitive superego.
 Powerlessness related to fear of disapproval from others.
 Social isolation related to panic level of anxiety.

The major nursing care planning goals for patients with Anxiety Disorders are:
 Client will verbalize ways to intervene in escalating anxiety within 1 week.
 Client will be able to recognize symptoms of onset of anxiety and intervene before reaching the panic
stage by time of discharge from treatment.
The nursing interventions for anxiety disorders are:
 Stay calm and be nonthreatening. Maintain a calm, nonthreatening manner while working with client;
anxiety is contagious and may be transferred from staff to client or vice versa.
 Assure client of safety. Reassure client of his or her safety and security; this can be conveyed by
physical presence of the nurse; do not leave client alone at this time.
 Be clear and concise with words. Use simple words and brief messages, speak calmly and clearly, to
explain hospital experiences to client; in an intensely anxious situation, client is unable to comprehend
anything but the most elementary communication.
 Provide a non-stimulating environment. Keep immediate surroundings low in stimuli (dim lighting,
few people, simple decor); a stimulating environment may increase level of anxiety.
 Administer medications as prescribed. Administer tranquilizing medication, as ordered by physician;
assess medication for effectiveness and for adverse side effects.
 Recognize precipitating factors. When level of anxiety has been reduced, explore with client possible
reasons for occurrence; recognition of precipitating factors is the first step in teaching client to interrupt
escalation of anxiety.
 Encourage client to verbalize feelings. Encourage client to talk about traumatic experience under
nonthreatening conditions; help client work through feelings of guilt related to the traumatic event; help
client understand that this was an event to which most people would have responded in like manner.
Evaluation
The outcome criteria for Anxiety Disorders include:
 Client is able to maintain anxiety at level in which problem solving can be accomplished.
 Client is able to verbalize signs and symptoms of escalating anxiety.
 Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level.
Documentation guidelines include the following:
 Plan of care.
 Teaching plan.
Eating Disorders are illnesses that are characterized by irregular eating habits and extreme distress or
concern about body weight or shape. Eating disturbances may involve inadequate or excessive food intake
which can basically cause harm to a person’s well-being. The most common forms of eating disorders are
anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, avoidant or restrictive food
intake disorder (ARFID), and other specified feeding or eating disorder (OSFED). Read this study guide and
learn more about eating disorders (anorexia nervosa and bulimia nervosa), its nursing care management,
interventions, and assessment.
What are Eating Disorders?

 Eating disorders are characterized by a repeated disturbance of eating or eating-related behavior that
results in the altered consumption or absorption of food and that significantly diminishes physical health
or psychosocial functioning. Eating disorders can be viewed on a continuum, with clients with anorexia
nervosa eating too little or starving themselves, client with bulimia eating chaotically, and clients with
obesity eating too much.
 Although many believe that eating disorders are relatively new, documentation from the Middle Ages
indicates willful dieting leading to self-starvation in female saints who fasted to achieve purity.
 In the late 1800s, doctors in England and France described young women who apparently used self-
starvation to avoid obesity.
 It was not until the 1960s, however, that anorexia nervosa was established as a mental disorder.
 Bulimia nervosa was first described as a distinct syndrome in 1979.
Types of Eating Disorders

The most common eating disorders found in the mental health setting are anorexia nervosa, bulimia nervosa,
binge-eating disorder, pica, rumination disorder, avoidant or restrictive food intake disorder (ARFID), and other
specified feeding or eating disorder (OSFED).
 Anorexia Nervosa. Anorexia nervosa is a life-threatening eating disorder characterized by the client’s
refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or
becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability
or refusal to acknowledge the seriousness of the problem or even that one exists.
 Bulimia Nervosa. Bulimia nervosa, often simply called bulimia, is an eating disorder characterized by
recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate
compensatory behaviors to avoid weight gain such as purging, fasting, or excessively exercising.
 Binge-Eating Disorder (BED). Binge-eating disorder is another eating disorder characterized by
recurrent episodes of binge eating but it is not associated with the recurrent use of inappropriate
compensatory behaviours as in bulimia nervosa, and does not occur exclusively during the course of
bulimia nervosa, or anorexia nervosa methods to compensate for overeating, such as self-induced
vomiting.
 Pica. Pica is an eating disorder that involves persistent eating of non-nutritive substances such as hair,
dirt, and paint chips for a period of at least one month.
 Rumination disorder. Rumination disorder is characterized by repeatedly and persistently
regurgitating food after eating, but it’s not due to a medical condition or another eating disorder such as
anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
 Avoidant/Restrictive Food Intake Disorder (ARFID). Avoidant or restrictive food intake disorder is an
eating or feeding disturbance characterized by persistent failure to meet appropriate nutritional or
energy needs due to having no interest in eating regarding food with certain sensory characteristics,
such as color, texture, smell or taste; or fear of choking.
 Other Specified Feeding or Eating Disorder (OSFED). Other specified feeding or eating disorders or
(OSFED) are eating behaviors that cause clinically compelling distress and impairment in areas of
functioning, but do not meet the full criteria for any of the other feeding and eating disorders.
Causes
A specific cause for eating disorders is unknown; initially, dieting may be the stimulus that leads to their
development.
 Biologic factors. Studies of anorexia nervosa have shown that these disorders tend to run in families;
genetic vulnerability also might result from a particular personality type or a general susceptibility to
psychiatric disorders.
 Developmental factors. Onset of anorexia nervosa usually occurs during adolescence or young
adulthood; some researchers believe its causes are related to developmental issues.
 Family influences. Girls growing up amid family problems and abuse are at higher risk for both
anorexia and bulimia; disorders eating is a common response to family discord.
 Sociocultural factors. Adolescents often idealize actresses and models as having the perfect “look” or
body even though many of these celebrities are underweight or use special effects to appear thinner
than they are; pressure from others also may contribute to eating disorders.

 Obesity has been identified as a major health problem in the United States; some call it an epidemic.
Millions of women are either starving themselves or engaging in chaotic eating patterns that can lead to
death.
 30% to 35% normal-weight people with bulimia have a history of anorexia nervosa and low body
weight, and about 50% of people with anorexia nervosa exhibit bulimic behavior.
 More than 90% of cases of anorexia nervosa and bulimia occur in females (American Psychiatric
Association, 2000).
 The prevalence of both eating disorders is estimated to be 1% to 3% of the general population in the
United States.
The following are the signs and symptoms of eating disorders:
Symptoms of anorexia nervosa include:
 Fear of gaining weight or becoming fat even when severely underweight.
 Body image disturbance.
 Amenorrhea or absence of menstrual period.
 Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia.
 Preoccupation with thoughts of food.
 Feelings of ineffectiveness.
 Inflexible thinking.
 Strong need to control environment.
 Limited spontaneity and overly restrained emotional expression.
 Complaints of constipation and abdominal pain.
 Cold intolerance.
 Lethargy.
 Emaciation.
 Hypotension, hypothermia, bradycardia.
 Hypertrophy of salivary glands.
 Elevated BUN.
 Electrolyte imbalances.
 Leukopenia and mild anemia.
 Elevated liver function studies.
Symptoms of bulimia nervosa include:

 Recurrent episodes of binge eating.
 Compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enema or other
medications, or excessive exercise.
 Self-evaluation overly influenced by body shape and weight.
 Usually within normal weight range, possible underweight or overweight.
 Restriction of total calorie consumption between binges, selecting low-calorie foods while avoiding
foods perceived to be fattening or likely to trigger a binge.
 Depressive and anxiety symptoms.
 Possible substance use involving alcohol and stimulants.
 Loss of dental enamel.
 Chipped, ragged, or moth-eaten appearance of teeth.
 basic testsIncreased dental caries.
 Menstrual irregularities.
 Dependence on laxatives.
 Esophageal tears.
 Fluid and electrolyte abnormalities.
 Metabolic alkalosis (from vomiting) or metabolic acidosis (from diarrhea).
 Mildly elevated serum amylase levels.

The following diagnostic tests and assessment cues are commonly used for patients suspected with eating
disorders:
 Physical and mental status evaluation.
 Complete blood count (CBC). The hemoglobin levels are typically normal, although elevations are
observed in states of dehydration; the white blood cell count (WBC) is typically low due to increased
margination, and thrombocytopenia is also observed.
 Blood chemistries. Hyponatremia (reflects excess water intake or the inappropriate secretion of
antidiuretic hormone), hypokalemia (results from diuretic or laxative use), hypoglycemia (results from
the lack of glucose precursors in the diet or low glycogen stores; low blood glucose may also be due to
impaired insulin clearance), elevated blood urea nitrogen (renal function is generally normal except in
patients with dehydration, in whom the BUN level may be elevated), Hypokalemic hypochloremic
metabolic alkalosis (observed with vomiting), acidosis (observed in cases of laxative abuse).
 Liver function tests. Liver function test results are minimally elevated, but levels encountered in
patients with active hepatitis are not observed; albumin and protein levels are usually normal, because
although the amount of food intake is restricted, it usually contains high-quality proteins.
 Medical Management
 Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and
correction of electrolyte imbalances.
 Nutritional rehabilitation and weight restoration. Clients receive nutritionally balanced meals and
snacks that gradually increase caloric intake to a normal level for size, age, and activity.
 Family-based therapy. Individuals with anorexia nervosa may respond best to family-based treatment,
also known as the Maudsley method, an established therapeutic modality for achieving and maintaining
remission from anorexia nervosa.
 Cognitive behavioral therapy (CBT). CBT is an evidence-based, effective treatment for bulimia
nervosa (BN); behavioral approaches to avoiding undesirable eating habits are used, including diary
keeping; behavioral analyses of the antecedents, behaviors, and consequences (so-called ABCs)
associated with binge eating and purging episodes; and exposure to food paired with progressive
response prevention regarding binge eating and purging.
 Interpersonal psychotherapy. Interpersonal psychotherapy (IPT) addresses specific issues in the
interpersonal arena that create the context for and stimulate dynamic tensions that spur the patient’s
symptoms; these generally encompass such processes as grief, role transitions, role conflicts or
disputes, and interpersonal deficits.
Several classes of drugs have been studied, but few have shown clinical success.
 Electrolyte supplements. Electrolyte repletion is necessary in patients with profound malnutrition,
dehydration, and purging behaviors; repletion may be done orally or parenterally, depending on the
patient’s clinical state.
 Fat-soluble vitamins. Vitamins are used to meet necessary dietary requirements. They are utilized in
metabolic pathways, as well as in deoxyribonucleic acid (DNA) and protein synthesis.
 Antidepressants, SSRIs. These agents have been reported to reduce binge eating, vomiting, and
depression and to improve eating habits, although their impact on body dissatisfaction remains unclear.
Nursing Management for Eating Disorders

Nursing care for a client with eating disorder include the following:
Nursing Assessment
Although anorexia and bulimia have several differences, many similarities are found when assessing.
 History. Family members often describe clients with anorexia nervosa as perfectionists with above-
average intelligence, achievement oriented, dependable, eager to please, and seeking approval before
their condition began; clients with bulimia, however, often have a history of impulsive behavior such as
substance abuse, shoplifting, as well as anxiety, depression, and personality disorders.
 General appearance and motor behavior. Clients with anorexia appear slow, lethargic, and fatigued;
they may be emaciated depending on the amount of weight loss; clients with bulimia may be
underweight or overweight but are generally close to expected body weight for age and size.
 Mood and affect. Clients with eating disorders have labile moods that usually correspond to their
eating or dieting behaviors.
 Though processes and content. Clients with eating disorders spend most of the time thinking about
dieting, food, and food-related behavior.
 Self-concept. Low self-esteem is prominent in clients with eating disorders.
Nursing Diagnosis
Nursing diagnoses for clients with eating disorders include the following:
 Imbalanced nutrition: less than body requirements related to purging or excessive use of laxatives.
 Ineffective coping related to inability to meet basic needs.
 Disturbed body image related to being excessively underweight.

Nursing care plans and goals for clients with eating disorders:
 The client will establish adequate nutritional eating patterns.
 The client will eliminate use of compensatory behaviors such as excessive exercise and use of
laxatives and diuretics.
 The client will demonstrate coping mechanisms not related to food.
 The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
 The client will verbalize acceptance of body image with stable body weight.
Nursing interventions for clients with eating disorders are:
 Establishing nutritional eating patterns. When clients can eat, a diet of 1200 to 1500 calories per
day is ordered, with gradual increases in calories until clients are ingesting adequate amounts for
height, activity level, and growth needs; the nurse is responsible for monitoring meals and snacks and
often initially will sit with a client during eating at a table away from other clients; after each meal or
snack, clients may be required to remain in view of staff for 1 to 2 hours to ensure that they do not
empty the stomach by vomiting.
 Identifying emotions and developing coping strategies. The nurse can help clients begin to
recognize emotions such as anxiety or guilt by asking them to describe how they are feeling and
allowing adequate time for response.
 Dealing with body image issues. The nurse can help clients to accept a more normal body image;
this may involve clients agreeing to weigh more than they would like, to be healthy, and to stay out of
the hospital; helping clients to identify areas of personal strength that are not food related broaden’s
client’s perceptions of themselves.
Evaluation
 The client was able to establish adequate nutritional eating patterns.
 The client was able to eliminate use of compensatory behaviors such as excessive exercise and use of
laxatives and diuretics.
 The client was able to demonstrate coping mechanisms not related to food.
 The client was able to verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
 The client was able to verbalize acceptance of body image with stable body weight.
Documentation in a client with eating disorder include:
 Plan of care.
 Teaching plan.
Amnestic disorders are a series of disorders that involve loss of memories formerly established, loss of the
ability to construct and establish new memories, or loss of the ability to gain or grasp new information. There
are various types of amnesia, including retrograde amnesia, anterograde amnesia, transient global amnesia,
and infantile amnesia. Learn more about amnestic disorders and its nursing care management, interventions,
assessment in this study guide.
What are Amnestic disorders?

 Amnestic disorders are characterized by an inability to learn new information (short-term memory
deficit) despite normal attention and an inability to recall previously learned information (long-term
memory deficit).
 Amnesia refers to a specific deficit in new learning and memory.
 Retrograde amnesia refers to a loss of memory for events before the onset of lesion or condition.
 Anterograde amnesia refers to an inability to acquire new information or experiences occurring during
the period of impairment.
 Transient global amnesia occurs with confusion or agitation that comes and goes repeatedly over the
course of several hours.
 Infantile amnesia is a common phenomenon wherein most people can’t remember the first three to
five years of life.
 Amnestic disorders can occur in isolation, but in practice, they are most commonly seen within the
more global syndromes of delirium or dementia.
Causes of Amnestic disorders

In general, amnestic disorders are caused by structural or chemical damage to parts of the brain. The DSM-
V identifies the following categories as etiologies for the syndrome of symptoms known as amnestic disorders:
 Amnestic disorder due to a general medical condition. The symptoms may be associated with head
trauma, cerebrovascular disease, cerebral neoplastic disease, cerebral anoxia, herpes simplex
encephalitis, poorly controlled insulin-dependent diabetes, and surgical intervention to the brain;
transient amnestic syndromes can also occur from epileptic seizures, electroconvulsive therapy, severe
migraine, and drug overdose.
 Substance-induced persisting amnestic disorder. This type of amnestic disorder is related to the
persisting effects of substances such as alcohol, sedatives, hypnotics, anxiolytics, and other
medications, and environmental toxins; the term “persisting” is used to indicate that the symptoms
persist long after the effects of substance intoxication or substance withdrawal has subsided.
The following symptoms have been identified with amnestic disorders:
 Disorientation. Disorientation to place and time may occur with profound amnesia.
 Inability to recall events. There is an inability to recall events from the recent past and events from the
remote past.
 Confabulation. The individual is prone to confabulation. That is, the individual may create imaginary
events to fill in the memory gaps.
 Other symptoms. Apathy, lack of initiative, and emotional blandness are common.

Laboratory studies may be helpful for ruling in or excluding specific diagnoses that cause amnestic disorder
symptoms.
 ABG. Oxygen saturation, or ABG with carbon monoxide level, may be diagnostic.
 Drug toxin levels. When alcohol, drugs and/or toxins are suspected, consider serum ethanol,
salicylate, acetaminophen, carbon monoxide, and other specific drug or toxins level as indicated.
 CT scan. A head CT scan without intravenous contrast should be obtained if CNS infection, trauma, or
a cerebral vascular accident is suspected.
Medical Management
Medical management of a patient with amnestic disorders and emergency care include:
 Patient’s safety. Prehospital care workers involved in the transport of an acutely confused, combative,
or delirious patient must ensure the safety of the patient and the staff.
 Supportive care. Treat suspected overdose-induced delirium based on ingestion history and/or
toxidromes; such treatment may range from simple observation and supportive care, activated
charcoal, gastrointestinal lavage, sedation, specific antidotes to intoxication and life support.
 Identify underlying cause. The treatment of amnestic disorders is dependent on the identification of
the underlying cause, which may not be elucidated during an ED stay.
 Consultations. Specific cases may require consultation with neurosurgery, neurology, or medicine
subspecialists.
Pharmacological Management
Medications typically used in the treatment of amnestic disorders include:
 Sedatives. These agents are used to calm acute agitation, to control the behavior of combative
patients, and to facilitate procedures.
 Glucose supplements. Monosaccharides absorbed from intestines after PO absorption of dextrose
results in rapid increase of blood glucose concentrations.
 Neuroleptics. These agents have more robust calming effects than benzodiazepines in acutely
agitated patients; they act fast when given IV.
 Atypical antipsychotics. These are newer neuroleptics with a lowered risk of extrapyramidal
syndrome and improved efficacy for the negative symptoms of psychosis because of their enhanced
serotonergic activity as compared to older-style neuroleptics.
 Antidotes. These agents are used when the toxic agent is known and has an antidote or as a coma
cocktail in patients who are stuporous or comatose.
Nursing Management
The nursing management of a client with amnestic disorders include the following:
Nursing Assessment
Assessment of a client with amnestic disorders include:
 Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status
with a thorough description of behavior, flow of thought and speech, affect, thought processes and
mental content, sensorium and intellectual resources, cognitive status, insight, and judgement.
 Serial assessment. Serial assessment of psychiatric status is necessary for determining fluctuating
course and acute changes in mental status, interviews with family members should be included and
can be crucial in the treatment of infants and young children with cognitive disorders.
Nursing Diagnosis
Nursing diagnosis for persons with amnestic disorders include:
 Risk for trauma related to chronic alteration in structure or function of brain tissue secondary to the
aging process, multiple infarcts, HIV disease, head trauma, chronic substance abuse, or progressively
dysfunctional physical condition.
 Chronic confusion related to alteration in structure or function of brain tissue secondary to long-term
abuse of drug or toxic substances.
 Self-care deficit related to cognitive impairment.
 Low self-esteem related to loss of capacity for remembering.

The major nursing care planning goals for patients with amnestic disorders are:
 Client will voluntarily spend time with staff and peers in day-room activities.
 Client will exhibit increased feelings of self-worth as evidenced by voluntary participation in own self-
care and interaction with others.
The nursing interventions for Amnestic disorders are:
 Encourage expression of feelings. Encourage client to express honest feelings in relation to loss of
prior level of functioning; acknowledge pain of loss; support client through process of grieving.
 Assist with memory deficit. Devise methods in assisting client with memory deficit; these aids may
assist client to function more independently, thereby increasing self-esteem.
 Encourage communication. Encourage client’s attempts to communicate; if verbalizations are not
understandable, express to client what you think he or she intended to say.
 Reminisce events with client. Encourage reminiscence and discussion of life review; also encourage
discuss present-day events; sharing picture albums, if possible, is especially good.
 Encourage group participation. Encourage participation in group activities; caregiver may need to
accompany client at first, until he or she feels secure that group members will be accepting, regardless
of limitations in verbal communication.
 Provide client support. Offer support and empathy when client expresses embarrassment at inability
to remember people, events, and places.
 Encourage independence. Encourage client to be as independent as possible in self-care activities;
provide written schedule of tasks to be performed.
Evaluation
Outcome criteria include:
Client initiates own self-care according to written schedule and willingly accepts assistance as needed.
Client interacts with others in group activities, maintaining anxiety level in response to difficulties with verbal
communication.
Documentation in client with amnestic disorders include:
 Plan of care.
 Teaching plan.
Personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment (DSM-V).
Description
Personality can be defined as an ingrained enduring pattern of behaving and relating to self, others, and the
environment; personality includes perceptions, attitudes, and emotions.
 Personality disorders are diagnosed when personality traits become inflexible and maladaptive and
significantly interfere with how a person functions in society or cause the person emotional distress.
 They usually are not diagnosed until adulthood, when personality is more completely formed
 No specific medication alters personality, and therapy designed to help clients make changes is often long-
term with very slow progress.
Categories
The DSM-V lists personality disorders as a separate and distinct category from other major mental illness; they
are on axis II of the multiaxial classification system.
 Cluster A. Cluster A includes people whose behavior appears odd or eccentric and includes paranoid,
schizotypal, and schizoid personality disorders.
 Cluster B. Cluster B includes people who appear dramatic, emotional, or erratic and includes antisocial,
borderline, histrionic, and narcissistic personality disorders.
 Cluster C. Cluster C includes people who appear anxious or fearful and includes avoidant, dependent, and
obsessive-compulsive personality disorders.
Cluster A: Personality Disorders

• Paranoid Personality Disorder. This personality is characterized by pervasive mistrust and suspiciousness
of others; clients with this disorder interpret others actions as potentially harmful.
• Schizoid Personality Disorder. This is characterized by a pervasive pattern of detachment from social
relationships and a restricted range of emotional expression in interpersonal settings.
• Schizotypal Personality Disorder. This disorder is characterized by a pervasive pattern of social and
interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as
by cognitive or perceptual distortions and behavioral eccentricities.
Cluster B: Personality Disorders

• Antisocial Personality Disorder. This disorder is characterized by a pervasive pattern of disregard for and
violation of the rights of others- and with the central characteristics of deceit and manipulation.
• Borderline Personality Disorder. This disorder is characterized by a pervasive pattern of
unstable interpersonal relationships, self-image, and affect, as well as marked impulsivity; borderline
personality disorder is the most common personality disorder found in clinical settings.
• Histrionic Personality Disorder. This is characterized by a pervasive pattern of excessive emotionality and
attention-seeking; clients usually seek treatment for depression, unexplained physical problems, and difficulties
in relationships.
• Narcissistic Personality Disorder. This disorder is characterized by a pervasive pattern of grandiosity (in
fantasy or behavior), need for admiration, and lack of empathy.
Cluster C: Personality Disorders
• Avoidant Personality Disorder. This disorder is characterized by a pervasive pattern of social discomfort
and reticence, low self-esteem, and hypersensitivity to negative evaluation.
• Dependent Personality Disorder. This is characterized by a pervasive and excessive need to be taken care
of, which leads to submissive and clinging behavior and fears of separation; these behaviors are designed to
elicit caretaking from others.
• Obsessive-Compulsive Personality Disorder. This disorder is characterized by a pervasive pattern of
preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility,
openness, and efficiency.

Personality disorders are relatively common, occurring in 10% to 13% of the general population.
• 15% of all psychiatric inpatients have a primary diagnosis of a personality disorder.
• 40% to 45% of those with a primary diagnosis of major mental illness also have a coexisting personality
disorder that significantly complicates the treatment.
• In mental health outpatient settings, the incidence of personality disorder is 30% to 50%.
• Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have
higher rates of suicide attempts, accidents, and emergency department visits and increased rates of
separation, divorce, and involvement in legal proceedings regarding child custody.
• Personality disorders have been correlated highly with criminal behavior (70% to 85% of criminals have
personality disorders), alcoholism (60% to 70% alcoholics have personality disorders), and drug abuse (70% to
90% of those who abuse drugs have personality disorders).
The clinical manifestations of a person with personality disorder include:
• Paranoid. Mistrusts and is suspicious of others; has guarded, restricted affect.
• Schizoid. Detached from social relationships; has restricted affect; involved with things more than people.
• Schizotypal. Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior.
• Antisocial. Disregard for rights of others, rule, and laws.
• Borderline. Unstable relationships, self-image, and affect; impulsivity; self-mutilation.
• Histrionic. Excessive emotionality and attention-seeking.
• Narcissistic. Grandiose; lack of empathy; need for admiration.
• Avoidant. Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation.
• Dependent. Submissive and clinging behavior; excessive need to be taken care of.
• Obsessive-compulsive. Preoccupation with orderliness, perfectionism, and control.
• Depressive. Pattern of depressive cognitions and behaviors in a variety of contexts.
• Passive-aggressive. Pattern of negative attitudes and passive resistance to demands for adequate
performance in social and occupational situations.

The following tests can be used in the diagnosis of personality disorders:
 Toxicology screen. Substance abuse is common in many personality disorders, and intoxication can
lead patients to present with some features of personality disorders.
 Screening for HIV and other sexually transmitted diseases. Patients with personality disorders
often exhibit impulse control, and may act without regard to risk; such behavior can lead to infection
with a sexually transmitted disease.
 CT scanning. Computed tomography scanning with appropriate blood work can be carried out if
organic etiology is suspected.
 Radiography. Radiography can be indicated for injuries from fighting, motor vehicle accidents, or self-
mutilation.
Medical Management
Caregivers should be vigilant about suicidal potential and should document their assessments in the medical
record at each visit.
 Psychotherapy. Psychotherapy is at the core of care for personality disorders; because personality
disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve
perceptions of and responses to social and environmental stressors.
 Inpatient care. Because the underlying disorder remains basically unchanged by inpatient
interventions, length of stay should be minimized to avoid dependency that subverts recovery from the
circumstances prompting the hospitalization.
 Transfers. Some patients hospitalized in the psychiatric units of general hospitals, where stays are
generally shorter than 2 weeks, may require transfer to psychiatric hospitals that can provide long-term
care.
Medications are in no way curative for any personality disorder; they should be viewed as an adjunct to
psychotherapy so that the patient may productively engage in psychotherapy.
 Antidepressants. The selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants are
safe and reasonable effective; however, because the depression of most patients with personality
disorders stems from their limited range of coping capacities, antidepressants are usually less effective
than in patients with uncomplicated major depression.
 Anticonvulsants. These agents are useful for stabilizing the affective extremes in patients with bipolar
disorder, but they are less effective in doing so in patients with personality disorders; they have some
demonstrated efficacy in suppressing impulsive and particularly aggressive behavior in patients with
personality disorder.
 Antipsychotics. Response to antipsychotics in patients with a personality disorder is less dramatic
than it is in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to
rejection may be reduced.
Nursing Management of Personality Disorders

The nursing management of a patient with personality disorder include the following:
Nursing Assessment
Assessment of the patient include:
 History. Many of these clients report disturbed early relationships with their parents that often begin at 18
to 30 months of age; 50% of these clients have experienced childhood sexual abuse; others have
experienced physical and verbal abuse and parental alcoholism.
 Mood and affect. The pervasive mood is dysphoric, involving unhappiness, restlessness, and malaise;
clients often report intense loneliness, boredom, frustration, and feeling “empty”.
 Thought process and content. Thinking about self and others is often polarized and extreme, which is
sometimes referred to as splitting; clients tend to adore and idealize other people even after a brief
acquaintance but then quickly devalue them if these others do not meet their expectations is some way.
 Sensorium and intellectual process. Intellectual capacities are intact, and clients are fully oriented to
reality.
Nursing Diagnosis
Nursing diagnoses for clients with personality disorder include the following:
• Risk for suicide related to low frustration tolerance.
• Risk for self-mutilation related to impulsive behavior.
• Risk for other directed violence related to lack of feelings of remorse.
• Ineffective coping related to failure to learn or change behavior based on past experience or punishment.
• Social isolation related to ineffective interpersonal relationships.

Nursing care plan goals for personality disorders may include:
 The client will be safe and free of significant injury.
 The client will not harm others or destroy property.
 The client will demonstrate increased control of impulsive behavior.
 The client will take appropriate steps to meet his or her own needs.
 The client will demonstrate problem-solving skills.
 The client will verbalize greater satisfaction with relationships.
Clients with personality disorder often are involved in long-term psychotherapy to address issues of family
dysfunction and abuse.
 Promoting client’s safety. The nurse must always seriously consider suicidal ideation with the
presence of a plan, access to means for enacting the plan, and self-harm behaviors and institute
appropriate interventions.
 Promoting therapeutic relationship. Regardless of the cllinical setting, the nurse must provide
structure and limit setting in the therapeutic relationship; in a clinic setting, this may mean seeing the
client for scheduled appointments of a predetermined length rather than whenever the client appears
and demands the nurse’s immediate attention.
 Establishing boundaries in relationships. The nurse must be quite clear about establishing the
boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries
are violated.
 Teaching effective communication skills. It is important to teach basic communication skills such as
eye contact, active listening, taking turns talking, validating the meaning of another’s communication,
and using “I” statements.
 Helping clients to cope and to control emotions. The nurse can help the clients to identify their
feelings and learn to tolerate them without exaggerated responses such as destruction of property or
self-harm; keeping a journal often helps clients gain awareness of feelings.
 Reshaping thinking patterns. Cognitive restructuring is a technique useful in changing patterns of
thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive
patterns of thinking; thought stopping is a technique to alter the process of negative or self-critical
thought patterns.
 Structuring the client’s daily activities. Minimizing unstructured time by planning activities can help
clients to manage time alone; clients can make a written schedule that includes appointments,
shopping, reading the paper, and going for a walk.
Evaluation
 The client will be safe and free of significant injury.
 The client will not harm others or destroy property.
 The client will demonstrate increased control of impulsive behavior.
 The client will take appropriate steps to meet his or her own needs.
 The client will demonstrate problem-solving skills.
 The client will verbalize greater satisfaction with relationships.
Documentation in a client with personality disorder include:
 Plan of care.
 Teaching plan.
omatoform Disorders
By
Marianne Belleza, R.N.
-
Last Updated on September 30, 2019

ADVERTISEMENTS
Somatoform disorders are characterized by physical symptoms suggesting medical

disease but without demonstrable organic pathology or a known pathophysiological
mechanism to account for them. Learn about the nursing management for somatoform
disorders in this nursing care plan guide.
 Types of Somatoform Disorders

 Pathophysiology
 Statistics and Incidences
 Causes of Somatoform Disorders
 Clinical Manifestations
 Assessment and Diagnostic Findings
 Medical Management of Somatoform Disorders
o Pharmacologic Management
 Nursing Management of Somatoform Disorders
o Nursing Assessment
o Nursing Diagnosis for Somatoform Disorders
o Nursing Care Planning and Goals
o Nursing Interventions
o Evaluation
o Documentation Guidelines
 References and Sources
Types of Somatoform Disorders

 Somatization disorder. Somatization disorder is a chronic syndrome of
multiple somatic symptoms that cannot be explained medically and are
associated with psychosocial distress and long-term seeking of assistance from
health-care professionals.
 Pain disorder. The essential feature of pain disorder is severe and prolonged
pain that causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Hypochondriasis. Hypochondriasis is an unrealistic preoccupation with the fear
of having a serious illness.
 Conversion disorder. Conversion disorder is a loss of or change in body
function resulting from a psychological conflict, the physical symptoms of which
cannot be explained by any known medical disorder or pathophysiological
mechanism.
 Body dysmorphic disorder. This disorder, formerly called dysmorphophobia, is
characterized by the exaggerated belief that the body is deformed or defective
in some specific way.
Pathophysiology
The pathophysiology of somatoform disorders is unknown.
 Primary somatoform disorders may be associated with a heightened awareness
of normal bodily sensations.
 This heightened awareness may be paired with a cognitive bias to interpret any
physical symptom as indicative of medical illness.
 Autonomic arousal may be high in some patients with somatoform disorders.
 This autonomic arousal may be associated with physiologic effects of
endogenous noradrenergic compounds such as tachycardia or gastric
hypermotility.
 Heightened arousal also may induce muscle tension and pain associated with
muscular hyperactivity, as is seen with muscle tension headaches.

Prevalence rates for the most restrictive previous diagnosis of somatoform disorder
appear low in community samples (0.1%).
 One review estimates that the prevalence of somatoform disorder in the

general population is approximately 5%-7%.
 A study in Belgium reported that somatoform disorder is the third highest
psychiatric disorder, with a prevalence rate of 8.9%
 Females tend to present with somatoform disorder more frequently than males,
with an estimated F:M ratio of 10:1.
 Somatoform disorders may begin in childhood, adolescence, or early adulthood
Causes of Somatoform Disorders

Predisposing factors to somatoform disorders include:
 Genetic. Studies have shown an increased incidence of somatization disorder,
conversion disorder, and hypochondriasis in first-degree relatives, implying a
possible inheritable disposition.
 Biochemical. Decreased levels of serotonin and endorphins may play a role in
the etiology of pain disorder.
 Psychodynamic. Some psychodynamics view hypochondriasis as an ego
defense mechanism; the psychodynamic theory of conversion disorder
proposes that emotions associated with a traumatic event that the individual
cannot express because of moral or ethical unacceptability are “converted” into
physical symptoms.
 Family dynamics. Some families have difficulty expressing emotions openly
and resolving conflicts verbally; when this occurs, the child may become ill, and
a shift in focus is made from the open conflict to the child’s illness, leaving
unresolved the underlying issues that the family cannot confront openly.
 Sociocultural/familial factors. Somatic complaints are often reinforced when
the sick role relieves the individual from the need to deal with a stressful
situation, whether it be within the society or within the family.
 Past experience with physical illness. Personal experience, or the experience
of close family members with serious or life-threatening illness can predispose
an individual to hypochondriasis.
 Cultural and environmental factors. Some cultures and religions carry implicit
sanctions against verbalizing or directly expressing emotional states, thereby
indirectly encouraging “more acceptable” somatic behaviors.
Symptoms of somatoform disorder include:
 Pain symptoms. Complaints of headache, pain in the abdomen, head, joints,

back, chest, rectum; pain during urination, menstruation, or sexual intercourse.
 Gastrointestinal symptoms. There is nausea, bloating, vomiting (other than
during pregnancy), diarrhea, or intolerance of several foods.
 Sexual symptoms. Sexual indifference, erectile or ejaculatory dysfunction,
irregular menses, excessive menstrual bleeding, and vomiting through
pregnancy.
 Pseudoneurologic symptoms. Conversion symptoms such as impaired
coordination or balance, paralysis or localized weakness, difficulty swallowing or
lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain
sensation, double vision, blindness, deafness, and seizures.

If indicated, specific studies used to rule out somatization due to general medical
conditions include the following:
 Thyroid function studies. Thyroid stimulating hormone (TSH) at 0.4-10 mIU/L
and thyroxine at 5.0-12.5 ng/dL.
 Pheochromocytoma screen. Urine catecholamines, homovanillic acid (HVA) 2-
12 mg per 24 hours, vanillylmandelic acid (VMA) 2-7 mg per 24 hours,
metanephrines less than 1.6 mg per 24 hours, and norepinephrine plus
epinephrine less than 100 mcg per 24 hours.
 Urine drug screen. Including cannabis, amphetamine, hallucinogens, cocaine,
opioids, and benzodiazepines.
 Blood studies. To screen for occult alcoholism.
 Psychological testing. Minnesota Multiphasic Personality Inventory (MMPI)
may provide insight into the likelihood of a somatic symptom disorder.
Medical Management of Somatoform

Disorders
Randomized trials have demonstrated the value of physician education in the
management of the patient with somatoform disorder.
 Cognitive-behavioral psychotherapy. Cognitive-behavioral psychotherapy

strategies may be specifically helpful in reducing distress and high medical use.
 Psychosocial therapies. Psychosocial interventions directed by phsyicians form
the basis for successful treatment; a strong relationship between the patient
and the primary care physician can assist in long-term management.
 Psychoeducation. Psychoeducation can be helpful by letting the patient know
that physical symptoms may be exacerbated by anxiety or other emotional
problems; however, be careful because patients are likely to resist suggestions
that their condition is due to emotional rather than physical problems.
Based on studies of somatoform disorder, medication approaches rarely are successful
for this condition.
 Antidepressants. SSRIs are greatly preferred over the other classes of

antidepressants; because the adverse effect profile of SSRIs is less prominent,
improved compliance is promoted.
Nursing Management of Somatoform

Disorders
Nursing management of a patient with somatoform disorders include the following:
Nursing Assessment
The nurse must investigate physical health status thoroughly to ensure there is no
underlying pathology requiring treatment.
 History. Clients usually provide a lengthy and detailed account of previous

physical problems, numerous diagnostic tests, and perhaps even a number of
surgical procedures.
 General appearance and motor behavior. Often, clients walk slowly or with an
unusual gait because of the pain or disability caused by the symptoms; they may
exhibit a facial expression of discomfort or physical distress.
 Mood and affect. Mood is often labile, shifting from seeming depressed and
sad when describing physical problems to looking bright and excited when
talking about how they had to go to the hospital in the middle of the night by
ambulance.
 Thought process and content. Clients who somatize do not experience
disordered thought processes; the content of their thinking is primarily about
often exaggerated physical concerns, for example, when they have a simple cold
they may be convinced it is pneumonia.
Nursing Diagnosis for Somatoform Disorders

Based on the assessment data, the major nursing diagnosis are:
 Chronic pain related to severe level of anxiety, repressed.

 Ineffective coping related to inadequate coping skills.
 Disturbed body image related to low self-esteem, severe level of anxiety.
 Disturbed sensory perception related to regression to, or fixation in, an earlier
level of development.
 Self-care deficit related to paralysis of body part, pain, discomfort.
 Deficient knowledge related to lack of interest in learning, severe anxiety.

The major nursing care plan goals for patients with somatoform disorders are:
 The client will identify the relationship between stress and physical symptoms.
 The client will verbally express emotional feelings.
 The client will follow an established daily routine.
 The client will demonstrate alternative ways to deal with stress, anxiety, and
other feelings.
 The client will demonstrate healthier behaviors regarding rest, activity, and
nutritional intake.
The nursing interventions for somatoform disorders are:
 Providing health teaching. The nurse must help the client establish a daily
routine that includes improved health behaviors.
 Assisting the client to express emotions. Clients may keep a detailed journal
of their physical symptoms; the nurse might ask them to describe the situation
at the time such as whether they were alone or with others, whether any
disagreements were occurring, and so forth.
 Teaching coping strategies. Emotion-focused strategies include progressive
relaxation, deep breathing, guided imagery, and distractions such as music or
other activities; problem-focused coping strategies include problem-solving
methods, applying the process to identified problems, and role-playing
interactions with others.
Evaluation
Treatment outcomes include:
 The client was able to identify the relationship between stress and physical
symptoms.
 The client was able to verbally express emotional feelings.
 The client was able to follow an established daily routine.
 The client was able to demonstrate alternative ways to deal with stress, anxiety,
and other feelings.
 The client was able to demonstrate healthier behaviors regarding rest, activity,
and nutritional intake.
Documentation in a client with somatoform disorders include the following:
 Individual findings, including factors affecting, interactions, nature of social

exchanges, specifics of individual behavior.
 Plan of care.
 Teaching plan.

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Mental Health and Mental Illness

Diagnostic and Statistical Manual of Mental Disorders

Historical Perspectives of the Treatment of Mental Illness

Period of Enlightenment and Creation of Mental Institutions

Sigmund Freud and Treatment of Mental Disorders

Mental Illness in the 21st Century

Psychiatric Nursing Practice

Types of Psychosocial Theories

Sigmund Freud: The Father of Psychoanalysis

Ego develops gradually from rudimentary structure

Anal 18 to 36 Anus and surrounding area are major source of interest.

Acquisition of voluntary sphincter control (toilet training).

Phallic/oedipal 3 to 5 years Genital focus of interest, stimulation, and excitement.

Penis is organ of interest for both sexes.

Penis envy (wish to possess penis) seen in girls; oedipal

Latency 5-11 or 13 Resolution of oedipal complex.

Sexual drive channeled into socially appropriate activities

Formation of the superego.

Final stage of psychosexual development.

Erik Erikson and Psychosocial Stages of Development

Trust vs. Mistrust (infant) Hope Viewing the world as safe;

Autonomy vs. Shame and Will Achieving a sense of control

Initiative vs. Guilt (preschool) Purpose Beginning development of a

Industry vs. Inferiority (school Competence Emerging confidence in own

Identity vs. role confusion Fidelity Formulating a sense of self and

Intimacy vs. Isolation (young Love Forming adult, loving

Generativity vs. Stagnation Care Being creative and productive;

Ego integrity vs. Despair Wisdom Accepting responsibility for

Jean Piaget and Cognitive Stages of Development

Sensorimotor Birth to 2 years The child develops a sense of self as separate

Harry Stack Sullivan: Interpersonal Relationships and Milieu Therapy

Carl Rogers: Client-Centered Therapy

Ivan Pavlov: Classical Conditioning

B.F. Skinner: Operant Conditioning

Blame of other’s or things for one’s own feelings or

Unconscious, purposeful forgetting of painful or

What are Dissociative Disorders?

Statistics and Incidences

Symptoms of dissociative identity disorder:

Symptoms of dissociative amnesia:

Symptoms of depersonalization/derealization disorder:

Nursing Care Planning and Goals

Statistics and Incidences

Argumentative and defiant behavior

Symptoms of conduct disorder include:

Aggression to people and animals

Serious violations of rules

Symptoms of antisocial personality disorder include:

Symptoms of pyromania include:

Symptoms of kleptomania include:

Nursing Care Planning and Goals

Statistics and Incidences

In addition, the following conditions must be met:

All criteria must be met for a diagnosis of ADHD in adults:

Assessment and Diagnostic Findings

Nursing Care Planning and Goals

Types of Sexual Dysfunctions

Statistics and Incidences

Predisposing factors to sexual dysfunction include: