Midterms Examination Reviewer

Major Depressive Disorder

• Definition: two or more weeks of a sad mood or a lack of interest in activities with at least four other symptoms of depression. This is the leading cause for worldwide disability, followed by Bipolar Disorder.
• DSM-5 TR: at least five symptoms displayed in a two-week period, representing differences from previous behavior
  • At least one of a generalized (a) depressed mood, and (b) loss of interest/pleasure
  • (1) significant appetite or weight loss or gain without organic causes, (2) insomnia or hypersomnia, (3) psychomotor retardation or agitation, (4) anergia or fatigue, (5) feelings of worthlessness, inappropriate guilt, (6) Inability to decide or concentrate, and (7) recurrent thoughts of death (ideation, planning, attempt)
• Onset: occurs at most ages, and may last up to years (20% become chronic), but often clears within 6 months. Recurrence is seen in 50% to 60% of patients.
• Incidence: twice as common in women except during the prepubertal age where the rates even out between sexes. As age increases, female rates decrease and male rates increase.
  • Having first degree relatives with depression increases rates by 1.5 to 3 times.
  • Being single and divorced produces the highest rates of depression.
• Symptoms: anhedonia, alterations in weight, sleep, energy, concentration, decision-making, self-esteem, and goals. Psychosis may be found in severe cases of depression. Hopelessness and helplessness are proportional to the degree of depression.
• Theories:
  • Neurochemical Imbalance: decreased norepinephrine and serotonin as a result of inadequate secretion, their reuptake being too fast, and dysfunction or decreased amounts of the postsynaptic receptors. SSRIs inhibit reuptake, and antidepressants improve postsynaptic receptor sensitivity.

Treatment/Management

• Psychopharmacology: Cyclic Antidepressants, Monoamine Oxidase Inhibitors (MAOIs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Atypical Antidepressants
  • SSRIs take full effect in 10 days. Fluoxetine (Prozac) produces less somnolence and has a shorter half-life than other SSRIs.
  • Cyclic Antidepressants (TCA) are the oldest antidepressants. They block norepinephrine and serotonin, and increase postsynaptic receptor site sensitivity. These take 10 to 14 days before reaching a therapeutic serum level, and six weeks to take full effect. These are cheaper. Contraindicated for severe liver impairment and the acute recovery phase of myocardial infarction. Should also be cautiously used for patients with glaucoma, benign prostatic hypertrophy, urinary retention/obstruction, diabetes mellitus, hyperthyroidism, renal impairment, or respiratory disorders due to its anticholinergic effects.
  • Atypical Antidepressants are used if SSRIs are ineffective. These include Venlafaxine (Effexor) among others. Part of this is the Esketaime (Spravato) Nasal Spray that is a Schedule III controlled substance. Patients receive and stay in the clinic for 2 hours after administration due to severe side effects.
  • Monoamine Oxidase Inhibitors e.g. Isocarboxazid (Marplan) may have potentially fatal side effects, and have numerous interactions with other drugs or food, most fatally resulting in a hypertensive crisis when combined with tyramine-rich foods. Selegiline (Emsam, Eldepryl, et.al) is a transdermal patch MAOI with lower risks for a hypertensive crisis. MAOIs have a 2 to 4 week lag period, and should be given time to discontinue before changing medications.
  • Antipsychotics are used for acute depression that produce psychotic symptoms.
  • Antidepressants have recently been studied to prevent recurrences by increasing the duration of prescription by 3 to 6 months longer than previously done. Tapering the dosage instead of discontinuing it may also be effective in decreasing relapses.
• Electroconvulsive Therapy (ECT) is still being studied, but has been effective. It is used for patients unresponsive to antidepressants, pregnant patients, high suicide risk patients, and psychotic patients. Sessions are done from six to fifteen (12 - 15 is best) treatments thrice a week. Short-acting anesthetics and muscle relaxants are given.
  • Grand mal seizures, disorientation, confusion, headaches, and short-term memory loss may occur.
  • NPO is required after midnight, fingernail polish is removed, and the patient voids before the procedure.
  • Monitor for the return of the gag reflex.

Nursing Care

1. History: subjective, objective, and from family members or significant others.
   • Assess client perception of the problem by asking about behavioral changes they are aware of (onset, duration, factors involved, and actions taken). Previous episodes and treatment is important.
   • Determine family history for mood disorders and (attempted) suicide.
2. MSE: psychomotor retardation or agitation, anhedonia, anergia, apathy, depressed or flat affect, withdrawing, negativism, pessimism, rumination, psychosis (persecutory delusions), suicidal thought (often readily admitted). Command hallucinations may induce suicide. Memory, focus, attention, and judgment are impaired. Insight may be intact or limited. Self-esteem is low, feelings of worthlessness, helplessness and hopelessness are found. Self-care and social roles/functions are impacted.
3. Assessment Priorities:
   • Risk for suicide
   • Inadequate nutrition: food and fluids
   • Anxiety, Hopelessness, Low Self-esteem
   • Ineffective Coping, Self-care Deficits
   • Disrupted, poor-quality sleep
   • Impaired social interaction
4. Diagnosis: Ineffective coping
   • Expected Outcomes:
     • Immediate: free from self-inflicted harm (immediate), engaged in reality-based interaction (24 hours), oriented to three spheres (48 to 72 hours), safe expression of anger and hostility (5 to 7 days)
     • Stabilization: express feelings with directly congruent verbal and nonverbal messages, free from psychotic symptoms, and demonstrate functional level of psychomotor activity.
     • Community: demonstrate compliance with and knowledge of medications, increased ability to cope with negative feelings, and identify support systems within their community.
5. Nursing Actions:
   • Safety: physical safety to prevent self-destructive actions.
   • Suicide watch: continuous assessment and awareness of suicide potential (thought, intent, plan).
   • Observation especially during initiation of medication (increased energy), limited or unstructured periods of activity, and changes in behavior, related to suicide awareness.
   • Reorientation to the three spheres: inform the client of their name, the place, and the time. Presentation of reality is concrete reinforcement for the client.
   • Spend time with the client. Your physical presence is reality.
     • Develop a therapeutic relationship. For example: “I’m Nurse K. I’ll be your nurse for today. I’ll be here for a few minutes. If you need anything or if you want to talk, please tell me”. After time has passed, “I’m going now. I’ll be back in an hour to see you again.”
   • Tackle Rumination. Limit attention given to ruminations, and talk about reality or about the client’s feelings. Reinforcement allows for reality orientation and is encouraged by expressing feelings.
   • Maintaining staff assignments for patients facilitates familiarity and trust, but the number of people interacting with the patients should increase when possible to minimize dependency.
   • Moderate-level tone of voice (not overly cheerful) allow the client to be comfortable with their emotions; being cheerful may cause them to think that cheerfulness is the goal, and their feelings are incorrect. Being talkative may also overwhelm the client and cause them to withdraw from talking.
   • Silence and active listening facilitates communication of interest and concern. Allow the client to know that they are not required to talk, and silence is okay.
   • Keep It Short and Simple; the client’s perception of complex stimuli may be impaired.
   • Avoid questioning, especially questions that only require short answers. These may discourage expression by the client.
   • Do not belittle or undermine the patient's feelings. Accept and support the client’s verbalizations of feelings. Do not cut off interactions with cheerful remarks or platitudes if you feel discomfort during conversation.
   • Support expression of any form by the client, and let them know you are ready to listen and accept their expressions. Remain nonjudgmental.
   • Allow and encourage the client to cry. Provide privacy or remain with the client if they desire and if it is safe to do so. It is among the healthiest forms of expression for sadness, hopelessness, and despair.
   • Do not probe for information. Allow the client to discuss what they are comfortable with. This may discourage communication and cause discomfort.
   • Discuss coping strategies that the client has used, looking for successful and unsuccessful results. Teach the client about positive coping strategies, stress management skills, and problem-solving processes (e.g. exploring options, examining consequences, using alternatives, evaluating results), which may also be a source of success and positive feedback if practiced in the clinical environment. Assist the patients in choosing, using, and changing strategies and provide the patient with positive feedback for each step of the process.
   • Promote ADLs and Physical Care. These are related to levels of psychomotor retardation. Ask the patient to perform global tasks first to assess their ability, then break the task into smaller segments if they are unable to comply. Use success in small steps to increase self-esteem and competency.
     • For example, the nurse may choose articles of clothing for the patient if they are unable to do so themselves e.g. “Here are your gray slacks. Put them on”. If they are still unable to comply, “Let me help you put on your slacks, M.”. Let the patient do as much as possible for themselves.
     • The nurse may acknowledge the client’s feelings while still promoting participation: “I know you feel like staying in bed, but it is time to get up for breakfast.”
   • Establish adequate nutrition and hydration. Smaller, more frequent feedings can avoid overwhelming the client. Staying with the client and monitoring intake can promote and may be necessary for patients until they are consuming adequate amounts.
   • Promote sleep: short-term sedatives and avoiding staying in bed during the day improve sleep duration and quality. Note length and whether the client feels refreshed when awakening.
   • Manage Medications: MAOIs and antidepressants may be fatal when overdosed, so only a one-week supply should be given to the patient if overdosing is a concern. Increased energy and mood after the initiation of medication may give the patient the energy required for suicide. Maintain watch. Inform the patient of side effects and to verbalize any if they experience them, and inform the patient of how often monitoring and diagnostic examination is required.
6. Outcome Evaluation:
   • The client will not injure themself.
   • The client will independently carry out ADLs.
   • The client will establish a balance of rest, sleep, and activity.
   • The client will establish a balance of adequate nutrition, hydration, and elimination.
   • The client will evaluate self-attributes realistically.
   • The client will socialize with staff, peers, and family/friends.
   • The client will return to occupation or school activities.
   • The client will comply with antidepressant regimen.
   • The client will verbalize symptoms of a recurrence.

Bipolar Disorder

• Definition: Extreme mood swings from episodes of mania to episodes of depression (hence its previous name of “manic-depressive illness). Manic episodes produces euphoria, grandiosity, high energy, and sleeplessness. Poor judgment, rapid thoughts, action, and speech are manifested. Depressive episodes manifest the same as major depressive episodes (also read: Major Depressive Disorder), and may result in an incorrect diagnosis of depression until an episode of mania occurs. A questionnaire for this mood disorder can be found here. It is the second leading cause of worldwide disability, following the major depressive disorder. It may be classified according to degrees of manic or depressive episodes:
  • Bipolar Manic: person experiencing cycles of mania and normal behavior.
  • Bipolar Depressed: person experiencing cycles of depression and normal behavior.
  • Bipolar Mixed: person experiencing cycles of mania and depression.
  • Bipolar Type I: bipolar manic, but with at least one depressive episode.
  • Bipolar Type II: bipolar depressed, but with at least one hypomanic episode.
• DSM-5 TR for Manic Episodes and Bipolar I Disorder
  • A manic episode must occur, where a distinct period of abnormally and persistently elevated/expansive/irritable mood and goal-directed activity or energy lasts for at least one week. During the period of mood disturbance, at least three of the following must be present: (1) grandiosity/inflated self-esteem, (2) decreased sleep requirements, (3) being talkative/pressured speech, (4) flight of ideas, “racing thoughts”, (5) distractibility, (6) goal-directed hyperactivity e.g. socially, occupational, academic, sexual or psychomotor agitation (purposeless activity), and (7) excessive involvement in risky activities.
  • A hypomanic or major depressive episode must also occur before or after the manic episode.
• Onset: first manic episodes often occur between the teens and 30s, typically suddenly and rapidly escalating symptoms over a few days. Manic episodes are often shorter than depressive episodes.
• Incidence: almost equal between sexes, and is more common in highly educated people. Adolescents display psychosis more commonly than other age groups.
• Symptoms: depression and thought of suicide may occur especially in young men and recently discharged, alcoholics, or previously suicidal individuals.

Treatment/Management

• Psychopharmacology: a lifetime regimen of medications is required. An antimanic agent (lithium) or anticonvulsant medications as mood stabilizers are used.
  • Lithium is a salt in the body found in trace amounts. In acute mania, lithium is effective in 70% to 80% of cases. It can “mute” and reduce the frequency and degree of manic and depressive episodes, potentially even eliminating manic episodes entirely. Its mechanism of action is unknown, but is thought to hasten catecholamine destruction, inhibit the release of neurotransmitters, and decrease postsynaptic receptor sensitivity.
    • Peaks in 30 minutes to 4 hours, or 4 to 6 hours in slow-release forms. The onset of action is 5 to 14 days, with its half-life being 20 to 27 hours.
    • Affects other ions (calcium, magnesium, potassium) and glucose metabolism.
    • Contraindicated in renal disease.
  • Anticonvulsants, whose mechanism of action is also unknown, has been theorized to raise the sensitivity of the brain to stimulants, which decreases or prevents mania.
    • Carbamezapine (Tegretol) was the first anticonvulsant to serve as a mood stabilizer, but risk for agranulocytosis requires regular serum level checking for therapeutic levels (~4 to 12 mcg/mL) or toxic levels. A baseline and periodic laboratory testing monitors for white blood cell supression.
    • Valproic Acid (Depakote) also requires regular monitoring (therapeutic levels are 50 to 125 mcg/mL) as well as liver function tests (ammonia levels, platelet and bleeding times).
    • Clonazepam (Klonopin) is only used in conjunction with lithium or other mood stabilizers, and may result in physiological dependence.
    • Antipsychotic medications (Abilify, Geodon, Seroquel) may also be combined with mood stabilizers or antidepressants to prevent a switch from a depressive to a manic episode.
  • Antipsychotics are used if psychotic symptoms are displayed.
• Psychotherapy may be used during normal portions or mildly depressive portions of the bipolar cycle (not in acute mania, as minimal benefit is gained due to impaired concentration and insight). This may also reduce suicide risk.

Nursing Care

1. History: obtaining data during mania is difficult; short sessions may be required. Data from family members may be required. Valuable information may be obtained through observation.
2. MSE: psychomotor agitation; “perpetual motion” that results in exhaustion or injury. Clothing may reflect mania. Thinking, moving, and speech are fast. Pressured Speech is a hallmark symptom. Euphoria, exuberant activity, grandiosity, and a false sense of well-being is felt. Projection of an all-knowing and all-powerful image may be used to defend against low self-esteem. Mood may be labile and alternate between tears and laughter. Thought is confused and jumbled, with a flight of ideas. They are unable to connect concepts, and thinking is circumstantial and tangential. Judgment is impaired, and actions reflect this in mania (spending, travelling, sexual activity). Psychosis (grandiose delusions) may occur. Concentration and attention is highly impaired. They are easily angered and irritated by “censorship” from others. They do not perceive and problems with their behavior and often blame others. These clients have a great need to socialize, but fail to do so. Their false sense of well-being can result in days of sleeplessness or starvation. They may destroy or throw away valued items.
3. Assessment Priorities:
   • Risk for violence
   • Risk for unintended injury
   • Inadequate nutrition: food and fluids
   • Ineffective coping
   • Noncompliance
   • Unable to fulfill roles
   • Self-care deficits
   • Low self-esteem
   • Inadequate rest and sleep.
4. Diagnosis:
5. Nursing Actions:
   • Ensure Safety: provide a safe environment for clients and others. Monitor for suicidal or violent thoughts, ideation, or planning.
   • Establish control: which may be external, done so with a nonjudgmental and empathetic attitude. If boundaries are invaded, limits should be set when the clients are not able to set limits on themselves e.g. “You are too close to my face. Please stand back two feet.” or “It is unacceptable to hug other clients. You may talk to others, but do not touch them”. Clearly identify the unacceptable behavior and the expected, appropriate behavior. All staff should enforce consistent limits.
   • Reorient the client to the three spheres. Repeated presentation of reality provides concrete reinforcement for the client.
   • Consistency
   • Meet Physiological Needs: decrease environmental stimuli, establish a (bedtime) routine, finger-foods high in protein and calories that can be eaten quickly are ideal, but some may be inadequate. Snacks in between meals can also be useful. Sleep, food, and fluids are monitored until regularly met. Taking food from others should be prevented.
   • Therapeutic Communication: clear, simple sentences is used for short attention span and impaired understanding. Asking the client to repeat brief sentences can ensure understanding.
     • Short explanations for laboratory tests allay anxiety. Printed information for tests, rules, schedules, rights, treatment, staff names, and client education can help reinforce verbal messages.
     • The client’s disordered speech requires an open channel of communication for clients from the nurses, regardless of speech pattern. Moving the responsibility for difficulty in communication to the nurse helps reduce client anxiety”Please speak more slowly. I’m having trouble following you.”
     • Pressured speech may cause “competition” for the nurse’s attention. Talking one-on-one avoids this problem. Setting limits on talking and listening is done.
   • Promoting Appropriate Behaviors: restlessness may be directed into socially acceptable, large motor activities such as arranging chairs for a community meeting or walking. In acute mania, the nurse may need to limit the client (social, sexual, financial) until their mania abates.
   • Managing Medications: lithium levesl (therapeutic: 0.8 - 1.5 mEq/L, maintenance: 0.5 - 1 mEq/L) toxicity (>1.5 mEq/L) manifests as N&V, diarrhea, ataxia, drowsiness, slurred speech, muscle weakness, hypertonicity, altered level of consciousness, or coma. etc.. The client and family should be informed of symptoms, and levels should be regularly checked.
     • High salt intake can reduce lithium receptor availability and increase lithium excretion. Adequate water intake should be monitored as well, as increased fluid intake dilutes and reduces lithium levels, and decreased water intake increases lithium levels. Daily weighing of the patient is done to monitor for shifts in fluid balance. Any conditions that can cause dehydration should be reported.
     • Renal status is checked as lithium is not metabolized, and is excreted in the urine. As such, lithium is contraindicated in patients with reduced renal function, urinary retention, and when taken with low-salt diets or diuretics. Brain or cardiovascular damage is also contraindicated.
     • Thyroid stimulating hormone (TSH) levels may elevate or depress in patients taking lithium.
   • Client and Family Education: the illness, symptoms, potential problems, and treatments are discussed with the client and family. Providing education about courses of action to take allows significant others to have “permission” to intervene with behaviors. Medication dosages, symptoms, and considerations for toxicity should be discussed.
6. Outcome Evaluation:
   • The client will not injure self or others.
   • The client will establish a balance of rest, sleep, and activity.
   • The client will establish adequate nutrition, hydration, and elimination.
   • The client will participate in self-care activities.
   • The client will evaluate personal qualities realistically.
   • The client will engage in socially appropriate, reality-based interactions.
   • The client will verbalize knowledge of their illness and treatment.

Anxiety

• Definition: anxiety by itself is a vague feeling of dread or apprehension normally as a response to external or internal stimuli, which may cause both psychological and physiological symptoms. It is unlike fear, where being afraid or threatened is a response to perceived danger. Anxiety disorders are a group of conditions that feature excessive anxiety and its psychological and physiological manifestations. Panic without reason, unwarranted fear, and unexplainable, overwhelming worry may appear. This distress significantly impairs multiple areas of functioning. Obsessive-Compulsive Disorder (OCD) and Posttraumatic Stress Disorder (PTSD) may also feature excessive anxiety. There are various levels
• Onset: highly variable
• Incidence: highest prevalence rates of all mental disorders for both children and adults. The lifetime incidence rate is 30%. Incidence is higher in women, and those less than 45 years of age.
• Symptoms:
  • Decreased attention span, restlessness, irritability, poor impulse control, feelings of discomfort, apprehension, or helplessness, hyperactivity, pacing, wringing hands, perceptual field deficits, decreased ability to communicate verbally
  • Mild: restless, butterflies, widened senses, effective problem-solving and learning.
  • Moderate: focus becomes limited, tension and physiological symptoms appear (strong heartbeat, diaphoresis, etc.).
  • Severe: tunnel vision, becoming non-functional, severe headache and vertigo, chest pain, trembling.
  • Panic: vision is limited to self, rationality is lost, suicide risk, flight/fight/freeze.
• Theories:
  • Genetic Theories: first-degree relatives with history increase incidence. Genetic susceptibility is clear, but further study is required.
  • Neurochemical Theories: GABA is believed to be dysfunctional in anxiety disorders. GABA is inhibitory, functioning as the body’s antianxiety agent. Norepinephrine naturally increases anxiety, and is suspected to be in excess for panic disorder, general anxiety disorder, and PTSD. The 5-Hydroxytryptamine type 1a subtype of Serotonin affects aggression, mood, and anxiety.
  • Psychodynamic Theories
    • Intrapsychic/Psychoanalytic Theories: anxiety is the stimulus for behavior. Defense mechanisms are used to maintain a sense of control and lessen discomfort. Overuse results in an inability to resolve anxiety-producing situations.
    • Interpersonal Theory: interpersonal relationships produce anxiety.
    • Behavioral Theory: anxiety is learned through experiences.

Treatment/Management

• Psychopharmacology: anxiolytic Medications may be used for short-term anxiety.
  • Benzodiazepines e.g. Diazepam (Valium), Lorazepam (Ativan), Alprazolam (Xanax) are only used short-term (4 to 6 weeks) due to their potential for abuse. Its use is to reduce anxiety to allow for resolution and learning coping skills or changes. It is not a cure.
    • Avoid CNS depressants (antihistamines, alcohol), caffeine, and hazardous activities such as driving.
    • Do not stop taking the drug abruptly. Use as prescribed. Maintain hydration.
  • Nonbenzodiazepines e.g. Buspirone (BuSpar) may also be used.
    • Avoid hazardous activities such as driving.
    • Report persistent restlessness, agitation, euphoria, and excitement.
    • Take with food.
• Cognitive-Behavioral Therapy is used successfully.
  • Positive Reframing is the conversion of negative messages to positive messages e.g. “I’m trembling. I’m going to die.” to “I can stand this. It will go away.”
  • Decatastrophizing involves the use of questions by the therapist to enforce realistic appraisal of situations. Thought-stopping and distractions stop negative thought such as splashing cold water on the face, snapping a rubber band on the wrist, or shouting when negative thoughts appear.
  • Assertiveness Training helps the patient control life situations. “I” statements communicate feelings and needs to others, like “I feel angry when you turn your back while I’m talking”.
• Mental Health Promotion: maintaining a positive attitude, self-assurance, communicating assertively, learning to relax, exercising, balanced diets, limited caffeine/alcohol intake, proper rest and sleep, realistic goals, and stress management techniques (relaxation, guided imagery, meditation)

Nursing Care

1. History:
2. MSE:
3. Assessment Priorities:
4. Diagnosis: Anxiety
   • Expected Outcomes:
     • Immediate: the client will be free from injury (safety), discuss negative feelings (24 to 48 hours), and respond to relaxation techniques with assistance from staff, displaying decreased anxiety level (48 to 72 hours).
     • Stabilization: demonstrate effective independent use of relaxation techniques, reducing own anxiety level without staff assistance.
     • Community: be free from anxiety attacks and manage anxiety responses to stress effectively.
5. Nursing Actions:
   • According to level:
     • Mild: the nurse does not need to intervene, and this form may even be beneficial.
     • Moderate: the nurse should make certain that the patient is paying attention to instructions. Keep it short and simple. Refocusing the patient may be required.
     • Severe: attention and information is no longer retainable. The goal now is to reduce the anxiety levels before proceeding. Remaining with the client is important as being alone may cause anxiety to increase. A low, soothing, calm voice can help. Walking with the patient while talking can reduce restlessness. Deep breaths can also help.
     • Panic: safety is priority. Judgment is impaired. Talking with the patient in a comforting manner even if conversation cannot occur can still help. A small, quiet, non-stimulating environment can reduce anxiety. Reassure safety and transience of the anxiety. It may last from 5 to 30 minutes.
   • Implementation:
     • Therapeutic Use of Self: presence reduces anxiety levels. Supervision is used to ensure safety for highly anxious patients. Be aware of the nurse’s own anxiety and discomfort to avoid becoming anxious due to the patient.
     • Use of the environment: reduce stimuli (small, quiet room)
     • Therapeutic Communication: remain calm. Displaying anxiety can elevate the client’s own anxiety. Short, concise sentences allow for understanding even during periods of elevated anxiety. Do not asking or forcing the client to make choices.
     • Relaxation Exercises such as deep breathing, progressive muscle relaxation, meditation, and imagining a “happy place”. Encourage the patient to participate in these activities.
     • Encourage the client to pursue relationships, personal interests, supportive resources and systems, or hobbies.

Panic Disorder

• Definition: discrete episodes of panic attacks, defined as 15 to 30 minutes of rapid, intense, escalating anxiety with great emotional fear as well as physiological discomfort. Four or more of the following are displayed: palpitations, sweating, tremors, shortness of breath, sense of suffocation, chest pain, nausea, abdominal distress, dizziness, paresthesia, chills, hot flashes
• DSM-5 TR: (1) recurrent, unexpected panic attacks, followed by (2) at least one month of persistent concern or worry about future attacks or their meaning may constitute a diagnosis of panic disorder.
• Onset: onset peaks from late adolescence to the mid-30s. Occurrences may be normal in certain situations, but a lack of stimulus characterizes a panic disorder. Avoidance behaviors may result from stimuli that trigger a panic attack. The patient may avoid riding a bus if they have had a panic attack in one before. They may also become homebound; agoraphobia may occur. Primary gain, where an action reduces anxiety (like staying at home) and secondary gain, a resulting attention primary gain produces (like being taken care of while homebound) are displayed in agoraphobia. These “gains” are related to many anxiety disorders, and may drive behavior.
• Incidence:
• Symptoms:
• Theories:

Treatment/Management

• Cognitive-Behavioral Therapy such as deep breathing and medication are used to treat panic disorder.
• Psychopharmacology
  • Benzodiazepines e.g. Diazepam (Valium), Lorazepam (Ativan)
  • Selective Serotonin Reuptake Inhibitor Antidepressants
  • Tricyclic Antidepressants (TCA)
  • Antihypertensives like Clonidine (Catapres)
  • Propranolol (Inderal)

Nursing Care

1. History: the client often looks for treatment after several panic attacks. They often cannot identify a trigger for the episodes. Assessment may be done through the Hamilton Rating Scale for Anxiety.
2. MSE: the client may be entirely normal or may have some anxiety about future panic attacks. Automatisms such as tapping fingers, jingling keys, or twisting hair may be elevated, which act to attempt to decrease anxiety. Its frequency and intensity is proportional to the severity of anxiety. Distress about their panic attacks may be evident. Anger, tearfulness, and feelings of depersonalization or derealization may be present. Alterations in social roles may occur from anxiety related to panic attacks.
   • During a panic attack, feelings of “losing control”, disorganized thought, loss of rationality, confusion, disorientation, suspended judgment, and impaired insight may occur. Thoughts of suicide may occur.
3. Assessment Priorities:
   • Risk of injury
   • Anxiety
   • Situational low self-esteem
   • Ineffective coping
   • Powerlessness
   • Ineffective role performance
   • Disturbed sleep pattern
4. Diagnosis: Panic; Anxiety
5. Nursing Actions:
   • Ensure safety. Provide a safe, private environment. Less stimulation may also help.
   • Therapeutic Use of Self: remain with the patient to prevent elevating anxiety and provide supervision and continued assessment. Use a soothing, calm voice and reassure the patient. If the patient feels like they have no control, the nurse can assure that they are in control until the client regains self-control.
   • Therapeutic Communication: utilize simple, calm communication. The nurse may talk to the patient while walking to relieve restlessness. Discussing panic attacks after cognition is regained allow for exploration of their experiences; their emotional responses to physiological processes and behaviors. This may allow them to regain a sense of control.
   • Manage Anxiety: relaxation techniques such as deep breathing, guided imagery, progressive relaxation, and cognitive restructuring techniques can be taught to the patient. They can be assisted in performing the techniques, but should eventually be able to perform them independently.
   • Decrease Stressors: explore how to decrease stressors and anxiety-provoking situations with the client.
6. Outcome Evaluation:
   • The client will be free from injury.
   • The client will verbalize feelings.
   • The client will demonstrate use of effective coping mechanisms.
   • The client will demonstrate effective use of methods to manage anxiety response.
   • The client will verbalize a sense of personal control.
   • The client will reestablish adequate nutritional intake.
   • The client will sleep at least 6 hours per night.

Phobias

• Definition: illogical, intense, and persistent fear of a specific object or situation, creating extreme distress and dysfunction. Oftentimes, these phobias are not preceded by a negative experiences. Contrarily, the person may not have ever experiences their phobia. Irrational fear is paired by irrational reactivity to the phobia. Recognition of the irrationality of the fear may not abate their control over it. There are three categories:
  • Agoraphobia, a fear of the outside
  • Specific phobia, a phobia of specific situations or objects
    • Natural environmental phobias: storms, water, heights, etc.
    • Blood-injection phobias: fear of seeing one’s own or other’s blood, traumatic injury, or other medical procedures.
    • Situational phobias: fear of being in a specific situation such as being on a bridge, a tunnel, elevator, small room, hospital, airplane, etc.
    • Animal phobia: fear of animals or insects (often of a specific type) that usually develop in childhood, sometimes continuing into adulthood. The most common objects of animal phobia are cats and dogs.
  • Social anxiety/phobia is provoked by certain social or performance situations.
• DSM-5 TR: a diagnosis is only made when phobias significantly interfere with the person’s life by creating marked distress or difficulty in interpersonal or occupational functioning.
• Onset: specific phobias occur in childhood or adolescence. 80% of specific phobias persist for a lifetime. Social phobia often develops during middle adolescence. This may occur in shy children and less intense during adulthood.
• Incidence: phobias may run in families.
• Symptoms: anticipatory anxiety develops and avoidance behavior may occur, limiting life quality. The anxiety is not abated by the avoidance behavior.

Treatment/Management

• Behavioral therapy: teaching the patient about anxiety, anxiety responses, relaxation techniques, goal-setting, and planning. Phobic situations are visualized with the patient, and development of self-esteem, self-control can be done with methods like positive reframing and assertiveness training.
  • Systematic (Serial) Desensitization is often used, tapering the intensity of the phobic item in a safe environment to condition the client’s anxiety to decrease.
  • Flooding is rapid desensitization where the client is “flooded” with a phobic object until it no longer produces anxiety. As expected, severe anxiety is produced by this method, and is only used by trained psychotherapists with consent.
• Psychopharmacology: the same drugs used for anxiety may be used for phobia-induced anxiety.

Generalized Anxiety Disorder (GAD)

• Description: excessive worrying and high anxiety for more than half the time for six months or more, causing greatly diminished quality of life, especially in older adults.
• Symptoms: unease, irritability, muscle tension, fatigue, difficulty in thinking, and sleep alterations.

Treatment/Management

• Buspirone (BuSpar) and SSRIs/SNRI Antidepressants are the most effective treatments for GAD.

Personality Disorders

• Definition: personality is an ingrained, enduring pattern of behavior and relating to the self, others, and the environment, including perceptions, attitudes, and emotions. These remain consistent across situations and do not change easily. Personality Disorders affect personality functioning (areas of identity, self-direction, empathy, and intimacy), and traits in a maladaptive way. Egocentrism is a common problem, and self-esteem is sourced from gaining power or pleasure, often at the expense of others. Non-conformity to social norms is normal.
• DSM-5 TR: for Borderline Personality Disorder; a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity including five or more of the following: (1) frantic efforts to avoid abandonment, whether real or not; (2) unstable and intense interpersonal relationships characterized by alternating idealization and devaluation; (3) identity disturbance; (4) self-damaging impulsivity in at least two areas; (5) recurrent suicidal or self-mutilating behaviors; (6) affective instability; (7) chronic feelings of emptiness; (8) inappropriate, intense, hard-to-control anger; (9) transient, stress-related paranoid ideation or severe dissociation
• Onset: 10% to 20% of the general population exhibit personality disorders. By age 40 or 50, personality disorders often reduce in severity.
• Incidence: lower socioeconomic groups and unstable or disadvantaged populations (prisoners, drug users) have increased incidence. Personality disorders commonly coexist with other mental illnesses (15% of inpatients, 30% of outpatients, 45% of those with major mental illnesses)
• Symptoms:
  • Behaviors: negative behaviors (being manipulative, dishonest, deceitful, or lying), anger, hostility, irritability, labile moods, lack of guilt/remorse, emotionally cold and uncaring, impulsivity, distractibility, distractibility, poor judgment, irresponsible, unaccountable, risk-taking, thrill-seeking, mistrust, exhibitionism, entitlement, dependency, insecurity, eccentric perceptions.
• Theories:
  • Biologic Theories: Temperament refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion. Genetic differences account for half of variance in temperament. There are four traits found in temperament:
    • (1) Harm Avoidance: excess in harm avoidance results in fear of uncertainty, social inhibition, shyness, rapid fatigability, and anticipatory pessimism. Deficiency in harm avoidance results in unwarranted optimism, and unresponsiveness to potential harm.
    • (2) Novelty Seeking: excess in novelty seeking results in being quick-tempered, curious, easily bored, impulsive, extravagant, and disorderly. Deficiency in novelty seeking results in slow-tempered, stoic, reflective, frugal, reserved, orderly behaviors that are tolerant of monotony, adhering to routine activities.
    • (3) Reward Dependence determines the responses of an individual to social cues. High reward dependence results in tender-hearted, sensitive, sociable, and socially dependent individuals. Overdependence on approval may cause a loss of adherence to one’s own beliefs or desires. Low reward dependence result in practical, tough-minded, cold, socially insensitive, irresolute, and indifferent to being alone. Social withdrawal, detachment, aloofness, and disinterest in others can result.
    • (4) Persistence: highly persistent people people are hardworking overachievers who perceive fatigue or frustration as a personal challenge. Even during situations where they must change or stop, they often persevere. Low persistence results in inactivity, indolence, instability, and erratic behavior. These individuals give up easily and rarely strive for higher accomplishments.
  • Psychodynamic Theories: character is changed by social learning, culture, and random life events. It consists of concepts about the self and the external world. There are three major character traits identified:
    • (1) Self-directedness: the extent to which a person is responsible, resourceful, reliable, goal-oriented, and self-confident. High levels result in realistic, effective, adaptive individuals. Deficiency results in blaming, helpless, irresponsible, unreliable, non-achieving individuals.
    • (2) Cooperativeness: the extent to which a person perceives themselves as an integral part of human society. High cooperativeness produce empathic, tolerant, compassionate, supporting, and principled individuals. Deficiency results in self-absorbed, intolerance, critical, unhelpful, revengeful, and opportunistic.
    • (3) Self-transcendence: the extent to which a person perceives themselves as an integral part of the universe. Development of self-transcendence help deal with suffering, illness, or death with spirituality, unpretentious, humility, and fulfillment. Low self-transcendence results in self-conscious, practical, materialistic, controlling individuals.

Treatment/Management

Patients are often “treatment-resistant”, which also adds to the slow progress of treatment for personality disorders. They are also often unable to perceive the dysfunctions of their behavior, and even defend them, thinking of suggested changes as threats.

• Psychopharmacology: often symptomatic.
  • Cognitive-perceptual Distortions including psychotic symptoms, magical thinking, odd beliefs, illusions, suspiciousness, ideas of reference. These respond to low-dose antipsychotic medications
  • Mood Dysregulation: Lithium (lability), MAOIs/SSRIs (atypical depression/dysphoria), SSRIs (emotional detachment)
  • Aggression and Behavioral Dysfunctions: Lithium, Antipsychotics, Anticonvulsants, Benzodiazepines
  • Anxiety: SSRIs, MAOIs, Benzodiazepines, Low-dose Antipsychotics (in severe anxiety)
• Psychotherapy, both individual and group forms: inpatient hospitalization is used for safety concerns. Psychotherapy goals include building trust, basic living skills, providing support, decreasing distress, improving interpersonal relationships, relaxation or stress management techniques.
• Cognitive-Behavioral Therapy: thought-stopping, positive self-talk, decatastrophizing
• Dialectical Behavioral Therapy is used for Borderline Personality Disorder.
• Schema Therapy is used for unmet emotional needs, developing self-worth, forming nurturing relationships, and achieving goals.

Paranoid Personality Disorder

• Definition: highly suspicious and mistrustful of others.
• Symptoms/Characteristics: aloof and maintains distance with the nurse, guarded or hypervigilant, restricted affect, potentially labile moods, distorted thought, use of projection as a defense mechanism, potential danger in fantasies of retribution.
• Onset, Incidence: 2% to 4% of the general population, more common in males.
• Nursing Actions:
  • Take a formal, business-like manner as the patients take everything seriously. Refrain from social chit-chat, jokes, etc. It is essential to be straightforward, reliable, and punctual.
  • Involve the patient in planning of treatment and care, as they prefer being in control. Ask the patient what they would like to gain from care, such as reducing problems at work or getting along with others.
  • Teach the patient to validate thoughts with at least one trusted individual before acting upon them.

Schizoid Personality Disorder

• Definition: a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. They lack desire to be involved with others in all aspects of life, and do not find fun in hobbies or leisures. They often involve themselves with computers or mathematics as they may see it as “productive”, but still not fun.
• Symptoms/Characteristics: they avoid treatment as much as they avoid relationships. Constricted affect and emotion even in stressful situations. Aloof, indifferent, cold, uncaring, or unfeeling. No leisure or pleasurable activities are reported. They often have rich, extensive fantasy life in stark contrast with reality. They seldom reveal these fantasies, and are aware that fantasies are fantasies.
• Onset, Incidence: 5% of the general population, being more common in males.
• Nursing Actions: improve community functioning, refer support systems and a case manager if necessary. It is not necessary to remove their isolation.

Schizotypal Personality Disorder

• Definition: social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as cognitive or perceptual distortions and behavioral eccentricities.
• Symptoms/Characteristics: transient psychotic episodes may occur in response to stress. They appear disheveled/unkempt, clothes do not match, speech is loose or vague, answers to questions are unsatisfactory, words are misused, ideas of reference, magical thinking, odd beliefs, and preoccupation with parapsychology are observed. Anxiety is present when in social settings and does not abate with time and familiarity.
• Onset, Incidence: 4% to 5% of the population.
• Nursing Actions:
  • “Disheveled and unkempt”: develop self-care e.g. through a daily hygiene routine.
  • “Reduced capacity for close relationships”: develop social skills. Find a community member or family member to be the one for the client to relay thoughts to.

Antisocial Personality Disorder

• Definition: a pervasive pattern of disregard for and violation of the rights of others. This has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder.
• Symptoms/Characteristics: deceit and manipulation
• Onset, Incidence: 3% of the general population, 3 or 4 times more common in men than women. Peaks in the 20s, diminishing significantly after 45 years of age.

Nursing Care

1. History: onset is often in childhood, though not formally diagnosed until the age of 18. Enuresis, sleepwalking, and syntonic acts of cruelty are characteristic predictors. Adolescents engage in lying, truancy, sexual promiscuity, smoking, substance use, and illegal activities. Childhood is often erratic, neglectful, harsh, or even abusive; containing depression, substance abuse, antisocial personality disorder, poverty, and divorce.
2. MSE: appearance is often normal and even engaging or charming. False emotions, evoking sympathy, and lack of guilt is common. There are no disordered thoughts, but worldviews may be distorted e.g. “It’s a dog-eat-dog world”. Orientation and perception is normal. Poor judgment is displayed due to illegality, immorality, and the need for immediate gratification (impulsivity). Insight is lacking, often resulting to projection. They are able to realistically assess their strengths and weaknesses, and display self-assurance, but are actually shallow.
3. Assessment Priorities:
   • Ineffective coping
   • Unable to fulfill life roles
   • Risk for violence
4. Diagnosis: Ineffective coping
   • Expected Outcomes
     • Immediate: refrain from harming self and others throughout hospitalization, identify behaviors leading to current situation (24 to 48 hours), function within the limits of the environment e.g. following no-smoking rules, participate in group activities (48 to 72 hours).
     • Stabilization: demonstrate nondestructive ways to deal with stress and frustration, identify ways to meet own needs without infringing on the rights of others
     • Community: achieve or maintain satisfactory work performance, meet own needs without infringing on the rights of others
5. Nursing Actions:
   • Limit-setting (stating behavior, consequence, and expected behavior) consistently in a matter-of-fact nonjudgmental manner.
   • Confrontation can manage manipulative or deceptive behavior, where incongruence in actions and words are brought up to the patient.
   • Problem-solving skills can be taught to avoid destructive forms of achieving goals: exploring alternatives, related consequences, and evaluating the results.
   • Managing emotions is a major problem. Time-outs may be required to avoid impulsive reactions and angry outbursts.
   • Improve role performance and identifying barriers to role fulfillment.
   • Eliminate drug or alcohol use
6. Outcome Evaluation:
   • The client will demonstrate nondestructive ways to express feelings and frustration
   • The client will identify ways to meet their own needs that do not infringe on the rights of others
   • The client will achieve or maintain satisfactory role performance.

Borderline Personality Disorder

• Definition: a pervasive pattern of unstable interpersonal relationships, self-image, and affect, as well as marked impulsivity. 8% to 10% of patients with BPD commit suicide, with many more with self-mutilation resulting in permanent. ~75% of patients with BPD self-mutilate potentially as a means for expressing anger, as a cry for help, or as self-punishment.
• Incidence: 2% to 3% of the general population, up to five times more common when with a first-degree relative also has the diagnosis, and up to three times more common in women.
• Symptoms: non-suicidal self-harm, labile moods

Nursing Care

1. History: disturbed parental relationships is observed in many clients, with 50% experiencing childhood sexual abuse and other forms of abuse.
2. MSE: behaviors vary from seemingly normal to disheveled, restless, and suicidal. The most pervasive mood displayed by patients is dysphoria (unhappiness, restlessness, malaise). Loneliness, boredom, frustration, and a feeling of “emptiness” is common. The pervasive depressed affect is not stable, and periods of irritability, hostility, and panic anxiety may occur. Hypersensitivity to others and their emotions may result in severe emotional crises e.g. when appointments are changed or delayed. Severe fear of abandonment result in potential trauma when their therapists take vacations. Polarized thought of others (idealization, devaluation) i.e. splitting is common. Dissociative episodes may precipitate self-harming behaviors. Transient psychotic symptoms may also occur during periods of acute stress, which can produce command hallucinations for self-harm. Intellect is intact except for during psychosis. Flashbacks to previous traumatic experiences like in PTSD is observed. Judgment is impaired and projection is a common defense mechanism. Self-concept is labile, shifting dramatically and suddenly. They may view themselves as “evil”. Suicidal threats, gestures, and attempts are common. They sometimes use these suicide threats to attempt to gain or maintain relationships. They have a great need for companionship but is hindered by their disorder, with their feelings for others also being distorted, erratic, or inappropriate. Role performance is highly impacted. Binging, purging, substance use, unprotected sex, and other reckless behaviors may occur.
3. Assessment Priorities:
   • Risk for suicide
   • Risk for non-suicidal self-injury
   • Risk for violence
   • Ineffective coping
   • Social isolation
4. Diagnosis: Risk for non-suicidal self-injury
   • Expected Outcomes
     • Immediate: be safe and free from injury, refrain from harming others or damaging property, respond to external limits (24 to 48 hours), participate in treatment plan (24 to 48 hours)
     • Stabilization: eliminate acting-out behaviors and develop a schedule or daily routine that involves socialization and daily responsibilities.
     • Community: independently control urges toward self-injurious behavior and demonstrate alternative expressions of feelings e.g. contacting therapists or significant others.
5. Nursing Actions:
   • Promote Safety: assess for self-mutilating or suicidal thought, behavior, etc., facilitate supervision, and clear the environment for dangerous items.
   • Limit-setting: set behavioral limits, expectations, and consequences. Maintain responsibilities, rules, regulations, and so forth with the client in a consistent manner.
   • Daily Activities: boredom and fear of abandonment are issues. Creating a written schedule with the patient can help patients manage time alone. This can include shopping, reading, going for a walk, etc., and may even involve more healthful behaviors.
   • Withdraw attention when the client acts out
   • Controlling Emotions: decreasing impulsivity, using delayed gratification, identifying feelings, and distractions can help mitigate extreme emotional responses. Cognitive restructuring techniques such as decatastrophizing, positive self-talk, and thought-stopping can be used to reshape thinking patterns.
   • Expression: encourage the client to identify feelings that precipitate self-destructive behaviors, and to express them directly. Help the client identify coping behaviors they have used successfully in the past, and teach them new positive coping strategies and stress management techniques e.g. exercise, journalling, meditation. When talking with the client, focus on self-responsibility and active approaches.
6. Outcome Evaluation:
   • The client will be safe and free from significant injury
   • The client will not harm others or destroy property
   • The client will demonstrate increased control of impulsive behavior
   • The cline twill take appropriate steps to meet their own needs
   • The client will demonstrate problem-solving skills

Histrionic Personality Disorder

• Definition: a pervasive pattern of excessive emotionality and attention seeking. Patients become uncomfortable and distressed when they are not the center of attention. They go to great lengths to gain this status, using clothing, lying, and even illness to do so. If they are disapproved of, temper tantrums or crying may be induced.
• Symptoms/Characteristics: exaggeration of relationships, occurrences, and emotions despite vague details and often being unable to explain why; extreme concern for impressing others, often resulting in being easily suggestible; emotions are shallow, insincere, and labile.
• Onset, Incidence: 2% of the general population, but as much as 15% in inpatient populations. More commonly diagnosed in women.
• Nursing Actions:
  • Provide concrete feedback on the client’s social interactions (verbal and nonverbal) with others. Be constructive and provide appropriate alternatives.
  • Improve the patient’s social functioning through teaching and role-playing in a safe, non-threatening environment. When teaching patients, the nurse should be specific and may also use content outlines for topics being discussed.
  • Developing self-esteem can help reduce anxiety related to disapproval. This may be done through genuine confidence in the client, exploring personal assets, and feedback about positive characteristics.

Narcissistic Personality Disorder

• Definition: a pervasive pattern of grandiosity (overt or subtle), need for admiration, and lack of empathy. When not receiving admiration, they may be puzzled or even angry.
• Symptoms/Characteristics: arrogant or haughty attitude; lack of empathy, often belittling the feelings of others; they may envy and begrudge when others receive recognition. Fantasies of unlimited success, power, talent, love, etc. may reinforce their sense of superiority. Thought processes are intact but with impaired insight. Projection is a primary coping mechanism. Underlying self-esteem is almost always fragile or vulnerable.
• Onset, Incidence: 6% of the general population, mostly being men.
• Nursing Actions:
  • Self-awareness skills by the nurse is required to avoid anger and frustration when dealing with clients. Use a matter-of-fact approach with the patient.
  • Gain cooperation and set limits on rude or verbally abusive behavior, explaining expected behaviors.
  • Educate the client on comorbid medical or psychiatric conditions, medication regimens, and other self-care skills that they require.

Avoidant Personality Disorder

• Definition: A pervasive pattern of social alienation, discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation. These clients often report over-inhibition as children and avoidance of unfamiliar situations and people. They are reluctant to do anything risky, which is most of everything to them. Contrastingly, they yearn for intimacy and acceptance but their fears hinder socialization. They often require excessive reassurance of guaranteed acceptance before they risk forming a relationship.
• Symptoms/Characteristics: shy, fearful, socially awkward, anxious; easily devastated by real or perceived criticism, becoming more reticent and withdrawn. Avoidant behavior distances them from situations they believe will cause failure, humiliation, and disapproval.
• Onset, Incidence: 2% to 3% of the general population, equally common in both sexes.
• Nursing Actions:
  • Support and reassurance. In a non-threatening relationship, the nurse can help them explore positive self-aspects and positive responses from others, as well as possible reasons for self-criticism.
  • Promote self-esteem: self-affirmation and positive self-talk. Cognitive restructuring techniques such as positive reframing and decatastrophizing may also be used.
  • Teach social skills: practice may be done in the safety of a nurse-patient relationship. It is often not too difficult as the need for social acceptance counterbalance the fear of rejection.

Dependent Personality Disorder

• Definition: a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. They may even avoid gaining competence as it may lead to being left by their caretaker. Clients may seek aid for anxious, depressed, or somatic symptoms. They exhibit tremendous difficulty in decision-making and believe they are unable to function outside of a submissive relationship. If a relationship ends, they desperately look for another, embodying “any relationship is better than no relationship at all.”
• Symptoms/Characteristics: frequently anxious and mildly uncomfortable. Pessimism and self-critique is common, reporting feelings of unhappiness or depression. They are excessively preoccupied with unrealistic fears of being left alone to care for themselves.
• Onset, Incidence: 1% of the general population, running in families and being more common in the youngest child.
• Nursing Actions:
  • Expressing emotions: help the client express grief and loss over relationships while fostering autonomy and self-reliance.
  • Autonomy and self-reliance: help the client identify their strengths and needs. Cognitive restructuring e.g. reframing and decatastrophizing may help. Assistance in daily functions may be required if they patient is inexperienced. Careful assessment for determining areas of need is crucial.
  • Teach problem-solving skills such as considering alternatives and exploring consequences. Avoid advising the patient despite requests to do so. Discuss with the patient and provide counsel to let them reach a decision. Provide positive feedback for their efforts in these areas.

Obsessive-Compulsive Personality Disorder

• Definition: a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.
• Symptoms/Characteristics: a formal, serious demeanor is often displayed; a restricted affect. Unwillingness to relinquish control is common. Judgment and decision-making is dysfunctional due to decision paralysis. Insight is limited; they often believe they are right, are not listening to others, and do not perceive their potentially “annoying” behavior. Their self-esteem is often low due to being unable to reach the perfection they strive for, with praise and reassurance not relieving anxiety.
• Onset, Incidence: among the most common personality disorders; 2% to 8% of the population, affecting men twice as often. Oldest children and professions involving facts, figures, and other focuses on detail show higher incidence. The feeling of needing perfection often begins in childhood, especially for parental approval.
• Nursing Actions:
  • Set Goals for the patient, with focus on being time-bound. The nurse may help the patient with the project as a different perspective or aid the patient in decision-making. Allowing the client to accept or tolerate “less-than-perfect” work is helpful. Encourage the client to take risks, like allowing other family members to plan a trip. This can reduce their need for control.
  • Cognitive restructuring techniques can benefit the thinking of clients. Asking the client questions like “What’s the worst that could happen?” or “How would your wife react to this situation?” helps reduce rigidity and inflexibility in thinking.

Summary

Disorder	Symptoms/Characteristics	Nursing Action
Paranoid	Suspiciousness; Restricted Affect	Serious, straightforward approach; teach thought validation before taking action; involve patient in treatment planning to reduce suspiciousness
Schizoid	Social Detachment; Restricted Affect	Improve community functioning; help find a case manager for the patient
Schizotypal	Acute discomfort in relationships; altered thought/perception; eccentricity	Develop self-care; improve community functioning; social skills training
Antisocial	Disregards for others, rules, and laws	Limit setting; confrontation; teach problem-solving; help cope with emotions.
Borderline	Unstable relationships, self-image, and affect; impulsive; self-mutilation	Promote safety; help cope with emotions; teach social skills; structure time; cognitive restructuring techniques
Histrionic	Excessive emotionality and attention-seeking behavior	Teach social skills; provide factual feedback about behavior
Narcissistic	Grandiosity; lack of empathy; need for admiration	Matter-of-fact approach; gain cooperation for treatment; teach self-care skills
Avoidant	Social inhibitions; inadequacy, hypersensitivity to negative evaluation	Support and reassurance; promote self-esteem; cognitive restructuring techniques
Dependent	Submissive and clinging behavior; excessive need for care	Foster self-reliance and autonomy; teach problem-solving and decision-making; cognitive restructuring techniques
Obsessive-Compulsive	Preoccupation with orderliness, perfectionism, and control	Encourage negotiation with others; assist in decision-making and completing work; cognitive restructuring techniques

Eating Disorders

• Definition: disorders characterized by alterations in eating patterns and disturbances in body image that interferes with relationships and occupational functioning.
• Theories:
  • Biologic Factors: eating disorders tend to run in families, as well as a family history of mood or anxiety disorders. There is also belief that disruption of the nuclei of the hypothalamus causes most symptoms of eating disorders, as it is responsible for hunger and satiety; the lateral hypothalamus decreases hunger responses (i.e. in anorexia) and the ventromedial hypothalamus decreases response to satiety, resulting in excessive consumption (i.e. in bulimia).
  • Developmental Factors: a lack of autonomy and unique identity reduce the ability for an individual to gain independence, and therefore may result in achieving control through eating. Body image disturbances may manifest in puberty due to unrealistic social expectations. Anorexia nervosa and bulimia nervosa often accompany a disturbed body image, with the individual believing they are overweight despite their actual weight.
  • Family Influences: eating disorders may arise as a response to family discord. Disordered eating becomes a distraction from emotions. Escaping emotions may result in latching onto something concrete, which may be physical appearance. Childhood adversity is a significant risk factor for eating disorders.
  • Sociocultural Factors: the perpetuation by society of an “ideal body type” which is normally unrealistic may distort body image. Being overweight is equated to being lazy, unproductive, and having a lack of self-control or discipline. Pressure from peers, family, and notably in athletes, may also result in eating disorders.

Anorexia Nervosa

• Definition: a life-threatening eating disorder characterized by (1) restriction of nutritional intake necessary to maintain minimally normal body weight, (2) fear of gaining weight or “becoming fat”, (3) disturbed perception of body image, and (4) steadfast inability to accept abnormality or severity of problem. Contrary to its name, patients do not experience a loss of appetite (anorexia) but still choose to ignore it. This may be done through two subtypes:
  • Restrictive Subtype: reduces overall food intake and participates in excessive exercise.
  • Purging Subtype: purges (vomiting, diarrhea via laxatives, enemas) to reduce food intake, potentially accompanied by binge eating.
• Onset and Clinical Course: typically begins during puberty/adolescence at 14 to 18 years old. Initially, negative body image is not present. A profound sense of emptiness is common. As it progresses, depression and lability become apparent. 10% to 20% of cases become chronic, and 30% to 50% fully recover.
• Symptoms: less than normal expected body weight, preoccupation with food and food-related activities and rituals e.g. not letting food touch their lips, cutting food into small bits, not eating with others, etc. There is potential amenorrhea, constipation, lanugo, cold intolerance, loss of body fat, muscle atrophy, hair loss, dry skin, dental caries, pedal edema, bradycardia, arrhythmia, orthostasis, enlarged parotid glands, hypothermia, and electrolyte imbalances (hyponatremia, hypokalemia)

Treatment/Management

• Hospitalization is used for patients with major life-threatening conditions e.g. severe metabolic, fluid, and electrolyte imbalances. Those who respond quickly to weight gain can maintain short hospital stays. If weight gain is slow, inpatient stays are longer. Outpatient therapy is more successful only for patients who have had the disorder for less than 6 months, is not purging or binging, and have parents likely to participate in family therapy.
• Cognitive-Behavioral Therapy is used to prevent relapses and improve overall outcomes.
• Medical Management: weight restoration, nutritional rehabilitation, rehydration, potential TPN or hyperalimentation for severe malnutrition. Supervision to the bathroom is initially suggested to avoid purging when consumption starts to increase.
• Psychopharmacology:
  • Amitriptyline (Elavil) and Cyproheptadine (Periactin) in high doses aid in weight gain.
  • Olanzapine (Zyprexa), an antipsychotic, has been used to treat bizarre body image distortions.
• Psychotherapy:
  • Family Therapy for clients younger than 18 years old can resolve familial discord.
  • Individual Therapy may be indicated, focusing on coping skills, self-esteem, self-acceptance, interpersonal relationships, and assertiveness. CBT can prevent relapses and improve outcomes. Enhanced forms of CBT (CBT-E) also tackle perfectionism, mood intolerance, low self-esteem, and interpersonal difficulties.

Bulimia Nervosa

• Definition: characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid gaining weight e.g. purging, fasting, and excessive exercise. These “binging episodes” are often precipitated by strong emotion, and is followed by guilt, remorse, shame, or self-contempt.
• Onset and Clinical Course: often begins in late adolescence from 18 to 19 years of age. 45% of clients fully recover, but ~25% remain chronically ill. 25% have been found to not receive treatment.
• Symptoms: usually normal body weight; induced vomiting causes oral pH imbalance resulting in dental caries or a “moth-eaten appearance” of the teeth. As such, dentists are often the first to identify patients with bulimia.

Treatment/Management

• Outpatient Therapy is only used if purging and binging behaviors are severe, and medical conditions arise. Being near-normal body weight reduces the concerns for malnutrition.
• Cognitive-Behavioral Therapy: the most effective form of treatment. Strategies are used to change cognition (thinking) and behavior (actions) about foods, where the main focus is breaking the cycle of dieting, binging, and purging. It is used to alter dysfunctional thoughts and beliefs about food, weight, body image, and overall self-concept.
• Psychopharmacology: (not certain, and is often short-term) antidepressants can improve mood and preoccupation with food. Episodes of binging were less common.

Related Eating Disorders

1. Binge Eating Disorder: a disorder characterized by recurrent episodes of binge eating with no compensatory behaviors. Marked psychological distress is noted with shame, guilt, remorse, and self-contempt felt after episodes.
   • Incidence: men older than 35 years old with no other eating disorders, and overweight/obese individuals especially since childhood.
2. Night Eating Syndrome: morning anorexia followed by evening hyperphagia. Over half of the caloric intake of these individuals are done after after the last evening meal and from night-time awakenings to consume meals.
3. Childhood eating disorders include Pica (eating non-food substances) and Rumination (repeated regurgitation followed by spitting or reswallowing).
   • Incidence: both are more common in children with Intellectual Developmental Disability
4. Orthorexia Nervosa is an obsession with healthful and proper eating. It is not yet recognized by DSM-5, but is suspected to be a separate diagnosis. This involves excessive checking of ingredients, excluding food groups from diets, and preoccupation with food and food-related things.
5. Eating disorders are often accompanied by depression, obsessive-compulsive disorder, anxiety disorders, mood disorders, substance abuse/dependence, perfectionism, neuroticism, negative emotionality, (read about Temperament) harm avoidance, low self-directedness, low cooperativeness, and traits of Avoidant Personality Disorder. High impulsivity, novelty seeking, and traits of Borderline Personality Disorder may also be noted. A history of sexual abuse is often present, especially if prepubertal, as well as childhood neglect.

Nursing Care

1. History: family members often describe the client as perfectionists with above-average intelligence, achievement-oriented, dependable, eager to please, and approval-seeking until the onset of the disorder. Bulimic patients often have histories of impulsive behavior e.g. substance use, shoplifting
2. MSE: slow, lethargic, fatigued appearance. Clothes are often loose fitting and in layers to hide weight loss and maintain body heat (may have cold intolerance). Eye contact is limited, and clients are unwilling to fully answer questions or discuss with the nurse for treatment. Bulimic patients may have normal body weight. Moods are labile, often correlated with their sense of control; being able to avoid “bad” foods make them feel powerful, while binging episodes cause anxiety, depression, and guilt. Anorexic patients are rarely cheerful, in contrast to the initial cheerfulness of bulimic patients only thwarted by discussions of their disorder. Thought process is preoccupied with food, body image (weight), and food. Body image may border on delusional. Paranoia about others trying to make patients fat may be present. Intellect is intact except for in severe malnutrition. Limited insight and poor judgment is observed; anorexic patients are ego-syntonic. Bulimic patients are ego-dystonic. Self-concept and self-esteem is low.
3. Assessment Priorities:
   • Bulimia Nervosa:
     • Inadequate nutrition
     • Ineffective coping
     • Body image disturbance
     • Low self-esteem
     • Other problems such as dehydration, constipation, fatigue, and inability to tolerate activity.
4. Diagnosis: Ineffective coping
   • Expected Outcomes (Anorexia)
     • Immediate: be free from self-inflicted injury, participate in a treatment program (2 to 3 days), demonstrate the beginning of a trusting relationship (3 to 4 days), verbalize recognition of perceptual distortions (4 to 5 days), identify non-food-related coping mechanisms (4 to 5 days), socialize in non-food-related ways (3 to 4 days), increased social skills (3 to 4 days)
     • Stabilization: demonstrate more effective interpersonal relationships with family or significant others, exhibit age-appropriate behavior
     • Community: participate in continuing therapy, demonstrate independence and age-appropriate behaviors, and verbalize a realistic perception of body image.
   • Expected Outcomes (Bulimia)
     • Immediate: be free from self-inflicted injury, identify non-food-related coping mechanisms (2 to 3 days), verbalize feelings of guilt, anxiety, anger, or need for excessive control (3 to 4 days)
     • Stabilization: demonstrate more effective interpersonal relationships with family or significant others, demonstrate alternative behaviors during stress, and express feelings in non-food-related ways.
     • Community: participate in continuing therapy, demonstrate independence and age-appropriate behaviors, and verbalize increased self-esteem, self-confidence, and a realistic perception of body image.
5. Nursing Actions:
   • Establish adequate nutritional intake: initial priority; implement nutritional rehabilitation.
     • TPN may be required during severe compromisation. If the client is able to eat, 1,200 to 1,500 calories a day is ordered, gradually increasing until normal. Division is generally between three meals and three snacks. Liquid protein supplements may be given.
     • The nurse is responsible for monitoring meals and snacks. Food rituals may be prohibited. Supervision for compensatory behaviors is also required.
     • Weight is measured regularly. Patients may sneak items into clothing to falsify weight gain. Minimal clothing is used when weighing the patient.
     • Bulimic patients are treated in an outpatient basis. They should be encouraged to (1) eat at a designated area, (2) eat with their family, (3) avoid common binging foods e.g. cookies, candy, potato chips, etc.
   • Identify Emotions and Develop Coping Strategies: self-monitoring (a CBT technique) helps bulimia patients identify behavior patterns that they can then avoid or replace, also imparting a sense of control. A food diary is used to record consumption and the surrounding emotions, moods, situations, and thoughts during them. Relaxation techniques, distractions, etc. can help manage emotions.
   • Body Image Issues: the client can agree to weight more, be healthy, stay out of the hospital, etc. to accept a more normal body image. Improved body image can be a product of self-esteem, decreased emotional distress, and positive coping mechanisms. The nurse should also introduce other aspects of body image besides weight and figure.
   • Client and Family Education: nutritional needs, effects of disorders, realistic goals for eating, healthy body image; provision of emotional support, remove preoccupation on food-related topics, and when to seek professional help.
6. Outcome Evaluation: using the Eating Attitudes Test
   • The client will establish adequate, balanced nutritional food and fluid intake.
   • The client will eliminate the 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 a stable body weight.