mental health chapter 9

8/14/2019 Mental Health Chapter 9

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5.A n infant* bornwith a d& plate. I?&& nursing 8-tegywodd bemst importantto fBeparents' sucewMmping?.G i i upPmt-afcume the infar

e theparer o hold and0 3, kplain tothep~repts aw cleftpalam dmelopd-g

Prwancy..Tell the parentsmt)uth. ot o lookthe

U D. how he parats a vidw aboutomcth.e $wg& ford& palate.

Brie answer the ull-1-Name four 4ttew~s f pregnanc~rhat the teenap mustfhce.

2. Name tbree actiom essential to the bon- prow%


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Moralistic nonnal i s an ideal It concerns setting and agoals thatmaybe expected bysoaetyorby the person. h d ~ dbecome conhtionedto a specificided. For example, theymayually tell themselvesthey arenot allowed to becomeinitableanremain calm at all times.Setting unrealistic or hpossible goalsunnecessary sstress.

behavior is practicedbythemajority of people, it is statisncallyThere are many misconceptions concerning the word4.omany people, the wordmeansweird or bizarre. Somepexpect to see a sharp difference between normal and a b n o mthere aremanyvariationsbetween thetwo. he disturbedperson

Psychiatry categorizespatems ofbehavior. Thenursemustizethat clientsdo not fitneatly into these categories because theirterns of behavior are i n W d eactions to stress.A diagnosis inehiatry is not as clearly defined as a physical diagnosis. The nshouldbe fully aware that the client does not necessarily conformset standardof diagnosed behavior.PSYCHOLO~ICALDISORDERS

&ma& and so l& mnuoI ovw theirbeha%or.Commonpsyddapic@dbordd@amBBI Psmif &disorderPI W e t y isorderB Phobic diwder

tions, end increased respirhtiuns.If he anxi* is ievcre or proi~ngedthcsc symptoms intensifyand i h c personmayneed to behospitalidAntianxiety mcdicatinn may bc given Zhhle 9-1).

major or minor attack,with anticipatory anxiety or situationalpanic.Sudden anxietyattadcs occurwitb little or no provocation. Some anxi-ety episodeo m hen a person anticipatesfacing a fearful situation- -tional fear ofbeing in open spaav ;e.g..shoppingmalls and spurts are-nas!. Symptoms of panic include diKiculty b m t h i i rapid andlor..- : wm t k )* , , ,aain,&@&m--,.seaa* &&-


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TRADE GENERIC I

FEAR OF PHOBIA

Maladapttve Behav~ors 2@1

When a phobia is limited the person can livea reasonably com-fortable life simply by avoiding the object of fear. HOW- phobiasoften spread to include assodated objects.When this happens, it m ybe ditfidt or impossible to keep the phobia &om intafering withdaily !.t@, One treatment often used to help people overcome pho-b i i s desensibtimPhobias include exaggerated fears of death snakes, dogs, openspaees,wnhnement,orheights.Table 9-2 lists somecommonphobias.Obsessive-CompulsiveDisorderAlthough differentin meaning, obsessionand compulsion aftenoccurtogethm An obsession is a p d t e n t , recurring thought or fe&ngthat is overpowering.ACOcomgtIlSi~ns an irresistible urge to engagein abehavior.CompWionmaybe in the form of frecpent handwash-ing or shoplifting.Whateverthe compulsionmaybe, it hasa symbolicmeaning.The behavior is engaged in becauseit lowers a r y d q . Whenthe anxietyI d uilda up, tbe obsessive-compulsiveact is performedagainThis process is cyclic andma y occupy the person's entire life

It is not unusual for a person to experiencemurrent thoughtsperiodically or to engage in ritualisticbehaviors (handwashing,count-ing and recountingeheclciqgand rechddngl.However, in thepersonwith an obsessive-compulsivedisorder, these thoughts and ritualisticactions interferewith dailyMug.The person is unable to controIhis

Acrophobla HelghtSAgoraphobla open spacerAndrophobla Man I Ophfdophobia snake5Claustrophobia Being closed inCvnophobla DogsOemophob~a CrowdsOamOphObla MarrlageHOdophObla wave1Kalnophobla Chane-Kakorrhaphiophobla FallUr~1 L- -

Pharmacophobia Medlcln I$Phasmophobia onosts ,tPonophobla work F , I ' ~ P ~ I

&'I.Pyrophobla Flre . 8Traumatophobla InJUNTrlSlfardeKaphobla Number 13Vaccinophobla vaccination "u 8 Fn


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Maladaptive f ieliav~c~~s

of hmor. Activives of daily hvtng become a problem, and hair and&thing may appear disheveled, Mmemenf5 are slow, posture issmoped, the br ay is h w e d , and sp& maybe kcpent inthe depresed ddmk pemn , tbm is an intense preocapation withheslth,Coniplaints ofvague acbesaBtipains, c0nStipationt and anorex-ia are e o m m The severely depressed w bemme @st-ed and appear to@ mberabk.oysthymlc DlsOrdeK The pe mn experiencing a dysthpic dbordwhas a prolonged feeling of .%Beme sadnw that is ammpanied byguilt feelingsI self-f-deprcmtion,and SOW ithdrawal. The &order isusually associated with a 10% such as loss of a Imed one, possessto&ars e l f - nepm on feels rejected. helpless, and wrthless. He orshe s wed she and disinterested in the surroundings and unable o"p"ience pleasme in life. He or she ha6 a low energy level and isalways tired Theperson may either be unable to sleep or mQ' sleepmceh;sive.lyTbe depressed persondwells on &e negative aspects ofMe,whjch otdy add to his or herfeekg8 &&pl easur ed @ Heor shemay cryoftea and wiIy and may have erious tho%& of sui&A dysthymic or depressive disorder o k ts horn p q l efeeling 0 ) hat theyham no mm1 over th& lives, [.2J l t hey @eti$Iureeg bemuse 'they havebeen unable to attain desired goals, or (31i n t d nger. Critical periods in the Mb yclewhen a d@&Jrmicdis-orderismore W y o ocnu areadolesmoe, menopaw, and old age.D&g adolescencq dep mi on mustbe &@erea?iated&.om em-porary stam of sadness. AdoleseenB are .su$jectto emotional ups mddowns. However, when a lack of feelings or a sense of' emptinessb e m e s s dominant mood, this swmidered a d or depm-sive &order, The adolescemwith a dys th Nc disorder is unablemdealwith or expresshis or her feehgs.Bm&m and resfl~$snesSand t arg useandun wan te d risk-takingcanbe symptom afhid-den depression.D u k g menopauser women must copewi& pb@d asthe aging proeess oan-6. Menopause may have pkpical symptomssuch as hot and cold %sheIp w e eadaches, h palpitiom*imomni&and wsrsbtent fat ime Someof these symptom am cawdbyzhe changededbomonaf~%ceetween estrogea and progesterone.Depression can be caused by by percdwd loss of womanhood andchiid- abilities.Women are not the onlp people who must mhtend with the& x t ~ f tncnopause.Me11miy &


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Maladaptive Behaviors

hg stop-start syndzome dam not usntpibute to medication &availvailabilityand, thd5m good medication effects.Research is r&etingh tmedieatienaneed tobe taken aqiuimumof ninety days f a eE-eaqand ph;rpsmen sixmonth3befom they a , t~ et ic id ,

Bipolar Disorders (BPD)Bipolar mood disorders are complm Emexchhers melao- at trio-chemicalslie,melatonin,phmylethlymine.) that intI~encerain*-t i o ~ d&deney of dopamme and s~~ translllttqs hbas beendiscomd in mania Internalb i ~ l ~ ~h- i&mdian) arebe*caref3Uyolmme4Qtherstudiesm fhcaaea on the &Tea oflig6t onmood patterns. It hw ken beenund fhat peapla with mood disbrdmma/ haw ab~lomLalhyroid S tud i e s bjh~dirrg,T3, T4, and TSEElectroencephalograms@'EOslmayfndicateapi- ofa m@ek orpar2i;ll &&are, ItlQ$and U.%E% EYA mkm faFhip* disorderwere located on chmmxrsome2, fhw naeasingourknowlemoftherole of genetics B.ipdat= isordm d d witb mods of ektion anddepmed01~.hey are subegped w bipolar disorder,manic bipolar dis-orde~ epmsed: and bipolar dia~rilw,izced. Litbbn and anemn-.-.--vul&ub aremood-scabilikngmedimw11~i q m t l y gigi\.enfor&ohdisordwCrable9.41.&.w d hase,wd* pwwnde&mrehppepa- ?liqp%pea* php3&%.me&e, andaotion&yj Thgrg,e~eral lyf&heym.owhwyto&te lime on eating sfeepq]The%houghtproeasesmagbeso apidd&t theyarf,dir8icut,tolow;This is d e d &fightrrfi&gsttW~eople arehitm andTheir m ~ d & ~nay &m .eupb~&G ,&&tion m,4-have @ei~pt imi sr i~erhapsd & d q I m:&&& p m , .T h q d&n. meddle n the &airs dforhe@w& retroeial ~~0~ Their r.wn@,&@,oudness, aa;l d p & &ploys only increasefh@ sam ~ve.rload

The- depressed p h e is .&axaste&sd by moderaw s m%d q r w o nI%1 of dep-n f l u a t e s]eontaneoUsIybughou t the dar Thw &mfs arehigh suicide even though& ~ ~ L% C J Bp p m ci be -mIrnderafe Du&g rkedepression sage,f h ~ndiddual'$ @~ezii%inw& behaviop are h y p a a ; PaeIlllggc&oughts, &@ ,$t@& a f e a b n d p d e m e d Heor shec ompbOf being &@@yctions slew, soan.- and !cons'tigatiinmeoaC,an@@&Q :& an.db&Je: ;< . , . , nd actions .a& b c -* d b % $ ~ ~ i $ ; ~ ~ ~ ~~ I ; ~ ~ f m m m t h e : h a n & .e5r~b:h;7Qpmm@ S& =mQ&$ and&$&&, &3.b epb.Bde?e?d$aw+&e:;-;gm~Y

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rRADE GENERIC IMaladaptive Behaviors 2+. .~

A cyclothymicdisorder is a mild form of b ipok disorder. If theperson is not treated, the disorder canbecome more serious.oissociative DisordersDissociative disorders were former1y ~lassifieds hysterical neuroses.This disorder is characterizedby changes in mnsciousness and identi-ty: Psychogenicamnesia p~ychogeni~fugue,ultiple personality, anddepersomhation disorderare included in this category.Psychogenic Amnesia. Thepersonwith psychogenic amnaia hasa sudden 105sOf memory regarding importam personal in fon t ionthat is too extensive tobe considered ordinary forgetfulness. There isno damage to the nervous system, Psychogenicamnesk usuallg fol-lows a stressfid went and is thought to be a way of escaping conftiwand relievhgoverwhelming tension.Psychogenic Fugue. Psychogenicm e nvolves suddw d u n e x -pected travel amyfrom home or work withUe nability ta remeaberthepast The person experiencingpsyc h~gdcugue mumes a newidentity,Pugueo h c(:~fsfollowings'weres m s . Usually it lasts forseveral h0.G tu several daysand involves onlylimited travel In somerare eases,h m , tmay last formanyman& and involvetraveL Therecoveryisrapid andrecurrencesdo not mually ocnn.Thisdisorder is more common after a n a t d disster or during &me.No damage to the nervous system isinvolvedDissociative Identity Disorder. DissohWe identiv (for-merly d e d multiple personality disarderl refeps m the existence ofNewerMedidbnS

.- - ~~ two or more &tin& personalitieswithin the same in&dual. Each of~epaKote qiiwl~rcltm these personarities is d~minant t a partkuh time. The p o n & t y~amlctal l a w h e that is $ominant determines the behavior of the individd &&pa -~aumntin ggbapqntln sondi@ s complex andhas its own h M o r p a t t w . The secondrvy~ g r e t o l wraa*@@l#e. personalities are usually quire opposite to the oliginalpersonality.The~opan9ax ' tupimmate original personality is not aware of the other personalities, although?he seandarypersgn.&ies are often M y aware of the thoqhts andacrions ofthe original personality.Transition&omone pe r s oM9 to~yclothy'mlcDisorder. The person with a disordB another is sudden and usually f~IIowtress.This disorder is -me-expefimm* m a d s of depre~$i~rind &tion-elationnsfee,he pmon iswarm andWdl%)um the 6 e ~ f e s s ~ 0 ~stage the emonj&ats himselfor herselfd dthdrW fromsgd DePersonalkation Disorder.Depers-tion disorder fnwlvesaactiaiQme personmay apeilmoe n o d mods between: mi change in the p&sOn's perception ofhimself or herself:A sense oftheperson's om reality is People are cut05rom a e W om aware-ness. They feel disa9r;odated~ I I Iheir m i n d s and bodies and my

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chwr 9-WIw frorn a &wee.They fimction in a &~JEJstate or order to meet a need of their o m Remember, manipulation can besense;9 aredded, h a m a f e a of viewed aS a positive or negative action Individuh who engage inn d b a ~complete coat& ~ftheir9 6 d adOmh manipulation fW&Iendyevoke anger in others,yet theu behavior is a

Tfiis bTdw &a S-e sires* depression ream- form of guarding a very fragile self by attempting to control others.fEc-tm W d t i u n , a&@& tQ&c illness, f p W 1 4 P* i5 Thereforeourgoal isto strengthenitlditidua~~,'nner,personal coI1tro~.

r a P ~ b u t r & c Q Y ~ i sa d dBeoplewith ad e ~ - * ~ ~ ~ ~ ~ staffmust approach clientswith a firm,onsistent idmy stp&nce m~gieryzk ~ o r h o ~ ~ t s ,nd a distded acting in a ludgmend way toward chents; rather,recognizeyour oms ewaf&&Tbeymmed fhattbeyare&% i I x + ~ e ~ ~ c I i e . feelin@ of~esenbnentOur goal is directed toward maintaining theseEesteem of our clients.

Begh bystating dearlyYour own expectations ofthe client a t ani n t e n l i s ~ p h a ~eeting where everyone should on one~u r ~ i n gare planned approach. with the client if there is a reason for thisCop% ~ f i8 hemduala peW10@ *Y behavior and then state clealy why the behavior is unaaeptablefm ~ n m e , m y thatd bF a s adqer* Clearly statethe team's expectation.OEer alteroativaby tating choic-er or f&e &co*d how-, fxz*dd needs es or options (eitherlor statements).By having choices, the clientwillhelp. he. a-0 should =ever k n y denfsWw PIainw begin to fee1more in controlandwil l learnh m o choose a]t-tivessh& be -@&& 1 e p t e . he

is ~ w Y S he best Ourre that work positively forhim orher.Thestaffmustpra* attentive&-dlfonaatioa Am&& -~on shouldbe [email protected] ride oat* tenfng [what3 this chmt really trying to say?).Help the client verbal-po~sibiIity fpbyhd jllaesS fze or her feelings in amore appropriateway.Be alertfork e w e dNw careofthe ~sy&~1op;irallierrtF o W n. m e w and refocus clients when they become distracted. RememberierJI; paon& a @ol~@sal di~orders oftenm&a that you areworking together to achieve a change in behavior.e.4- psycho-" cljenm oibn fed !Im3- Freguentlyawrityea contractworks best A contract clearlystatestarion fl q iem ~n the uni't, psydh~be;id im* needto 2~ the m u m y agreed upon expectations and the tyay to arrive at this$lW~&kmstkin& decis'i,Tbis fhek@SSsindl go d Look at the clienfs strengths, resources, arid energy for changeMaybe the client ism t l y n just a survivdpattem that wil~eed tobe addressed We want fo make reasonablerequests SO &t the clientbe held accountable, and we want s m d success expeemc~othatwe can give the client positive feedbackAreas to considerw hMmg a contract are personal safe@,amount of sleep and rest foodintakepstructured m e , aetiviaes of d a ~ yiving, probl-o]hg tech-and theclient's level ofsacid hteradon.

The bipolar clients concentration is lessened, and he or she isQ s u ~ istracted and provoked. Sodd activities must be p h e dthis in m d xerdse can be advantageous, but competitive acmtie

sbsmand alkati-

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clients have been WelI-bahve&pd&pist youths wko restrletedtheir p w n a l f and did notv W y otnmunicatte.A s&a&-6ehgat6tude prevails.InitiaUp atisgdim&%& clientsmwtbe closely evaluatedDo thy need a hospltllsdmlssionto s a b h hem met*?bolick@?Will dose observationwith a b&dv2mal approach be bend-cial? Coople or family therapy can be in&@ted.Bulimia appear -mgres4wi& group therapy Cornunity education pmgram5 am anecessity in a time when eating&dram are of epidemic pmp0rrioIL-2Maladaptive Behaviors a@$

& A..

Bne ofthe most mportant factomin as c hhpbn i cdisorda-isloss of&-esteem. Thismaybemanifested in.9yd-denandviolent out-bursts. It m y esult in dissoaation or an exaggeratedmnsem merbo* hcriam and appmance.Dismbznces intbhkhgmay rangefrom a h % f claatji in thepersonb ideasto t& incoherence.His orher thorufkts are illogically cmaecte& so t h v are di86cultm under-stand The person maym l e words SO they make no s a e i W is& ord salad.He Ox she may make up words to a p e s 8 con-fused tltou&ts; tlwe arr cded neologbrm Echolalia is the pur-poseless isep&tion ofa ward ox phmrse,C-haxar3erktics of f h n i a indude dekxziam, ~~~tiansI dbturbedthought pm%es.9es,andpeculiarhehador.Delusionsare f&e id- rhet eannotbe chwgedby logid argument Delusionsa?eoftenaSsoQiated d t hhl lua- . Theymayoccur n anytype ofpsg.c$otic ma ionDelusional ideas may be in the form of guil.? or perseatian.Clientsmay feel that they have anmitted grave sins or tbey m yexaggerate a d e e d . Ptwplewih delusions of persecutionbelimefhatanargankd graq htmds to harm them. hey nay per-m i ll happeningsinrelationm t h e delusion,nsing eaen uxdatedevents asproof of* delusion.Personswith s&impBr~&m y Qhave deImfon8 ofgrandew:, be&- hafTheyhave greatpower.Thwmay see t ,bawdva as Napoleon or@us GhfistHalfa@hionsre pmeptiom that OW E in the &ma fs t lmd and have no bash in Ilrey nelude hmhgnonexistentVOWaudiforp],ha&pision$ [oimd),~mdkt~g01.kctor3g or t w wthjngs e;uStatbryl, or having 4 senwtion of being tcluehed (%Me).C0nmzm.d haUui3n.at?om taa be very ~~g fox fhs: client andmay cpmmand theclient to dosomethin$dangerousto seXor othe%s,h npmtantpart of-dw dbtwbanceof &en@withsrhizo-phrenia is their pmgfessive uiM.ragval 'Theys&Wte faztasy fof

reallife,Theiractionsmayseemhqpmp14atetatlie sitnationbeisuse%ey be incm&n&indifferent to their outsidemvbonment a dfeel alienared and isolatedIn an acute m e t afschizophrenia, them fs' usuallynormdIU anormal hdin fuactioning, rhe absenee ofnegah symptom Cable9%), and (igoodresponse to anfipsyihofic mdicatiom.With a filmonset, there areenlargedana l ventricles, praminmtneg&?e s$mpand a poor mpgnse to antipychoticp,.m o t i c 'iedi8.W possw many side&mts thatneed tobe 856es9d by the nursing staffand repurred to thep--Wt ITab1e9-6).A 8erlous,Wrewsible sideeffect & tardfverfy~kine&a ITD). 'RJ detectTD at is e d& st- an inwIun*lymamnent s d %W&fsl needs to @me ai a-lum of w r y ixmonths @-?I2L


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OSITIVE: NEGATIVE:

PoorPoor

ZbDE GENERIC

D~PQ'NEU~CILBPTI~%Haldol demnoate halopesidoi decanoateProlixln decanoate fluphenai.[nedecanoateDepot neuroieptlcsare Ueslgnedfofindigduals who need anfTpsychotlcmedlcatlonye t have d i m~ u l t yemembering totake ito,r paranoidideation. Medication is Wea loh form atid u$uallvgiven;eQ@y W o w e mFor P r o l i n decanoateandevery four WeeKs fo r Haldol#@%noate.

impaired self-care,BIrarre behaviors. Eliminationo r signfircant redudtion of hai~u~inabans,Judement Poor delusions, anxiety, and troubleso.me thou$htS,lnnght Papr feelines; and behaviors

retentlon

matiies.la;sg~irming,. estlessness, fdgegng, A,.agmubn%dive civbnesia: SueHng movement9, invoiuntan/ chewing, tonaudProtFusron; this i s m e n RreversibieDo netuse atcoholAvoid prolonged exposure to sun; i f outside, use asunscreen,wlth PABA-the. htgher th e number, ti%greater the protection.'.', , . ,, ., & .,;.. . .ATYPICAL ANTIPSYCHOTICS - . ., : .Clozaril Ic l~zauine l typical antiusychotlcs that %'b l a ^RiSPerdai Irisperidone) dopamlne and serotonin-hlpeanntagonlsts ZJ)..:zvprexa (olanzapine)

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I CLIENT ACTION STAFF OBSERVATION

-2 s Chapter9 Maladaptive Behaviors 2&7~by othm This is offen accompanied by musde twitching. EEchopr&ainvolvesimitathg he motions of others.paranold Wpe. Clients uvith paranoid schizophrenia are suspi-cious, aggressive, and hostile.They sufFer fiom mrspidon and jealousy,

konQW rw e ~ n s n t s and delusions of grandeur and persecution, EIalludnations are wm-mon. Clients often hear voices commandmgthem. They may becomen pmm&Witheaon ~ac@!:and ~ S ~ v emenk ~ombat ive or eatample,they may break the teI&ion setbemuse theyWer as ,mPWY tls ~Ossrblp.6abprDx I&% SeGondsl believe it is s them bad messages orperhapsreadingtheirmindAt thebegin&& other symptomsmaybe difficulttodetect As the con-~ e n qoch arms in nun&,&, mouem~wm@b , dirton propses , behaviorbecomes more inappropriate and unpre-front,wlms down dictable. Sincetheir debions are o h izme, theycanbe dangerous.wglla s ewpaces, turn HandWldandw k ack Undtfferentiated m e . Undifferenfiated achkopbrenia is diag-slt in shstrWth hands nosed when the symptoms do not fit in ather categaria for s& oEn#rebod~ O ~ novemWposittuned on knees, phreda. Symptom may indude delusions, hanudaatiom incoher-ence, andgrossly disdrganked Behavior.

Psychosis,NOS (NotOtherwise Specified)A deterioration in Etlnctioning and a lack of recopition of reality istermed psydzdtasis.Usually,psychosis,NOS isabriefpychotic &orderof no longer than one month. A serious stressorm q or may not beDisorganized Type. This eatwry was formerly classified aq present Note whether delusions or hallucinations (specify auditoq,heb~phrenic -hrmh The disorganhd schimphrenic &hi&, visual, oIEactaiy,or tade l are present and specify a generalmedidinappmpriate behaviac smiling and ti-equentllyat mq tbhg# condition that may be present ifthepsychasis is substance-induced,or nothing at all.There are gross fhoughib b a n m , ncluding rhe specify the substance that was used and whetherthe client is intoxi-use of mrd salad and neologisms. Ddusiom and hallucinations mE cated or in withdrawal,w m n , s is extremesocialWithdrawaLCatatolllc me.The mtatonicperson'sbehamor varied, but thee%%

PARANOLD DISORDERmuallyan a w e onsetBehaviorm y akethe orm ofstupoxarexcite Clientswith a paranoid disorder,likethe&atwith schizophrenksuf-ment In mratonic stupor, the &ent is immobile, mate, andnegativa fbr fmm erSistent delusions.These delusions rrrz generallydelusionsThere is no interest in the envimment; thb apathy complerelycuts, of jealousy, pementtioa or sometimes grandem The paranoid clientthedient oEfrom outside st imuli. He or shemay-in in oneposi- does not have hallucinations but possesrtes a heightened suspicious-tion with wry rigid musdw urpossess- lexibility fawDditi~n ness that may progress topspchosis. The client is fw6.l andguardedin which a hmb remains in one po&ion, even a veqy u a c om f d k e and ases he defensemechanism ofprojection,one, for a period of time). Clients with paranoid disorder usually da not show disoxganiza-Catatonic people &bit mpredictable behrsvior because their tion dtheirpersonalities, other than the delusions.Their actions seembehavior is con'tmkd by their delusions en d hallucinations. h ' p ~ r to be appropriate to their delusionaryaperknces.There is seldom fur-may & q e apidly and unexpectedly to excitement At these tlmes~ theh deterioration in their personaIity; They speak and act rationallyt h q are extremelyrentless and may become violent The aenT Mth and are well oriented to time and place. They may be ableto eany oncatatonic sdakmphrenia &bib two p e d h m n n e d s t n s - e c ~ ~ a prodaniw oeeupanan evenwhen their condition is well developed.and echopraria. Echolalia is an inwohntmyrepetit ion ~f or& qokefl However, socialwdm a l unctioning are usuallyadverselyaffected.-- - A L - - - - . --.---


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ChaNer 9

a g s f anger and resentment are m ~ o nith a paranoiddi9order.These &in r:dmgp~ou6s t h q strike outin s d -&'knse. Bkme deteriofatio~ r incoberens 3s mf seen in these&eats.Nursing careW.ossing pm &r the t h e t suffkhg &mi a g & i m p M e or p"anoiddisorder mu* be based on an as6essment of behavior and pmblem~b e a u s he% &eats bvean ndMdWed arrapo E ~@@ om ~ .with & p W a have a ofisohtian m-edby fear of&&a fas or her behavior refleets a la& of s&c~n4iden~e.fienurse needs to demo-ate a hopeful attitude c g m f a*@;m,,sewdty,and ca&enoe. Avoiding the elient o m n&fcms hisor her fedin@&ow self- The u r n hodd ob- The &entw i d schiz0phrmh b r any$pedaliamests.InvolVhghim or ba: n av&&y ofactfvitiessaohaschecke~s,ad $ames, a& ts,hobWies Canbe a method ofstipxnlating thesenses. &mine pr@e rainfreinforcemfidenee.Itmaybe tLrmpmtiet~ the env2ronmmtb&-io$ autdabrs or taking a ride in he wuntty.For a client wKh a paranoid ttimde~+fldble but coBsistentappma* should be m a i a M at oilltima. 'Izlis c l i d s in&-ersmu&be~ e h ~t isimportantfor thenursetabe aware of ,his or &P own a v ioc W p e t i n g or pointing when in the &&SF ,e n w m t must be amkbd. P r o w questiom may pmwke p~@-noidbeh&w Theparillraid elient reqDira G&X soothhgvoicetan&at alL=&ma.m e num's gaalis to provide supportd ~JW~XES &the &e~&in order to d e w s is or h a &ety and d e m ~ t i o f l fism,cp- emiron~~entwriIIfidlitat~he client* reroeery fmrn ast&$ofinnerd i s o ~ ~ t i a pIn peparaton f9Ia rera~no the W y nd their C O ~ - Iwith s&impMa m d a be educated abmi the uYariltnp,sylnptomsof a rekpse of tire disease. A @pof-*e c h e ~ d dbe ben&dal for clienm and their families andmuId bean exc&%tm@d ofeda-n as p@iof dischargep l w m igns&& p e includea lass ofWb%in doingw,atin$, ndto aetivtties9f daily k i n g trouble m c m @ a ~r s&st tho@ts; increased imubJewtth decisionamkW p wwithreligion; fear of'othm YLdg thw m that otbmwith their minds; increased W t a b W over W e bi~@?h ~ o r k m l ~ s ~ a n d a n ~ ~ l n s ewar&$ & p s id&xxteWt a relapse ma^m a d s oseak pmkwianalhelp fn sremep . .. _


the client needs to go to the emergencymom of theirhospitaL Eachclientneedsan emergencyplan.for sevaerelapseHiIdegarde P @ L Ul962) tated that to heIp clientsisto remem-b a and n n d m d itllgwhatis happening to them n thepresentsit-uation You want to assist clients m integrating thiswith other experperi-ences in their lives. Avofd isolating the experience because that willonly increase thought fragmentation.Assist clients to recognize mal-adaptive behavior and its eauses, motives, and consequences. Assmtclients to look for alternate choices for their behavior and inmeasetheir constructive productive&styIe. The n m e s building trust andnurturingthe client,which is called a correctiveemotional experience.PEiRSaNALITY DISORDERPersonality can be defined as an individual's character traits,attitudes,thoughts, behaviors, and habits. It encompasses the individual'sbehav-ioral and emotional tendencies. It aIso &olw the individual's adapta-tion to internal and exrernalproblems,

Persnnality disorders are maladaptive patems of seeing, rrlatlngto, and thinkingabout the endronment and relatiomhips with othem,5 i n e the patterns am nflexible and deeplyingrained, there s impair-ment in adaptive func th i rg . Disturbances in emotional developmentande m r i m re seen There is amalaqiustment to the social epvi-ronment Some personality disorders are -dated with changes nthe normal lwek of nemommsmittersThe American PsychtmicAssociarian'sDiagnostic andS W d dMunud CExt Revision) DSM-W-TR) M Several subdivisions underthe Category of Personal@ Disorders. W e ubdivisions and charac-taieties are shavn in TabIe 9-8. erson* disorders ean begin inchidhood but ~lsually re ?mn ih t ed at adOIes~enee,an d interferewith social or mle funqkming.men, personswith personality disor-ders do not seek mental health care.NursingCarePeoplewith personality dtsorden arevery diBcnlt to deal with, andtreatment mamag be ineifetiv~ n caring for b e lients, the n m eshouldbe able fnhmdle the htxatiom caused by their behavi01: Heor she also slxluld be aware that some clientsmay be very manipula-tive. Manipulative dients want aIl needs to be met immediately andmay become aggressiva or hostile when the3arenot met Respond tomanjpulation Wflsistent einforcement of~mits.

The n m emight directlydl clientswith a personality disorderthat thek blaming accuhg,and intmd&tq m e r lienatespeople.


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Chapter 9

q~ersvns&NWxaL3gbraUOnof~IHicult lernabUttvtorelax, coldend unemotionalof warm tenderfewnngs M r others zrculw lnmalmninaIndlweAe; ew close friends; "IOnW &tbactow relatlonMIP5%,cia1 isolation; oddltles of mlnbng ~ n t r t oand speech: Illusion$ sU$P~CIOanypersenSmvihl~ ve t l v ramtlc expressions of ~tamaticandmotionalmot ion, overreactton o eve*seRlndulgsntr wnrrpnt drawlfig ofattentlon o 9 et IrmtJonaloutbur*.dncanslderatlon of othen; Vahlanddemamllng: constantseem9 dfreassurance: ackof 8enulneneS;mavlngof excitementmaggeratedsense of senpQ%aneedfQr canstant a ttentionandadmlratloII: preoowbledwlihfantarles;

lacks abllityto reCOgNZe how othenfeel$eels Immediate pleasure;selRsh; oefective udamentp o ~ r o c c ~ p a ~ o n a ~rformance; ntr~skofubstanceunablemmamtaln astingrelatlonshltcrr abuse and harmpoor sexual adlusimenti ailure t oaccept social norms; Irritability anllaggreslveness; fallura to Plan ?hUu~impulslvevel:kreeanlM I nemth:recklessvlolatlon of the PTahtsof ottheKimpulsiveand unpreMctable; umtable nfer- Erraticpersonalmatlonshlps; hec(U8ntdkplaysofanger, ldentiw problems,shim Inmoods;Intensed~scomfcrt hen alone: pnyslcallyqelf.damaglng act% eoumngPeellngSof boredom m d emptmessHypersenslbW o relechon, Social AnXloUSwithdrawal: low self-esteemLac& 9elf.cOnfldence; avolds relying on self; Fearfulallowsothers o assumeresponslbllltY

Pre~ccUpaUon t h rivial detallS; overlyconventionaland serlous, InSlStS Ohown way; lndeoisive

lndlreetly resistsdemands MI adeauatsperfurrnance;IntenttonalIi7efUClenWforamml;stubbQ~ReSS,rauaSMrlaU0n.aawunna rwn t fu l

C).q A small success experlence for cllents may be seeingtneW artwork displayed; this builds self-esteem.Ber pressure can fiequatry be used tomodify behavior. Guidance inasserkness is hdpM for same clients. T h e clients need positivefeedback foropen,dbeet fflmunicatioa Thenurse should enwrmger e k d rather than hostile exchaqps.He or she should setappropi+ate limits and be sure the client knows the limitations. Dimsionalaaivities are important The nursemight help by presentinggmwthopportunttiw, chances to assme responsibility, and small suecessexp6enee.smgure 3-11.There is nowamove tnward special&dm-Gal homes for some clientsMth persor&tydisordaImpulse ControlDisorderClients with an impulse disorder have uncon~oU&lempulses thatresult in hmfd behaviare to seIf or othw. Their poor insight andinabilitytoMect and think of an alternative beharriorrmults in exit-ing, dangerousbehaviors that redue their sense oftension and pleas-nre. As a result thv experience relief: hpulsive behaviors hdudeklepto- pyromania, pathologicalgambIirig, trichorikmlania, andcompulsiveskinpickingCsometimwto thepoint ofexcoriation). Someof the literatwe also includes compulsiwbuying as a n impulse &or-der. Comorbidtty Mtith other disarders, such as bipolar disorder, psy-choactive sabstance Use, attention defidtihyperactive disorderCaDHDJ,malor borderline and antisocial pemamlity disordersneedto be -sea


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Sympu~msfADHD include a pesistentpattern of inattentionhyper-activty, and i m p W t y wfth the fc l lcdng obsemabk behaviom: fidg-& d i t y , intenupthg inattention,d iEcultywithwait-ina, folbwing instructions, sustaining attention and remaining task-fo-wed

A neuropsychalopid ass-ent for a differential diagnosis isimportant asthe complexity ofa multiple &agnosisor dnd Wnosis&Inauence the use of medicatim and matment in-tiomCornorbiditis include learning disorders, mood disordem, and sub-stance abuse or use. Manyyouthswith ADHD haveconmu~entocialand b&aviotd problems that pbce thm at risk forco~lX&tbgandbecoming iw01w.din the a im id ustice system.Medicatiom presded ~IER h h @l&ylph&date) andCylem@emoline).However, the subjectof mediatim usagefor orafmmt ofN E D s eontrowrsia1.and the d a n c e on drugsforchildrenand ado-1 is being questioned. Con- research in gmetia, braini n j q , and psychophamacology is lik* to conhibute to a betterundatanding of this disorder md effectivetreatment a p p m a b .s L e m DISORDERSMare than 30million AmericanswiU be affectedby ins- at somepointin their ives.Hauri [I9883defmedthree typesof insomnia:tm-sienti n s o d caused by a brief pdod of stress or vjben one travelsfromdifferent timenes, insamniacausedby pmrsleepinghabits ordruganddmholdependencp,andchronicinsonmia. f e loudsnoriog is present the client needs to be evaluated by the p S n wdepment, which assesses breathing bctions and then consultswith a sleep disorders clinic. Many people expeace shaIlOwOW-merited sleepand n m eel restedor refreshed S N d b suggests&pprotocols that involve no naps; arising kom bed when you cannotsleep and doing some quiet a&!$ forappmda* ninqminutes,then retiring to the bebed;Ieaming andpracticing relaxatfm techniWI?S.- . . .MiLlIU THERAPY .Uetl includes al l snrrounm in the physical emir~nrnent ndthose interpersonal intaactim thatcontributeto the individualfap&sonal growth and adaptionThe environwmt is structured top&desecurig and safery. Qn admission to the udt+ he stimul i m y bedecreed while trust s b 3 t but g r a d e n-ed resp&jJigand inwolvanent is encouraged.The envimnmt is fldbIe,pet limit.

MaladaptiveBehaviors 3-&\Is e w s consistent Personal respect and cooperation modeled bythest af fina ae s the seIfanfidence and sense of autonomy of the dientThe eventualg d or the client is inawed motivation andsocializa-tion Themi l ieu aids in the mg ni tion of ma ladam behaviom andallows for confrontation of the dient when these behavim areobserved.The physical environment needs to be clean and safe.Harmonious colorsand comfortable andsafe f i nm sh g s contribute tothe Overan sense of well-hemgMilieu ineludesmanfr&awodal-fie.% gmup therapy art and music therapy (a means t o socialize andsmctnre free timeand ncrease seIf-confidenceJ, pet therapy [comfonwiih the expression ofmrhgrhrough touCb@, ho rt id tw (garden-ing andits re~ponsibiEtie8)~ulritia~ourseling, 0ccupationaI theram( ' ' g swngths and one's response to the environment),vaca-tional mr k (counselor explores work and job options), and educa-tional groups (communication s$iUs, se l fa tem social interaction,h c i a I Ianningl.An mteniisapIinary team coordinates thesemt-ment actidtie8 and evaluates the clients partidpation and p r o m atweekly team ms An i n W t d h d care plan fadbates thedient's participation throq$ the client's review of fhe plan and con-sent (ei the rda l OFwritten3 thathe or she accepts the treatment plan,Another aspect of the milieu is the communigr meeting. A corn-munigmeetingis a schedaled meetbg with a set time and pre&er-mined dedsion that there will be no interruptionsby staff or clients.On admission to theunit theclient is an observer at the meetingbutthen becomes a participant The cammunitymetinggives everyaneavoice in d e d s imaking. It pmvides a time o review pmMems andtensions an the ward and decreases m d c t hrough discussion Unitrules and roles are clarified irnd enforced in a consistentmanner.Attimes, unit upkeep may be the meeting focus, with assignments ofchores or tasks. The mah concept is to increase client mpons1Wlyand acu)u nWt yand therebyincreaseselfawpenessand selfesteem.

PrequentIy requests for a therapeutic pass are generated at theWn u n u d y meeting. .A thempeutie pass is a leave of absenceWAlh m he hospital for two ormoreh o w t is authorizedby the physi-dan.Before thepass is issued, a m b a f the team meetswith thedientand they decide onthepurpose of the leave. Papas are Ned outhanded in on mum hat reflect the positive and negathre aspectsoftheLOB The client may visitvvithfamily,nm erran& or seek after-careplacementThis s an importantpart ofthe dischargep h ecauseitpromotes the client's resociallzation and assists him or her to identi-fyand cope wEh stressors and begin ta utilize cornmu@ support%y third-pa@ feimbursernent agenda do not &ow therapeuticpasses.


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234 Chapter 9

SUMMARYMaladaptive behavim can develop anytime &om ihfancy throughold age. Three critical times are adolescence, menopawe, an d oldage.Coping acthity is required throughout the life cycle.The word m m l canbe viewed in a sod&WcaLm o d orstatistical way There is no sharp distinction between normal andabnonndPsychiaaycategorizes patterns ofbehavior, but it must beremembered tbat &en@ do not fit neatly into these categories.Eachclient has an individual reaction to stress and therefore an individ-uaI pattern of behauior.Psychological disorders aredisturhanm characterized bymal-adaptive behavior aimed at dealing with high levels of d t r :Arydety disorders, somatoform disorders, affective disorders, anddiswociative disddm are some common psychological disorders.Nursing m e ocuses on reducing anxieqAffective disorders deal with mood and emotions. This cat*gory d u d e s dysthymi~ epressive major, cyclothymic and bipolardisorders, Bipolar disorders are sub wed as m a ni~ epressed, ormixed Dissocfative disorde~sre characterized by changes in con-sciousness and identi@This category includes psychogenic amne-eia, psychogenic fugue, multiple personality, and d e p e r s o ~ o ndisordm Schizophrenia is characterized by delusions, hallucina-tions, disturbed thought processes, and peculiar behavior. Personswith schiz~phreniaxperience conaiding feelings and demonstrateinappropriate affect word saIa& neologism, delusions, and haIluci-nations. The m e s of schizophrenia are disorgdzed catatonic,paranoid, and undEerentiat-ed. The client with a paranoid disorders d e n h m ersistent delusions, generally of jealousy, persecution,or grandeur. Personality disorders involvean indivi&alals adaptationto internal and external problems. The disorder interferes withsocial or role functioni~g~Many psychia'tric clients are lugh risk for suicide. Thedepressed client is the client most likely to commit suicide. Thenurse should he able to recognize indirect cues that the client may;be considwing suicide Talking about suicide is a plea for help andmust be recognized as such. (See Chapter 10, Violence and

as tbry elatetoD In a &s discuwion, mmlatethe developmentalstage of ado

leswcewith the devdopmt o f m mring dkorrler.D Investigatethea d m h h np~cedma0a day-freattllentcent*armental h d t h &tin ydtr coamm~@%pon your kdhgsto the cla~3.Wain and review pamphlets from:M c m eytWatrich a ,Divisionnf RiblicL*OO K *et NWWa8bqton, DC. 200051-202m-62.20me fy mrd e rsAssadation o fAmerica@DAQUaOU Parlam Drive,bib 1.00R d d & MD 2085d-2-1-301-2313350wwwxka.orgCMdren a i dAdultswithAtiwdirn DefW Dipordw [ C w . . D . )499N.% 70thAvenue, SSuite101P W t i Q PI,333171-800-2334050-chaddqPood andDrugAhinbmtion WA]5800Elshem,LaneR o M e , MD tQB71-800-3320178MedWarch:16iJ0-33~-1088www.vrn.~dagoliNationaI Alkane fortheMen* Ill@AMD200 NoahGleheRoa& 3ta 1015Arhgroq, VA 22203-97541-800-950-NAMINational Dqressiveand M&c Dlepmwiae DisordersA s s o W n730 N. FXankbS tws S e e 501chicage, 6UQO1400-826-3G32

Maladantbe Behaviors


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Chapter 9

National Foundation forDepmiive 11l0e$$ I=POBox 2557Nw?Cork,M! 10.1161-800$39;1265rndep1%95iOmgi??a'ti.osdm t e f h M H d r h6001ExecutiveB o d e dRrrom&I$&SG 9663aethesda,MD 208921-301-443-4519r n a a . g O vNationalMenralHe&& &sO&tiOnl 0 ~6& swet&mdr ia , VPI233141-800-968-6645m e wObsessivpCxrm~iveoundation337 No& Hin PaadNor@Bradkrd, CT 064n1-203-315-ZI90~ .oc founda&&argCroup &c&wion on folkwingM D S ~ ,Communic~onwim Communicatingwith %entsj30mD3fferent @ l t W , B96.

REVIEW-NOWARID C O ~ E ~A Mdtipie choice Select the onebe& mWWmZ Anabnonnal,aces~iveear ofa s p e a c stmationor object isealled 4m

Q A obsession . . .Q B. wmpulsion. . . . .Q C. phobiaa n.pv&oss.

2.A reaming 0wzp-g tharght or fedhg iscalldtJanA Q ~ W S ~ U I Ln B.~ampu]sion.P G. phobiaU D. p&osis.

3.Ap Irresistibleurge to engageIn behavior is d e d@an0 A. obsession.0 B. compuIsion.U C phobiaa D. psychosis.

4. The@pesf schhphrenic disorder characte&ed by stuporand waxy E d i l i t y is d e dP A. dimganizsdU B.atatonicn C unMwatiat.ed.R D. parmaid

5. he affectivedismdef thatdeals with altemste moods 6fdepressionand elation is theD A d@We ctisurder,Ci B.depersmahtiondisarde.0 C.ppchogeenief5gue.D D. bipolar disorder.

5.For o r s t bWdnals, uBe of compulsive behdyior results inwhich ofthe folowing7P A occupybgthemindD B.manipulating the envbnment0 C. lowe* &eq0 D.preventing mist&e6

'7.Psychogenicamnesia isM d s danD A f l e c k disorder.D B.pasonaNtjrdisoder.0 C. dissociative &arrler.Q D. wnvemion disorder.

4. Thepereonwith a conmion disorderQ A wnverts anndetJr o b o w symptoms.Q B. expwienm.seven: m o d swings.Q C,is cut offfrom bis or her a v e e mR D.word@about self obsessively.

9. Behavio~hat the person with an ar~tisodaletsondffg s like-lytpdisplay isD A withdra- &omp n p ctivityD B.medmical obedience.D C. ~ u l a r i a nf others.D, ritwhtic behavior.


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10.W c h of the Mowing clients would hawe thea;gh&st isk krsuidde?A client ctiapaed ~ 4 t hiand A @genic m e s kP B. antisocialper6onality disorda.0 Cmajor depressimD cych&puc disorda.

APPLYmm LEARWrnGB.MnZtipIecho1ce. Seled f&eone,be& amwe%

1.A &ent diagnosedwithparanoid a ~ p ~ells thenm& I"mJuusCbrirrtpourLord and Smior,Codeasyouralns to ma" Whichresponse by. he n m e would be most~ P P ~ P ~ WP A. "Iamof theJewibbf&thand do not acceptJesus as Lordand Sadosd0 B.Tour admission p a p a donor Iist pour run%?sJesw?P C. "Youareout oftouch with red*. Your belief is a sympTom ofyour illness?R D. Y respectgourbeliefbut1 o net sharethe eliePa. A & a t nith w t a t o n i c s c h k p ~ as mute and sits forh m n a rigidposture. l%kb Cimmldmtim s t r a t ewould be most appmpxkie far the m e o use?0 A. PrqueriTl$ pat the & i t ' s shovMerto demonstratecar-in&0 B. Anoid verbd inferadan untiltke antips+&c metifa-tion takes e f f e c t0 C.Ask the dien'tls&@ant other to obtain infamatian

fmm the &mY,Q D.Offer short caringpbrases to ccmmd* mnsm forthe client3. A client has a medial &a@.& of bipolar disodm,manicphase and a diagnosis ofhbalancednuDitio~essthanbody r-ents Which n m b g interamtianmuldbe most imp~rtant?0 A Reeord how much the dietit eats aeachmad.Q B. Ask he clientto keep a journal about eat@ ham.Q C.Record the clie11tS intake and output0 D. FrequenIr offer he d i a t ma& d evePagpSt

4. Thenlnse prepares to administer fluphenzine d e w a t e(Prolixin d8canoate33E5 mg IlM to a dim diagnoed&hparaoid s&mphr& Whtch needle should the hurseedect?r;l A 18g, l/bD B,20&142'o c. 22 g,31aa D. 26g, 2"$. TheW e xepaed to administtr hatcJ@dol d ~ ~CEaldoldeanoatel Ihd ta a &ent d B g ~ 0 6 d ith parnoidsddmphreniaa. hen m e could usa any ofthe follow@*s escqt:Q A the ahdomaCl B.deltoid.P C.gIut9w -w.12. bteralis.

Q;.The nmSe gathers informafionhr a nmly admiW &entdiagn~sed ith an eaiing &order. What info~mation ouldhaw the highest priority to obtain?D &age0 B.heaa are HLld rhythm0 62.m a w mP D. body m g e

W: A clldntwithhipolar disordertakes i.thinmWhichh d iwould prompt the nlnse to mitthold thehe oseandptoqt lp the &aician?9 mstipation5 B. inffequent udnatton0 C.1-and coRfusic9~Q D, fncmaveddbt

8. The nurse finds a dent, who is diagnosedwithma% depres-sion,done aq i qing .Which e s m e by the nursewould bemost therapeutic?D. A.Administer the clfent's antidepressant medkatioa5 B. Offer to sit quietlywiththe slientLl C.A& the ellent, %at% the matter7".0 D. Qffer the clfen't-arecrational actiuity,

mental health chapter 9

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