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237 Cards in this Set

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Define crisis.
A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem.
What characteristics describe a crisis?
1. Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology.
2. Crises are precipitated by specific identifiable events.
3. Crises are personal by nature. What may be considered a crisis situation by one individual may not be so for another.
4. Crises are acute, not chronic, and will be resolved in one way or another within a brief period.
5. A crisis situation contains the potential for psychological growth or deterioration.
What is phase 1 in the development of a crisis?
Phase 1: The individual is exposed to a precipitating stressor.

Anxiety increases; previous problem-solving techniques are employed.
What is phase 2 in the development of a crisis?
Phase 2: When previous problem-solving techniques do not relieve the stressor, anxiety increases further.

The individual begins to feel a great deal of discomfort at this point. Coping techniques that have worked in the past are attempted, only to create feelings of helplessness when they are not successful. Feelings of confusion and disorganization prevail.
What is phase 3 in the development of a crisis?
Phase 3: All possible resources, both internal and external, are called on to resolve the problem and relieve the discomfort.

The individual may try to view the problem from a different perspective, or even to overlook certain aspects of it. New problem-solving techniques may be used, and if effectual, resolution may occur at this phase, with the individual returning to a higher, a lower, or the precious level of premorbid functioning.
What is phase 4 in the development of a crisis?
Phase 4: If resolution does not occur in previous phases, Claplan states that, "the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occur."

Anxiety may reach panic levels. Cognitive functions are disordered, emotions are labile, and behavior may reflect the presence of psychotic thinking.
Aguilera's 3 balancing factors in crises
1. The individual's perception of the event.
2. The availability of situational supports.
3. The availability to adequate coping mechanisms.
The Six Types of Crises
Class 1: Dispositional Crises
Class 2: Crises of Anticipated Life Transitions
Class 3: Crises Resulting From Traumatic Stress
Class 4: Maturational/Developmental Crises
Class 5: Crises Reflecting Psychopathology
Class 6: Psychiatric Emergencies
Define Class 1: Dispositional Crises
An acute response to an external situational stressor.

Example: Husband gets stressed from work and beats up wife and baby daughter.

Intervention: Wife's physical sounds are cared for in ER. The mental health counselor provided support and guidance in terms of presenting alternatives to her. Needs and issues were clarified, and referrals for agency assistance were made.
Define Class 2: Crises of Anticipated Life Transitions
Normal life-cycle transitions that may be anticipated but over which the individual may feel a lack of control.

Example: College student's wife had a baby and quit her job. He took a full-time job and his grades suffered. Complains to NP of numerous vague physical complaints.

Intervention: Physical examination should be performed (physical Sx could be caused by depression) and ventilation of feelings encouraged. Reassurance and support should be provided as needed. He should be referred to services that can provide financial and other types of needed assistance. Problematic areas should be identified and approaches to change discussed.
Define Class 3: Crises Resulting From Traumatic Stress
Crises precipitated by unexpected external stresses over which the individual has little or no control and as a result of which he or she feels emotionally overwhelmed and defeated,

Example: Waitress leaves work at night and is kidnapped, raped, and beaten. Her physical sounds have healed, but she cannot be alone. She is constantly fearful; relieves the experience in flashbacks and dreams; and is unable to eat, sleep, or work at her job.

Intervention: The nurse should encourage her to talk about the experience and to express her feelings associated with it. The nurse should offer reassurance and support; discuss stages of grief and how rape causes a loss of self-worth, triggering the grief response; identify support systems that can help her to resume her normal activities; and explore new methods of coping with emotions arising from a situation with which she has had no previous experience.
Define Class 4: Maturational/Developmental Crises
Crises that occur in response to situations that trigger emotions related to unresolved conflicts in one's life. These crises are of internal origin and reflect underlying developmental issues that involve dependency, value conflicts, sexual identity, control, and capacity for emotional intimacy.

Example: 40 y/o male is passed over job promotion 3rd time. He has moved many times within the company, usually after angering/alienating himself from the boss. His father was domineering and became abusive when client did not comply with every command. Over time, client's behavioral response become one of passive-aggressiveness - first with his father, then with his bosses. This third rejection has created feelings of depression and intense anxiety.

Intervention: The primary intervention is to help client identify the unresolved developmental issue that is creating the conflict. Support and guidance are offered during the initial crisis period, then assistance is given to help client work through the underlying conflict in an effort to change response patterns that are creating problems in his current life situation.
Define Class 5: Crises Reflecting Psychopathology
Emotional crises in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution. Examples of psychopathology that may precipitate crises include borderline personality, severe neuroses, characterological disorders, or schizophrenia.

Example: 29 y/o female Dx with borderline personality at 18. In weekly therapy for 10 years, with several hospitalizations for suicide attempts. Her therapist of 6 years is getting married and moving across the country. Client is distraught and experiencing intense feelings of abandonment; she is found wandering in and out of traffic on a busy expressway, obviously to her surroundings.

Intervention: The initial intervention is to help bring down the level of anxiety in client that has created feelings of unreality in her. She requires that someone stay with her and reassure her of her safety and security. After the feelings of panic anxiety has subsided, she should be encouraged to verbalize her feelings of abandonment. Regressive behaviors should be discouraged. Positive reinforcement should be given for independent activities and accomplishments. The primary therapist will need to pursue this issue of termination with client at length. Referral to a long-term care facility may be required.
Define Class 6: Psychiatric Emergencies
Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility. Examples include acutely suicidal individuals, drug overdoses, reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and alcohol intoxication.

Example: 16 y/o female went to high school party with boyfriend, where he broke up with her. She became hysterical; friend provided a Valium and left her sleeping on parent's bed. One hour later, friend came back to find client has swallowed entire bottle of Valium.

Intervention: The crisis monitored vital signs, ensured maintenance of adequate airway, initiated gastric lavage (washing out), and administered activated charcoal to minimize absorption. Client's parents were notified and rushed to the hospital. The situations was explained to them and they were encouraged to stay by client's side. When physical crisis was resolved, client was transferred to a psychiatric unit. In therapy, client was encouraged to ventilate her feelings regarding the rejection and subsequent overdose. Family therapy sessions were conducted in an effort to clarify interpersonal issue and to identify areas for change. On an individual level, client's therapist worked with her to establish more adaptive methods of coping with stressful situations.
Aguilera's Four Phases of Crisis Intervention
Phase 1: Assessment
Phase 2: Planning of Therapeutic Intervention
Phase 3: Intervention
Phase 4: Evaluation of Crisis Resolution and Anticipatory Planning
Roberts' Seven-Stage Crisis Intervention Model
Stage 1: Psychosocial and Lethality Assessment
Stage 2: Rapidly Establish Rapport
Stage 3: Identify the Major Problems or Crisis Precipitants
Stage 4: Deal with Feelings and Emotions
Stage 5: General and Explore Alternatives
Stage 6: Implement an Action Plan
Stage 7: Follow-up
Fact or Fiction: People who talk about suicide do not commit suicide. Suicide happens without warning.
Fiction: 8 out of 10 people who kill themselves have given definite clues and warnings about their suicidal intensions. Very subtle clues may be ignored or disregarded by others.
Fact of Fiction: You cannot stop a suicidal person. They are fully intent on dying.
Fiction: Most suicidal people are very ambivalent about their feelings regarding living or dying. Most are "gambling with death" and see it as a cry for someone to save them.
Fact or Fiction: Once a person is suicidal, they are suicidal forever.
Fiction: People who want to kill themselves are only suicidal for a limited time. If they are saved from feelings of self-destruction, they can go on to lead normal lives.
Fact or Fiction: improvement after severe depression means that the suicide risk is over.
Fiction: Most suicides occur within about 3 moths after the beginning of "improvement," when the individual has the energy to carry out the suicidal intentions.
Fact or Fiction: Suicide is inherited, or "runs in families."
Fiction: Suicide is not inherited. It is an individual matter and can be prevented. However, suicide by a close family member increases an individual's risk factor for suicide.
Fact or Fiction: All suicidal individuals are mentally ill, and suicide is the act of a psychotic person.
Fiction: Although suicidal persons are extremely unhappy, they are not necessarily psychotic. They are merely unable at that point in time to see an alternative solution to what they consider an unbearable problem.

However, about 95% of all people who commit or attempt suicide have a diagnosed mental disorder.
Fact or Fiction: Suicidal threats and gestures should be considered manipulative or attention-seeking behavior, and should not be taken seriously.
Fiction: All suicidal behavior must be approached with the gravity of the potential act in mind. Attention should be given to the possibility that the individual is issuing a cry for help.
Fact or Fiction: People usually commit suicide by taking an overdose of drugs.
Fictions: Gunshot wounds are the leading cause of death among suicide victims.
Fact or Fiction: If an individual has attempted suicide, they will not do it again.
Fiction: Between 50-80% of all people who ultimately kill themselves have a history of a previous attempt.
What is the suicide rate within marital status?
The suicide rate for single persons is twice that of married persons. Divorced, separated, or widowed persons have rates 4-5 times greater than those of the married.
What is the suicide rate within gender?
Women attempt suicide more, but men succeed more often. Successful suicides number about 70% for men and 30% for women. This has to do with the lethality of the means. Women tend to overdose; men use more lethal means such as firearms
What is the suicide rate within ethnicity?
Statistics show that white are at highest risk for suicide (Caucasian male over 75 y/o have the greatest risk.), followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans.
Durkheim's Sociological Theory and Three Social Categories of Suicide
1. egoistic suicide
2. altruistic suicide
3. anomic suicide
Describe Egoistic Suicide.
Egoistic suicide is the response of the individual who feels separate and apart from the mainstream society. Integration is lacking and the individual does not feel a part of any cohesive group (such as a family or a church).
Describe Altruistic Suicide.
Altruistic suicide is the opposite of egoistic suicide. The individual who is prone to altruistic suicide is excessively integrated into the group. The group is often governed by cultural, religious, or political ties, and allegiance is so strong that the individual will sacrifice his or her life for the group.
Describe Anomic Suicide.
Anomic suicide occurs in response to changes that occur in an individual's life (e.g., divorce, loss of job) that disrupts feelings of relatedness to the group. An interruption in the customary norms of behavior instills feelings of "separateness," and fears of being without support from the formerly cohesive group.
What is the biological theory regarding genetics and suicide?
Twin studies have shown a much higher concordance rate for monozygotic (identical) twins than for dizygotic (non-identical) twins.
What is the biological theory regarding neurochemical factors and suicide?
Some studies have revealed a deficiency of serotonin (measured as a decrease in the levels of 5-hydroxyindole acetic acid [5-HIAA] of the cerebrospinal fluid) in depressed clients who attempted suicide.
What are the psychological theories regarding suicide and predisposing factors?
There is a high correlation between hopelessness and suicide, between desperation (including guilt and self-recrimination) and suicide, violent behavior and suicide, and "face-saving" mechanism and suicide.
What are the principal stressors associated with suicidal behavior?
In the 40-60 y/o group, it's economic problems. Medical illness plays an increasingly significant role after age 60 and becomes the leading predisposing factor to suicidal behavior in individuals older than age 80.
Name comorbidities associated with suicide,
-major depressive disorder
-schizophrenia
-bipolar disorder
-alcoholism, substance abuse
-borderline personality disorder
-panic disorder
-other personality disorder
What is the age demographic for suicide?
Suicide is highest in persons older than 50. Adolescents are also at high risk.
What is the gender demographic for suicide?
Males are at higher risk than females.
What is the ethnicity demographic for suicide?
Caucasians are at higher risk than are Native Americans, who are at higher risk than African Americans.
What is the marital status demographic for suicide?
Single, divorced, and widowed are at higher risk than married.
What is the socioeconomic demographic for suicide?
Individuals in the highest and lowest socioeconomic classes are at higher risk than those in the middle classes.
What is the occupation demographic for suicide?
Professional health care personnel and business executives are at highest risk.
What is the method demographic for suicide?
Use of firearms presents a significantly higher risk than overdose of substances.
What is the religion demographic for suicide?
Individuals who are not affiliated with any religious group are at higher risk than those who have this type of affiliation.
What is the family history demographic for suicide?
Higher risk if individual has family history of suicide.
Name protective factors associated with suicide.
-pregnancy, except with postpartum psychosis
-children in home
-spiritual connections, life satisfaction
-positive coping skills & social support
-positive therapeutic relationships with provider
-learned skills in conflict resolution
-nonviolent ways to resolve conflict
-restricted access to lethal means
-family and community support
-easy access to clinical intervention
-consistency in clinical care
How to you measure the lethality of an individual's suicide plan?
1. specificity of details of plan
2. proposed method
3. availability of means
What are the high-risk methods associated with suicide?
-firearms
-jumping off a high structure
-hanging, suffocation
-poisoning with carbon monoxide
-staging a car crash
What are the low-risk methods associated with suicide?
-cutting one's wrist
-inhaling substances
-ingesting pills
Name specific treatments for suicide?
-psychotherapy / CBT
-ECT is used for short-term suicidal behavior
-medications per Axis 1 Dx
-continuous reassessment of the client
-encourage verbalization of honest feelings
-identify community resources for support
Other key points about suicide...
-Most suicidal people are very ambivalent.
-People contemplating suicide are only suicidal for a limited time.
-Suicide is not inherited; risk increases if a close family member commits suicide.
-Suicidal persons are not necessarily mentally ill; unable to see alternative
-8/10 people who commit suicide have given clues/warnings
-If pt doesn't have Axis I Dx, will not be admitted to hospital.
Define cognitive.
Relating to the mental processes of thinking and reasoning.
Define cognitive therapy.
Cognitive therapy is a type of psychotherapy based on the concept of pathological mental processing. The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors.
What are the goals of cognitive therapy, according to Beck and associates?
The client will:
1. Monitor their negative, automatic thoughts
2. Recognize the connections between cognition, affect, and behavior.
3. Examine the evidence for and against distorted automatic thoughts.
4. Substitute more realistic interpretations for these biased cognitions.
5. Learn to identify and alter the dysfunctional beliefs that predispose them to distort experiences.
What is the 1st principle of cognitive therapy?
Cognitive therapy is based on an ever-evolving formulation of the client and their problems in cognitive terms.
What is the 2nd principle of cognitive therapy?
Cognitive therapy requires a sound therapeutic alliance. (A trusting relationship between therapist and client must exist for cognitive therapy to succeed.)
What is the 3rd principle of cognitive therapy?
Cognitive therapy emphasizes collaboration and active participation. (Teamwork between therapist and client is emphasized.)
What is the 4th principle of cognitive therapy?
Cognitive therapy is goal oriented and problem focused.
What is the 5th principle of cognitive therapy?
Cognitive therapy initially emphasizes the present.

Resolution of distressing situations that are based in the present usually lead to symptom reduction. It is therefore of more benefit to begin with current problems and delay shifting attention to the past until (1) the client expresses a desire to do so, (2) the work on current problems produces little or no change, or (3) the therapist decides it is important to determine how dysfunctional ideas affecting the client's current thinking originated.
What is the 6th principle of cognitive therapy?
Cognitive therapy is educative, aims to teach the client to be their own therapist, and emphasizes relapse prevention.
What is the 7th principle of cognitive therapy?
Cognitive therapy aims to be time limited.
What is the 8th principle of cognitive therapy?
Cognitive therapy sessions are structured.
What is the 9th principle of cognitive therapy?
Cognitive therapy teaches clients to identify, evaluate, and response to their dysfunctional thoughts and beliefs.
What is the 10th principle of cognitive therapy?
Cognitive therapy uses a variety of techniques to change thinking, mood, and behavior.
What are automatic thoughts?
Automatic thoughts are those that occur rapidly in response to a situation and without rational analysis. These thoughts are often negative and based on erroneous logic. Often called cognitive errors.
Name examples of automatic thoughts, or cognitive errors.
-arbitrary inference
-overgeneralization (absolute thinking)
-dichotomous thinking
-selective abstraction
-magnification
-minimization
-catastrophic thinking
-personalization
Describe arbitrary inference.
The individual automatically comes to a conclusion about an incident without the fact to support it, or even sometimes despite contradictory evident to support it.

Example: Two months ago, Mrs. B send a wedding gift to the daughter of an old friend. She has not yet received acknowledgement of the gift and she think, "They obviously think I have poor taste."
Describe overgeneralization (absolute thinking).
Sweeping conclusions made based on one incident - a type of "all-or-nothing" thinking.

Example: Frank submitted an article to a nursing journal and it was rejected. He thinks, "No journal will ever be interested in anything I write."
Describe dichotomous thinking.
An individual views situations in terms of all-or-nothing, black-or-white, or good-or-bad.

Example: Frank submits an article to a nursing journal and the editor returns it, asking Frank to rewrite part of it. Frank thinks, "I'm a bad writer," instead of recognizing that revision is a common part of the publication.
Describe selective abstraction.
A "mental filter" or conclusion that is based on only a selected portion of the evidence. The selected portion is usually the negative evidence or what the individual views as a failure, rather than any successes that have occurred.

Example: Jackie just graduated from high school with a 3.98 GPA. She won a scholarship to a large state university. However, she is very depressed and dwells on the fact that she did not earn a scholarship to a prestigious Ivy League college to which she applied.
Describe magnification.
Exaggerating the negative significance of an event.

Example: Nancy hears that her colleague at work is having a cocktail party over the weekend and she is not invited. Nancy thinks, "She doesn't like me."
Describe minimization.
Undervaluing the positive significance of an event.

Example: Mrs. M is feeling lonely. She calls her granddaughter Amy, who lives in a nearby town, and invites her to visit. Amy apologizes that she'll be out of town. While Amy is out, she calls Mrs. M twice, but Mrs. M will feels unloved by her granddaughter.
Describe catastrophic thinking.
Always thinking that the worst will occur without considering the possibility of more likely positive outcomes.

Example: On Janet's first day in her secretarial job, her boss asked her to write a letter to another firm and put it on his desk for his signature. She did so and left for lunch. When she returned, the letter was on her desk with a typographical error circled in red and a note from her boss to redo the letter. Janet thinks, "This is it! I will surely be fired now!"
Describe personalization.
The person takes complete responsibility for situations without considering that other circumstances may have contributed to the outcome.

Example: Jack, who sells vacuum cleaners door-to-door, has just given a 2-hr demonstration to Mrs. W. At the end of the demonstration, Mrs. W tells Jack that she appreciates his demonstration, but she won't be purchasing a vacuum cleaner from him. Jack thinks, "I'm a lousy salesman," when in fact, Mrs W's husband lost his job last week and they have no extra money to buy a new vacuum cleaner at this time.
What are cognitive schemas (core beliefs)?
Structures that contain the individual's fundamental beliefs and assumptions. Schemas develop early in life from personal experience and identification with significant others. These concepts are reinforced by further learning experiences and thus influence the formation of beliefs, values, and attitudes.
How are cognitive schemas different from automatic thoughts?
Schemas differ from automatic thoughts in that they are deeper cognitive structures that serve to screen information from the environment. For this reason, they are often more difficult to modify than automatic thoughts.
What are the categories for cognitive schemas?
Helplessness and unlovability.
What are the three major components of cognitive therapy?
-didactic or educational aspects
-cognitive techniques
-behavioral interventions
Describe Socratic questioning.
In Socratic questioning, or guided discovery, the therapist questions the client about their situation and asked to describe their feelings associated with specific situations.
Describe the "two-column" thought recording.
The client is asked to keep a written record of situations that occur and the automatic thoughts that are elicited by the situation.
Describe the "three-column" thought recording.
The client is asked to keep a written record of situations that occur and the automatic thoughts that are elicited by the situation, plus a description of the emotional response also associated with the situation.
What is decatastrophizing?
With the technique of decatastrophizing, the therapist assist the client to examine the validity of a negative automatic thought. Even if some validity exists, the client is then encouraged to review ways to cope adaptively, moving beyond the current crisis situation.
What is a Daily Record of Dysfunctional Thoughts (DRDT)?
In addition to the "three-column" thought recording, two more columns are added:
1. The client describes a more rational cognition than the automatic thought in the 2nd column, and rate the intensity of the belief in the rational thought.
2. The client records any changes that have occurred as a result of modifying the automatic thought and the new rate of intensity associated with it.
What are the behavior interventions in cognitive therapy?
-activity scheduling
-graded task assignments
-behavioral rehearsal
-distraction
-miscellaneous techniques (i.e., relaxation techniques, assertiveness training, role modeling, and social skills training)
Janet failed her first nursing school exam. She thinks, "Well, that's it! I'll never be a nurse." What automatic thought does this statement represent? Overgeneralization? Magnification? Catastrophic thinking? Personalization?
Catastrophic thinking: Always thinking that the worst will occur without considering the possibility of more likely positive outcomes.
When Jack is not accepted at the law school of his choice, he thinks, "I'm so stupid. No law school will ever accept me." What automatic thought does this statement represent? Overgeneralization? Magnification? Selective abstraction? Minimization?
Overgeneralization: Sweeping conclusions made based on one incident - a type of "all-or-nothing" thinking. Also called absolute thinking.
Nancy's new in-laws came to dinner for the first time. When Nancy's mother-in-law left some food on her plate, Nancy thought, "I must be a lousy cook." What automatic thought does this statement represent? Dichotomous thinking? Overgeneralization? Minimization? Personalization?
Personalization: The person takes complete responsibility for situations without considering that other circumstances may have contributed to the outcome.
Barbara burned the toast. She thinks, "I'm a totally incompetent person." What automatic thought does this statement represent? Selective abstraction? Magnification? Minimization? Personalization?
Magnification: Exaggerating the negative significance of an event.
Define personality.
The totality of emotional and behavioral characteristics that are particular to a specific person and that remain somewhat stable and predictable over time.
How does the DSM-IV-TR define personality traits?
Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.

Personality disorders occur when these traits become inflexible and maladaptive; cause significant functional impairment or subjective distress in 2 or more areas:
-cognition functioning
-affect
-interpersonal
-impulse control
Name the Cluster A personality disorders.
Behaviors described as odd or eccentric:
1. Paranoid personality disorder
2. Schizoid personality disorder
3. Schizotypal personality disorder
Name the Cluster B personality disorders.
Behaviors described as dramatic, emotional, or erratic.
1. Antisocial personality disorder
2. Borderline personality disorder
3. Histrionic personality disorder
4. narcissistic personality disorder
Name the Cluster C personality disorders.
Behaviors described as anxious or fearful.
1. Avoidant personality disorder
2. Dependent personality disorder
3. Obsessive-compulsive personality disorder
What is the general population prevalence for personality disorders?
10-15% of the general population
What comorbidities are associated with personality disorders?
Comorbidities include mood disorders, generalized anxiety disorder, agoraphobia, obsessive-compulsive disorder, substance use, ADHD, PTSD, eating disorders, somatization disorder.
How does the DSM-IV-TR define paranoid personality?
Paranoid personality disorder is a "pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts."

A characteristic feature is "long-standing suspiciousness and mistrust of people"
Describe the Cluster A personality disorders.
-referred to as "odd or eccentric" behaviors
-more common in men than women
-hypervigilance, tense, irritable, intimidating
-insensitive to the feelings of others
-feels as though others are going to take advantage of them
-oversensitive, misinterprets cues
-blames other for shortcomings
What cluster does paranoid personality disorder belong to?
Cluster A.
Describe paranoid personality disorder.
-suspects without bases that others are exploiting, harming, or deceiving them
-preoccupied with unjustified doubts about the loyalty of friends/associates
-reluctant to confide in others for fear that info will be used against them
-reads hidden or threatening meanings into benign remarks or events
-persistently bears grudges (unforgiving)
-perceives attacks on character or reputation that are not apparent to others and quick to react angrily (will attack first)
-recurrent suspicious without justification, regarding fidelity of spouse or partner
What are the predisposing factors to paranoid personality disorder?
-There is a possible hereditary link with increased incidence among relatives of clients with schizophrenia.
-Clients may have been subjected to parental antagonism and harassment. They likely served as scapegoats for displaced parental aggression and gradually relinquished all hope of affection and approval.
What cluster does schizoid personality disorder belong to?
Cluster A.
Describe schizoid personality disorder.
-profound defect in one's ability to form personal relationships or to respond to others in a meaningful, emotional way
-social withdrawn, discomfort with human interaction
-diagnosed more frequent in men
-aloof, indifferent, works in isolation, unsociable, invests energy in intellectual pursuits, affect is bland/constricted
What are the predisposing factors for schizoid personality disorder?
Psychosocially, the development of schizoid personality disorder is probably influenced by eraly interactional patterns that the person found to be cold and unsatisfying. The childhood is characterized as bleak, cold, and notably lacking empathy and nurturing. A child brought up with this type of parenting may become a schizoid adult if that child possesses a temperamental disposition that is shy, anxious, and introverted.
What is the diagnostic criteria for schizoid personality disorder?
Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood, indicated by four or more:
-does not desire nor enjoy close relationships
-almost always chooses solitary activities
-little, if any interest in sexual experiences
-takes pleasure in few activities
-lacks close friends
-appears indifferent to praise or criticism
-shows emotional coldness, detachment
What cluster does schizotypal personality disorder belong to?
Cluster A.
Describe schizotypal personality disorder.
-more severe than schizoid personality disorder
-"latent schizophrenics"
-magical thinking or perceptual distortions that are not clear delusions or hallucinations
-belief in telepathy "others can feel my feelings"
-personalized style of speech, eccentric appearance
-can become psychotic under stress
Name predisposing factors for schizotypal personality disorder.
Some evidence suggests that schizotypal personality disorder is more common among the first-degree biological relatives of people with schizophrenia than among the general population, indicating a possible hereditary factor.

The early family dynamics of the client may have been characterized with indifference, impassivity, or formality, leading to a pattern of discomfort with personal affection and closeness. Early on, affective deficits made them unattractive and unrewarding social companions. They were likely shunned, overlooked, rejected, and humiliated by others, resulting in low self-esteem and a marked distrust of interpersonal relations.
What is the diagnostic criteria for schizotypal personality disorder?
Pervasive pattern of social & interpersonal deficits with acute discomfort and inability to form close relationships; cognitive or perceptual distortions; eccentricities of behavior beginning by early childhood; five or more:
-ideas of reference
-odd beliefs or magical thinking
-unusual perceptual experiences (bodily illusions)
-odd thinking and speech
-suspiciousness or paranoid ideation
-inappropriate or constricted affect
-odd, eccentric, or peculiar behavior
-lack of close friends other than first degree relatives
-excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self
Describe Cluster B personalities.
Exhibits drama, emotional, or erratic behaviors.
What cluster does antisocial personality disorder belong to?
Cluster B.
What is the diagnostic criteria for antisocial personality disorder?
3 or more:
-failure to conform to social norms with respect to lawful behavior (repeated arrests)
-deceitfulness, with repeated lying, use of aliases, or conning others for personal profit/pleasure
-impulsivity or failure to plan ahead
-irritability and aggressiveness (physical fights, assaults)
-reckless disregard for safety of self or others
-consistent irresponsibility by disregarding obligations
-lack of remorse by being indifferent to having hurt, mistreated, or stolen from others
What is the prevalence for antisocial personality?
Behaviors exhibited between ages 15-18; conduct disorder diagnosed before age 15.

When seen in clinical settings, a way to avoid legal consequences; can be court-ordered for a psych evaluation.
Describe antisocial personality disorder.
-intimidating, argumentative
-difficulty sustaining consistent employment
-lack warmth and compassion
-low tolerance for frustration
-unable to delay gratification
-"thrill-seeking"
-exploit others to fulfill their own desires
-do not accept responsibility for behaviors
-cannot develop interpersonal relationships
Name predisposing factors to antisocial personality disorder.
-first-degree biological relatives with same disorder
-chaotic home environment
-physically abused in childhood
-absence of parental discipline
-extreme poverty
-removal from the home
-growing up without parents figures of both sexes
-erratic and inconsistent methods of discipline
-being "rescued" each time they are in trouble (never having to suffer the consequences of one's own behavior)
-maternal deprivation
Name possible NANDA diagnoses for antisocial personality disorder.
-risk for other-directed violence
-defensive coping
-chronic low self-esteem
-impaired social interaction
-ineffective health maintenance
What cluster does borderline personality disorder belong to?
Cluster B.
Describe borderline personality disorder.
-pattern of intense and chaotic relationships with affective instability and fluctuating attitudes towards others
-impulsive: substance abuse, gambling, promiscuity, binging & purging, reckless driving
-self-destructive: suicide attempts, cutting, scratching, burning
-manipulation: to allay fears of abandonment by parents in early childhood; little tolerance for being alone
-always in a state of crisis
-chronic depression is common
-lacks a clear sense of identity
-splitting
What is the prevalence of borderline personality disorder?
Prevalence of borderline personality disorder is estimated at 1-2% of the population. It is more common in women than in men, with female-to-men ratios being estimated as high as 4:1.
What is splitting?
A primitive ego defense mechanism in which hte person is unable to integrate and accept both positive and negative feelings. In the view of these individuals, people - including themselves - and life situations are either all good or all bad.
Splitting is exhibited in what personality disorder?
Borderline personality disorder.
Name predisposing factors for borderline personality disorder.
-decrease of serotonin on PET scans
-relatives with mood disorders
-reared in families with chaotic environment
-childhood trauma: sexual and physical abuse (PTSD-like)
-becomes fixed in "rapprochement phrase of development;" 16-24 months when awareness of separateness of the self becomes acute
Name NANDA diagnoses for borderline personality disorder.
-risk for self-mutilation
-risk for self-directed violence
-suicide
-other-directed violence
-complicated grieving
-impaired social interaction
Name diagnosis criteria for borderline personality disorder.
Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood; 5 or more:
-unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
-identity disturbance: unstable self-image or sense of self
-frantic efforts to avoid real or imagined abandonment
-impulsivity in at least two areas that are potentially self damaging
-recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
-affective instability due to marked reactivity of mood (intense episodic dysphoria, irritability, anxiety lasting a few hours and rarely more than a few days)
-chronic feelings of emptiness
-inappropriate, intense anger or difficulty controlling anger
-transient, stress-related paranoid ideation or severe dissociative symptoms
What cluster does histrionic personality disorder belong in?
Cluster B.
What are the diagnostic criteria for histrionic personality disorder?
Pervasive pattern of excessive emotionality and attention seeking behavior, with early adulthood onset; five or more:
-uncomfortable in situations in which the person is not the center of attention
-interaction with others is characterized by inappropriate sexually seductive or provocative behavior
-rapidly shifting emotions
-excessively impressionistic style of speech, lacking in detail
-uses physical appearance to draw attention to self
-dramatic, theatrical, exaggerated expression of emotion
-easily influenced by others or circumstances
-considers relationships to be more intimate than they are
Name predisposing factors of histrionic personality disorder.
-decreased serotonin, heightened noradrenergic activity
-common among first-degree biological relatives
-learned behavior (lack of positive or negative feedback)
What cluster does narcissistic personality disorder belong in?
Cluster B.
What personality disorder is the oldest and best researched of all the personality disorders and has been included in all the editions of DSM?
Antisocial personality disorder
What is the prevalence of histrionic personality disorder?
Prevalence of this disorder is thought to be about 2-3% and it is more common in women.
Describe narcissistic personality disorder.
-overly self-centered and exploitative due to their fragile self-esteem
-view themselves as "superior" with special rights
-do not see their behavior as objectionable
-choose partners who provide continual praise and do not ask for much in return
-exaggerated sense of self-worth
What is the prevalence of narcissistic personality disorder?
The DSM-IV-TR estimates that this disorder occurs in 2-16% of the clinical population and less than 1% of the general population. It is diagnosed more often in men than women.
Name the diagnostic criteria for narcissistic personality disorder.
Pervasive pattern of grandiosity, need for admiration, lack of empathy, beginning by early adulthood; five or more:
-grandiose sense of self-importance
-preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
-belief in being special, unique or should associate with high-status people
-requires excessive admiration
-sense of entitlement
-interpersonally exploitative
-lacks empathy: unwilling to recognize or identify with the feelings/need of others
-envious or others or believes others are envious of them
Name predisposing factors for narcissistic personality disorder.
-narcissistic parents (modeling) - critical, perfectionistic
-parents overindulge their children or are inconsistent
-child's dependency needs responded to with criticism, neglect, or disdain
-parents attempt to live their lives vicariously through their child; expect their child to achieve better than them
Describe cluster C personality disorders.
Reflect anxious or fearful behaviors.
What cluster does avoidant personality disorder belong in?
Cluster C.
Describe avoidant personality disorder.
-awkward and uncomfortable in social situations
-sensitive to rejection, extreme shyness
-slow and constrained speech with frequence hesitations
-fragmented thoughts
-feelings of being unwanted and lonely
-parental rejection, criticism, low self-worth
-view the world as hostile and dangerous
Name diagnostic criteria for avoidant personality disorder.
Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood; four or more:
-avoids occupational activities that involve significant interpersonal contact, due to fear of criticism, disapproval, or rejection
-unwilling to get involved with people unless certain of being liked
-shows restraint within intimate relationships due to the fear of being shamed or ridiculed
-preoccupied with being criticized or rejected in social situations
-inhibited in new interpersonal situations due to feelings of inadequacy
-views self as socially inept, unappealing , inferior
-reluctant to take personal risks or to engage in new activities that may prove to be embarrassing
What is the prevalence for avoidant personality disorder?
Prevalence of the disorder in the general population is between 0.5-1%, and it appears to be equally common in men and women.
What are predisposing factors of avoidant personality disorder?
The primary psychosocial predisposing influence is parental rejection and censure, which is often reinforced by peers. These children are often reared in families in which they are belittled, abandoned, and criticized, such that any natural optimism is extinguished and replaced with feelings of low self-worth and social alienation.

Some infants who exhibit traits of hyperirritability, crankiness, tension,m and withdrawal behaviors may possess a temperamental disposition toward an avoidant pattern.
What cluster does dependent personality disorder belong in?
Cluster C.
Name diagnostic criteria for dependent personality disorder.
Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior, fears of separation, beginning by early adulthood; five or more:
-difficulty making everyday decisions without an excessive amount of advice and reassurance from others
-difficulty expressing disagreement with others due to fear of loss of support or approval
-needs others to assume responsibility for most major areas of life
-difficulty initiating projects or doing things on one's own due to a lack in self-confidence
-goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do unpleasant tasks
-feels uncomfortable or helpless when alone due to exaggerated fears of being unable to care for oneself
-urgently seeks another relationship as a source of care and support when a close relationships ends
-unrealistically preoccupied with fears of being left to take care of oneself
What is the most commonly seen personality disorder in the clinical setting for anxiety/mood disorders?
Dependent personality disorder
What is the prevalence of dependent personality disorder?
This disorder is relatively common. One study of personality disorders showed that 2.5% of the sample were diagnosed with dependent personality disorder. It is more common in women than in men and more common in the youngest children in a family.
Name predisposing factors for dependent personality disorder.
Twin studies measuring submissiveness have shown a higher correlation between identical twins than fraternal twins, indicating an infant may be predisposed to a dependent temperament.

Psychosocially, dependency is fostered in infancy when stimulation and nurturance are experienced exclusively from one source. The infant becomes attached to one source and if it continues as the child grows, the dependency is nurtured. A problem may arise when parents become overprotective and discourage independent behaviors on the part of the child.
What cluster does obsessive-compulsive personality disorder belong in?
Cluster C.
Name diagnostic criteria for obsessive-compulsive personality disorder.
Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood; four or more:
-preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
-shows perfectionism that interferes with task completion (strict standards interfere with project)
-excessively devoted to work and productivity to the exclusion of leisure activities and friendships
-overconscientious, scrupulous, inflexible about matters of morality, ethics, values
-unable to discard worn-out or worthless objects even when they have no sentimental value
-reluctant to delegate tasks or to work with others unless they submit to exactly his/her way of doing things
-adopt a miserly spending style toward both self and others
-shows rigidity and stubbornness
What is the prevalence of obsessive-compulsive personality disorder?
It is relatively common and occurs more often in men than women.
Name predisposing factors of obsessive-compulsive personality disorder.
-parenting style of being "over-controlling"
-imposed standards of conduct by parents with condemnation
-children learn what they must NOT DO to avoid punishment and condemnation rather than what they CAN do to achieve attention and praise
-rigid restrictions and rules
-positive achievement are expected by parents and not necessarily acknowledged
What cluster does passive-aggressive personality disorder belong in?
Haha, trick question! It does not belong in a cluster; the DSM-IV-TR notes it as a separate personality disorder.
Name diagnostic criteria for passive-aggressive personality disorder.
Pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood; four or more:
-passively resists fulfilling routine social and occupational tasks
-complains of being misunderstood and unappreciated by others
-is sullen and argumentative
-unreasonably criticizes and scorns authority
-expresses envy and resentment toward those more fortunate
-voices exaggerated and persistent complaints of personal misfortune
-alternates between hostile defiance and remorse
Name predisposing factors for passive-aggressive personality disorder.
-contradictory parental attitudes are internalized by children
-approach-avoidance pattern is modeled by children
-learns to control anger for fear of provoking parental withdrawal and not receiving love and support - even on an inconsistent basis
Which axis does acute care focus on?
Axis I; acute care focuses on the primary psychiatric disorder.
Define complicated grieving.
A disorder that occurs after the death of a significant other (or any other loss of significance to the individual), in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment.
Define defensive coping.
Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.
Name treatment modalities for personality disorders.
-interpersonal psychotherapy
-milieu or group therapy
-cognitive behavioral therapy
-dialectical behavioral therapy
-psychopharmacology for symptomatic relief
What is Dialectical Behavior Therapy (DBT)?
-form of psychotherapy developed by Marsha Linehan, PhD
-Tx for chronic self-injurious behavior of clients with borderline personality disorder
-combination of cognitive, behavioral, and interpersonal therapies with Eastern mindfulness practices
Name the five functions of DBT.
1. enhance behavioral capabilities
2. improve motivation to change
3. ensure that new capabilities can be adapted to the normal environment
4. structure treatment to enhance the reinforcement of effective behaviors
5. enhance therapist capabilities and motivation to treat clients effectively
Name the four primary modes of treatment in DBT.
1. Group skills training
2. Individual psychotherapy
3. Telephone contact
4. Therapist consultation/team meeting
Can drugs have DIRECT effects on personality disorders?
Nope! But some symptomatic relief can be achieved.
What drug can be used for Sx of paranoid, schizotypal, and borderline personality disorders?
Antipsychotics
What drugs can help decrease impulsive acts and self-mutiliation in personality disorders?
SSRIs and MAOIs
What drugs are used to treat dysphoria, mood instability, impulsivity with borderline personality disorder?
SSRIs and atypical antipsychotics
Which has a higher risk for fatality from overdose: SSRIs or MAOIs?
MAOIs.
What is mental retardation?
It is defined by deficits in general intellectual functioning and adaptive functioning.
What are the risk factors for childhood and adolescent psychiatric disorders?
-neglect and abuse
-genetic link
-parental dysfunction
-children witnessing violence in the home, community
-bullying
-poverty
-exposure to alcohol and drugs
-lead exposure
What is resilience?
-adaptability to changes in environment
-ability to form nurturing relationships with other adults
-ability to distance oneself from emotional chaos
-effective social skills
-problem-solving abilities
What are the four levels of degree of severity of mental retardation?
Mild (50-70)
Moderate (35-49)
Severe (20-34)
Profound (below 20)
What are pervasive developmental disorders?
Characterized by server and pervasive impairment in reciprocal social interaction and communication skills (Axis II disorders)
What are autism spectrum disorders?
A group of disorders that are characterized by impairment in several areas of development, including social interaction skills and interpersonal communication. Included in this category are autistic disorders, Rett's disorder, childhood distintegrative disorder, pervasive developmental disorder NOS, and Asperger's disorder.
Describe autistic disorder.
It is characterized by withdrawal of the child into the self and into a fantasy world of his or her own creation. The child has markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests. Activities and interests may be considered somewhat bizarre.

-Abnormal language patterning or absence of language
-Impairments in verbal/nonverbal communication
-neurological and developmental disability
What is the prevalence of autistic spectrum disorders?
9 per 1,000 in the U.S. Autistic disorder occurs about four times more often in boys than in girls. Onset occurs before age 3 and often runs into adulthood.
-70-90% of identical twins
Which two drugs has the FDA approved for the treatment of autism?
-risperdone (Risperdal) in 5-16 years
-apripiprazole (Abilify) in 6-17 years
Describe Asperger's Disorder.
-no significant delays in cognitive and language development
-etiology unknown
-common in males, familial link with high occurrence in fathers
-social deficits
-restricted and repetitive patterns of behavior and idiosyncratic interests
What is hyperactivity?
Excessive psychomotor activity that may be purposeful or aimless, accompanied by physical movements and verbal utterances that are usually more rapid than normal. Inattention and distractibility are common with hyperactive behavior.
What is impulsiveness?
The trait of acting without reflection and without thought to the consequences of the behavior. An abrupt inclination to act (and the inability to resist acting) on certain behavioral urges.
What is the prevalence of Attention-Deficit Hyperactivity Disorder (ADHD)?
-symptoms present before age 7 in at least 2 settings (home, school)
-more common in males
-occurrence in 3-10% of children worldwide
What is the diagnostic criteria for ADHD?
At least 6 for at least 6 months:
-inattention
-hyperactivity
-impulsivity
-intrusive
-difficulty waiting one's turn
-talks excessively
-does not pay attention to social cues
-fidgeting, climbing, unable to sit still
-avoids, dislikes, reluctant to engage in tasks that require sustained mental effort
-does not follow through on instructions
-difficulty organizing tasks and activities
-loses important items
-easily distracted by extraneous stimuli
-forgetful in daily activities
-"on the go" or "driven by a motor"
What are the predisposing factors to ADHD?
-possible genetic imbalance of catecholamine metabolism in cerebral cortex
-deficits in prefrontal cortex (response inhibition area)
-dietary contributing factors: sugar, food additives, vitamin deficiencies, food allergies
-lead poisoning, maternal smoking
-fetal alcohol syndrome
-birth complications
What are the 3 subtypes of ADHD?
1. ADHD Combined type
2. ADHD Predominantly inattentive type
3. ADHD Predominantly hyperactive-impulsive type
Describe the ADHD Combined Type.
At least six symptoms of inattention and at least six symptoms of hyperactivity-inpulsivity have persisted for at least 6 months. Is most common.
Describe ADHD Predominantly Inattentive Type.
At least six symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least six months.
Describe ADHD Predominantly Hyperactive-Impulsive Type.
At least six symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) have persisted for six months.
Describe the treatment for ADHD.
-DNA sequencing: abnormal regulation of dopamine transport gene and dopamine receptor resulting in abnormal dopamine transmission (less extracellular dopamine)
-Treatments involve dopamine and norepinephrine to improve executive functioning; regulation of arousal for improved performance
-Ritalin increases extracellular levels of dopamine
What functional areas of the brain are affected in ADHD?
-prefrontal cortex: relating to maintaining attention, organization, executive function; modulates behavior inhibition (serotonin's role)
-basal ganglia: regulation of high-level movements, interruption can cause inattention and impulsivity
-hippocampus: learning and memory
-limbic system: regulation of emotions
-reticular activating system: center of arousal and motivation
What is the nursing assessments for ADHD?
-comprehensive testing: medical, social, family hx
-developmental stages
-educational progress
-psychosocial impairment
-Dx of Axis I psychiatric disorders
-Neurological testing
What type of comorbidities are associated with ADHD?
-oppositional defiant behavior
-conduct disorder
-learning disorders
-anxiety
-depression
-bipolar disorder
-substance use
What type of stimulants do we use in the treatment of ADHD?
CNS stimulants: all block dopamine and norepinephrine re-uptake with increasing catecholamine release.

Decrease fatigue, enhance wakefulness, mood elevation, increase in speech/motor activity, stimulate respiratory center, depress appetite

Considered first line therapy.
What CNS stimulant drugs do we use to use treat ADHD?
-Methylphenidate (Ritalin): most common agent: short, intermediate, and long-acting dosing; Methylin, Concerta
-Dexmethyphenidate (Focalin): short and long-acting
-Mixed amphetamine salts (Adderall): short and long-acting (Adderall XR)
-Dextroamphetamine (Dexedrine, Dextrostat: short and intermediate acting
-Lisdexamphetamine (Vyvanse)
What are the adverse effects of CNS stimulants?
-Can exacerbate bipolar/psychotic conditions
-Sudden death from undiagnosed cardiac conditions
Inhibition or decreased growth of about 1cm/year along with weight loss of 3kg/year
-Monitor growth and use drug holidays during the summer when school is not in session
-G.I. s/s; headache; irritability; abnormal movements; hypertension; psychosis (hallucinations)
What are the non-stimulant treatments for ADHD?
-Atomoxetine (Strattera): SNRI – only increases norepinephrine (not dopamine); effective in clients with anxiety, insomnia, substance use disorders; less growth suppression; takes 2-4 weeks to work; black box warning for severe liver injury and suicidality
-Anticonvulsants (valproate, carbamazepine)
-Antipsychotics to control aggression or explosive behaviors
-Bupropion (Wellbutrin): weak dopamine and norepinephrine inhibitor; less toxicity in overdose; less appetite suppression (the kids get hungry); contraindicated in seizure disorders; rash and nausea
-Tricyclic antidepressants (TCAs): Imipramine, desipramine, nortriptyline
-Clonidine (alpha-2-adrenergic agonist)
-Guanfacine (Intuniv, Tenex)
What is Oppositional Defiance Disorder (ODD)?
-Recurrent pattern of negative, disobedient, hostile, defiant behavior towards authority figures without serious violations of others’ basic rights (APA, 2000)
-Persistent stubbornness, testing of limits, argumentative, unwilling to negotiate, refusal to accept blame
-Behaviors cause significant impairment in home, social relationships, school & occupational functioning (Axis IV)

-Substantial overlap with ADHD
-Problems sustaining friendships
-Associated with anxiety, mood disorders
What is the prevalence of Oppositional Defiant Disorder (ODD)?
-Usually evident by 8 years of age (2-12%)
-Common in males until puberty; after puberty, equal numbers between males and females
What is the prevalence of conduct disorders?
-Usually evident by 8 years of age (2-12%)
-Common in males until puberty; after puberty, equal numbers between males and females
What are the comorbidities associated with conduct disorders?
Anxiety, depression, ADHD, learning disabilities, and substance abuse.

Direct correlation to later diagnosis of antisocial personality disorder
What are the two subtypes of conduct disorders?
-Child onset: prior to 10 years, males
-Adolescent onset: more females become aggressive; act out with peer group
What are the diagnostic criteria for conduct disorders?
DSM-IV-TR identifies 4 types of behavior:
-Aggression towards people and animals
-Destruction of property
-Deceitfulness or theft
-Serious violations of rules
What are the diagnostic criteria for Separation Anxiety Disorder?
1. Excessive distress when separated from or anticipates separation from home or parental figure
2. Excessive worries one will get lost, be kidnapped, parents will be harmed, or home will be damaged
3. Fear of being home alone or in situations without significant adults
4. Refusal to sleep unless near a parental figure; refusal to sleep away from home
5. Refusal to attend school or other activities without parents
6. Exhibits physical s/s of anxiety
What is the prevalence of Separation Anxiety Disorder?
Can happen at any age before 18, but most commonly diagnosed around 5-6 years when child goes to school. In 4% of school-age children.
Any comorbidities with Separation Anxiety Disorder?
Depression accompanies anxiety.
What are the predisposing factors for Separation Anxiety Disorder?
Genetic and environmental factors.
Tell me about PTSD in children/adolescents.
-Exposed to traumatic events or witnessing harm to others; s/s last more than 1 month
-Shows up as anxiety, dissociative symptoms (feel outside their bodies), emotionally re-experiencing the trauma, avoidance of specific situations
-Sleep problems, nightmares
-Impaired academic performance
-Repetitive playing out of trauma
-Hypervigilance (don't approach them from behind)
-Somatic complaints; depression; self-mutilation
What is the prevalence of OCD in children/adolescents?
-Can be identified in children as young as 5 years of age
-2-3% of adolescents
Describe OCD in children/adolescents.
-Attempts to resist ritualized behaviors typically increase anxiety and intensify the urge to perform the compulsion
-Common obsessions in children and adolescents include the fear of harm to self or family; contamination; worry about acting on unwanted aggressive impulses; concern about order
-Common compulsions: hand washing, cleaning rituals, ordering and arranging of objects, checking
What is the diagnostic criteria for OCD in children/adolescents?
Behavior interferes with daily activities at least 1 hour per day (DSM-IV-TR)
How does OCD in children/adolescents affect the brain?
Dysregulation of brain circuits that connect the cerebral cortex, basal ganglia, and thalamus
What are the comorbidities associated with OCD in children/adolescents?
Comorbidities: anxiety disorders, depression, dysthymia
Tell me about Major Depressive Disorder (MDD) in children/adolescents,
-Children might be less able to verbalize their feelings and exhibit increased irritability
-Males are at slightly higher risk in younger age groups; more common in females in adolescence
-Apathy, anger, sadness, crying, isolation, risky behaviors, suicidal gestures
Tell me about Bipolar Disorder in children/adolescents.
-Difficulty differentiating between ADHD and bipolar disorder in children and adolescents
-Children who exhibit mania are significantly impaired between manic episodes
-Mood instability, impulsive behaviors, hyperactivity
-Approximately 4-6% of adolescents present with core symptoms
-Less likely than adults to experience psychosis; hallucinations more common than delusions if psychosis occurs
Describe Tourette's Disorder.
-Motor and verbal tics causing marked distress and impairment in social & occupational functioning for more than 1 year
-Genetic studies show more than one gene involved
-Inherited developmental disorder of neurotransmission
-Duration may be lifelong; periods of remission; symptoms can resolve
What is the prevalence of Tourette's Disorder?
-Average age of onset between 6 and 7 years
-More prevalent in boys
Describe vocal tics.
Vocal tics: spontaneous production of words and sounds, throat clearing, grunting, repetitive noises
Describe motor tics.
-Motor tics: usually involve the head but can involve the torso and limbs
-Motor tics can change in location, frequency, and severity over time (tongue protrusion, touching, squatting, hopping, skipping, twirling, retracing steps)

-Simple: eye blinking, neck jerking, shoulder shrugging, facial grimacing, and coughing.
What is coprolalia?
Coprolalia: uttering of obscenities; occurs in less than 10% of cases
Describe transient motor tic.
Transient tic disorder: motor and/or verbal tics for at least 2 weeks, but less than 1 year
Describe chronic motor dic.
Chronic tic disorder: either motor or verbal tics for more than 1 year.
Describe complex motor/vocal tics.
-Complex motor and vocal symptoms: hand gestures, jumping, touching, stomping, facial contortions, repeatedly smelling an object, squatting, deep knee bends; sudden expression of single words or phrases, speech blocking, sudden change in pitch, emphasis, or volume of speech, repeating sounds or words, sudden use of inappropriate obscenities or slurs

-Complex: touching, squatting, hopping, skipping, deep knee bends, retracing steps, and twirling when walking.
Describe simple motor/vocal tics.
Simple motor & vocal symptoms: eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing abdominal tensing; grunting, throat clearing, snorting, clicking, chirping, barking
What meds are used for Tourette's Disorder?
Common meds include haloperidol, pimozide, clonidine, guanfacine, atypical antipsychotics.

Adverse reactions are EPS, which can look like Tourette's.
Describe behavioral therapy.
It is based on the concepts of classical conditioning and operant conditioning. Rewards are given for appropriate behaviors and withheld when behaviors are disruptive or otherwise inappropriate.
Tell me about Adjustment Disorders in children/adolescents.
-Emotional responses to an identifiable stressor that do not meet criteria for DSM-IV-TR psychiatric disorders
-Begins within 3 months of the stressor and lasts no longer than 6 months after the stressor has ended
-Impairs school performance and social relationships
-Usually does not require hospitalization
-Symptoms of anxiety, depressed mood (usually because of specific stressor)
What is enuresis?
-Nocturnal: involuntary bed-wetting at least 2x/week for 3 months and at least 5 years of age
-Diurnal (during the day): repeated urination on clothing during waking hours
-Boys more than girls
-Prevalence decreases with age
What is encopresis?
-Child soils clothing with feces or deposits feces in inappropriate places
-4 years of age or older
-Soiling occurs at least once per month and is not the result of a medical disorder
-More common in boys
-1.5% of school-age children
-Most common cause is leakage of stool around a fecal impaction
What is the specific pharmacology for Pervasive Developmental Disorders (PDDs) in children/adolescents?
-atypical antipsychotics to decrease hyperactivity and aggression
What is the specific pharmacology for Autistic Disorders in children/adolescents?
antipsychotics (Haldol), SSRIs
What is the specific pharmacology for ADHD in children/adolescents?
stimulants, non-stimulants, amphetamines
What is the specific pharmacology for conduct disorders in children/adolescents?
Antipsychotics, antidepressants, mood stabilizers
What is the specific pharmacology for panic and social phobias in children/adolescents?
SSRIs, Tofranil
What is the specific pharmacology for OCD in children/adolescents?
SSRIs, Anafranil
What is the specific pharmacology for separation anxiety disorder in children/adolescents?
SSRIs, Tofranil
What is the specific pharmacology for social phobias in children/adolescents?
Social phobia: SSRIs, Tofranil
What is the specific pharmacology for PTSD in children/adolescents?
PTSD: risperidone for control of aggression and flashbacks
What is the specific pharmacology for insomnia in children/adolescents?
Insomnia: Benadryl, Vistaril
What is the specific pharmacology for Major Depressive Disorder and dysthymia (mild depression) in children/adolescents?
MDD and dysthymia: SSRIs
What is the specific pharmacology for psychosis in children/adolescents?
Psychosis: atypical antipsychotics
What is the specific pharmacology for tics in children/adolescents?
Tics: clonidine
What is the specific pharmacology for mania in children/adolescents?
Mania: lithium, anticonvulsants