Mental Health Nursing Chap. 16,18,19

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personality disorder : Diagnosis is made when the person exhibits enduring behavioral patterns that deviate from cultural r expectations in two or more of the following areas:

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cognition
affect
interpersonality function
impulse control

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Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal personality disorders)

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Cluster A:

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Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, and narcissistic personality disorders)

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Cluster B:

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Individuals who appear anxious or fearful (avoidant, dependent, and obsessive-compulsive personality disorders)

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Cluster C:

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Number 1 disorder seen in clinical setting

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borderline

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those with personality
disorders:
criminals
alcoholics
drug abusers

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70-85%
60-70%
70-90%

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is characterized by pervasive mistrust and suspiciousness of others. more common in men

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Paranoid personality disorder

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Clients also may appear guarded or hypervigilant; stand at great distance from nurse

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Paranoid

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use 'projection' ego defense mechanism

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paranoid

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nursing interventons for paranoid

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do not joke with the client-staff be matter-of-fact. Teach client to validate facts before taking action. Involve client is tx plan

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is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings

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Schizoid personality disorder

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Nevertheless, these clients can distinguish
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fantasies from reality, and no disordered or delusional thought processes are evident.

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Schizoid personality disorder

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having no pleasure or joy in life

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anhedonia

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Involved more with things than people.

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Schizoid personality disorder

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Rich fantasy life, but can distiguish fantasies from reality-No disordered or delusional thought processes.

nursing interventions:

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Schizoid personality disorder

improve client's functioning in the community and help get case manager

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may experiece transient pschotic episodes due to extreme stress

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Schizotypal personality disorder

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Have "odd" appearance

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Schizotypal personality disorder

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bizarre speech
more common in men

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Schizotypal personality disorder

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ideas of reference (client believes events have special meaning for him

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Schizotypal personality disorder

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Magical thinking

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Schizotypal personality disorder

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extreme anxiety around people they don't know

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Schizotypal personality disorder

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nursing interventions :develop self-care skills, improve community functioning, and social skills training

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Schizotypal personality disorder

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is characterized by a pervasive pattern of disregard for and violation of the rights of others—and with the central characteristics of deceit and manipulation

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Antisocial personality disorder

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_______________, about 50% are diagnosed with antisocial personality disorder.

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In prison populations

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nursing interventions for antisocial personality disorder:

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limit setting,
confrontation
time-out

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5 times more common in those with a first-degree relative with the dx.
3 times more common in women

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borderline

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most common personalilty disorder in clinical setting

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borderline

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poorly regulated emotions

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borderline

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area of the brain located above the brain stem. disturbances in this system have been implicated in a varety of mental ilnesses such as poorly controlled emotions ad impulses

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limbic system

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dialectical behavior therapy
risk for self-mutilation

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borderline

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clients usually have disturbed relationships with parents at 18-30 months of age.
50% childhood sexual abuse, physical and verbal abuse, parental alcoholism.

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borderline

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impulsive, labile mood, unstable self-imae, unstable relationships, sabotage self, fear of being alone

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borderline

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use transtional objects for comfort and security; teddy bears

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borderline

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Pervasive mood is dysphoric.
Hypersensitive to others' emotions
minor changes may precipitate a severe emotional crisis

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borderline

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rumination, posttraumatic stress disorder common

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borderline

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5 times more common in those with a first-degree relative with the dx.
3 times more common in women

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borderline

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most common personalilty disorder in clinical setting

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borderline

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poorly regulated emotions

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borderline

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area of the brain located above the brain stem. disturbances in this system have been implicated in a varety of mental ilnesses such as poorly controlled emotions ad impulses

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limbic system

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dialectical behavior therapy
risk for self-mutilation

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borderline

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clients usually have disturbed relationships with parents at 18-30 months of age.
50% childhood sexual abuse, physical and verbal abuse, parental alcoholism.

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borderline

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impulsive, labile mood, unstable self-imae, unstable relationships, sabotage self, fear of being alone

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borderline

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use transtional objects for comfort and security; teddy bears

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borderline

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Pervasive mood is dysphoric.
Hypersensitive to others' emotions
minor changes may precipitate a severe emotional crisis

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borderline

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rumination, posttraumatic stress disorder common

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borderline

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complain of difficulty sleeping

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borderline

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nursing interventions for borderline

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promote safety, help control evotions, cognitive restructuring, thought stopping, positive self-talk, decatastrophizing. Minimize unstructured time with a written plan for the client to follow. staff be aware of client using "splitting".

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must be center of attention- will dress inappropriately and fake illess.

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Histronic

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clients seek tx for depression
unexplained physical problems, and difficulties in relationships. excessive emotionality, attention seeking, gregarious(sociable), effusive(unrestrained)

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Histronic

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refer to any relationship as "dear,dear, friend". Use people and will agree with a person to get attention.

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Histronic

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Tx: teach social skills, approacch another person and stand t least 2 feet away, r5% are menoleplay, assertive .comunication statements with "I"

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histrionic

B

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sense of entitlement; the world owes me, I love myself.
Hypersensitive to any critism.

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narcissistic

B

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Need for admiration not just attention. blame others(thought processing intact, but limited insight). Arrogant. Become bored and impatient when others discussing themselves. Tx: set limits, individual psychotherapy works best for them.
50-7

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narcissistic
cluster B

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Tx: teach social skills, approach another person and stand at least 2 feet away, are roleplay, assertive comunication with "I" statements

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histrionic

B

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sense of entitlement; the world owes me, I love myself.
Hypersensitive to any critism.

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narcissistic

B

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Need for admiration not just attention. blame others(thought processing intact, but limited insight). Arrogant. Become bored and impatient when others discussing themselves. Tx: set limits, individual psychotherapy works best for them.
50-75%

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narcissistic
cluster B

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equal in male and females. Hypersensitive to negative evauation. avoid unfamiliar situations and people. very low self-esteem. tx: practice self-affirmations and positive self-talk

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Avoidant

cluster C

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Often youngest child in family Excessive need to be taken care of and excessive fear of separation. can't make decisions, no matter how small. Many tolerate abuse.3 x more common in females than males

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Dependent

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tx: foster autonomy and
self-reliance, teach problem solving and decision making for daily life use.

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Dependent

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usually odest child, 2x more common in males, feel need to be perfect from childhood and punished for expressing emotions or asserting independence.

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obsessive-compulsive personality disorder

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preoccupation with
1. perfectionism
2. interpersonal control
3. orderliness

self-critical
frugal
praise does not change belief

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obsessive-compulsive personality disorder

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tx: attempt to complete work on time, let others work on projects, negotiate with others, take some risks

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obsessive-compulsive personality disorder

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less severe than major depression. equal in males and frmales. can't relax. have no sense of humor, and are pessimistic

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depressive

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tx: be specific with praise and not general

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depressive

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Anger is usually underlying emotion. May appear cooperative and them not do it. Feel misunderstood, and unappreciated.

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Passive-Aggressive

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Want to be the martyr. Manipulative, May adopt sick role. tx: Journal and role-play

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Passive-Aggressive

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personality disorders are mostly treated in

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community based settings

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the biological processes of sensation, association and motivation that underlie the integration of skills and habits based on emotion.

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temperament

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Limit setting is an effective technique that involves three steps:

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1. Stating the behavioral limit (describing the unacceptable behavior)
2. Identifying the consequences if the limit is exceeded
3. Identifying the expected or desired behavior

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The nurse points out a client's problematic behavior while remaining neutral and matter-of-fact; he or she avoids accusing the client. keep clients focused on the topic and in the present. The nurse can focus on the behavior itself rather than on attempts by clients to justify it

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Confrontation

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leaving the area and going to a neutral place to regain internal control is often a helpful strategy. help clients to avoid impulsive reactions and angry outbursts in emotionally charged situations, regain control of emotions, and engage in constructive problem solving

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time-out

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The four temperament traits are

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harm avoidance,
novelty seeking,
reward dependence,
persistence.

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difficulty identifying and expressing feelings

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alexithymia

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lack of clear role boundaries

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enmeshment

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Erosion of dental enamel

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perimyolysis

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The pervasive mood is dysphoric, involving unhappiness, restlessness, and malaise. Clients often report intense loneliness, boredom, frustration, and feeling “empty.”

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Borderline Personality Disorder

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Polarized thinking about self and others (“splitting”)

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Borderline Personality Disorder

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Thinking about self and others is often polarized and extreme, which is sometime referred to as

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splitting.

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Clients tend to adore and idealize other people even after a brief acquaintance but then quickly devalue them if these others do not meet their expectations in some way. Clients have excessive and chronic fears of abandonment even in normal situations; this reflects their intolerance of being alone. They also may engage in obsessive rumination about almost anything, regardless of the issue's relative importance.

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Borderline Personality Disorder

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Clients frequently report behaviors consistent with impaired judgment and lack of care and concern for safety, such as gambling, shoplifting, and reckless driving. They make decisions impulsively based on emotions rather than facts.
Clients have difficulty accepting responsibility for meeting needs outside a relationship. They see life's problems and failures as a result of others' shortcomings. Because others are always to blame, insight is limited. A typical reaction to a problem is “I wouldn't have gotten into this mess if so-and-so had been there.”

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Borderline Personality Disorder

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Unstable relationships, affect, and self-image

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Borderline personality disorder

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Disregard for the rights of others

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Antisocial personality disorder

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Detachment from social relationships, restricted affect

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Schizoid personality disorder

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Social inhibitions, feelings of inadequacy

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Avoidant personality disorder

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When working with a client with a paranoid personality disorder, the nurse would use which of the following approaches?

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Serious

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Which of the following underlying emotions is commonly seen in a passive-aggressive personality disorder?

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Anger

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Cognitive restructuring techniques include all the following except
A. Decatastrophizing
B. Positive self-talk
C. Reframing
D. Relaxation

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D. Relaxation

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Transient psychotic symptoms that occur with borderline personality disorder are most likely treated with

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Antipsychotics

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Clients with a histrionic personality disorder are most likely to benefit from which of the following nursing interventions?

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Teaching social skills

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When interviewing any client with a personality disorder, the nurse would assess for which of the following?

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Disruption in some aspects of his or her life

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The nurse would assess for which of the following characteristics in a client with narcissistic personality disorder?

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Entitlement

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The most important short-term goal for the client who tries to manipulate others would be to

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Acknowledge own behavior

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is a circulatory collapse when a client's completely compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid intake resumes. Implement over at least 7 days
carefully monitor serum elctrolytes and intervene as prescribed.

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Refeeding syndrome

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Metabolic alkalosis from:

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vomiting

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Metabolic acidosis from

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diarrhea

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Night eating syndrome is characterized by .

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morning anorexia, evening hyperphagia (consuming 50% of daily calories after the last evening meal), and nighttime awakenings (at least once a night) to consume snacks

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Because clients with _________ have problems with self-awareness, they often have difficulty identifying and expressing feelings (alexithymia).

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anorexia

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Treating clients with anorexia nervosa with a selective serotonin reuptake inhibitor antidepressant such as fluoxetine (Prozac) may present

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Fluoxetine can cause appetite suppression and weight loss.

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Which of the following is an example of a cognitive-behavioral technique?
A. Distraction
B. Relaxation
C. Self-monitoring
D. Verbalization of emotions

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Self-monitoring

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All but which of the following are initial goals for treating the severely malnourished client with anorexia nervosa?
A. Correction of body image disturbance
B. Correction of electrolyte imbalances
C. Nutritional rehabilitation
D. Weight restoration

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Correction of body image disturbance

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The nurse is evaluating the progress of a client with bulimia. Which of the following behaviors would indicate that the client is making positive progress?

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The client identifies healthy ways of coping with anxiety.

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A teenaged girl is being evaluated for an eating disorder. Which of the following would suggest anorexia nervosa?

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Unrealistic perception of body size

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A client with bulimia is learning to use the technique of self-monitoring. Which of the following interventions by the nurse would be most beneficial for this client?
A.

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Ask the client to write about all feelings and experiences related to food.

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Client puts on a pleasant and cheerful face for others.

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Bulimia

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Client spends the majority of time thinking about food and food-related activities.

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both

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Client believes if she starts eating, she will not be able to stop.

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both

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Client believes there is no problem with her dieting behavior.

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Anorexia

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Client is guilty and ashamed about her eating behavior

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Bulimia

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Identify four compensatory behaviors that clients with bulimia use to avoid weight gain.

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1. Self-induced vomiting; fasting;
use of laxatives, diuretics,
enemas;
excessive exercise

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The three central features of somatoform disorders are as follows:

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Physical complaints suggest major medical illness but have no demonstrable organic basis.
Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms.
Symptoms or magnified health concerns are not under the client's conscious control (Hollifield, 2005).

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is defined as the transference of mental experiences and states into bodily symptoms.

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Somatization

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The five specific somatoform disorders are as follows

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Somatization disorder, Conversion disorder,
Pain disorder
Hypochondriasis
Body dysmorphic disorder

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is characterized by multiple physical symptoms. It begins by 30 years of age, extends over several years, and includes a combination of pain and gastrointestinal, sexual, and pseudoneurologic symptoms.

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Somatization disorder

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involves unexplained, usually sudden deficits in sensory or motor function (e.g., blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. An attitude of la belle indifférence, a seeming lack of concern or distress, is a key feature.

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Conversion disorder, sometimes called conversion reaction,

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has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance.

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Pain disorder

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is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions.

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Hypochondriasis

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is preoccupation with an imagined or exaggerated defect in physical appearance such as thinking one's nose is too large or teeth are crooked and unattractive.

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Body dysmorphic disorder

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la belle indifférence, a seeming lack of concern or distress,

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can happen as early as 10 years old

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Body dysmorphic disorder

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usually around 25 yeas old

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All the somatoform disorders are either

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chronic or recurrent, lasting for decades for many people.

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is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs

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Malingering

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People who _________ have no real physical symptoms or grossly exaggerate relatively minor symptoms. Their purpose is some external incentive or outcome that they view as important and results directly from the illness

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malinger

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occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention.

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Factitious disorder

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The common term for factitious disorder is .

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Munchausen syndrome

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occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a “hero” for saving the victim

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Munchausen syndrome by proxy,

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are the direct external benefits that being sick provides, such as relief of anxiety, conflict, or distress.

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Primary gains

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are the internal or personal benefits received from others because one is sick, such as attention from family members and comfort measures

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Secondary gains

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Which of the following statements would indicate that teaching about somatization disorder has been effective?
A. “The doctor believes I am faking my symptoms.”
B. “If I try harder to control my symptoms, I will feel better.”
C. “I will feel better when I begin handling stress more effectively.”
D. “Nothing will help me feel better physically

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“I will feel better when I begin handling stress more effectively.”

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Paroxetine (Paxil) has been prescribed for a client with a somatoform disorder. The nurse instructs the client to watch for

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Nausea

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Emotion-focused coping strategies are designed to accomplish which of the following outcomes?
A. Helping the client manage difficult situations more effectively
B. Helping the client manage the intensity of symptoms
C. Teaching the client the relationship between stress and physical symptoms
D. Relieving the client's physical symptoms

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Helping the client manage the intensity of symptoms

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Which of the following is true about clients with hypochondriasis?
A. They may interpret normal body sensations as signs of disease.
B. They often exaggerate or fabricate physical symptoms for attention.
C. They do not show signs of distress about their physical symptoms.
D. All the above are true statements.

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They may interpret normal body sensations as signs of disease.

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A client with somatization disorder has been attending group therapy. Which of the following statements indicates that therapy is having a positive outcome for this client?
A. “I feel better physically just from getting a chance to talk.”
B. “I haven't said much, but I get a lot from listening to others.”
C. “I shouldn't complain too much; my problems aren't as bad as others.”
D. “The other people in this group have emotional problems

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“I feel better physically just from getting a chance to talk.”

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A client who developed numbness in the right hand could not play the piano at a scheduled recital. The consequence of the symptom, not having to perform, is best described as
A. Emotion-focused coping
B. Phobia
C. Primary gain
D. Secondary gain

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Primary gain

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The nurse is caring for a client with a conversion disorder. Which of the following assessments will the nurse expect to see?
A. Extreme distress over the physical symptom
B. Indifference about the physical symptom
C. Labile mood
D. Multiple physical complaints

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Indifference about the physical symptom

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Multiple physical symptoms including pain and gastrointestinal, sexual, and pseudoneurologic symptoms

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Somatization disorder

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Sudden, unexplained deficits in sensory or motor function

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Conversion disorder

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is the indifference about physical symptoms seen in clients with a conversion disorder.
Example:
A man who is paralyzed and cannot walk is cheerful and seems unconcerned about the paralysis

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La belle indifference

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is a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory.

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Dissociation

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The client cannot remember important personal information (usually of a traumatic or stressful nature).

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Dissociative amnesia:

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The client has episodes of suddenly leaving the home or place of work without any explanation, traveling to another city, and being unable to remember his or her past or identity. He or she may assume a new identity

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Dissociative fugue:

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(formerly multiple personality disorder): The client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. This is accompanied by the inability to recall important personal information.

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Dissociative identity disorder

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: The client has a persistent or recurrent feeling of being detached from his or her mental processes or body. This is accompanied by intact reality testing; that is, the client is not psychotic or out of touch with reality.

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Depersonalization disorder