Mental Health Chapter 9

5. A n infant* born with a d& plate. I ? & nursing 8-tegy wodd be mst important to fBe parents' sucewM mping? e the parer o hold and G i i supPmt-af cume the infar 0 3, kplain to the p~reptshaw cleft palam dmelop d-g

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Brie answer the full1-Name four 4ttew~sof pregnanc~rthat the teenap must

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2. Name tbree actiom essential to the bon-

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Moralistic nonnal is an ideal It concerns setting and a goals that may be expected by soaety or by the person. h d ~ d become conhtioned to a specific ided. For example, they may ually tell themselves they are not allowed to become initable an remain calm at all times.Setting unrealistic or hpossible goals unnecessary sstress. behavior is practiced by the majority of people, it is statisncally There are many misconceptions concerning the word 4. To many people, the wordmeans weird or bizarre. Some p expect to see a sharp difference between normal and a b n o m there are many variations between the two.The disturbed person

Psychiatry categorizes patems of behavior. The nurse must izethat clients do not fit neatly into these categories because their terns of behavior are i n W d reactions to stress. A diagnosis in ehiatry is not as clearly defined as a physical diagnosis. The n should be fully aware that the client does not necessarily conform set standard of diagnosed behavior.

tions, end increased respirhtiuns. Ifthe anxi* is ievcre or proi~nged thcsc symptoms intensify and ihc person may need to be hospitalid Antianxiety mcdicatinn may bc given Zhhle 9-1).

PSYCHOLO~ICALDISORDERS major or minor attack, with anticipatory anxiety or situational panic. Sudden anxiety attadcs occur witb little or no provocation. Some anxiety episode o m when a person anticipates facing a fearful situation

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tional fear ofbeing in open spaav ;e.g..shopping malls and spurts arenas!. Symptoms of panic include diKiculty b m t h i..i rapid andlor -:w . * ,m , tk) pain, &@&m--,.seaa* &&-

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&ma& and so l& mnuoI ovw their beha%or. Common psyddapic@dbordd@ am BBI Psmif &disorder

PI W e t y disorder

B Phobic diwder

Maladapttve Behav~ors 2@1

TRADE

GENERIC

I

When a phobia is limited the person can live a reasonably comfortable life simply by avoiding the object of fear. HOW-, phobias often spread to include assodated objects. When this happens, it m y be ditfidt or impossible to keep the phobia &om intafering with daily !.it@, One treatment often used to help people overcome phob i i is desensibtim Phobias include exaggerated fears of death snakes, dogs, open spaees, wnhnement, or heights. Table 9-2 lists some common phobias.

Obsessive-Compulsive Disorder Although different in meaning, obsession and compulsion aften occur togethm An obsession is a p d t e n t , recurring thought or fe&ng that is overpowering.A COcomgtIlSi~nis an irresistible urge to engage in a behavior. CompWion may be in the form of frecpent handwashing or shoplifting. Whatever the compulsion may be, it has a symbolic meaning. The behavior is engaged in because it lowers a r y d q . When the anxiety I d builda up, tbe obsessive-compulsive act is performed again This process is cyclic and may occupy the person's entire life It is not unusual for a person to experience murrent thoughts periodically or to engage in ritualistic behaviors (handwashing, counting and recounting eheclciqg and rechddngl. However, in the person with an obsessive-compulsivedisorder, these thoughts and ritualistic actions interfere with daily Mug. The person is unable to controI his

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Maladaptive Behaviors

Chapter 9 or her thoughts and actiom even though the person k n m they are irratondj however irrational, they release pent-up anxiety and tension. Obsessivecompulsive behavior is often caused by repressed &oughts and feeltngs. It is an attempt to relieve anxiety and is another example of converting anxiety into other symptoms.

ment disorder of mixed disturbance of mood and conduc~The dlient appears wonied and upset about an event that occurmi in the past thtee months and describes trouble handkg the SRSSOTS. Usually, there is no personal or family history uf mood disorders, although a pmo* disorder needs to be ruled om

somatoform DiSOrder

MOOD/AFFRCTIVe DISORDERS

Somatoform disorders are dmaaerized by a loss or an alteration of physical functionbg that has no physical basis. It is thought the physical impairment is caused by a psycholopical conflict or need of the peaon. However, & must be remembered thatthe symptoms are very A - t h e oerson aoes not have conscious control over them. Somatoh- disorders are divided into s d sub?hro common subtypes are conversion &or& and hypochondtiasis.

As the name may suggest affectivedisorders deal with emotions and

conversion Disorder 43nwmion disordet was fonnerly know as hpterid n e w a h In ronwneion &order, the person mnverts his or her overwhelmtng anxiety into physical symptoms. This is an unconscious response The person may experience paralysis of an exwemi@*blindness, de&~ess,or numbness. The aisabfityhas no physical basis fndividuals usually complain about their pain and discomfo~but are calm and irdifbmt about their symptoms. The physical symptom is symbd-cof the unresolved anxiety produring the conflict The symptoms enable people to avoid actions tJ& are unacceptable Mthem. They also enable people to get attention and support fromothers that t h m g h t notget otbautise.

Hypochondriasis is an abnormaI anxiety about me's health. This disorder was formerly known as hypochonatiacal mum&. People with hypoeho~&%~is are preoccupied with their bodies and Their imaginary illnesses.They have unrealistic feats or beliefs fhar they are ill despitemedid assurance that this is not so. Such people ha* dB?culty establishq meanine;ful relationships with others since much of their time and energy is spent worrying about themselves. Hypochondriasis can affect both social and occupational funatoning.

Hypoohon-

Adlustment Disorder Maladaptive copin$ to a We event that is s@essfdis an adjustmmt h* order. The DSM IV-TR lists several subtypes; the most commonly seen are adjustment disorder with anxiety anam d e g m and adjust-

mood Included in this category are: B Major Depressive Disorder (MDD) dysthwa Bipolar Disorder cydothymia The National InsMute of Mental Health l N I ' estimates that 36 million Americans are depmsed at some time in their k. Depressionis a major public health problem Research is indicating a corollary between depression and brain biochemicals (ie, norepinephrine and serotonin deficiaql. There is a pmblem with the mmissions ofneurotransmitters m s s a brain synapse. Litemam puinta to depression being bMogically determined and influenced by muhiple situational fhors. Researchers are gath* data on seasonal affective &order [SAD), whereby anindividual is depressed in winter when there is hght available

Major Dspresshfe Disorder [MDD) Wi major depression the symptoms have been present for a two week period and q m e n t a change from m o w functioning. Dep~essedm o d and anhedo* (a loss of intwmt or pleasure] are present most of the day. Subjectively, the client reports feehg sad or empty or is o b s d by othm to be sad or tatrfdOther symptoms indude s w c a n t weight loss, insomnisk hypersotnnh psychomotm agitation, or retardation. Clients endorse feelings of worthlessness, excessive g3t and &minished ab'jty to think;they often have recurrent thoughts of death or suicide Depression over time that is chronic Bnd recurrent can manifest as psychosis, which is an inability to re* ogrrize reality and Communic~teor relate to othas. Eldezlypersons,o h expaience depression. The elderly person's eelfperceptianmaybecame distorted andhe or she may feel worthless and ashamed A in selfmngdenceand loss ofself-esteemmay o w A ne&ktWS@SnCept results ininitab*, apathy, and a lalack

Maladaptive fieliav~c~~s

of hmor. Activives of daily hvtng become a problem, and hair and &thing may appear disheveled, Mmemenf5 are slow, posture is smoped, the bray is h w e d , and sp& maybe kcpent in the depresed ddmk pemn, tbm is an intense preocapation with heslth, Coniplaints ofvague acbes aBti pains, c0nStipationtand anorexia are e o m m The severely depressed w bemme @sted and appear to€@ mberabk.

oysthymlc DlsOrdeK The pemn experiencing a dysthpic dbordw has a prolonged feeling of .%Beme sadnw that is ammpanied by guilt feelingsI self-f-deprcmtion,and SOW withdrawal. The &order is usually associated with a 10% such as loss of a Imed one, possessto& ar s e l f -Tne pmon feels rejected. helpless, and wrthless. He or she is wedshe and disinterested in the surroundings and unable to "p"ience pleasme in life. He or she ha6 a low energy level and is always tired The person may either be unable to sleep or mQ' sleep mceh;sive.lyTbe depressed person dwells on &e negative aspects of Me, whjch otdy add to his or herfeekg8 &&pleasured @ t He or she may cry oftea and wiIy and may have serious tho%& of sui& A dysthymic or depressive disorder o k &ts horn p q l e feeling 0) that they ham no mm1 over th& lives, [.2J l t they @e ti$Iureeg bemuse 'they have been unable to attain desired goals, or (31 i n t d anger. Critical periods in the Mb ycle when a d@&Jrmic disorder is more W y to ocnu are adolesmoe, menopaw, and old age. D&g adolescencq depmion must be &@erea?iated&.omtemporary stam of sadness. AdoleseenB are .su$ject to emotional ups md downs. However, when a lack of feelings or a sense of' emptiness b e m e s s dominant mood, this is wmidered ac-d or depmsive &order, The adolescem with a dysthNc disorder is unable m dealwith or express his or her feehgs. Bm&m and resfl~$snesSran d t Darg use and unwanted risk-taking can be symptom af hidden depression. as D u k g menopauser women must cope wi& pb@d the aging proeess oan-6. Menopause may have pkpical symptoms such as hot and cold %sheI p w e headaches, h- palpitiom* imomni&and wsrsbtent fatime Some of these symptom am cawd byzhe changededbomonaf~%ce between estrogea and progesterone. Depression can be caused by by percdwd loss of womanhood and chiidabilities. Women are not the onlp people who must mhtend with the & x t ~of tncnopause. Me11miy &<;experience menopausal changes, which accompany the normal dirnirlution of sexual activity that ocnlrs nith advandng age They may reduce their social interadion at-this

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time and become preoccupied with feelings of ft

Theymay com-

municate depression via facial expressions of sadness Qrnegatiae verbal renmks. Daily stressom encountered on the job may bave an ]Increasinglynegative impact on their outlooks. The effects of the aging prodess on men m y also become cause for heightened coneern. Social isolation and boredom may be symptoms of a dysthymic +disorde~ The inmvidual has a facial expression of sadnw, a blunted or :flat affectand decreased verbal communication W~th lessened e n w 1& and migratoly aches and pains, they frequenay withdraw kom a&% With soclal imeractions mluced, feelings of guilt and sadness prevail. Some peopIe experience agitatian and restlessness that result In pacing the floor and wringing the hands.The menopausal persm Who feels meless and less attractive turns feelings of refection inward. These feebgs of self-auger and destmction can make a person with a eerious dystlgmic disorder a real suicide ri& Any indieations of suieidal hughts should be dealt with. (See Cha$er M ViDlence and Diswed Behvior.) Some antidepressant medicanom are listed in Table 9-3. The selective serotonin reuptake inhibitors (SSRI) subdue h y p e m a 4 symptoms, decrease avoidance symptom, and decrease emotional rtysconrtul symptoms: mger, hostility, and irritability. kamplw of SSItIs include fiuoxetine (Prozacl),m a h e (Zoloft3, and paroxetine ipaxil]. The side &&s to be monitored are irritability, insomnia, and sehlre3.

TRADE

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Maladaptive Behaviors h g stop-start syndzome dam not usntpibute to medication &availvail ability and, thd5m good medication effects. Research is r&eting h t medieatiena need to be taken a qiuimum of ninety days f a eEeaq and ph;rps men six month3 befom they a , t ~heticid,

Bipolar Disorders (BPD)

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Bipolar mood disorders are complm Emexchhers me laoat triochemicals lie,melatonin, phmylethlymine.) that intI~encebrain tio~ k d&deney of dopamme and s~~ translllttqs hbas been discomd in mania Internal b i ~ rh- l ~ i&mdian) ~ are be* caref3Uy olmme4 Qther studies m fhcaaea on the &Tea oflig6t on mood patterns. It hw ken beenund fhat peapla with mood disbrdm ma/ haw ab~lomLalthyroid Studies bjh~dirrg,T3, T4, and TSE Electroencephalograms @'EOsl mayfndicate a piof a m@ek or par2i;ll &&are, Itl Q$and U.%E% EYA mkm faF hip* disorder were located on chmmxrsome 2, fhwinaeasing our knowlem of the role of genetics B.ipdat=disordm d d witb m o d s of ektion and depmed01~.They are subegped w bipolar disorder, manic bipolar diso r d e ~depmsed: and bipolar dia~rilw,mizced. Litbbn and anemn-.-.-vul&ub are mood-scabilikng medimw11~ f i q m t l y gigi\.enfor &oh disordw Crable 9.41. &.w dphase, wd* qpww and e&mB are hppepa?liqp %pea* php3&%.me&e, and aotion&yj Thgr g,e~erallyf&they m.tow hwyto &te lime on eating sfeepq] The% thought proeases magbe so rapidd&t they arf, dir8icut,to low; This is d e d &fightrrfi&gsttW~ people are hitm and Their m ~ d & inay ~ &m .eupb~&G ,&&tion m,4have @ei~ptimisri~ perhaps d & d q I dm:&&& p m , . T h q d&n. meddle in the &airs df orhe@w&are troeial ~~0~ Their r.w on@,&@,loudness, aa;l d p & & ploys only increase fh@ sam ~ve.rload The- depressed p h e is .&axaste&sd by moderaw s m % d q r w o n'I% 1-1 of dep-n f l u a t e s]eontaneoUsIy b u g h o u t the dar Thw &mfs are high suicide even though &~~L%C a pJ B p m rci be -mIrnderafe Du&g rke depression sage, f h indiddual'$ ~ @~ezii%inw & behaviop are h y p a a ; PaeIlllggc &oughts, &@ I , $t@& a f e a b n d p d e m e d He or she c o m p b Of being &@@y hctions slew, so an.and !cons'tigatiinm . . ,and actions .a& b c eoaC,a @@&Q :& an.d b&Je * d b % $ ~ ~ i $ ; ~~ ~~ I ~; ~~ ~ f m m m t h e : h Be an&.

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A cyclothymic disorder is a mild form of bipok disorder. If the person is not treated, the disorder canbecome more serious. rRADE

I

GENERIC

oissociative Disorders Dissociative disorders were former1y ~lassifiedas hysterical neuroses. This disorder is characterized by changes in mnsciousness and identity: Psychogenic amnesia p~ychogeni~fugue, multiple personality, and depersomhation disorder are included in this category.

Psychogenic Amnesia. Theperson with psychogenic amnaia has a sudden 105s Of memory regarding importam personal infontion that is too extensive 'to be considered ordinary forgetfulness. There is no damage to the nervous system, Psychogenic amnesk usuallg follows a stressfid went and is thought to be a way of escaping conftiw and relievhg overwhelming tension.

Psychogenic Fugue. Psychogenic m e involves suddw d u n e x pected travel amy from home or work with Ue inability ta remeaber the past The person experiencing p s y c h ~ g d cfugue mumes a new identity, Pugue o h oc(:~fs ,followings'were s m s . Usually it lasts for several h0.G tu several days and involves only limited travel In some rare eases,h m , it may last for many man& and involve traveL The recovery israpid and recurrences do not mually ocnn. This disorder is more common after a n a t d disster or during &me. No damage to the nervous system is involved Newer MedidbnS

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m a d s of depre~$i~ri and &tion w elationnsfee,the pmon is warm and Wdl% I)um the 6 e ~ f e s s ~ 0 ~ stage the emonj&ats himselfor herself d vdthdrW fromsgd actiaiQ me person may apeilmoe n o d mods between: mi

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Dissociative Identity Disorder. DissohWe identiv (formerly d e d multiple personality disarderl refeps m the existence of two or more &tin& personalities within the same in&dual. Each of these personarities is d~minantat a partkuh time. The p o n & t y that is $ominant determines the behavior of the individd &&pasondi@is complex and has its own h M o r p a t t w . The secondrvy personalities are usually quire opposite to the oliginal personality.The original personality is not aware of the other personalities, although ?he seandary persgn.&ies are often M y aware of the thoqhts and acrions ofthe original personality. Transition &om one persoM9 to another is sudden and usually f~IIowstress. This disorder is -meDePersonalkation Disorder. Depers-tion disorder fnwlvesa change in the p&sOn's perception of himself or herself:A sense ofthe person's o m reality is People are cut 05from a e W om awareness. They feel disa9r;odated ~ I I their I minds and bodies and my

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*Y Cop% ~ f%8i hemdual a peW10@ F a is a dqer* that d b fm ~ n m eN-, my how-, fxz*dd needs er or f&e &*co*d, denfs W w -PIainw help. he. a-0 should =ever k n y -is ~ w Y S the best 'Ourre sh& be -@&& 1 e p t e . The -~on should be [email protected] ride oat* dlfonaatioa A m&& po~sibiIityofpbyhd jllaesS Nw care ofthe ~sy&~1op;iral Clierrt F o W an. a @ol~@sal di~orderis often m& ierJI; paon d& ! I m 3 e.4psycho-" cljenm oibn fed the uni't, psydh~be;iddim* need to 2~ tarion flh q fiem ~n fhek@SSsindl

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order to meet a need of their o m Remember, manipulation can be viewed aS a positive or negative action Individuh who engage in manipulation fW&Iendyevoke anger in others, yet theu behavior is a form of guarding a very fragile self by attempting to control others. Therefore our goal is to strengthen itlditidua~~,' inner, personal coI1tro~. staffmust approach clients with a firm,consistent id ~ acting in a ludgmend way toward chents; rather, recognize your om feelin@ of ~esenbnentOur goal is directed toward maintaining the seEesteem of our clients. Begh by stating dearly Your own expectations of the client at an i n t e n l i s ~ p h ameeting ~ where everyone should on one planned approach. with the client if there is a reason for this behavior and then state clealy why the behavior is unaaeptable Clearly state the team's expectation. OEer alteroativa by stating choices or options (eitherlor statements). By having choices, the client will begin to fee1more in control and will learn h m to choose a]t-tives that work positively for him or her. The staffmustpra* attentive&tenfng [what 3 this chmt really trying to say?).Help the client verbalfze or her feelings in a more appropriate way. Be alert fork e w e d m e w and refocus clients when they become distracted. Remember that you are working together to achieve a change in behavior. Freguently a writyea contract works best A. contract clearly states the m u m y agreed upon expectations and the tyay to arrive at this god Look at the clienfs strengths, resources, arid energy for change Maybe the client is m t l y in just a survivdpattem that wil~ need to be addressed We want fo make reasonable requests SO &t the client be held accountable, and we want s m d success expeemc~so that we can give the client positive feedback Areas to consider w h Mmg a contract are personal safe@,amount of sleep and rest food intakepstructured m e , aetiviaes of d a ~ living, y probl-o]hg techand the client's level of sacid hteradon. The bipolar clients concentration is lessened, and he or she is Q s u ~distracted and provoked. Sodd activities must be p h e d this in m d Exerdse can be advantageous, but competitive acmtie

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Maladaptive Behaviors

clients have been WelI-bahve&pd&pist youths wko restrleted their p w n a l s-f and did not v W y cotnmunicatte.A s&a&6ehg at6tude prevails. InitiaUpeatisg dim&%& clientsmwt be close ly evaluated Do thy need a hospltll sdmlssionto s a b h them met*? bolick@? Will dose observationwith a b&dv2mal approach be bendcial? Coople or family therapy can be [email protected] appear pmgres4 wi& group therapy Cornunity education pmgram5 am a necessity in a time when eating &dram are of epidemic pmp0rrioIL

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Bne ofthe most important factom in a s c h h p b n i c disorda-is loss of&-esteem. This may be manifested in.9yd-den and violent outbursts. It m y result in dissoaation or an exaggerated mnsem mer bo* hcriam and appmance. Dismbznces in tbhkhg may range from a h %of claatji in the personb ideas to t& incoherence. His or her thorufkts are illogically cmaecte& so t h v are di86cult m understand The person may m l e words SO they make no s a e i W is &word salad. He Ox she may make up words to a p e s 8 confused tltou&ts; tlwe arr cded neologbrm Echolalia is the purposeless isep&tion ofa ward ox phmrse, C-haxar3erktics of f h n i a indude dekxziam, tiansI dbturbed thought pm%es.9es, and peculiar hehador. Delusions are f&e id- rhet eannot be chwged by logid argument Delusions a?e often aSsoQiated d t h hllua-. They may occur in any type of psg.c$otic m a i o n Delusional ideas may be in the form of guil.? or perseatian. Clients may feel that they have anmitted grave sins or tbey m y exaggerate a d e e d . Ptwple wih delusions of persecution belime fhat an argankd g r a q htmds to harm them.They !nay perm i all happenings inrelation m t h e delusion,nsing eaentuxdated events as proof of* delusion. Persons with s&impBr~& m y &Q have deImfon8 of grandew:, be&€hafThey have great power. Thw may see t,bawdva as Napoleon or @us Ghfist Halfa@h€ionsare pmeptiom that OWE in the &ma gf stlmd and have no bash in Ilreyinelude hmhg nonexistent VOW [audiforp],ha&pision$ [oimd),~mdkt~g (01.kctor3g or t w w thjngs e;uStatbryl, or having 4 senwtion of being tcluehed (%Me). C0nmzm.d haUui3n.at?om taa be very ~~g fox fhs: client and may cpmmand the client to do somethin$ dangerous to seX or othe%s, hinpmtant part of-dw dbtwbance of &en@with srhizophrenia is their pmgfessive uiM.ragval 'They s&Wte faztasy fof real life, Their actionsmay seem hqpmp14atetatlie sitnation beisuse %ey beincm&n&indifferent to their outside mvbonment a d feel alienared and isolated In an acute m e t af schizophrenia, them fs' usually normdIU a normal hdin fuactioning, rhe absenee ofnegah symptom Cable 9%), and (i good response to anfipsyihofic mdicatiom. With a film onset, there are enlarged anal ventricles, praminmtneg&?e s$mp and a poor mpgnse to antipychoticp,. m o t i c n'iedi8.W possw many side &mts that need to be 856es9d by the nursing staffand repurred to the pWt ITab1e 9-6).A 8erlous, Wrewsible side effect & tardfve rfy~kine &a ITD). 'RJ detect TD at is e d & st-, an inwIun*ly mamnent s d %W&fsl needs to @me ai a -lum of w r y six

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D~PQ'NEU~CILBPTI~% Haldol demnoate halopesidoi decanoate Prolixln decanoate fluphenai.[nedecanoate Depot neuroieptlcsare Ueslgned fofindigduals who need anfTpsychotlc medlcatlon yet have dim~ultyremembering totake it o,r paranoid ideation. Medication is Wealoh form atid u$uallvgiven;eQ@y W o w e m For P r o l i n decanoateand every four WeeKs for Haldol #@%noate. impaired self-care, BIrarre behaviors. Poor

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Elimination or signfircant redudtion of hai~u~inabans, delusions, anxiety, and troubleso.me thou$htS, feelines; and behaviors retentlon matiies.la;sg~irming,.restlessness, fdgegng, A,. agmubn %dive civbnesia: SueHng movement9, invoiuntan/ chewing, tonaud ProtFusron; this i s m e n Rreversibie Do net use atcohol Avoid prolonged exposure to sun; if outside, use a sunscreen,wlth PABA-the. htgher the number, ti% greater the protection. '.', ,

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-. . ATYPICAL ANTIPSYCHOTICS , : ;. Clozaril Icl~zauinel typical antiusychotlcs that %'b la^ RiSPerdai Irisperidone) dopamlne and serotonin-hlpeanntagonlsts ZJ)..: zvprexa (olanzapine)

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Maladaptive Behaviors 2&7~

2 s Chapter9

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by othm This is offen accompanied by musde twitching. EEchopr&a involves imitathg the motions of others. CLIENT ACTION

STAFF OBSERVATION

paranold Wpe.

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Clients uvith paranoid schizophrenia are suspicious, aggressive, and hostile. They sufFer fiom mrspidon and jealousy, and delusions of grandeur and persecution, EIalludnations are wmmon. Clients often hear voices commandmg them. They may become ~ombativeFor eatample, they may break the teI&ion set bemuse they believe it is *s them bad messages or perhaps reading theirmind At the begin&& other symptoms maybe difficult todetect As the condirton propses, behaviorbecomes more inappropriate and unpredictable. Since their debions are o h bizme, they can be dangerous.

Undtfferentiated m e . Undifferenfiated achkopbrenia is diagnosed when the symptoms do not fit in ather categaria for s&o phreda. Symptom may indude delusions, hanudaatiom incoherence, and grossly disdrganked Behavior.

Psychosis, NOS (Not Otherwise Specified)

Disorganized Type. This eatwry was formerly classified aq heb~phrenics-hrmh The disorganhd schimphrenic &hi&, ti-equentlly at mqtbhg# inappmpriate behaviac smiling and or nothing at all. There are gross fhoughi b b a n m , including rhe

use of mrd salad and neologisms. Ddusiom and hallucinations mE w m n , as is extreme social WithdrawaL Catatolllc m e . The mtatonicperson's behamor varied, but thee %% mually an a w e onset Behavior m y taketheform of stupox ar excite ment In mratonic stupor, the &ent is immobile, mate, and negativa

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There is no interest in the envimment; thb apathy complerely cuts, the dient oEfrom outside stimuli. He or she may -in in one position with wry rigid musdw ur possess flexibility fa wDditi~n in which a hmb remains in one po&ion, even a veqy uacomfdke one, for a period of time). Catatonic people &bit mpredictable behrsvior because their behavior is con'tmkd by their delusions end hallucinations. h ' p ~ r may & q e zapidly and unexpectedly to excitement At these tlmes~ t h q are extremely rentless and may become violent The aenT Mth catatonic sdakmphrenia &bib two p e d h m n n e d s t n s - e c ~ ~ and echopraria. Echolalia is an inwohntmyrepetition ~fwor& qokefl

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A deterioration in Etlnctioning and a lack of recopition of reality is termed psydzdtasis. Usually, psychosis, NOS is abriefpychotic &order of no longer than one month. A serious stressor m q or may not be present Note whether delusions or hallucinations (specify auditoq, visual, oIEactaiy, or tadel are present and specify a general medid condition that may be present if the psychasis is substance-induced, specify the substance that was used and whether the client is intoxicated or in withdrawal,

PARANOLD DISORDER Clients with a paranoid disorder, like the & atwith schizophrenk suffmm perSistent delusions. These delusions rrrz generally delusions of jealousy, pementtioa or sometimes grandem The paranoid client does not have hallucinations but possesrtes a heightened suspiciousness that may progress to pspchosis. The client is fw6.l and guarded and ases the defense mechanism of projection, Clients with paranoid disorder usually da not show disoxganization dtheirpersonalities, other than the delusions. Their actions seem to be appropriate to their delusionaryaperknces.There is seldom furtheh deterioration in their personaIity; They speak and act rationally and are well oriented to time and place. They may be able to eany on a prodaniw oeeupanan even when their condition is well developed. However, social wd m a l functioning are usually adversely affected. fbr

A

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7

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Maladaptive Behaviors

ChaNer 9

a g s of anger and resentment are m ~ o with n a paranoid strike out in s d &inbr: dmgp~ou6as t h q di9order. These &'knse. Bkme deteriofatio~or incoberens 3s mf seen in these &eats. Nursing care W.ossing pm &r the t h e t suffkhg &mi a g & i m p M e or p"anoid

disorder mu* be based on an as6essment of behavior and pmblem~ b e a u s the% &eats b v e an indMdWed arrap o E ~ @ @ o m ~ . with & p W a have a ofisohtian m-edby fear of &&a fas or her behavior refleets a la& of s&c~n4iden~e. Tfie nurse needs to demo-ate a hopeful attitude c g m gf a*@ ;m,,sewdty, and ca&enoe. Avoiding the elient o m n&fcms his or her fedin@&ow selfThe u r n shodd obThe &ent w i d schiz0phrmh b r any $pedaliamests.InvolVhg him or ba: in a v&&y ofactfvities saoh as checke~s,tad $ames, a& ts,hobWies Can be a method ofstipxnlating the senses. &mine pr@e rainfreinforce mfidenee. It may be tLrmpmtiet~ the env2ronmmt b&io$ autdabrs or taking a ride inihe wuntty. For a client wKh a paranoid ttimde~+ a fldble but coBsistent appma* should be m a i a M at oill tima. 'Izlis c l i d s in &ers mu& be ~ e It isimportant h for the ~ nurse ta be aware of , his or &P ownb a v i o c W p e t i n g or pointing when in the &&SF , e n w m t must be amkbd. P r o w questiom may pmwke p~@noid beh&w The parillraid elient reqDira G&X soothhg voice tan&

at alL =&ma. m e num's gaalis to provide support d S~JW~XES &the &e~& in order to d e w s his or h a &ety and d e m ~ t i o fAl fism, cp-t emiron~~entwriII ffidlitat~the client* reroeery fmrn a st&$ of inner d i s o ~ ~ t i a p In peparaton f9I a rera~nto the W y and their C O ~ I with s&impMa m d ra be educated abmi the uYariltnp, sylnptoms of a rekpse of tire disease. A @pof-*e c h e ~ d d be ben&dal for clienm and their families and muId be an exc&%t m@d ofeda-n as p@i of discharge p l w W m signs & & p e include a lass ofWb%in doing eatin$,and to aetivtties 9f daily k i n g trouble m c m @ aor~ str* &st tho@ts; increased imubJe wtth decision amkW p w with religion; fear of' othm YLdg thw m that otbm with their minds; increased W t a b W over W e tbi~@? h ~ o r k m l ~ s ~ a n d a n ~ ~ l n s e war&$ & p s id&xxteWt a relapse ma^ m a d s to seak pmkwianal help fnasreme p

w,

... . ._

the client needs to go to the emergency mom of their hospitaL Each client needs an emergency plan. for sevae relapse HiIdegardeP @ L U 1l962)stated that to heIp clients is to rememb a and n n d m d fitllgwhatis happening to them in the present situation You want to assist clients m integrating this with other experperiences in their lives. Avofd isolating the experience because that will only increase thought fragmentation. Assist clients to recognize maladaptive behavior and its eauses, motives, and consequences. Assmt clients to look for alternate choices for their behavior and inmease their constructive productive &styIe. The n m e is building trust and nurturing the client, which is called a corrective emotional experience.

PEiRSaNALITY DISORDER Personality can be defined as an individual's character traits, attitudes, thoughts, behaviors, and habits. It encompasses the individual's behavioral and emotional tendencies. It aIso &olw the individual's adaptation to internal and exrernal problems, Persnnality disorders are maladaptive patems of seeing, rrlatlng to, and thinking about the endronment and relatiomhips with othem, 5 i n e the patterns am inflexible and deeply ingrained, there is impairment in adaptive functhirg. Disturbances in emotional development and e m r i m are seen There is amalaqiustment to the social epvironment Some personality disorders are -dated with changes in the normal lwek of nemommsmitters The American Psychtmic Associarian's Diagnostic and S W d d Munud CExt Revision) DSM-W-TR) M Several subdivisions under the Category of Personal@ Disorders. W e subdivisions and charactaieties are shavn in TabIe 9-8.Person* disorders ean begin in chidhood but ~lsuallyare ?mnihted at adOIes~enee,and interfere with social or mle funqkming.men, persons with personality disorders do not seek mental health care.

Nursing Care People with personality dtsorden are very diBcnlt to deal with, and treatment mamag be ineifetiv~In caring for b e clients, the n m e should be able fnhmdle the htxatiom caused by their behavi01: He or she also slxluld be aware that some clients may be very manipulative. Manipulative dients want aIl needs to be met immediately and may become aggressiva or hostile when the3 are not met Respond to manjpulation Wflsistentreinforcement of~mits. The n m e might directlydl clients with a personality disorder that thek blaming accuhg, and intmd&tq m e r alienatespeople.

Chapter 9

q~ersvns&NWexaL3gbraUOn of ~IHicultlerInabUttv torelax, cold end unemotional of warm tenderfewnngs M r others IndlweAe; few close friends; "IOnW %,cia1 isolation; oddltles of mlnbng and speech: Illusion$ sU$P~CIOa nypersenSmvihl ~vetlvdramtlc expressions of motion, overreactton to eve* seRlndulgsntr wnrrpnt drawlfig of attentlon to 9et IrmtJonaloutbur*. dncanslderatlonof othen; Vahland demamllng: constant seem9 df reassurance: lackof 8enulneneS; mavlng of excitement maggeratedsense ofn-npfsQ e% lincIat need fQr canstant attention and admlratloII: preoowbledwlihfantarles; lacks abllityto reCOgNZe how othenfeel $eels Immediate pleasure; selRsh; p o ~ r o c c ~ p a ~ wrformance; ona~ unablem mamtaln lasting relatlonshltcrr poor sexual adlusimentifailure t o accept social norms; Irritability anll aggreslveness; fallura to Plan ?hUu ~impulslvevel: dkreeanlM I tnemth: recklessvlolatlon of the PTahts of ottheK impulsiveand unpreMctable; umtable inferpersonal matlonshlps; hec(U8ntdkplays of anger, ldentiw problems, shim In moods; Intense d~scomfcrtwhen alone: pnyslcally qelf.damaglng act%reoumngPeellngS of boredom m d emptmess HypersenslbWto relechon, Social withdrawal: low self-esteem Lac& 9elf.cOnfldence; avolds relying on self; allowsothersto assumeresponslbllltY Pre~ccUpaUon N t h trivial detallS; overly conventional and serlous, InSlStS Oh own way; lndeoisive lndlreetly resists demands MI adeauats perfurrnance; Intenttonal Ii7efUClenW foramml; stubbQ~ReSS, prauaSMrlaU0n. aawunna rwntful

zrculw ln malmnina &tbactow relatlonMIP5 ~ntrto ~tamaticandemotional

C).q A small success experlence for cllents may be seeing tneW artwork displayed; this builds self-esteem.

oefective judament

nt r~skofsubstance abuse and harm

Ber pressure can fiequatry be used to modify behavior. Guidance in asserkness is hdpM for same clients. T h e clients need positive feedback for open, dbeet fflmunicatioa The nurse should enwrmge r e k d rather than hostile exchaqps. He or she should set appropi+ ate limits and be sure the client knows the limitations. Dimsional aaivities are important The nurse might help by presenting gmwth opportunttiw, chances to assme responsibility, and small suecess exp6enee.s mgure 3-11. There is now a move tnward special &dmGal homes for some clients Mth persor&tydisorda

Erratic

Impulse Control Disorder

AnXloUS Fearful

Clients with an impulse disorder have uncon~oU&leimpulses that result in hmfd behaviare to seIf or othw. Their poor insight and inability to Mect and think of an alternative beharrior rmults in exiting, dangerous behaviors that redue their sense oftension and pleasnre. As a result thv experience relief: hpulsive behaviors hdude kleptopyromania, pathological gambIirig, trichorikmlania, and compulsive skin picking Csometimw to the point of excoriation). Some of the literatwe also includes compulsiw buying as a n impulse &order. Comorbidtty Mtith other disarders, such as bipolar disorder, psychoactive sabstance Use, attention defidtihyperactive disorder CaDHDJ, malor borderline and antisocial pemamlity disorders need to be -sea

Maladaptive Behaviors 3 @&\I -a

Sympu~ms of ADHD include a pesistent pattern of inattention hyperactivty, and i m p W t y wfth the fcllcdng obsemabk behaviom: fidg& d i t y , intenupthg inattention, d diEculty with waitina, folbwing instructions, sustaining attention and remaining taskfo-wed A neuropsychalopid ass-ent for a differential diagnosis is important asthe complexity of a multiple &agnosis or dnd Wnosis &I inauence the use of medicatim and matment in-tiom Cornorbiditis include learning disorders, mood disordem, and substance abuse or use. Manyyouths with ADHD have conmu~entsocial and b&aviotd problems that pbce thm at risk for co~lX&tbg and becoming iw01w.din the aimid justice system. Medicatiom presded ~IE R h h @l&ylph&date) and Cylem @emoline).However, the subject of mediatim usage forforafmmt of N E D is eontrowrsia1.and the d a n c e on drugs for children and ado-1 is being questioned. Conresearch in gmetia, brain i n j q , and psychophamacology is lik* to conhibute to a better undatanding of this disorder md effective treatment a p p m a b .

s L e m DISORDERS Mare than 30 million Americans wiU be affectedby insat some point in theirlives. Hauri [I9883defmed three types of insomnia: tmsient i n s o d caused by a brief p d o d of stress or vjben one travels from different timenes, insamnia caused by pmr sleeping habits or drug and dmhol dependencp, and chronic insonmia.If exloud snoriog is present the client needs to be evaluated by the p S n w depment, which assesses breathing bctions and then consults with a sleep disorders clinic. Many people expeace shaIlOwOW merited sleep and n m feel rested or refreshed S N d b suggest s&p protocols that involve no naps; arising kom bed when you cannot sleep and doing some quiet a&!$' for appmda* ninqminutes, then retiring to the bebed;Ieaming and practicing relaxatfm techniWI?S.

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MiLlIU THERAPY includes all s n r r o u n m in the physical emir~nrnentand those interpersonal intaactim that contribute to the individualfap& sonal growth and adaption The environwmt is structured to p&de securig and safery. Qn admission to the udt+the stimuli m y be decreed while trust is b 3 t but g r a d e in-ed resp&jJig and inwolvanent is encouraged. The envimnmt is fldbIe,pet limit.

U e t l

s e w is consistent Personal respect and cooperationmodeled bythe staffinaaes the seIfanfidence and sense of autonomy of the dient The eventual g d for the client is inawed motivation andsocialization The milieu aids in the mgnition of m a l a d a m behaviom and allows for confrontation of the dient when these behavim are observed. The physical environment needs to be clean and safe. Harmonious colors and comfortable andsafe finmshgs contribute to modalthe Overan sense of well-hemg Milieu ineludes manfr&aw fie.% gmup therapy art and music therapy (a means t o socialize and smctnre free time and increase seIf-confidenceJ, pet therapy [comfon wiih the expression of mrhg rhrough touCb@, h o r t i d t w (gardening and its re~ponsibiEtie8)~ nulritia~ courseling, 0ccupationaI theram ' ' g swngths and one's response to the environment), vaca( tional m r k (counselor explores work and job options), and educational groups (communication s$iUs, selfatem social interaction, h c i a I pIanningl. A n mteniisapIinary team coordinates these mtment actidtie8 and evaluates the clients partidpation and p r o m at weekly team m-s. An i n W t d h d care plan fadbates the dient's participation throq$ the client's review of fhe plan and consent (eitherdal OF written3 thathe or she accepts the treatment plan, Another aspect of the milieu is the communigr meeting. A cornmunigmeeting is a schedaled meetbg with a set time and pre&ermined dedsion that there will be no interruptions by staff or clients. On admission to the unit the client is an observer at the meeting but then becomes a participant The cammunity meting gives everyane a voice in d e d s i making. It pmvides a time to review pmMems and tensions an the ward and decreases m d c t through discussion Unit rules and roles are clarified irnd enforced in a consistent manner.At times, unit upkeep may be the meeting focus, with assignments of chores or tasks. The m a h concept is to increase client mpons1Wly and acu)unWtyand therebyincrease selfawpeness and selfesteem. PrequentIy requests for a therapeutic pass are generated at the W n u n u d y meeting. .A thempeutie pass is a leave of absence WAl h m the hospital for two or more h o w It is authorized by the physidan.Before the pass is issued, a m b a of the team meets with the dient and they decide on the purpose of the leave. Papas are Ned out handed in on mum that reflect the positive and negathre aspects ofthe LOB The clientmay visit vvith family, nm erran& or seek aftercare placement This is an important part ofthe discharge p h because it promotes the client's resociallzation and assists him or her to identify and cope wEh stressors and begin ta utilize cornmu@ support %y third-pa@ feimbursernent agenda do not &ow therapeutic passes.

234 Chapter 9

SUMMARY Maladaptive behavim can develop anytime &om ihfancy through old age. Three critical times are adolescence, menopawe, and old age. Coping acthity is required throughout the life cycle. The word m m l can be viewed in a sod& W c a L m o d or statistical way There is no sharp distinction between normal and abnonnd Psychiaay categorizes patterns ofbehavior, but it must be remembered tbat &en@do not fit neatly into these categories.Each client has an individual reaction to stress and therefore an individuaI pattern of behauior. Psychological disorders are disturhanm characterized bymaladaptive behavior aimed at dealing with high levels of d t r : Arydety disorders, somatoform disorders, affective disorders, and diswociative disddm are some common psychological disorders. Nursing m e focuses on reducing anxieq Affective disorders deal with mood and emotions. This cat* gory d u d e s dysthymi~depressive major, cyclothymic and bipolar disorders, Bipolar disorders are subwed as m a n i ~depressed, or mixed Dissocfative disorde~sare characterized by changes in consciousness and identi@ This category includes psychogenic amneeia, psychogenic fugue, multiple personality, and d e p e r s o ~ o n disordm Schizophrenia is characterized by delusions, hallucinations, disturbed thought processes, and peculiar behavior. Persons with schiz~phreniaexperience conaiding feelings and demonstrate inappropriate affect word saIa& neologism, delusions, and haIlucinations. The m e s of schizophrenia are disorgdzed catatonic, paranoid, and undEerentiat-ed. The client with a paranoid disorder s d e n h m persistent delusions, generally of jealousy, persecution, or grandeur. Personality disorders involve an indivi&alalsadaptation to internal and external problems. The disorder interferes with social or role functioni~g~ Many psychia'tric clients are lugh risk for suicide. The depressed client is the client most likely to commit suicide. The nurse should he able to recognize indirect cues that the client may; be considwing suicide Talking about suicide is a plea for help and must be recognized as such. (See Chapter 10, Violence and

as tbry relate to D In a &s

discuwion, mmlate the developmental stage of ado leswce with the d e v d o p m t o f m mring dkorrler. D Investigate the a d m h h n p~cedma$0a day-freattllentcent* ar mental h d t h &tin ydtr coamm~@l%pon your kdhgs to the cla~3. Wain and review pamphlets from: M c m PeytWatric h a ,Division nf Riblic L*OO K S*et NW Wa8bqton, DC. 20005 1-202m-62.20

m e f y m r d e r s Assadation of America @DA'Q UaOU Parlam Drive, bib 1.00 R d d & MD 2085d-21-301-2313350 wwwxka.org CMdren a i d Adults with Atiwdirn DefW Dipordw [ C w . . D . ) 499 N.% 70th Avenue, SSuite 101 P W t i Q PI, 33317 1-800-2334050 -chaddq

Pood and DrugAhinbmtion WA] 5800 Elshem, Lane R o M e , MD t Q B 7 1-800-3320178 Med Warch: 16iJ0-33~-1088 www.vrn.~dagoli NationaI Alkane for the Men* Ill @AMD 200 Noah Glehe Roa& 3ta 1015 Arhgroq, VA 22203-9754 1-800-950-NAMI

National Dqressive and M&c Dlepmwiae Disorders A s s o W n 730 N. FXankb S t w s S e e 501 chicage, 6UQO 1400-826-3G32

Maladantbe Behaviors

Chapter 9 National Foundation for Depmiive 11l0e$$ I= PO Box 2557 Nw?Cork,M! 10.116 1-800$39;1265 rndep1%95iOmg

3. Ap Irresistible urge to engage In a behavior is d e d @an 0 A. obsession.

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4. The @pesf schhphrenic disorder characte&ed by stupor and waxy E d i l i t y is d e d P A. dimganizsd U B. atatonic n C unMwatiat.ed. R D. parmaid 5.The affective dismdef that deals with altemste moods 6f depression and elation is the D A d@We ctisurder,

0 B. compuIsion.

U C phobia

a D. psychosis.

1-301-443-4519 r n a a . g O v

National Menral He&& &sO&tiOn l 0 &6& ~ swet &mdria, VPI 23314 1-800-968-6645

Ci B. depersmahtion disarde.

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0 C. ppchogeenie f5gue.

ObsessivpCxrm~ive Foundation 337 No& Hin Paad Nor@Bradkrd, CT 064n 1-203-315-ZI90 ~.ocfounda&&arg

D D. bipolar disorder.

Croup &c&wion on folkwing M D S ~~Communic~on , Swim Communicating with €%ents j30mD3fferent @ l t W , B96.

REVIEW KNOW ARID C

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A Mdtipie choice Select the one be& mWWm Z Anabnonnal, aces~ive fear ofa s p e a c stmation or object is ealled 4m Q

A obsession

Q B. wmpulsion. Q C. phobia

. . . . . ..

a n. pv&oss.

2. A reaming 0wzp-g

A Q~WS~UIL n B. ~ampu]sion. P G. phobia U D. p&osis.

tharght or fedhg is calld tJan

5. For o r s t bWdnals, uBe of compulsive behdyior results in which ofthe folowing7 P A occupybg the mind D B. manipulating the envbnment 0 C. lowe* &eq 0 D. preventing mist&e6 '7.Psychogenic amnesia is M das dan D A f l e c k disorder. D B.pasonaNtjr disoder. 0 C. dissociative &arrler. Q D. wnvemion disorder. 4. The pereon with a conmion disorder Q A wnverts anndetJrto b o w symptoms. Q B. expwienm.seven: m o d swings. Q C,is cut off from bis or her a v e e m R D. word@ about self obsessively. 9. Behavio~ that the person with an ar~tisodalpetsondffgi s likely tp display is D A withdra&om p n p activity D B. medmical obedience. D C. ~ u l a r i a of n others. D, ritwhtic behavior.

Maladaptive Behaviors 4. The nlnse prepares to administer fluphenzine d e w a t e

10.W c h of the Mowing clients would hawe the a;gh&strisk kr

(Prolixin d8canoate3 3E5 mg IlM to a dim diagnoed &h paraoid s&mphr& Whtch needle should the hurse edect? r;l A 18 g, l/b D B,20&142'

suidde? A client ctiapaed ~ 4 t aian h d A @genic mesk P B. antisocial per6onality disorda. 0 C major depressim D cych&puc disorda.

APPLY mm LEARWrnG B. MnZtipIe cho1ce. Seled f&eone, be& amwe% 1. A &ent diagnosed with paranoid a ~ tells the p n m &"I"m JuusCbrirrt pour Lord and Smior, Codeas your alns to ma" Which response by.the n m e would be most ~ P P ~ P ~ W P A. "I am of the Jewibb f&th and do not accept Jesus as Lord and Sadosd 0 B.Tour admission p a p a do nor Iist pour run%?as Jesw? P C. "You are out oftouch with red*. Your belief is a symp Tom of your illness? R D. Y respectgour beliefbut 1do net share thebelieP a. A &atinith w t a t o n i c s c h k p ~ isa mute and sits for h m in a rigid posture. l%kb Cimmldmtim s t r a t e would be most appmpxkie far the m e to use? 0 A. PrqueriTl$ pat the & i t ' s shovMer to demonstrate carin& 0 B. Anoid verbd inferadan untiltke antips+&c

metifation takes e f f e c t 0 C. Ask the dien'tls &@ant other to obtain infamatian fmm the &mY, Q D. Offer short caring pbrases to ccmmd* mnsm for the client

3. A client has a medial &a@.& of bipolar disodm, manic diagnosis ofhbalancednuDitio~less phase and a than body r-ents. Which n m b g interamtianmuld be most imp~rtant? 0 A Reeord how much the dietit eats a€each mad. Q B. Ask the client to keep a journal about eat@ ham. Q C. Record the clie11tSintake and output 0 D. Frequen€Ir offerthe d i a t ma& dbevePagpSt

o c. 22 g, 31a

a D. 26 g, 2" ~

$. The W e pxepaed to administtr hatcJ@dol d ~ CEaldol deanoatel Ihd ta a &ent d B g ~ 0 6 with d parnoid sddmphreniaa.The n m e could usa any ofthe follow@

*s

escqt:

Q A the ahdoma Cl B. deltoid.

P C.gIut9w -w. 12 D. bteralis. Q;.The nmSe gathers informafion hr a nmly admiW &ent diagn~sedwith an eaiing &order. What info~mationwould haw the highest priority to obtain? D &age 0 B. heaa rare HLld rhythm 0 62. m a w p m P D. body m g e W: A clldnt with hipolar disorder takes li.thinm Which h d i would prompt the nlnse to mitthold the hedose and ptoqtlp the &aician? 9 A mstipation 5 B. inffequent udnatton 0 C. 1-and coRfusic9~ Q D, fncmaved dbt 8. The nurse finds a dent, who is diagnosed with ma% depression,done aqi qing. Which r e s m e by the nurse would be most therapeutic? D. A. Administer the clfent's antidepressant medkatioa 5 B. Offer to sit quietly with the slient Ll C. A& the ellent, %at% the matter7". 0 D. Qffer the clfen't-arecrational actiuity,

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