NCLEX-RN PREPARATION PROGRAM

1. NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 2 of 3

2. Major Mental Health Disorders PERSONALITY DISORDERS (PD) • Diagnostic criteria (Axis II, DSM-IV): “Enduring pattern of inner experience & behavior that deviates from expectations in 2 or more areas”: • Cognition • Affectivity • Interpersonal functioning • Impulse control • Hinders one’s ability to • Maintain meaningful relationships • Feel fulfilled & enjoy life • Adjust psychosocially (cope)

3. Personality Disorder Clusters A. Odd-eccentric • Paranoid • Schizoid • Schizotypal B. Dramatic-Emotionally Erratic • Borderline (BPD) • Antisocial (APD) • Narcissistic • Histrionic C. Anxious-Fearful Dependent • Obsessive-Compulsive • Avoidant

4. Personality DisordersCluster A: Odd-Eccentric A profound deficit in the ability to form personal relationships or respond to others in a meaningful way. Appear indifferent, aloof and/or unresponsive to praise or criticism. Typically have no close friends and prefer to be alone. Social detachment and consequent impairment in social & occupational functioning. • Paranoid - pervasive distrust • Cognitive impairment is more serious with Cluster A personality disorders than with cluster B & C disorders • Most peculiar & maladaptive defensive styles • Observed in families with schizophrenia, especially schizotypal

5. Personality DisordersCluster B: Dramatic and Emotional • Present oriented and want immediate gratification • Act without evaluating consequences (impulsive) • BPD more likely to hurt self. APD more likely to aggress outward • APD commonly involved in criminal activities and lack remorse or guilt - emotionally retarded • Self-centered and manipulative • Splitting (the inability to integrate the positive and negative qualities of oneself or others into a cohesive image)

6. Personality DisordersCluster C: Anxious-Fearful • Present as primarily anxious or fearful • Experience impairment as • Restricted affect: problems expressing feelings • Non-assertiveness, avoids conflict • Unrealistic expectations of others • Rely on others for support and decision-making • Unable to function without a partner or family member - stays in abusive relationship rather than be alone

7. Bistro of the Personality Disorders (PDs) Schizoid - Orders home delivery; ingests food through mail slot Schizotypal - Eats soup using gardening equipment & chop sticks Paranoid - Sits with back to the wall; spies on food prep area Antisocial P.D. - Steals tip left by narcissist Borderline P.D. - When informed her boyfriend plans to go duck hunting, throws a drink at him, then uses glass to cut self Histrionic - Does a belly dance in the center of the restaurant Narcissist - Expects best table without a reservation Avoidant - Tips generously for take-out service Dependent - Vegetarian non-smoker eats veal in smoking area to please date OCPD - Aligns cutlery & dispenses etiquette tips

8. Personality Disorders Interventions • Establish therapeutic relationship • Control • Milieu therapy • Provide experienced, consistent staff • Implement a structure with rules that are firm & consistently enforced (limit setting with consequences) • Protection from self-harm • Modify impulsive behavior • Incorporate behavioral strategies

9. Personality Disorders Interventions (continued) • Medications have a limited role: Decrease impulsivity, mood swings, anxiety • Teach how to get needs met without manipulation • Maintain matter-of-fact but caring approach; mobilize healthy aspects of personality

10. Personality DisordersGoals • Less impulsive • Able to meet needs without manipulating • Increased satisfaction with quality of relationships • Participates in close relationships • Expresses recognition of positive behavioral change

11. A client recently released from prison for embezzlement has a history of becoming defensive and angry when criticized and blaming others for personal problems. The client has expressed no remorse or emotion about the actions that resulted in the prison term, but instead says that the embezzlement was justifiable because the employer “did not treat me fairly.” The nurse concludes these behaviors are consistent with which of the following mental health problems? • A. Narcissistic personality disorder • B. Histrionic personality disorder • C. Antisocial personality disorder • D. Borderline personality disorder

12. Which intervention strategy should the nurse routinely include in the nursing care plan for a client with antisocial personality disorder? • A. Establish clear and enforceable limits. • B. Vary unit rules based on client demands. • C. Vary unit rules based on staff needs. • D. Let the client have a voice in when unit rules should apply.

13. Anxiety Disorders Description An unrealistic fear in which the cause may or may not be identified. • Symptoms: Anxiety and avoidance behavior • Familial predisposition • Results from • Exposure to traumatic and stressful life events • Observing others experiencing trauma or behaving fearfully • Vicariously through watching movies and TV • Physical symptoms occur

14. Anxiety Disorders Central Features • Pervasive anxiety • Feelings of inadequacy • Tendency to avoid • Self-defeating behavior blocks growth • Can stimulate action to alter stressful situation • Most symptoms of the body involved • See physician vs. psychiatrist for treatment

15. Anxiety Disorders Assessment • Restlessness and inability to relax • Episodes of trembling and shakiness • Chronic muscular tension • Dizziness • Inability to concentrate • Fatigue and sleep problems • Inability to recognize connection between anxiety and physical symptoms • Focused on the physical discomfort

16. Anxiety DisordersGeneralized Anxiety Disorder GAD • Chronic excessive worry about a number of events or activities for at least 6 months. • History of uncontrollable & unpredictable life stress -prone to Generalized Anxiety Disorder (GAD) • Unrealistic/excessive • Motor tension, autonomic hyperactivity, apprehensive expectations, vigilance & scanning • Experiences at least 3 of the following: • Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance

17. Anxiety Disorders Panic Disorders Panic Disorders • Panic Disorder - discrete episode of intense fear Sense of impending doom, helplessness, or being trapped Peaks within 10 minutes Occurs unexpectedly and on an intermittent basis Concern about additional attacks • Panic Disorder with agoraphobia Avoidance of places or situations in which escape is difficult or help not available in the event of a panic attack (i.e., outside the home alone, being in a crowd…)

18. Anxiety Disorders Post-traumatic Stress Disorder PTSD • Development of physiologic/behavioral symptoms following a psychologically traumatic event • A traumatic event is unavoidable (terrorist attacks, war, rape, crime events, disasters, fires, childhood sexual abuse, kidnapping, hostages) • Before exposure did not have psychological problems • Symptoms include: re-experiencing the trauma, avoiding reminders of the trauma, numbing of affect

19. Anxiety Disorders Phobic Disorders Phobic Disorders • Social phobia - • Fear of scrutiny (evaluated or judged) by others • Fearful of doing something or acting in a way that will be humiliating or embarrassing • Specific Phobia • Persistent irrational fears of specific objects or situations • i.e., Animals (zoophobia), fear of closed places (claustrophobia), & fear of heights (acrophobia) • What are some other common phobias?

20. Anxiety Disorders Obsessive-Compulsive Disorder OCD • Obsessions • Unwanted, persistent, & intrusive thoughts, impulses or images that cause anxiety or distress • Compulsions • Irrational impulse to act • Behaviors or mental rituals performed to neutralize/prevent the distressing thoughts or images • Thoughts about dirt, contamination and danger most common obsessions; cleaning & checking for danger most common ritual

21. Anxiety DisorderMedications • Buspirone (Buspar) • Minimal CNS depressant actions • Does not enhance effects of alcohol, barbiturates & other general CNS depressants. Takes several weeks to establish effectiveness. • Benzodiazpam • Adverse effects: • CNS Depression • Amnesia • Respiratory Depression • Dependence and abuse • E.g. Valium, Librium, Xanax

22. Anxiety Disorder Medications • Beta-adrenergic blocking agents such as propranolol (Inderal) can relieve symptoms caused by autonomic hyperactivity • Selective Serotonin Reuptake Inhibitors (Paxil, Proxac…), Tricyclic Antidepressants (Imipramine - Tofranil) • Barbituates • CNS depression • High abuse potential • Powerful respiratory depressants with strong potential for fatal overdose

23. Anxiety DisorderAssessment • Take steps to lower anxiety level • Encourage trust/calm approach • Assess current feelings • What happened immediately prior to onset? • Client’s perspective of situation • Thought processes • Affect, expression, nonverbal behaviors • Communication ability, thought blocking

24. Anxiety DisorderInterventions • Establish trusting relationship • Nurses’ self-awareness • Recognition of anxiety • Insight into anxiety • Modifying environment • Encouraging activity • Promote relaxation response • Learn new ways to cope with stress • Medication • Goal: Client will demonstrate adaptive ways of coping with stress

25. A client who is hospitalized for panic disorder is experiencing increased anxiety. The client exhibits selective inattention and tells the nurse, “I’m anxious now.” The nurse determines that the degree of the client’s anxiety is: • A. Mild • B. Moderate • C. Severe • D. Panic

26. During an assessment interview, the client tells the nurse, “I can’t stop worrying about my makeup. I can’t go anywhere or do anything unless my makeup is fresh and perfect. I wash my face and put on fresh makeup at least once and sometimes twice an hour.” The nurse’s priority should be to adjust the client’s plan of care so the client will be: A. Required to spend daytime hours out of own room B. Given advance notice of approaching time for all group therapy sessions C. Asked to keep a diary of feelings experienced if unable to groom self at will D. Allowed to use own cosmetics and grooming products

27. A client asks why a beta blocker (Inderal) medication has been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety? A. Cognitive dissonance and confusion B. Depression and suicidal ideations C. Insomnia and nightmares D. Palpitations and rapid heart beat

28. Somatoform Disorders Focus: Physical symptoms with absence of a pathophysiological problem • Somatization Disorder • Hypochondriasis • Conversion Disorder • Pain Disorder • Body Dysmorphic Disorder

29. Somatoform Disorders Somatization Disorder • Involvement of multiorgan system symptoms: pain, GI, sexual, pseudoneurological • Lack physical signs or structural abnormalities • Different than hypochondriasis in that preoccupation occurs only during episode Hypochondriasis • Preoccupation with fear of having serious illness and hypersensitive to body functions • Becomes central feature of self-image, topic of social interaction and response to life stresses

30. Somatoform Disorders Conversion Disorder • A symptom or deficit that affects motor or sensory functioning • Inappropriately unconcerned about symptoms • Symptoms remit within 2 wks, recurrence common • Common symptoms are blindness, deafness, paralysis and the inability to talk Pain Disorder • Preoccupation with pain after confirmation of absence of pathophysiologic causes

31. Somatoform Disorders Body Dysmorphic Disorder • Preoccupation with an imagined/exaggerated defect in physical appearance • Crooked lip, bumpy nose, falling face • Somatoform Interventions: Client education • Medications, Rx, lifestyle changes, ways to cope with anxiety & stress, relaxation training, physical activity • Goal: Client will express feelings verbally rather than through physical symptoms

32. An older client with chronic low back pain receives cooking and cleaning help from her extended family. The mental health nurse anticipates that this client benefits from which of the following in this situation? A. Primary gain B. Secondary gain C. Attention-seeking D. Malingering

33. What would the nurse expect a client who has a somatization disorder to reveal in the nursing history? A. Abrupt onset of physical symptoms at menopause B. Episodes of personality dissociation C. Ignoring physical symptoms until role performance was altered D. Numerous physical symptoms in many organ areas

34. A client treated for hypochondriasis would demonstrate understanding of the disorder by which statement to the nurse? A. “I realize that tests and lab results cannot pick up on the seriousness of my illness.” B. “Once my family realizes how severely ill I am, they will be more understanding.” C. “I know that I don’t have a serious illness, even though I still worry about my symptoms.” D. “I realize that exposure to toxins can cause significant organ damage.”

35. Dissociative Disorders

36. Dissociative Disorders • Avoids stress by dissociating self from core personality, characterized by sudden or gradual disruption in identity, memory or consciousness • Dissociative Amnesia • Dissociative Fugue • Dissociative Identity Disorder • Depersonalization Disorder

37. Dissociative Disorders Dissociative Amnesia • Inability to recall important personal information • Too extensive to be explained by ordinary forgetfulness Dissociative Fugue • Sudden, unexpected travel away from home or work • Inability to recall one’s past • Confusion about personal identity (ID) or assumption of a new ID

38. Dissociative Disorders Dissociative Identity Disorder • Formally “Multiple Personality Disorder” • Presence of 2 or more distinct identities that recurrently take over behavior • Inability to recall important personal info • Identity fragmentation • Often a history of physical &/or sexual abuse Depersonalization Disorder • Recurrent feeling of being detached from one’s mental processes or body • Intact reality testing

39. Dissociative Disorders: Interventions • Development of insight • Identify stressors • Clarify beliefs in relationship to feelings and behaviors • Explore use of coping resources • Decrease anxiety through stress management Goal • Obtain the maximum level of self-actualization to realize potential

40. The spouse of a client who is experiencing a fugue state asks the nurse if the spouse will be able to remember what happened during the time of fugue. What is the nurse’s best response? A. “Your spouse will probably have no memory for events during the fugue.” B. “Your spouse will be able to tell you – if you can gently encourage talking.” C. “It is not possible to predict whether your spouse will remember the fugue state.” D. “Avoid mentioning it, or your spouse may start alternating old and new identities.”

41. Mood Disorders: Major Depressive Disorder and Bipolar Disorders Mood Disorder A mood disorder is characterized by: • Depressed mood or cycles of depressed and elated mood • Feelings of hopelessness and helplessness • Decrease in interest or pleasure in usual activities

42. Mood Disorders: Major Depressive Disorders Depression Models of Causation • Biological factors • Serotonin, norepinephrine, and acetylcholine deficiencies • Effect of light on mood • Genetic factors • Familial predisposition • Situational, physiological, and psychosocial stressors • Learned hopelessness and helplessness and a negative self-view

43. Mood Disorders Depression: Signs and Symptoms • Cognitive: Difficulty concentrating, focusing, and problem solving; ambivalence, confusion, sleep disturbances • Loss of interest or motivation, anhedonia • Decrease in personal hygiene • Anxiety, worthlessness, helplessness, hopelessness • Psychomotor retardation/agitation • Vegetative signs: Hypersomnia, slowed bowel function • Risk of harm to self or other: Suicidal ideation or thoughts, self-destructive acts, violence, overt hostility often connected with suicidal thoughts

44. Mood Disorders Depression: Psychotrophics • Selective Serotonin Reuptake Inhibitors • Rapid onset, fewer side effects, higher rate of compliance, lower overdose harm • Citalopram (Celexa) • Paroxetine (Paxil) • Fluoxetine (Prozac) • Sertraline (Zoloft) • Escitalopram (Lexapro) • Fluvaxamine (Luvox)

45. Mood Disorders SSRI Considerations Selective Serotonin Reuptake Inhibitors (SSRIs): • Physical assessment: renal, liver function, seizures • Agitation vs. vegetative symptoms • Level of anxiety • Ease of compliance • Risk for suicide by overdose

46. Mood Disorders Serotonin Syndrome • Cause: Excess Serotonin at receptor sites • Onset 3-9 days • Symptoms: fever, confusion, restlessness, agitation, hyper-reflexia, diaphoresis, shivering, diarrhea, fever, poor coordination • Triggered by high doses, concurrent MAOI, lithium or Trazadone administration • Interventions: Hold meds, notify MD, give P.O. fluids, supervise and support patient, antipyretics, cooling blanket • Resolves without specific treatment over 24 hours

47. Mood Disorders Depression: Psychotrophics • Novel antidepressants: • Bupropion (Wellbutrin) • Nefazadone (Serzone) • Trazadone (Desyrel) • Venlafaxine (Effexor) • Mirtazipine (Remeron) • Duloxetine (Cymbalta)

48. Mood Disorders Depression: Psychotrophics • Tricyclic antidepressants • Amitriptyline (Elavil) • Clomipramine (Anafranil) • Desipramine (Norpramin) • Doxepin (Sinequan) • Imipramine (Tofranil) • Nortriptyline (Pamelor) • Trimipramine (Surmontil)

49. Mood Disorders Depression: Psychotrophics • Monoamine Oxidase Inhibitors • Tranylcypromine (Parnate) • Phenelzine (Nardil) • Isocarboxazid (Marplan) • Tyramine-rich foods to avoid: aged cheese, sausage, beer on tap, sauerkraut, soy sauce,red wine • OTC cold remedies, tricyclic antidepressants, narcotics, antihypertensives, stimulants

50. Mood Disorders Nursing Interventions for Depression: • Maintain safety • Question negative beliefs • Encourage activities to increase self-esteem • Encourage ADLs • Encourage physical activity • Medication teaching • Milieu, group and/or individual therapy Goals • No self-harm • Resolution of negative self-image and situational insight • Restoration of normal physical functioning • Medication compliance, relapse prevention