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

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nclex rn preparation program




Module 6, Part 2 of 3

major mental health disorders
Major Mental Health Disorders


  • 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)

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
personality disorders cluster a odd eccentric
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
personality disorders cluster b dramatic and emotional
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)
personality disorders cluster c anxious fearful
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

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

personality disorders interventions
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
personality disorders interventions continued
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
personality disorders goals
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

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
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.

anxiety disorders
Anxiety Disorders


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
anxiety disorders1
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
anxiety disorders2
Anxiety Disorders


  • 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
anxiety disorders generalized anxiety disorder
Anxiety DisordersGeneralized Anxiety Disorder


  • 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
anxiety disorders panic disorders
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…)

anxiety disorders post traumatic stress disorder
Anxiety Disorders Post-traumatic Stress Disorder


  • 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
anxiety disorders phobic disorders
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?
anxiety disorders obsessive compulsive disorder
Anxiety Disorders Obsessive-Compulsive Disorder


  • 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
anxiety disorder medications
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
anxiety disorder medications1
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
anxiety disorder assessment
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
anxiety disorder interventions
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

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

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


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

somatoform disorders
Somatoform Disorders

Focus: Physical symptoms with

absence of a pathophysiological problem

  • Somatization Disorder
  • Hypochondriasis
  • Conversion Disorder
  • Pain Disorder
  • Body Dysmorphic Disorder

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


  • 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
somatoform disorders1
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
somatoform disorders2
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

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

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

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.”

dissociative disorders1
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
dissociative disorders2
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
dissociative disorders3
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
dissociative disorders interventions
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


  • Obtain the maximum level of self-actualization to realize potential

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.”

mood disorders major depressive disorder and bipolar disorders
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
mood disorders major depressive disorders
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
mood disorders
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
mood disorders1
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)
mood disorders2
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
mood disorders3
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
mood disorders4
Mood Disorders

Depression: Psychotrophics

  • Novel antidepressants:
    • Bupropion (Wellbutrin)
    • Nefazadone (Serzone)
    • Trazadone (Desyrel)
    • Venlafaxine (Effexor)
    • Mirtazipine (Remeron)
    • Duloxetine (Cymbalta)
mood disorders5
Mood Disorders

Depression: Psychotrophics

  • Tricyclic antidepressants
    • Amitriptyline (Elavil)
    • Clomipramine (Anafranil)
    • Desipramine (Norpramin)
    • Doxepin (Sinequan)
    • Imipramine (Tofranil)
    • Nortriptyline (Pamelor)
    • Trimipramine (Surmontil)
mood disorders6
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
mood disorders7
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


  • No self-harm
  • Resolution of negative self-image and situational insight
  • Restoration of normal physical functioning
  • Medication compliance, relapse prevention

The nurse has explained to a client the biologic theories of depression. The nurse concludes that the teaching has been effective if the client says, “I now know that my depression may be caused from:

A. Excessive serotonin activity in the central nervous system (CNS).”

B. Insufficient serotonin activity in the CNS.”

C. Excessive norepinephrine in the CNS.”

D. Insufficient acetylcholine activity in the CNS.”

E. A genetic mutation on chromosome 6.”


A 63-year-old male client expresses feelings of hopelessness and helplessness about his spouse’s illness and anticipated death. On which of the following issues should the nurse initially assist the client to focus?

A. The nature of the spouse’s present illness

B. The client’s response to past losses

C. The dying spouse’s feelings about impending loss and death

D. The client’s relationship with the spouse

mood disorders bipolar disorder
Mood Disorders: Bipolar Disorder

Bipolar Disorder

  • A mood disorder, formerly known as manic depression, characterized by recurrent and typically alternating episodes of depression and mania.
  • Either phase may be predominant at any given time or elements of both phases may be present simultaneously.
mood disorders8
Mood Disorders

Bipolar Disorder

  • Biological Factors
  • Possible excess of norepinephrine, serotonin and dopamine
  • Increased intracellular sodium and calcium
  • Neurotransmitters supersensitive to transmission of impulses
  • Defective feedback mechanism in limbic system
mood disorders9
Mood Disorders

Bipolar Disorder: Signs and Symptoms of Mania

  • Impulsivity: Spending money, giving away money or possessions, hypersexual behavior
  • Racing thoughts, hyper-social
  • Increased activity, grandiose view of self and abilities
  • Mood elation, progressively more hostile
  • Speech loud, jovial, pressured
  • Poor judgment
  • Reduced sleep
  • Impairment in social and occupational functioning
mood disorders10
Mood Disorders

Bipolar Disorder: Psychotrophics

  • Lithium Carbonate (Carbolith, Eskalith..)
  • Anticonvulsants
    • Valproate, (Depakote)
    • Carbamazepine (Tegretol)
    • Gabapentin (Neurontin)
    • Topiramate (Topamax)
    • Lamotrogene (Lamictal)
  • Benzodiazapines
  • Antipsychotics such as Olanzapine (Zyprexa) and Arpiprazole (Abilify)
  • Electroconvulsive therapy
mood disorders11
Mood Disorders

Bipolar Disorder: Medical Management

  • Lithium can have potentially harmful effects on the kidney, thyroid gland, heart and developing fetus
  • Pre-lithium treatment lab tests
    • Thyroid Function Tests (e.g. TSH),
    • CBC (benign elevation of WBCs),
    • BUN, serum creatinine, electrolytes
    • Urinalysis,
    • ECG,, pregnancy test
    • During Lithium treatment: TSH, BUN, serum creatinine, ECGs every 6 to 12 months
mood disorders12
Mood Disorders

Bipolar Disorder: Medical Management


  • Monitor serum levels or lithium (0.5-1.0 mEg/L) to prevent toxicity and confirm compliance. Report sub-therapeutic or toxic levels to prescribing practitioner
  • Encourage adequate hydration and adequate dietary salt
  • Therapeutic improvement takes 1-3 weeks
  • Tremors and a metallic taste are side effects

Anticonvulsants as Mood Stabilizers

  • Monitor serum levels every 2-4 months (liver function tests, complete blood count, electrolytes, ECG, pregnancy test every 6-12 months)
mood disorders13
Mood Disorders

Bipolar Disorder Nursing Interventions and Goals

  • Maintain physical safety (self harm, assault, impulse control, exhaustion)
  • Decrease sensory stimulation
  • Establish normal sleep/rest cycle
  • Establish adequate food/fluid intake
  • Limit escalation of behavior
  • Provide reality orientation
  • Psychoeducation: Disease process, target symptoms, self monitoring, alternative coping behaviors, self-care measures, medication management, medication compliance, laboratory monitoring, side effect management, community resources, relapse prevention, reinforce abstinence from drugs and alcohol

The client has bipolar I disorder. Lithium carbonate (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

A. “Minor hand trembling often happens for a few days after Lithium is started. It usually decreases in 1 to 2 weeks.”

B. “There’s no reason to worry about that. We won’t, unless it lasts longer than a couple of weeks.”

C. “Just in case your blood level is too high, I am not going to give you your next dose of Lithium.”

D. “I wouldn’t worry about it if I were you. It’s a small tremor that doesn’t interfere with your functioning.”

thought disorders
Thought Disorders


  • Involves disturbances in:
    • Reality, thought processes, perception, affect, social and occupational functioning
    • 1.5% of the population
    • 75% of cases diagnosed between ages 17 and 25
    • Causation: Heredity/genetic transmission, psychodynamics, stress, drug abuse, excessive dopamine. CT and MRI studies show decreased brain volume, enlarged ventricles, deeper fissures, and/or underdevelopment of brain tissue
thought disorders1
Thought Disorders

Schizophrenia: Types

  • Catatonic
  • Disorganized
  • Paranoid
  • Undifferentiated
  • Residual
thought disorders2
Thought Disorders

Schizophrenia: Types

  • Catatonic Type

Catatonic stupor, evidenced by extreme psychomotor retardation and posturing, and catatonic excitement, extreme psychomotor agitation with purposeless movements that may harm self or others

thought disorders3
Thought Disorders

Schizophrenia: Types

  • Disorganized Type

Flat or inappropriate affect (such as silliness or giggling), bizarre behavior and social impairment

  • Paranoid Type

Paranoid delusions in which the individual falsely believes that others are out to harm him/her. The individual may be hostile, argumentative and aggressive

thought disorders4
Thought Disorders

Schizophrenia: Types

  • Undifferentiated Type

Bizarre behavior that does not meet the criteria of other types of schizophrenia. Delusions and hallucinations are prominent

  • Residual Type

Individual who has had one major episode of schizophrenia with prominent psychotic symptoms and who has lingering symptoms

thought disorders5
Thought Disorders

Schizophrenia: Diagnostic Criteria

  • Delusions, hallucinations, disorganized speech and/or behavior
  • Social and/or occupational impairment
  • Symptoms for at least 6 months
  • Not attributable to another disorder
thought disorders6
Thought Disorders


Positive and Negative Symptoms

  • Positive: delusions, hallucinations, bizarre behavior, agitation, pressured speech, suicidal ideation
  • Negative: Flat affect, poor eye contact, withdrawal, anhedonia, poverty of speech, apathy, inattention, lack of motivation
thought disorders7
Thought Disorders


Positive Signs and Symptoms

  • Hallucinations: Auditory, visual, olfactory, gustatory, tactile
  • Illusions: False interpretations of external sensory stimuli and inappropriate responses to the perception.
  • Alterations in thinking

Delusions - Fixed false beliefs (grandiose, persecutory, somatic…)

Thought broadcasting, insertion

  • Ideas of reference
  • Flight of ideas
  • Thought/language disruption
thought disorders8
Thought Disorders


Co-Morbid Conditions and Effects

  • Anxiety, depression, suicidal ideation
  • Substance abuse
  • Impaired occupational and interpersonal relationships
  • Decreased self-care
  • Poor social functioning
  • Lowered quality of life
thought disorders9
Thought Disorders

Schizophrenia: Psychotrophics

  • Antipsychotic medications decrease the intensity and frequency of psychotic symptoms.
  • Anti-Parkinsonian medications are used to counteract the extrapyramidal symptoms (EPS) associated with antipsychotic medications.

Thought Disorders

Schizophrenia: Psychotrophics

  • Phenothiazines
    • Chlorpormazine (Thorazine), trifluoperazine (Stelazine), Thioridazine (Mellaril)…
  • Atypical
    • Clozapine (Clozaril), Olanzapine (Zyprexa), Risperidone (Risperdal), Ziprasidone (Geodon), Arpiprazole (Abilify), Quetiapine Fumarate (Seroquel)
thought disorders10
Thought Disorders

Schizophrenia: Psychotrophic Side Effects

  • Acute
    • Dystonic reaction
    • Ocular crisis
    • Agranulocytosis
    • Neuroleptic malignant syndrome
  • Chronic
    • Tardive dyskinesia
    • Pseudoparkinsonism
    • Photo sensitivity
    • Weight gain
thought disorders11
Thought Disorders


Psychotrophic Side Effects

  • Sudden onset muscular rigidity, fever, elevated CPK
  • Escalates over 24-48 hours
  • Late: hypertension, confusion-coma, gross diaphoresis, dysphagia, tachycardia
  • High potency neuroleptics, dosage, mood disorders, concurrent lithium and polypharmacy
thought disorders12
Thought Disorders

Schizophrenia: Factors Supporting Compliance

  • Perception of illness
  • Risk for relapse
  • Knowledge/involvement with treatment plan
  • Optimism regarding positive effects
  • Awareness of unpleasant effects when meds stopped
  • Psychoeducation regarding psychotropic medications’ action, purpose, intended effects, management of side effects, toxic or dangerous effects and treatment for side effects
thought disorders13
Thought Disorders

Schizophrenia: Factors Inhibiting Compliance

  • Delusions about medications
  • Return of enjoyable symptoms
  • Lack of social support regarding taking meds
  • Side effects distressing
  • Requires multiple changes in habits
  • Multiple medications
thought disorders14
Thought Disorders

Schizophrenia: Interventions

  • Establish & maintain safe environment
  • Establish trust
  • Manage delusions
  • Focus on feelings versus delusions
  • Engage in reality testing
  • Validate functional behaviors
  • Anxiety management
  • Stress reduction strategies
The major advantage of the newer atypical antipsychotics over older phenothiazines and high potency antipsychotic medication is:
  • A. Less chance for agranulocytosis
  • B. Availability as a long-lasting injection
  • C. Absence of EPS
  • D. Resolution of positive and negative symptoms

A patient with schizophrenia tells you that voices in his head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

A. “I know these voices are very real to you, but I don't

hear them.”

B. “You need to get out of your room and get your mind

occupied so you don't hear the voices."

C. “Don't worry. You're safe in the hospital. I won't let

anything happen to you.”

D. “The voices are coming from your imagination.”

substance abuse dependence
Substance Abuse/Dependence
  • Incidence
    • Alcohol dependence/abuse 14%
    • Drug dependence 3%
    • Co-morbidity common
  • Defense Mechanisms
    • Rationalization, projection, denial
  • CNS depressants
    • Alcohol, benzodiazapines, barbituates
substance abuse
Substance Abuse
  • Maladaptive, recurring use of substance accompanied by repeated detrimental effects of drug
  • Present for one year or more
  • Episodic binges
  • Can occur without dependency
  • Encounters with law, school suspension, family/marital problems
substance intoxication
Substance Intoxication
  • Maladaptive, reversible pattern of behavior
    • Perceptual disturbances
    • Sleep—wake cycle changes
    • Disturbs attention, concentration, thinking, judgment, psychomotor activity
    • Interferes with relationships
substance dependence
Substance Dependence
  • Craving–strong inner drive to use substance - unsuccessful efforts to control use
  • Tolerance – decreased effectiveness of drug over time with need for increased doses of substance to achieve same effect
  • Withdrawal– unpleasant, maladaptive changes in behavior as blood/tissue concentrations of substance decline after prolonged heavy use
  • Much time used in obtaining substance
  • Activities given up in lieu of substance use
  • Continued use in spite of negative problems from usage

Substance Dependence

  • Larger amounts over longer time period than intended
  • Persistent desire/unsuccessful efforts to control use
  • Much time used in obtaining substance
  • Activities given up in lieu of substance use
  • Continued use in spite of negative problems from usage
substance dependence1
Substance Dependence


  • Phase 1
    • Mood swings, altered emotional state
  • Phase 2
    • Hangover effects, guilt about behavior
  • Phase 3
    • Dependent lifestyle, control over substance is lost
  • Phase 4
    • Dependency, addiction, blackouts, paranoia,


substance abuse dependence1
Substance Abuse/Dependence

Possible long-term effects of chronic alcohol abuse

  • Gastritis
  • Esophagitis
  • Acute or chronic pancreatitis
  • Cirrhosis
  • Cardiac problems
  • Neurological problems
  • Wernicke-Korsakoff’s syndrome
  • Osteoporosis and myopathy
alcohol withdrawal
Alcohol Withdrawal

Accompanied by physiologic/cognitive symptoms from reduction in prolonged substance use

  • Early Signs
    • Develop within few hours after cessation/peak at 24-48 hours
    • Anxiety, anorexia, insomnia, tremors, hyperactivity, irritability, “shaking inside,” hallucinations, illusions, nausea/vomiting, Increased Temp, pulse, and BP
  • Delirium Tremens (DTs)
    • Peak in 48-72 hours after cessation of drinking – last 2-3 days
    • 20% fatality rate
nursing interventions alcohol dependence
Medication – sedation

High protein, high vitamin diet (B/C)

Replace fluid/ electrolytes (I/O)

Diuresis with blood alcohol level increase

Fluid retention may occur (overhydration)

MgSO4 to increase body’s response to thiamine/raise seizure threshold

VS q hour x 12 h, then q4h

Pulse good indicator of progress through withdrawal

Nursing Interventions: Alcohol Dependence
vitamin b1 deficiency
Vitamin B1 Deficiency
  • Vitamin B1 (Thiamine) and niacin deficiency
  • Encephalopathy and psychosis primarily in alcoholics caused by thiamine deficiency, due to poor dietary intake and malabsorption (Wernicke-Korsakoff Syndrome)
  • Permanent progressive cognitive loss
substance dependence alcohol
Substance Dependence: Alcohol
  • Maintaining abstinence
    • Antidepressents - SSRIs and Buspirone (BuSpar)
    • Naltrexone (ReVia), Nalmefene (Revex) -opioid antagonists that help with alcohol dependence - reduces cravings and increases abstinence
    • Disulfiram (Antabuse) - Treat alcoholism. Inhibits aldehyde dehydrogenase, if alcohol ingested, causes facial flushing, tachycardia, decreased BP, nausea, vomiting, SOB, seating dizziness and confusion
substance dependence alcohol1
Substance Dependence: Alcohol
  • Relapse prevention
    • Accept as a chronic disease
    • Self-help groups, AA
    • Stress management
    • Family support
substance abuse dependence2
Substance Abuse/Dependence
  • Narcotic opiates commonly abused
    • Heroin, Demerol, Dilaudid, Oxycontin
  • Treatment
    • Recognition of drug seeking
    • Manage intoxication/overdose
    • Opioid withdrawal: Naltrexone (ReVia), Buprenophine (Buprenex), Dolophine (Methadone)
    • Self-help groups, Narcotics Anonymous (NA)
    • Relapse prevention
substance abuse dependence3
Substance Abuse/Dependence

Types of Drugs Frequently Abused

  • Barbiturates, antianxiety drugs, hypnotics
  • Opioids (narcotics): heroin, morphine, meperidine, methadone, hydromorphone
  • Amphetamines: amphetamine, dextroamphetamine, methamphetamine (speed), some appetite suppressants
  • Cocaine, hydrochloride cocaine (crack)
  • Phencyclidine (PCP)
  • Hallucinogens: LSD, mescaline
  • Cannabis: marijuana, hashish, THC
  • Assessment findings and nursing interventions for overdose vary with particular drug
  • Polydrug abusers: Synergistic effect and additive effect
substance abuse dependence4
Substance Abuse/Dependence

Reasons nurses are at high risk for substance use.

  • Nurses see medication as solutions to problems
  • Access to drugs at work
  • Access to physicians who prescribe drugs
  • Compassion fatigue: Pressure and emotional pain felt

at work

  • Anger and frustration nurses feel at work
  • Emotions felt at work respond to drugs– short term
substance abuse dependence5
Substance Abuse/Dependence

Signs of substance abuse in nurses

  • Change in nurse’s behavior
  • Mood changes, irritability, isolation
  • Change in work performance
  • Multiple medication errors, missed deadlines, poor

judgment, absenteeism

  • Signs of drug use or withdrawal
  • Red eyes, ataxia, anxiety, use of breath mints and

perfume, slurred speech

substance abuse dependence6
Substance Abuse/Dependence

Action plan if you suspect a peer

Report the peer suspected of drug abuse to a manager or supervisor to:

  • Protect the clients from harm
  • Protect the peer from harming clients or self
  • Get diagnosis and treatment for impaired peers

A client says, “I have a very small drink every morning to calm my nerves and stop my hands from trembling.” The nurse concludes that this client is describing which of the following?

A. An anxiety disorder

B. Tolerance

C. Withdrawal

D. Alcohol abuse


A client asks the nurse to provide information about the detoxification process and withdrawal from a benzodiazepine. The nurse should inform the client that the process will involve which of the following?

A. Rapid reduction in amount and frequency of the drug normally used

B. Abrupt discontinuation of the drug commonly used

C. Gradual downward reduction in dosage of the drug commonly used

D. Planned, progressive addition of an anti-psychotic drug

When the nurse is caring for a client experiencing delirium tremens, what is the most important nursing intervention?

A. Present psycho-education on the dangers of drug and alcohol use.

B. Encourage the client to develop a relapse prevention plan.

C. Administer anti-craving medications.

D. Provide withdrawal care based on unit protocol.


Photo Acknowledgement:All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.