010-Psychiatric-Mental Health Nursing, 5th Edition-Sheila L. Videbeck-160547861X-Lippincott Willi

2Brodbeck:“Das Wort „Kreativität“ stammt aus der Theologie und bezeichnetursprünglich den Creator (Schöpfergott). Der Creator wird als ein Subjektgedacht, das aus Nichts etwas Neues erschafft. Die theologische Traditionspricht dem Menschen diese Fähigkeit der creatio ex nihilo ab. Im 17.Jahrhundert wurde der Begriff des Schöpferischen dann auf herausragendeMenschen, die „Genies“, übertragen. Der Begriffsinhalt blieb hierbei diffus.Spätere Versuche, den Begriff der Kreativität zu spezifizieren, lassen sichanhand von vier Aspekten umreißen (C.W. Taylor, 1988, S. 101): (1) Produkt, (2)Prozess, (3) Person und (4) Situation. Ferner lässt sich der Kreativitätsbegriffnoch hinsichtlich einer Innenperspektive (Erleben) und einer Außenperspektive(Verhalten) aufteilen. Die kreative Situation wiederum kann unterschiedlichaufgefasst werden: Individuell, als Gruppe, systemtheoretisch oder als sozialerProzess. Je nach Wahl des Ausgangspunktes ergibt sich ein anderer Begriff derKreativität.“Brodbeck: “ Versuch einer Definition:Daraus lässt sich der Schluss ziehen, dass man den Begriff der Kreativität nichtbruchlos objektivieren kann; er enthält stets ein ethisches oder Wertelement.Man kann Kreativität deshalb nur dann definieren, wenn man dieWertdimension ausdrücklich mit aufnimmt. Zudem, das hat sich in derKreativitätsforschung schrittweise herauskristallisiert, lässt sich das Feld, dieDomäne der Kreativität nicht sinnvoll einschränken. Prinzipiell sind kreativeLeistungen und Produkte bei allen menschlichen Handlungen zu entdecken. Umdiesem Sachverhalt gerecht zu werden, ist die kreative Situation ins Zentrumder Aufmerksamkeit gerückt.Ein Modell der kreativen Situation lässt sich aus fünf Elementen aufbauen:1)Äußeren Produkte, 2) Emotionen, 3) Wahrnehmung, 4) Bewegungsmusterund 5) Denkprozesse (K.-H. Brodbeck 1999; 2000). Damit ist gesagt, dass auchemotionale Prozesse (emotionale Intelligenz), eine veränderte Wahrnehmungoder veränderte Bewegungsmuster (des Körpers, des Denkens, des Fühlens,der sozialen Interaktion usw.) zur Domäne der Kreativität zu zählen sind, nichtnur objektivierbare Produkte oder fixierbare Denkprozesse.Aus dieser situativen Perspektive ergibt sich dann auch eine Definition derKreativität: Man kann mit „kreativ“ alle Formen menschlicher Aktivitätbezeichnen, die neu und wertvoll sind (K.-H. Brodbeck 1998; 2000). Neuheiten,die aus einer Wertschätzung herausfallen, sind keine kreativen Leistungen,sondern nur zufällige Änderungen. Wert können andererseits Dinge oderHandlungen auch dann haben, wenn sie als Wiederholung und Routinecharakterisierbar sind. Erst beide Teilbegriffe umfassen also das, was man als„kreativ“ bezeichnen kann. Der Kreativitätsbegriff bildet die Schnittmenge ausden Begriffen Neuheit und Wert.

Psychiatric–MentalHealth NursingFIFTH EDITIONSHEILA L. VIDEBECK, PhD, RNProfessor, NursingDes Moines Area Community CollegeAnkeny, IowaIllustrations by Cathy J. Miller

Acquisitions Editor: Jean RodenbergerProduct Manager: Katherine BurlandEditorial Assistant: Laura ScottDesign Coordinator: Holly McLaughlinVendor Manager: Cynthia RudyManufacturing Coordinator: Karin DuffieldPrepress Vendor: MPS Limited, A Macmillan CompanyFifth EditionCopyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.Copyright © 2008 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2006, 2004, 2001by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this bookmay be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or otherelectronic copies, or utilized by any information storage and retrieval system without written permission from thecopyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in thisbook prepared by individuals as part of their official duties as U.S. government employees are not covered by theabove-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 WalnutStreet, Philadelphia, PA 19106, via email at permissions@lww.com, or via our website at lww.com (products andservices).9 8 7 6 5 4 3 2 1Printed in ChinaLibrary of Congress Cataloging-in-Publication DataVidebeck, Sheila L.Psychiatric-mental health nursing / Sheila L. Videbeck; [illustrations by Cathy J. Miller]. — 5th ed.p.; cm.Includes bibliographical references and index.ISBN 978-1-60547-861-6 (alk. paper)1. Psychiatric nursing. I. Title.[DNLM: 1. Psychiatric Nursing. 2. Mental Disorders—nursing. WY 160 V652p 2011]RC440.V536 2011616.89’0231—dc222009045890Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.However, the author, editors, and publisher are not responsible for errors or omissions or for any consequencesfrom application of the information in this book and make no warranty, expressed or implied, with respect to the currency,completeness, or accuracy of the contents of the publication. Application of this information in a particular situationremains the professional responsibility of the practitioner; the clinical treatments described and recommendedmay not be considered absolute and universal recommendations.The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth inthis text are in accordance with the current recommendations and practice at the time of publication. However, inview of ongoing research, changes in government regulations, and the constant flow of information relating to drugtherapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indicationsand dosage and for added warnings and precautions. This is particularly important when the recommended agent is anew or infrequently employed drug.Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearancefor limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDAstatus of each drug or device planned for use in his or her clinical practice.

ReviewersMARGE BLONDELL, MS, RNAssistant Professor of NursingGenesee Community CollegeBatavia, New YorkMARTHA M. COLVIN, PhD, RN, APRN-PMHNAssociate Dean, College of Health Sciences and ProfessorGeorgia College & State University, School of NursingMilledgeville, GeorgiaKAREN CUMMINS, CRNP-BC, MSN, CNEProfessor of NursingCommunity College of Allegheny CountyPittsburgh, PennsylvaniaNursing InstructorSlippery Rock UniversitySlippery Rock, PennsylvaniaPATRICIA H. DAVIS, RN, BSN, MNProfessor of NursingLake City Community CollegeLake City, FloridaMARIAN T. DOYLE, RN, MSN, MSAssociate Professor of NursingNorthampton Community CollegeBethlehem, PennsylvaniaROSEMARY GATES, RN, MSProfessorCrouse Hospital School of NursingSyracuse, New YorkBARBARA J. GOLDBERG, APRN, BCAdjunct Professor of NursingOnondaga Community CollegeSyracuse, New YorkDEBORAH A. GREENAWALD, RN, MSN, PhD(c)Assistant Professor of NursingAlvernia UniversityReading, PennsylvaniaALICE P. JENSEN, MS, RNAssociate Professor of NursingMaryville UniversitySt. Louis, MissouriSOPHIE KNAB, MS (Psychiatric Clinical Nurse Specialist)Professor, Nursing DivisionNiagara County Community CollegeSanborn, New YorkKARREN BROWN LIEBERT, BSN, RN, MSN(doctoral candidate)Assistant ProfessorLong Island University School of NursingBrooklyn, New YorkSUSAN MADSON, MSN, RNProfessor of NursingHorry Georgetown Technical CollegeMyrtle Beach, South CarolinaJOAN C. MASTERS, EdD, MBA, RNAssociate Professor of NursingBellarmine UniversityLouisville, KentuckyKIMBERLEY R. MEYER, RN, BAN, MSN, EdDAssociate Professor of NursingBethel UniversitySt. Paul, MinnesotaMAGDALENA MORRIS, RN, MSNFaculty, LPN and ASN ProgramsApollo College (DeVry)Boise, IdahoPENNY R. PAK, RN, MSNAssistant Professor NursingPasco Hernando Community CollegeDade City, FloridaCOLLEEN PRUNIER, MS, APRN, CARNAssistant Professor of NursingSuffolk County Community College, School of NursingBrentwood Campus, New YorkCARLA E. RANDALL, RN, PhDUniversity of Southern Maine, Lewiston-AuburnCampusLewiston, MaineELLEN STUART, MSN, RNProfessor of NursingGrand Rapids Community CollegeGrand Rapids, MichiganPAMELA WEAVER, MSN, PMHCNS, BCNursing Instructor IUPMC Shadyside School of NursingPittsburgh, Pennsylvaniaiii

PrefaceThe fifth edition of Psychiatric–Mental Health Nursingmaintains a strong student focus, presenting sound nursingtheory, therapeutic modalities, and clinical applicationsacross the treatment continuum. The chapters areshort and the writing style is direct in order to facilitatereading comprehension and student learning.This text uses the nursing process framework and emphasizesassessment, therapeutic communication, neurobiologictheory, and pharmacology throughout. Interventionsfocus on all aspects of client care, including communication,client and family education, and community resources,as well as their practical application in various clinicalsettings.This new edition is supported with an ancillary packagedesigned to assist instructors with course planning and execution,and student evaluation, and to assist studentswith comprehensive knowledge synthesis.ORGANIZATION OF THE TEXTUnit 1: Current Theories and Practice provides a strongfoundation for students. It addresses current issues in psychiatricnursing as well as the many treatment settings inwhich nurses encounter clients. It discusses thoroughlyneurobiologic theories, psychopharmacology, and psychosocialtheories and therapy as a basis for understandingmental illness and its treatment.Unit 2: Building the Nurse–Client Relationship presentsthe basic elements essential to the practice of mentalhealth nursing. Chapters on therapeutic relationshipsand therapeutic communication prepare students tobegin working with clients both in mental health settingsand in all other areas of nursing practice. The chapter onthe client’s response to illness provides a framework forunderstanding the individual client. An entire chapter isdevoted to assessment, emphasizing its importance innursing.Unit 3: Current Social and Emotional Concerns coverstopics that are not exclusive to mental health settings, includinglegal and ethical issues; anger, aggression, andhostility; abuse and violence; and grief and loss. Nurses inall practice settings find themselves confronted with issuesrelated to these topics. Additionally, many legal and ethicalconcerns are interwoven with issues of violence and loss.Unit 4: Nursing Practice for Psychiatric Disorders coversall the major categories identified in the DSM-IV-TR. Eachchapter provides current information on etiology, onsetand clinical course, treatment, and nursing care.PEDAGOGICAL FEATURESPsychiatric–Mental Health Nursing incorporates several pedagogicalfeatures designed to facilitate student learning:• Learning Objectives focus the students’ reading andstudy.• Key Terms identify new terms used in the chapter. Eachterm is identified in bold and defined in the text.• Application of the Nursing Process sections use the assessmentframework presented in Chapter 8, so studentscan compare and contrast various disorders more easily.• Critical Thinking Questions stimulate students’ thinkingabout current dilemmas and issues in mental health.• Key Points summarize chapter content to reinforce importantconcepts.• Chapter Study Guides provide workbook-style questionsfor students to test their knowledge and understandingof each chapter.SPECIAL FEATURES• Clinical Vignettes are provided for each major disorderdiscussed in the text to “paint a picture” for betterunderstanding.• Drug Alerts highlight essential points about psychotropicdrugs.• Cultural Considerations sections appear in each chapter,as a response to increasing diversity.• Therapeutic dialogues give specific examples of nurse–client interaction to promote therapeutic communicationskills.• Internet Resources to further enhance study are locatedat the end of each chapter.• Client/Family Teaching boxes provide information thathelp strengthen students’ roles as educators.• Symptoms and Interventions are highlighted for chaptersin Units 3 and 4.• Sample Nursing Care Plans are provided for chapters inUnits 3 and 4.• Self-Awareness features appear at the end of each chapter,which encourage students to reflect on themselves,their emotions, and their attitudes as a way to fosterboth personal and professional development.iv

PREFACEvANCILLARY PACKAGE FORTHE FIFTH EDITIONFacultyThis fifth edition comes with a collection of ancillary materialsdesigned to help you plan class and clinical learningactivities and evaluate students’ learning. The InstructorResource DVD-ROM contains information and activitiesthat will help you engage your students throughout thesemester, including• PowerPoint Slides• Image Bank• Test GeneratorAdditional content and technology resources are availableonline at ThePointn—http://thepoint.lww.com—allowinginstructors easy access to an extensive selection of materialsfor each chapter, including• Pre-lecture Quizzes• Discussion Topics• Written, Group, Clinical, and Web Assignments• Guided Lecture Notes• Online eBook• Journal ArticlesStudentsFree and bound in the book, the fifth edition DVD-ROMsupplies the following learning tools:• Movie-Viewing Guides highlighting films depicting individualswith mental health disorders and providingstudents the opportunity to approach nursing care relatedto mental health and illness in a novel way.• Clinical Simulations on Schizophrenia, Depression,and the Acutely Manic Phase that walk students throughcase studies and put them in real-life situations.• Drug Monographs of commonly prescribed psychotropicdrugs.These and other valuable student resources, includingNCLEX-style psychiatric nursing questions designed tohelp students prepare to face exams armed with confidenceand knowledge, are also available on ThePointn—http://thepoint.lww.com.

AcknowledgmentsAs always, I am grateful to all the nursing students whocontribute to this book in more ways than they mightimagine. Their continued questions and feedback guideme to keep this text useful, easy to read and understand,and focused on student learning.I want to thank the people at Lippincott Williams &Wilkins for their valuable assistance in making this textbooka reality. Their contributions to its success are greatlyappreciated. I thank Jean Rodenberger, Katherine Burland,Laura Scott, and Cynthia Rudy for a job well done onceagain.My friends, Sheri and Beth, continue to listen, support,and encourage me in all that I do while keeping me fromtaking myself too seriously. And the women in my neighborhoodwho help me to laugh and enjoy life––their supportis greatly appreciated.vi

ContentsUNIT 1 • CURRENT THEORIES AND PRACTICE 1Chapter 1 Foundations of Psychiatric-Mental Health Nursing 2Mental Health and Mental Illness 2Diagnostic and Statistical Manual of Mental Disorders 3Historical Perspectives of the Treatment of Mental Illness 4Mental Illness in the 21st Century 5Psychiatric Nursing Practice 8Chapter 2 Neurobiologic Theories and Psychopharmacology 17The Nervous System and How It Works 18Brain Imaging Techniques 21Neurobiologic Causes of Mental Illness 23The Nurse’s Role in Research and Education 24Psychopharmacology 24Cultural Considerations 37Chapter 3 Psychosocial Theories and Therapy 43Psychosocial Theories 44Cultural Considerations 56Treatment Modalities 56The Nurse and Psychosocial Interventions 60Chapter 4 Treatment Settings and Therapeutic Programs 65Treatment Settings 66Psychiatric Rehabilitation Programs 69Special Populations of Clients with Mental Illness 71Interdisciplinary Team 72Psychosocial Nursing in Public Health and Home Care 73UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIP 79Chapter 5 Therapeutic Relationships 80Components of a Therapeutic Relationship 81Types of Relationships 86Establishing the Therapeutic Relationship 87Avoiding Behaviors That Diminish the Therapeutic Relationship 91Roles of the Nurse in a Therapeutic Relationship 93Chapter 6 Therapeutic Communication 98What Is Therapeutic Communication? 99Verbal Communication Skills 101Nonverbal Communication Skills 107Understanding the Meaning of Communication 109Understanding Context 110Understanding Spirituality 110Cultural Considerations 110The Therapeutic Communication Session 111Assertive Communication 114Community-Based Care 115vii

viiiCONTENTSChapter 7 Client’s Response to Illness 119Individual Factors 120Interpersonal Factors 123Cultural Factors 124Chapter 8 Assessment 138Factors Influencing Assessment 139How to Conduct the Interview 140Content of the Assessment 140Assessment of Suicide or Harm Toward Others 143Data Analysis 145UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNS 155Chapter 9 Legal and Ethical Issues 156Legal Considerations 156Ethical Issues 161Chapter 10 Anger, Hostility, and Aggression 166Onset and Clinical Course 167Related Disorders 168Etiology 168Cultural Considerations 169Treatment 169Applying the Nursing Process 170Workplace Hostility 176Community-Based Care 176Chapter 11 Abuse and Violence 180Clinical Picture of Abuse and Violence 181Characteristics of Violent Families 181Cultural Considerations 182Intimate Partner Violence 182Child Abuse 185Elder Abuse 188Rape and Sexual Assault 190Community Violence 193Psychiatric Disorders Related to Abuse and Violence 194Application of the Nursing Process 196Chapter 12 Grief and Loss 205Types of Losses 206The Grieving Process 206Dimensions of Grieving 208Cultural Considerations 211Disenfranchised Grief 213Complicated Grieving 213Application of the Nursing Process 215UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS 225Chapter 13 Anxiety, Anxiety Disorders, and Stress-Related Illness 226Anxiety as a Response to Stress 227Incidence 232Onset and Clinical Course 232

CONTENTSixRelated Disorders 232Etiology 232Cultural Considerations 234Treatment 234Elder Considerations 235Community-Based Care 235Mental Health Promotion 235Panic Disorder 236Application of the Nursing Process: Panic Disorder 237Phobias 240Obsessive–Compulsive Disorder 242Application of the Nursing Process: Obsessive–Compulsive Disorder 243Generalized Anxiety Disorder 246Posttraumatic Stress Disorder 246Acute Stress Disorder 247Chapter 14 Schizophrenia 251Clinical Course 253Related Disorders 254Etiology 254Cultural Considerations 256Treatment 256Application of the Nursing Process 260Elder Considerations 274Community-Based Care 274Mental Health Promotion 274Chapter 15 Mood Disorders 280Categories of Mood Disorders 281Related Disorders 282Etiology 283Cultural Considerations 284Major Depressive Disorder 284Application of the Nursing Process: Depression 290Bipolar Disorder 298Application of the Nursing Process: Bipolar Disorder 303Suicide 308Community-Based Care 312Mental Health Promotion 313Chapter 16 Personality Disorders 319Categories of Personality Disorders 320Onset and Clinical Course 320Etiology 321Cultural Considerations 322Treatment 322Paranoid Personality Disorder 324Schizoid Personality Disorder 325Schizotypal Personality Disorder 326Antisocial Personality Disorder 327Application of the Nursing Process: Antisocial Personality Disorder 327Borderline Personality Disorder 332Application of the Nursing Process: Borderline Personality Disorder 332Histrionic Personality Disorder 337Narcissistic Personality Disorder 337Avoidant Personality Disorder 328

xCONTENTSDependent Personality Disorder 339Obsessive–Compulsive Personality Disorder 340Depressive Personality Disorder 341Passive-Aggressive Personality Disorder 342Elder Considerations 342Community-Based Care 343Mental Health Promotion 343Chapter 17 Substance Abuse 348Types of Substance Abuse 349Onset and Clinical Course 350Related Disorders 350Etiology 350Cultural Considerations 351Types of Substances and Treatment 352Treatment and Prognosis 357Application of the Nursing Process 363Elder Considerations 366Community-Based Care 366Mental Health Promotion 366Substance Abuse in Health Professionals 367Chapter 18 Eating Disorders 372Overview of Eating Disorders 372Categories of Eating Disorders and Related Disorders 373Etiology 375Cultural Considerations 377Anorexia Nervosa 377Bulimia 379Application of the Nursing Process 380Community-Based Care 387Mental Health Promotion 387Chapter 19 Somatoform Disorders 392Overview of Somatoform Disorders 393Onset and Clinical Course 394Related Disorders 394Etiology 395Application of the Nursing Process 401Community-Based Care 404Mental Health Promotion 404Chapter 20 Child and Adolescent Disorders 410Autistic Disorder 412Attention Deficit Hyperactivity Disorder 414Application of the Nursing Process: Attention Deficit Hyperactivity Disorder 418Conduct Disorder 422Application of the Nursing Process: Conduct Disorder 425Community-Based Care 429Mental Health Promotion 429Chapter 21 Cognitive Disorders 440Delirium 441Application of the Nursing Process: Delirium 442Community-Based Care 447Dementia 447

CONTENTSxiApplication of the Nursing Process: Dementia 452Community-Based Care 458Mental Health Promotion 459Role of the Caregiver 459Related Disorders 460Answers to Chapter Study Guides 465Appendix A DSM-IV-TR Classification 471Appendix B NANDA-Approved Nursing Diagnoses 479Appendix C Drug Classification Under the Controlled Substances Act 481Appendix D Canadian Standards of Psychiatric and Mental Health Nursing Practice (3rd ed.) 482Appendix E Canadian Drug Trade Names 486Appendix F Mexican Drug Trade Names 493Appendix G Sleep Disorders 494Appendix H Sexual and Gender Identity Disorders 496Glossary of Key Terms 498Index 508

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CURRENT THEORIESAND PRACTICEUnit 1Chapter 1 Foundations of Psychiatric–MentalHealth NursingChapter 2 Neurobiologic Theoriesand PsychopharmacologyChapter 3 Psychosocial Theories and TherapyChapter 4 Treatment Settings and TherapeuticPrograms

1Foundations ofPsychiatric-MentalHealth NursingLearning ObjectivesAfter reading this chapter, you should be able to1. Describe characteristics of mental health and mental illness.Key Terms• asylum• case management• deinstitutionalization• Diagnostic and StatisticalManual of Mental Disorders,4th edition, Text Revision(DSM-IV-TR)• managed care• managed care organizations• mental disorder• mental health• phenomena of concern• psychotropic drugs• self-awareness• standards of care• utilization review firms2. Discuss the purpose and use of the American Psychiatric Association’s Diagnosticand Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR).3. Identify important historical landmarks in psychiatric care.4. Discuss current trends in the treatment of people with mental illness.5. Discuss the American Nurses Association standards of practice forpsychiatric–mental health nursing.6. Describe common student concerns about psychiatric nursing.AS YOU BEGIN THE STUDY OF psychiatric–mental health nursing, you may beexcited, uncertain, and even a little anxious. The field of mental healthoften seems a little unfamiliar or mysterious, making it hard to imaginewhat the experience will be like or what nurses do in this area. This chapteraddresses these concerns and others by providing an overview of thehistory of mental illness, advances in treatment, current issues in mentalhealth, and the role of the psychiatric nurse.MENTAL HEALTH AND MENTAL ILLNESSMental health and mental illness are difficult to define precisely. Peoplewho can carry out their roles in society and whose behavior is appropriateand adaptive are viewed as healthy. Conversely, those who fail to fulfillroles and carry out responsibilities or whose behavior is inappropriate areviewed as ill. The culture of any society strongly influences its values andbeliefs, and this in turn affects how that society defines health and illness.What one society may view as acceptable and appropriate, another societymay see as maladaptive and inappropriate.Mental HealthThe World Health Organization defines health as a state of complete physical,mental, and social wellness, not merely the absence of disease or infirmity.2Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 3This definition emphasizes health as a positive state of wellbeing.People in a state of emotional, physical, and socialwell-being fulfill life responsibilities, function effectively indaily life, and are satisfied with their interpersonal relationshipsand themselves.No single universal definition of mental health exists.Generally, a person’s behavior can provide clues to his orher mental health. Because each person can have a differentview or interpretation of behavior (depending on his or hervalues and beliefs), the determination of mental health maybe difficult. In most cases, mental health is a state of emotional,psychological, and social wellness evidenced by satisfyinginterpersonal relationships, effective behavior andcoping, positive self-concept, and emotional stability.Mental health has many components, and a wide varietyof factors influence it. These factors interact; thus, aperson’s mental health is a dynamic, or ever-changing,state. Factors influencing a person’s mental health can becategorized as individual, interpersonal, and social/cultural.Individual, or personal, factors include a person’s biologicmakeup, autonomy and independence, self-esteem, capacityfor growth, vitality, ability to find meaning in life, emotionalresilience or hardiness, sense of belonging, realityorientation, and coping or stress management abilities.Interpersonal, or relationship, factors include effectivecommunication, ability to help others, intimacy, and a balanceof separateness and connectedness. Social/cultural, orenvironmental, factors include a sense of community,access to adequate resources, intolerance of violence, supportof diversity among people, mastery of the environment,and a positive, yet realistic, view of one’s world.Individual, interpersonal, and social/cultural factors arediscussed further in Chapter 7.Mental IllnessThe American Psychiatric Association (APA, 2000) definesa mental disorder as “a clinically significant behavioral orpsychological syndrome or pattern that occurs in an individualand is associated with present distress (e.g., a painfulsymptom) or disability (i.e., impairment in one or moreimportant areas of functioning) or with a significantlyincreased risk of suffering death, pain, disability, or animportant loss of freedom” (p. xxxi). General criteria todiagnose mental disorders include dissatisfaction withone’s characteristics, abilities, and accomplishments; ineffectiveor unsatisfying relationships; dissatisfaction withone’s place in the world; ineffective coping with life events;and lack of personal growth. In addition, the person’sbehavior must not be culturally expected or sanctioned.However, deviant behavior does not necessarily indicate amental disorder (APA, 2000).Factors contributing to mental illness can also be viewedwithin individual, interpersonal, and social/cultural categories.Individual factors include biologic makeup, intolerableor unrealistic worries or fears, inability to distinguish realityfrom fantasy, intolerance of life’s uncertainties, a sense ofdisharmony in life, and a loss of meaning in one’s life. Interpersonalfactors include ineffective communication, excessivedependency on or withdrawal from relationships, nosense of belonging, inadequate social support, and loss ofemotional control. Social/cultural factors include lack ofresources, violence, homelessness, poverty, an unwarrantednegative view of the world, and discrimination such asstigma, racism, classism, ageism, and sexism.DIAGNOSTIC AND STATISTICAL MANUALOF MENTAL DISORDERSThe Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision (DSM-IV-TR) is a taxonomy publishedby the APA. The DSM-IV-TR describes all mental disorders,outlining specific diagnostic criteria for each based onclinical experience and research. All mental health clinicianswho diagnose psychiatric disorders use the DSM-IV-TR.The DSM-IV-TR has three purposes:• To provide a standardized nomenclature and languagefor all mental health professionals• To present defining characteristics or symptoms thatdifferentiate specific diagnoses• To assist in identifying the underlying causes ofdisorders.A multiaxial classification system that involves assessmenton several axes, or domains of information, allows thepractitioner to identify all the factors that relate to a person’scondition:• Axis I is for identifying all major psychiatric disordersexcept mental retardation and personality disorders.Examples include depression, schizophrenia, anxiety,and substance-related disorders.• Axis II is for reporting mental retardation and personalitydisorders as well as prominent maladaptive personalityfeatures and defense mechanisms.• Axis III is for reporting current medical conditions thatare potentially relevant to understanding or managing theperson’s mental disorder as well as medical conditionsthat might contribute to understanding the person.• Axis IV is for reporting psychosocial and environmentalproblems that may affect the diagnosis, treatment,and prognosis of mental disorders. Included are problemswith the primary support group, the social environment,education, occupation, housing, economics,access to health care, and the legal system.• Axis V presents a Global Assessment of Functioning,which rates the person’s overall psychological functioningon a scale of 0 to 100. This represents the clinician’sassessment of the person’s current level of functioning;the clinician also may give a score for prior functioning(e.g., highest Global Assessment of Functioning in thepast year or 6 months ago).

4UNIT 1 • CURRENT THEORIES AND PRACTICEAll clients admitted to a hospital for psychiatric treatmentwill have a multiaxial diagnosis using the DSM-IV-TR.Although student nurses do not use the DSM-IV-TR to diagnoseclients, they will find it a helpful resource to understandthe reason for the admission and to begin buildingknowledge about the nature of psychiatric illnesses.HISTORICAL PERSPECTIVES OF THETREATMENT OF MENTAL ILLNESSAncient TimesPeople of ancient times believed that any sicknessindicated displeasure of the gods and, in fact, was a punishmentfor sins and wrongdoing. Those with mentaldisorders were viewed as being either divine or demonic,depending on their behavior. Individuals seen as divinewere worshipped and adored; those seen as demonic wereostracized, punished, and sometimes burned at the stake.Later, Aristotle (382–322 BC) attempted to relate mentaldisorders to physical disorders and developed his theorythat the amounts of blood, water, and yellow and blackbile in the body controlled the emotions. These four substances,or humors, corresponded with happiness, calmness,anger, and sadness. Imbalances of the four humorswere believed to cause mental disorders, so treatment wasaimed at restoring balance through bloodletting, starving,and purging. Such “treatments” persisted well into the19th century (Baly, 1982).In early Christian times (1–1000 AD), primitive beliefsand superstitions were strong. All diseases were againblamed on demons, and the mentally ill were viewed aspossessed. Priests performed exorcisms to rid evil spirits.When that failed, they used more severe and brutal measures,such as incarceration in dungeons, flogging, andstarving.In England during the Renaissance (1300–1600), peoplewith mental illness were distinguished from criminals.Those considered harmless were allowed to wander thecountryside or live in rural communities, but the more“dangerous lunatics” were thrown in prison, chained, andstarved (Rosenblatt, 1984). In 1547, the Hospital ofSt. Mary of Bethlehem was officially declared a hospital forthe insane, the first of its kind. By 1775, visitors at theinstitution were charged a fee for the privilege of viewingand ridiculing the inmates, who were seen as animals, lessthan human (McMillan, 1997). During this same period inthe colonies (later the United States), the mentally illwere considered evil or possessed and were punished.Witch hunts were conducted, and offenders were burnedat the stake.Period of Enlightenment and Creation ofMental InstitutionsIn the 1790s, a period of enlightenment concerning personswith mental illness began. Phillippe Pinel in France andWilliam Tukes in England formulated the concept of asylumas a safe refuge or haven offering protection at institutionswhere people were whipped, beaten, and starved justbecause they were mentally ill (Gollaher, 1995). With thismovement began the moral treatment of the mentally ill. Inthe United States, Dorothea Dix (1802–1887) began a crusadeto reform the treatment of mental illness after a visit toTukes’s institution in England. She was instrumental inopening 32 state hospitals that offered asylum to the suffering.Dix believed that society was obligated to those whowere mentally ill; she advocated adequate shelter, nutritiousfood, and warm clothing (Gollaher, 1995).The period of enlightenment was short-lived. Within100 years after establishment of the first asylum, state hospitalswere in trouble. Attendants were accused of abusingthe residents, the rural locations of hospitals were viewedas isolating patients from their families and homes, andthe phrase insane asylum took on a negative connotation.Sigmund Freud and Treatment ofMental DisordersPossessed by demonsThe period of scientific study and treatment of mental disordersbegan with Sigmund Freud (1856–1939) and others,such as Emil Kraepelin (1856–1926) and Eugene Bleuler(1857–1939). With these men, the study of psychiatry and

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 5the diagnosis and treatment of mental illness started inearnest. Freud challenged society to view human beingsobjectively. He studied the mind, its disorders, and theirtreatment as no one had done before. Many other theoristsbuilt on Freud’s pioneering work (see Chapter 3). Kraepelinbegan classifying mental disorders according to their symptoms,and Bleuler coined the term schizophrenia.Development of PsychopharmacologyA great leap in the treatment of mental illness began inabout 1950 with the development of psychotropic drugs,or drugs used to treat mental illness. Chlorpromazine(Thorazine), an antipsychotic drug, and lithium, an antimanicagent, were the first drugs to be developed. Overthe following 10 years, monoamine oxidase inhibitorantidepressants; haloperidol (Haldol), an antipsychotic;tricyclic antidepressants; and antianxiety agents, calledbenzodiazepines, were introduced. For the first time,drugs actually reduced agitation, psychotic thinking, anddepression. Hospital stays were shortened, and many peoplewere well enough to go home. The level of noise,chaos, and violence greatly diminished in the hospitalsetting.Move Toward Community Mental HealthThe movement toward treating those with mental illness inless restrictive environments gained momentum in 1963with the enactment of the Community Mental Health CentersConstruction Act. Deinstitutionalization, a deliberateshift from institutional care in state hospitals to communityfacilities, began. Community mental health centers servedsmaller geographic catchment, or service, areas that providedless restrictive treatment located closer to individuals’homes, families, and friends. These centers providedemergency care, inpatient care, outpatient services, partialhospitalization, screening services, and education. Thus,deinstitutionalization accomplished the release of individualsfrom long-term stays in state institutions, the decrease inadmissions to hospitals, and the development of communitybasedservices as an alternative to hospital care.In addition to deinstitutionalization, federal legislationwas passed to provide an income for disabled persons:Supplemental Security Income (SSI) and Social SecurityDisability Income (SSDI). This allowed people with severeand persistent mental illness to be more independentfinancially and to not rely on family for money. States wereable to spend less money on care of the mentally ill thanthey had spent when these individuals were in state hospitalsbecause this program was federally funded. Also, commitmentlaws changed in the early 1970s, making it moredifficult to commit people for mental health treatmentagainst their will. This further decreased the state hospitalpopulations and, consequently, the money that states spenton them.MENTAL ILLNESS IN THE 21ST CENTURYThe National Institute of Mental Health (NIMH, 2008)estimates that more than 26% of Americans aged 18years and older have a diagnosable mental disorder—approximately 57.7 million persons each year. Furthermore,mental illness or serious emotional disturbancesimpair daily activities for an estimated 15 million adultsand 4 million children and adolescents. For example,attention deficit hyperactivity disorder affects 3% to 5%of school-aged children. More than 10 million childrenyounger than 7 years grow up in homes where at leastone parent suffers from significant mental illness or substanceabuse, a situation that hinders the readiness ofthese children to start school. The economic burden ofmental illness in the United States, including both healthcarecosts and lost productivity, exceeds the economicburden caused by all kinds of cancer. Mental disorders arethe leading cause of disability in the United States andCanada for persons 15 to 44 years of age. Yet only one infour adults and one in five children and adolescentsrequiring mental health services get the care they need.Some believe that deinstitutionalization has had negativeas well as positive effects. Although deinstitutionalizationreduced the number of public hospital beds by 80%,the number of admissions to those beds correspondinglyincreased by 90%. Such findings have led to the termrevolving door effect. Although people with severe and persistentmental illness have shorter hospital stays, they areadmitted to hospitals more frequently. The continuousflow of clients being admitted and discharged quicklyoverwhelms general hospital psychiatric units. In somecities, emergency department visits for acutely disturbedpersons have increased by 400 to 500%.Revolving door

6UNIT 1 • CURRENT THEORIES AND PRACTICEShorter hospital stays further complicate frequent,repeated hospital admissions. People with severe and persistentmental illness may show signs of improvement in a fewdays but are not stabilized. Thus, they are discharged intothe community without being able to cope with communityliving. The result frequently is decompensation and rehospitalization.In addition, many people have a dual problem ofboth severe mental illness and substance abuse. Use of alcoholand drugs exacerbates symptoms of mental illness, againmaking rehospitalization more likely. Substance abuse issuescannot be dealt with in the 3 to 5 days typical for admissionsin the current managed care environment.Homelessness is a major problem in the United States today.One third of adult homeless persons are estimated to have aserious mental illness and more than one half also have substanceabuse problems. The segment of the homeless populationconsidered to be chronically homeless numbers 200,000,and 85% of this group has a psychiatric illness or a substanceabuse problem. Those who are homeless and mentally ill arefound in parks, airport and bus terminals, alleys and stairwells,jails, and other public places. Some use shelters, halfwayhouses, or board-and-care rooms; others rent cheap hotelrooms when they can afford it. Homelessness worsens psychiatricproblems for many people with mental illness who end upon the streets, contributing to a vicious cycle. The TreatmentAdvocacy Center (2008) reports that rates of mental illness, particularlymajor depression, bipolar disorder, and substanceabuse, are increasing among the homeless population.Many of the problems of the homeless mentally ill, aswell as of those who pass through the revolving door of psychiatriccare, stem from the lack of adequate communityresources. Money saved by states when state hospitals wereclosed has not been transferred to community programsand support. Inpatient psychiatric treatment still accountsfor most of the spending for mental health in the UnitedStates, so community mental health has never been giventhe financial base it needs to be effective. In addition, mentalhealth services provided in the community must be individualized,available, and culturally relevant to be effective.In 1993, the federal government created and fundedAccess to Community Care and Effective Services andSupport (ACCESS) to begin to address the needs of peoplewith mental illness who were homeless either all or part ofthe time. The goals of ACCESS were to improve access tocomprehensive services across a continuum of care, reduceduplication and cost of services, and improve the efficiencyof services. Programs such as these provide services topeople who otherwise would not receive them and haveproved successful in treating psychiatric illness and indecreasing homelessness.Objectives for the FutureUnfortunately, only one in four affected adults and one infive children and adolescents receive treatment (Departmentof Health and Human Services [DHHS], 2008).Statistics like these underlie the Healthy People 2010 objectivesfor mental health proposed by the U.S. DHHS (2000;Box 1.1). These objectives, originally developed as HealthyPeople 2000, were revised in January 2000 to increase thenumber of people who are identified, diagnosed, treated,and helped to live healthier lives. The objectives also striveto decrease rates of suicide and homelessness, to increaseemployment among those with serious mental illness, andto provide more services both for juveniles and for adultswho are incarcerated and have mental health problems. Atthis time, work has begun on Healthy People 2020 goals,which will be released in January 2010.Community-Based CareAfter deinstitutionalization, the 2,000 community mentalhealth centers that were supposed to be built by 1980 hadnot materialized. By 1990, only 1,300 programs providedvarious types of psychosocial rehabilitation services. Personswith severe and persistent mental illness were eitherignored or underserved by community mental health centers.This meant that many people needing services were,and still are, in the general population with their needsunmet. The Treatment Advocacy Center (2008) reportsthat about one half of all persons with severe mental illnesshave received no treatment of any kind in the previous12 months. Persons with minor or mild cases are morelikely to receive treatment, whereas those with severe andpersistent mental illness are least likely to be treated.Community support service programs were developedto meet the needs of persons with mental illness outsidethe walls of an institution. These programs focus on rehabilitation,vocational needs, education, and socializationas well as on management of symptoms and medication.These services are funded by states (or counties) and someprivate agencies. Therefore, the availability and quality ofservices vary among different areas of the country. Forexample, rural areas may have limited funds to providemental health services and smaller numbers of peopleneeding them. Large metropolitan areas, although havinglarger budgets, also have thousands of people in need ofservice; rarely is there enough money to provide all theservices needed by the population. Chapter 4 provides adetailed discussion of community-based programs.Unfortunately, the community-based system did not accuratelyanticipate the extent of the needs of people with severeand persistent mental illness. Many clients do not have theskills needed to live independently in the community, andteaching these skills is often time consuming and labor intensive,requiring a 1:1 staff-to-client ratio. In addition, thenature of some mental illnesses makes learning these skillsmore difficult. For example, a client who is hallucinating or“hearing voices” can have difficulty listening to or comprehendinginstructions. Other clients experience drastic shiftsin mood, being unable to get out of bed one day and thenunable to concentrate or pay attention a few days later.

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 7Box 1.1 HEALTHY PEOPLE 2010 MENTAL HEALTH OBJECTIVES• Reduce suicides to no more than 6 per 100,000 people• Reduce the incidence of injurious suicide attempts by1% in 12 months for adolescents aged 14 to 17• Reduce the proportion of homeless adults who have seriousmental illness to 19%• Increase the proportion of persons with serious mentalillnesses who are employed to 51%• Reduce the relapse rate for persons with eating disorders,including anorexia nervosa and bulimia nervosa• Increase the number of persons seen in primary healthcare who receive mental health treatment screening andassessment• Increase the proportion of children with mental healthproblems who receive treatment• Increase the proportion of juvenile justice facilities thatscreen new admissions for mental health problems• Increase the proportion of adults with mental disorderswho receive treatment by 17%• Adults 18 to 54 with serious mental illness to 55%• Adults 18 and older with recognized depression to 50%• Adults 18 and older with schizophrenia to 75%• Adults 18 and older with anxiety disorders to 50%• Increase the population of persons with concurrent substanceabuse problems and mental disorders who receivetreatment for both disorders• Increase the proportion of local governments withcommunity-based jail diversion programs for adults withserious mental illness• Increase the number of states that track consumers’ satisfactionwith the mental health services they receive to30 states• Increase the number of states with an operational mentalhealth plan that addresses cultural competence• Increase the number of states with an operational mentalhealth plan that addresses mental health crisis intervention,ongoing screening, and treatment services forelderly personsU.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives.Washington, DC: DHHS.Despite the flaws in the system, community-based programshave positive aspects that make them preferable fortreating many people with mental illness. Clients canremain in their communities, maintain contact with familyand friends, and enjoy personal freedom that is not possiblein an institution. People in institutions often lose motivationand hope as well as functional daily living skills,such as shopping and cooking. Therefore, treatment in thecommunity is a trend that will continue.Cost Containment and Managed CareHealth-care costs spiraled upward throughout the 1970sand 1980s in the United States. Managed care is a conceptdesigned to purposely control the balance between thequality of care provided and the cost of that care. In a managedcare system, people receive care based on need ratherthan on request. Those who work for the organization providingthe care assess the need for care. Managed carebegan in the early 1970s in the form of health maintenanceorganizations, which were successful in some areas withhealthier populations of people.In the 1990s, a new form of managed care, calledutilization review firms or managed care organizations,was developed to control the expenditure of insurancefunds by requiring providers to seek approval before thedelivery of care. Case management, or management ofcare on a case-by-case basis, represented an effort to providenecessary services while containing cost. The client isassigned to a case manager, a person who coordinates alltypes of care needed by the client. In theory, this approachis designed to decrease fragmented care from a variety ofsources, eliminate unneeded overlap of services, providecare in the least restrictive environment, and decreasecosts for the insurers. In reality, expenditures are oftenreduced by withholding services deemed unnecessary orsubstituting less expensive treatment alternatives for moreexpensive care, such as hospital admission.Psychiatric care is costly because of the long-termnature of the disorders. A single hospital stay can cost$20,000 to $30,000. Also, there are fewer objectivemeasures of health or illness. For example, when a personis suicidal, the clinician must rely on the person’sreport of suicidality; no laboratory tests or other diagnosticstudies can identify suicidal ideas. Mental health careis separated from physical health care in terms of insurancecoverage: There are often specific dollar limits orpermitted numbers of hospital days in a calendar year.When private insurance limits are met, public fundsthrough the state are used to provide care. As states experienceeconomic difficulties, the availability of state fundsfor mental health care decreases as well.Mental health care is managed through privately ownedbehavioral health-care firms that often provide the services

8UNIT 1 • CURRENT THEORIES AND PRACTICEand manage their cost. Persons without private insurancemust rely on their counties of residence to provide fundingthrough tax dollars. These services and the money to fundthem often lag far behind the need that exists. In addition,many persons with mental illness do not seek care and infact avoid treatment. These persons are often homeless orin jail. Two of the greatest challenges for the future are toprovide effective treatment to all who need it and to findthe resources to pay for this care.The Health Care Finance Administration administers twoinsurance programs: Medicare and Medicaid. Medicare coverspeople 65 years and older, people with permanent kidneyfailure, and people with certain disabilities. Medicaid isjointly funded by the federal and state governments and coverslow-income individuals and families. Medicaid variesdepending on the state; each state determines eligibilityrequirements, scope of services, and rate of payment for services.Medicaid covers people receiving either SSI or SSDIuntil they reach 65 years of age, although people receivingSSDI are not eligible for 24 months. SSI recipients, however,are eligible immediately. Unfortunately, not all people whoare disabled apply for disability benefits, and not all peoplewho apply are approved. Thus, many people with severe andpersistent mental illness have no benefits at all.Another funding issue is mental health parity, or equality,in insurance coverage provided for both physical andmental illnesses. In the past, insurers had spending capsfor mental illness and substance abuse treatment. Somepolicies placed an annual dollar limitation for treatment,whereas others limited the number of days that would becovered annually or in the insured person’s lifetime (of thepolicy). In 1996, Congress passed the Mental Health ParityAct, which eliminated annual and lifetime dollar amountsfor mental health care for companies with more than50 employees. However, substance abuse was not coveredby this law, and companies could still limit the number ofdays in the hospital or the number of clinic visits per year.Thus, parity did not really exist. Insurance is governed bythe laws of each state, so some states have full parity, whileothers have “limited” parity for mental health coverage—and some states have no parity laws on the books (NationalAlliance for the Mentally Ill [NAMI], 2007).Cultural ConsiderationsThe U.S. Census Bureau (2000) estimates that 62% of thepopulation has European origins. This number is expectedto continue to decrease as more U.S. residents trace theirancestry to African, Asian, Arab, or Hispanic origins. Nursesmust be prepared to care for this culturally diverse population,which includes being aware of cultural differences thatinfluence mental health and the treatment of mental illness.See Chapter 7 for a discussion of cultural differences.Diversity is not limited to culture; the structure of familieshas changed as well. With a divorce rate of 50% in theUnited States, single parents head many families and manyblended families are created when divorced persons remarry.Twenty-five percent of households consist of a single person(U.S. Census Bureau, 2000), and many people live togetherwithout being married. Gay men and lesbians form partnershipsand sometimes adopt children. The face of the familyin the United States is varied, providing a challenge tonurses to provide sensitive, competent care.PSYCHIATRIC NURSING PRACTICEIn 1873, Linda Richards graduated from the New EnglandHospital for Women and Children in Boston. She went onto improve nursing care in psychiatric hospitals and organizededucational programs in state mental hospitals in Illinois.Richards is called the first American psychiatric nurse;she believed that “the mentally sick should be at least aswell cared for as the physically sick” (Doona, 1984).The first training of nurses to work with persons withmental illness was in 1882 at McLean Hospital in Belmont,Massachusetts. The care was primarily custodial and focusedon nutrition, hygiene, and activity. Nurses adapted medical–surgical principles to the care of clients with psychiatric disordersand treated them with tolerance and kindness. Therole of psychiatric nurses expanded as somatic therapies forthe treatment of mental disorders were developed. Treatments,such as insulin shock therapy (1935), psychosurgery(1936), and electroconvulsive therapy (1937), requirednurses to use their medical–surgical skills more extensively.The first psychiatric nursing textbook, Nursing MentalDiseases by Harriet Bailey, was published in 1920. In 1913,Johns Hopkins was the first school of nursing to include acourse in psychiatric nursing in its curriculum. It was notuntil 1950 that the National League for Nursing, whichaccredits nursing programs, required schools to include anexperience in psychiatric nursing.Two early nursing theorists shaped psychiatric nursingpractice: Hildegard Peplau and June Mellow. Peplau publishedInterpersonal Relations in Nursing in 1952 and InterpersonalTechniques: The Crux of Psychiatric Nursing in 1962.She described the therapeutic nurse–client relationship withits phases and tasks and wrote extensively about anxiety (seeChapter 13). The interpersonal dimension that was crucialto her beliefs forms the foundations of practice today.Mellow’s 1968 work, Nursing Therapy, described herapproach of focusing on clients’ psychosocial needs andstrengths. Mellow contended that the nurse as therapist isparticularly suited to working with those with severemental illness in the context of daily activities, focusingon the here and now to meet each person’s psychosocialneeds (1986). Both Peplau and Mellow substantially contributedto the practice of psychiatric nursing.In 1973, the division of psychiatric and mental healthpractice of the American Nurses Association (ANA) developedstandards of care, which it revised in 1982, 1994,2000, and 2007. Standards of care are authoritative statementsby professional organizations that describe the

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 9Box 1.2 PSYCHIATRIC–MENTAL HEALTH NURSING PHENOMENA OF CONCERNPhenomena of concern for psychiatric–mental health nursesinclude:• Promotion of optimal mental and physical health andwell-being and prevention of mental illness• Impaired ability to function related to psychiatric, emotional,and physiological distress• Alterations in thinking, perceiving, and communicatingdue to psychiatric disorders or mental health problems• Behaviors and mental states that indicate potentialdanger to self or others• Emotional stress related to illness, pain, disability, and loss• Symptom management, side effects, or toxicities associatedwith self-administered drugs, psychopharmacologicalintervention, and other treatment modalities• The barriers to treatment efficacy and recovery posed byalcohol and substance abuse and dependence• Self-concept and body image changes, developmentalissues, life process changes, and end-of-life issues• Physical symptoms that occur along with alteredpsychological status• Psychological symptoms that occur along with alteredphysiological status• Interpersonal, organizational, sociocultural, spiritual, orenvironmental circumstances or events that have aneffect on the mental and emotional well-being of theindividual and family or community• Elements of recovery, including the ability to maintainhousing, employment, and social support, that helpsindividuals re-engage in seeking meaningful lives• Societal factors such as violence, poverty, and substanceabuseresponsibilities for which nurses are accountable. They arenot legally binding unless they are incorporated into thestate nurse practice act or state board rules and regulations.When legal problems or lawsuits arise, these professionalstandards are used to determine safe and acceptablepractice and to assess the quality of care.This document also outlines the areas of practice andphenomena of concern for today’s psychiatric–mental healthnurse. The phenomena of concern describe the 13 areas ofconcern that mental health nurses focus on when caring forclients (Box 1.2). The standards of care incorporate thephases of the nursing process, including specific types ofinterventions, for nurses in psychiatric settings and outlinestandards for professional performance: quality of care, performanceappraisal, education, collegiality, ethics, collaboration,research, and resource utilization (Box 1.3). Box 1.4summarizes specific areas of practice and specific interventionsfor both basic and advanced nursing practice.Box 1.3 PSYCHIATRIC–MENTAL HEALTH NURSING: SCOPE AND STANDARDSOF PRACTICESTANDARDS OF PRACTICEStandard 1. AssessmentThe psychiatric–mental health registered nurse collects comprehensivehealth data that is pertinent to the patient’shealth of situation.Standard 2. DiagnosisThe psychiatric–mental health registered nurse analyzesthe assessment data to determine diagnoses of problems,including level of risk.Standard 3. Outcomes IdentificationThe psychiatric–mental health registered nurse identifiesexpected outcomes for a plan individualized to the patientor the situation.Standard 4. PlanningThe psychiatric–mental health registered nurse develops aplan that prescribes strategies and alternatives to attainexpected outcomes.Standard 5. ImplementationThe psychiatric–mental health registered nurse implementsthe identified plan.Standard 5A. Coordination of CareThe psychiatric–mental health registered nurse coordinatescare delivery.continued on page 10

10UNIT 1 • CURRENT THEORIES AND PRACTICEBox 1.3 PSYCHIATRIC–MENTAL HEALTH NURSING: SCOPE AND STANDARDSOF PRACTICE ContinuedStandard 5B. Health Teaching and HealthPromotionThe psychiatric–mental health registered nurse employsstrategies to promote health and a safe environment.Standard 5C. Milieu TherapyThe psychiatric–mental health registered nurse provides,structures, and maintains a safe and therapeutic environmentin collaboration with patients, families, and otherhealth-care clinicians.Standard 5D. Pharmacological, Biological,and Integrative TherapiesThe psychiatric–mental health registered nurse incorporatesknowledge of pharmacological, biologic, and complementaryinterventions with applied clinical skills to restore the patient’shealth and prevent further disability.Standard 5E. Prescriptive Authorityand TreatmentThe psychiatric–mental health advanced practice registerednurse uses prescriptive authority, procedures, referrals, treatments,and therapies in accordance with state and federallaws and regulations.Standard 5F. PsychotherapyThe psychiatric–mental health advanced practice registerednurse conducts individual, couple, group, and familypsychotherapy using evidence-based psychotherapeuticframeworks and nurse–patient therapeutic relationships.Standard 5G. ConsultationThe psychiatric–mental health advanced practice registerednurse provides consultation to influence the identified plan,enhance the abilities of other clinicians to provide servicesfor patients, and effect change.(Note: Standards 5D–G are advanced practice interventionsand may be performed only by the psychiatric–mental healthadvanced practice registered nurse.)Standard 6. EvaluationThe psychiatric–mental health registered nurse evaluatesprogress toward attainment of expected outcomes.STANDARDS OF PROFESSIONAL PERFORMANCEStandard 7. Quality of PracticeThe psychiatric–mental health registered nurse systematicallyenhances the quality and effectiveness of nursing practice.Standard 8. EducationThe psychiatric–mental health registered nurse attains knowledgeand competency that reflect current nursing practice.Standard 9. Professional Practice EvaluationThe psychiatric–mental health registered nurse evaluatesone’s own practice in relation to the professional practicestandards and guidelines, relevant statues, rules, andregulations.Standard 10. CollegialityThe psychiatric–mental health registered nurse interactswith and contributes to the professional development ofpeers and colleagues.Standard 11. CollaborationThe psychiatric–mental health registered nurse collaborateswith patients, family, and others in the conduct of nursingpractice.Standard 12. EthicsThe psychiatric–mental health registered nurse integratesethical provisions in all areas of practice.Standard 13. ResearchThe psychiatric–mental health registered nurse integratesresearch findings into practice.Standard 14. Resource UtilizationThe psychiatric–mental health registered nurse considersfactors related to safety, effectiveness, cost, and impact onpractice in the planning and delivery of nursing services.Standard 15. LeadershipThe psychiatric–mental health registered nurse provides leadershipin the professional practice setting and the profession.Reprinted with permission from the American Nurses Association. (2007). Psychiatric–mental health nursing: Scope and standards of practice. Silver Spring,MD: Nursebooks.org.

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 11Box 1.4 AREAS OF PRACTICEBASIC-LEVEL FUNCTIONS• CounselingInterventions and communication techniquesProblem-solvingCrisis interventionStress managementBehavior modification• Milieu therapyMaintain therapeutic environmentTeach skillsEncourage communication between clients and othersPromote growth through role modeling• Self-care activitiesEncourage independenceIncrease self-esteemImprove function and health• Psychobiologic interventionsAdminister medicationsTeachObserve• Health teaching• Case management• Health promotion and maintenanceA nurse who possesses these elements but says somethingthat sounds out of place can simply restate it bysaying, “That didn’t come out right. What I meantwas . . .”• What will I be doing?In the mental health setting, many familiar tasks andresponsibilities are minimal. Physical care skills ordiagnostic tests and procedures are fewer than thoseconducted in a busy medical–surgical setting. The ideaof “just talking to people” may make the student feelas though he or she is not really doing anything. Thestudent must deal with his or her own anxiety aboutapproaching a stranger to talk about very sensitive andpersonal issues. Development of the therapeuticnurse–client relationship and trust takes time andpatience.• What if no one will talk to me?Students sometimes fear that clients will reject themor refuse to have anything to do with student nurses.Some clients may not want to talk or are reclusive,but they may show that same behavior with experiencedstaff; students should not see such behavior asa personal insult or failure. Generally, many people inemotional distress welcome the opportunity to havesomeone listen to them and show a genuine interestin their situation. Being available and willing to listenADVANCED-LEVEL FUNCTIONS• Psychotherapy• Prescriptive authority for drugs (in many states)• Consultation and liaison• Evaluation• Program development and management• Clinical supervisionStudent ConcernsStudent nurses beginning their clinical experience inpsychiatric–mental health nursing usually find the disciplineto be very different from any previous experience. Asa result, they often have a variety of concerns; these concernsare normal and usually do not persist once the studentshave initial contacts with clients.Some common concerns and helpful hints for beginningstudents follow:• What if I say the wrong thing?No one magic phrase can solve a client’s problems;likewise, no single statement can significantly worsenthem. Listening carefully, showing genuine interest,and caring about the client are extremely important.“What if I say the wrong thing?”

12UNIT 1 • CURRENT THEORIES AND PRACTICEis often all it takes to begin a significant interactionwith someone.• Am I prying when I ask personal questions?Students often feel awkward as they imagine themselvesdiscussing personal or distressing issues with a client. Itis important to remember that questions involving personalmatters should not be the first thing a student saysto the client. These issues usually arise after some trustand rapport have been established. In addition, clientsgenuinely are distressed about their situations and oftenwant help resolving issues by talking to the nurse. Whenthese emotional or personal issues are addressed in thecontext of the nurse–client relationship, asking sincereand necessary questions is not prying but is using therapeuticcommunication skills to help the client.• How will I handle bizarre or inappropriate behavior?The behavior and statements of some clients may beshocking or distressing to the student initially. It is importantto monitor one’s facial expressions and emotionalresponses so that clients do not feel rejected or ridiculed.The nursing instructor and staff are always available toassist the student in such situations. Students shouldnever feel as if they will have to handle situations alone.• What happens if a client asks me for a date or displayssexually aggressive or inappropriate behavior?Some clients have difficulty recognizing or maintaininginterpersonal boundaries. When a client seeks contactof any type outside the nurse–client relationship, it isimportant for the student (with the assistance of theinstructor or staff) to clarify the boundaries of the professionalrelationship (see Chapter 5). Likewise, settinglimits and maintaining boundaries are needed when aclient’s behavior is sexually inappropriate. Initially, thestudent might be uncomfortable dealing with suchbehavior, but with practice and the assistance of theinstructor and staff, it becomes easier to manage. It isalso important to protect the client’s privacy and dignitywhen he or she cannot do so.• Is my physical safety in jeopardy?Often students have had little or no contact with seriouslymentally ill people. Media coverage of those withmental illness who commit crimes is widespread, leavingthe impression that most clients with psychiatricdisorders are violent. Actually, clients hurt themselvesmore often than they harm others. Staff members usuallyclosely monitor clients with a potential for violencefor clues of an impending outburst. When physical aggressiondoes occur, staff members are specially trainedto handle aggressive clients in a safe manner. The studentshould not become involved in the physical restraintof an aggressive client because he or she has nothad the training and experience required. When talkingto or approaching clients who are potentially aggressive,the student should sit in an open area rather than in aclosed room, provide plenty of space for the client, orrequest that the instructor or a staff person be present.• What if I encounter someone I know being treated onthe unit?In any clinical setting, it is possible that a student nursemight see someone he or she knows. People often haveadditional fears because of the stigma that is still associatedwith seeking mental health treatment. It is essentialin mental health that the client’s identity andtreatment be kept confidential. If the student recognizessomeone he or she knows, the student shouldnotify the instructor, who can decide how to handlethe situation. It is usually best for the student (andsometimes the instructor or staff) to talk with the clientand reassure him or her about confidentiality. Theclient should be reassured that the student will notread the client’s record and will not be assigned to workwith the client.• What if I recognize that I share similar problems or backgroundswith clients?Students may discover that some of the problems, familydynamics, or life events of clients are similar to their ownor those of their family. It can be a shock for students todiscover that sometimes there are as many similaritiesbetween clients and staff as there are differences. There isno easy answer for this concern. Many people havestressful lives or abusive childhood experiences; somecope fairly successfully, whereas others are devastatedemotionally. Although we know that coping skills are akey part of mental health, we do not always know whysome people have serious emotional problems and othersdo not. Chapter 7 discusses these factors in more detail.SELF-AWARENESS ISSUESSelf-awareness is the process by which thenurse gains recognition of his or her ownfeelings, beliefs, and attitudes. In nursing,being aware of one’s feelings, thoughts, andvalues is a primary focus. Self-awareness is particularlyimportant in mental health nursing. Everyone, includingnurses and student nurses, has values, ideas, and beliefsthat are unique and different from others’. At times, anurse’s values and beliefs will conflict with those of theclient or with the client’s behavior. The nurse must learn toaccept these differences among people and view each clientas a worthwhile person regardless of that client’s opinionsand lifestyle. The nurse does not need to condone theclient’s views and behavior; he or she merely needs toaccept them as different from his or her own and not letthem interfere with care.For example, a nurse who believes that abortion iswrong may be assigned to care for a client who has had anabortion. If the nurse is going to help the client, he or shemust be able to separate his or her own beliefs about abortionfrom those of the client: the nurse must make surepersonal feelings and beliefs do not interfere with or hinderthe client’s care.

CHAPTER 1 • FOUNDATIONS OF PSYCHIATRIC–MENTAL HEALTH NURSING 13The nurse can accomplish self-awareness throughreflection, spending time consciously focusing on how onefeels and what one values or believes. Although we all havevalues and beliefs, we may not have really spent time discoveringhow we feel or what we believe about certainissues, such as suicide or a client’s refusal to take neededmedications. The nurse needs to discover himself orherself and what he or she believes before trying to helpothers with different views.Points to Consider When Working onSelf-Awareness• Keep a diary or journal that focuses on experiencesand related feelings. Work on identifying feelings andthe circumstances from which they arose. Review thediary or journal periodically to look for patterns orchanges.• Talk with someone you trust about your experiencesand feelings. This might be a family member, friend,coworker, or nursing instructor. Discuss how he or shemight feel in a similar situation, or ask how he or shedeals with uncomfortable situations or feelings.• Engage in formal clinical supervision. Even experiencedclinicians have a supervisor with whom they discusspersonal feelings and challenging client situations togain insight and new approaches.• Seek alternative points of view. Put yourself in the client’ssituation and think about his or her feelings,thoughts, and actions.• Do not be critical of yourself (or others) for having certainvalues or beliefs. Accept them as a part of yourself,or work to change those values and beliefs you wish tobe different.Critical Thinking Questions1. In your own words, describe mental health. Describethe characteristics, behavior, and abilities of someonewho is mentally healthy.2. When you think of mental illness, what images orideas come to mind? Where do these ideas comefrom—movies, television, personal experience?3. What personal characteristics do you have that indicategood mental health?KEY POINTS• Mental health and mental illness are difficultto define and are influenced by one’sculture and society.• The World Health Organization defineshealth as a state of complete physical, mental, and socialwellness, not merely the absence of disease or infirmity.• Mental health is influenced by individual factors, includingbiologic makeup, autonomy and independence, self-esteem,capacity for growth, vitality, ability to find meaning in life,resilience or hardiness, sense of belonging, reality orientation,and coping or stress management abilities; by interpersonalfactors, including effective communication, helpingothers, intimacy, and maintaining a balance of separatenessand connectedness; and by social/cultural factors, includingsense of community, access to resources, intolerance of violence,support of diversity among people, mastery of the environment,and a positive yet realistic view of the world.• Historically, mental illness was viewed as demonic possession,sin, or weakness, and people were punishedaccordingly.• Today, mental illness is seen as a medical problem withsymptoms causing dissatisfaction with one’s characteristics,abilities, and accomplishments; ineffective orunsatisfying interpersonal relationships; dissatisfactionwith one’s place in the world; ineffective coping with lifeevents; and lack of personal growth.• Factors contributing to mental illness are biologicmakeup; anxiety, worries, and fears; ineffective communication;excessive dependence or withdrawal from relationships;loss of emotional control; lack of resources;and violence, homelessness, poverty, and discrimination.• The DSM-IV-TR is a taxonomy used to provide a standardnomenclature of mental disorders, define characteristicsof disorders, and assist in identifying underlyingcauses of disorders.• A significant advance in treating persons with mentalillness was the development of psychotropic drugs inthe early 1950s.• The shift from institutional care to care in the communitybegan in the 1960s, allowing many people to leaveinstitutions for the first time in years.• One result of deinstitutionalization is the revolving doorof repetitive hospital admission without adequate communityfollow-up.• It is estimated that one third of the homeless population havea mental illness and one half have substance abuse problems.• The National Institute of Mental Health estimates thatmore than 26% of Americans 15 to 44 years of age havea diagnosable mental illness but that only one in fouradults and one in five children and adolescents receivetreatment.• Community-based programs are the trend of the future,but they are underfunded and too few in number.• Managed care, in an effort to contain costs, has resultedin withholding of services or approval of less expensivealternatives for mental health care.• The population in the United States is becoming increasinglydiverse in terms of culture, race, ethnicity,and family structure.• Psychiatric nursing was recognized in the late 1800s,although it was not required in nursing education programsuntil 1950.

14 UNIT 1 • CURRENT THEORIES AND PRACTICEINTERNET RESOURCESRESOURCES• Center for the Study of the History of Nursing• Department of Health and Human Services• National Alliance for the Mentally Ill• National Mental Health Association• World Health Organization• Treatment Advocacy CenterINTERNET ADDRESShttp://www.nursing.upenn.edu/historyhttp://www.dhhs.govhttp://www.nami.orghttp://www.nmha.orghttp://www.who.inthttp://www.psychlaws.org• Psychiatric nursing practice has been profoundly influencedby Hildegard Peplau and June Mellow, who wroteabout the nurse–client relationship, anxiety, nurse therapy,and interpersonal nursing theory.• The American Nurses Association has published standardsof care that guide psychiatric–mental health nursingclinical practice.• Common concerns of nursing students beginning a psychiatricclinical rotation include fear of saying the wrongthing, not knowing what to do, being rejected by clients,being threatened physically, recognizing someonethey know as a client, and sharing similar problems orbackgrounds with clients.• Awareness of one’s feelings, beliefs, attitudes, values,and thoughts, called self-awareness, is essential to thepractice of psychiatric nursing.• The goal of self-awareness is to know oneself so thatone’s values, attitudes, and beliefs are not projected tothe client, interfering with nursing care. Self-awarenessdoes not mean having to change one’s values or beliefs,unless one desires to do so.REFERENCESAmerican Nurses Association. (2007). Psychiatric–mental healthnursing: Scope and standards of practice. Washington, DC: AmericanNurses Publishing, American Nurses Foundation/American NursesAssociation.American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Baly, M. (1982). A leading light. Nursing Mirror, 155(19), 49–51.Department of Health and Human Services. (2000). Healthy people 2010.Washington, DC: Department of Health and Human Services.Department of Health and Human Services. (2008). The Department ofHealth and Human Services on Mental Health Issues. Available at:http://www.dhhs.gov.Doona, M. (1984). At least well cared for . . . Linda Richards and thementally ill. Image, 16(2), 51–56.Gollaher, D. (1995). Voice for the mad: The life of Dorothea Dix. New York:Free Press.McMillan, I. (1997). Insight into bedlam: One hospital’s history. Journalof Psychosocial Nursing, 3(6), 28–34.Mellow, J. (1986). A personal perspective of nursing therapy. Hospitaland Community Psychiatry, 37(2), 182–183.National Alliance for the Mentally Ill. (2007). Mental health parity laws.Retrieved November 15, 2008, from http://www.nami.org.National Institute of Mental Health. (2008). Mental health statistics.Available at: http://www.nimh.nih.gov.Rosenblatt, A. (1984). Concepts of the asylum in the care of the mentallyill. Hospital and Community Psychiatry, 35, 244–250.Treatment Advocacy Center. (2008). Fact sheet: Homelessness. RetrievedNovember 15, 2008, from http://www.pychlaws.org.U.S. Census Bureau. (2000). 2000 Census survey results. Available at:http://www.census.gov.ADDITIONAL READINGSForchuk, C., & Tweedell, D. (2001). Celebrating our past: The historyof Hamilton Psychiatric Hospital. Journal of Psychosocial Nursing,39(10), 16–24.Zahourek, R.P. (2008). Integrative holism in psychiatric–mental healthnursing. Journal of Psychosocial Nursing, 46(10), 31–37.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Approximately how many Americans have a diagnosablemental illness?A. 10%B. 19%C. 26%D. 35%2. The Department of Health and Human Services estimatesthat of the 200,000 chronically homeless personsin the United States, the prevalence of mental illnessand substance abuse isA. 25%B. 40%C. 70%D. 85%3. Hospitals established by Dorothea Dix were designed toprovide which of the following?A. AsylumB. ConfinementC. Therapeutic milieuD. Public safety4. Hildegard Peplau is best known for her writing aboutwhich of the following?A. Community-based careB. Humane treatmentC. PsychopharmacologyD. Therapeutic nurse–client relationship5. How many adults in the United States who need mentalhealth services actually receive care?A. 1 in 2B. 1 in 3C. 1 in 4D. 1 in 5FILL-IN-THE-BLANK QUESTIONSIndicate what type of information is recorded for each axis of the DSM-IV._______________________________________________________________________________________________________________________________________________________________________________________________________________________Axis IAxis IIAxis IIIAxis IVAxis V15

16UNIT 1 • CURRENT THEORIES AND PRACTICESHORT-ANSWER QUESTIONS1. Discuss ideas for increasing the number of people receiving treatment for mental illness.2. Discuss three trends of mental health care in the United States.3. Provide three different concerns nursing students might have as they begin psychiatricnursing clinical experiences.

2NeurobiologicTheories andPsychopharmacologyLearning ObjectivesAfter reading this chapter, you should be able to1. Discuss the structures, processes, and functions of the brain.Key Terms• akathisia• anticholinergic side effects• antidepressant drugs• antipsychotic drugs• anxiolytic drugs• black box warning• computed tomography (CT)• depot injection• dopamine• dystonia• efficacy• epinephrine• extrapyramidal symptoms (EPS)• half-life• kindling process• limbic system• magnetic resonance imaging(MRI)• mood-stabilizing drugs• neuroleptic malignant syndrome(NMS)• neurotransmitter• norepinephrine• off-label use2. Describe the current neurobiologic research and theories that are the basisfor current psychopharmacologic treatment of mental disorders.3. Discuss the nurse’s role in educating clients and families about currentneurobiologic theories and medication management.4. Identify pertinent teaching for clients and families about brain imagingtechniques.5. Discuss the categories of drugs used to treat mental illness and theirmechanisms of action, side effects, and special nursing considerations.6. Identify client responses that indicate treatment effectiveness.7. Discuss common barriers to maintaining the medication regimen.8. Develop a teaching plan for clients and families for implementation of theprescribed therapeutic regimen.• positron emissiontomography (PET)• potency• pseudoparkinsonism• psychoimmunology• psychopharmacology• psychotropic drugs• rebound• serotonin• serotonin syndrome• single photon emissioncomputed tomography(SPECT)• stimulant drugs• tardive dyskinesia (TD)• withdrawalVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!17

18UNIT 1 • CURRENT THEORIES AND PRACTICEALTHOUGH MUCH REMAINS UNKNOWN about what causes mentalillness, science in the past 20 years has made great stridesin helping us understand how the brain works and in presentingpossible causes of why some brains work differentlyfrom others. Such advances in neurobiologic research arecontinually expanding the knowledge base in the field ofpsychiatry and are greatly influencing clinical practice. Thepsychiatric–mental health nurse must have a basic understandingof how the brain functions and of the current theoriesregarding mental illness. This chapter includes anoverview of the major anatomic structures of the nervoussystem and how they work—the neurotransmission process.It presents the major current neurobiologic theories regardingwhat causes mental illness, including genetics and heredity,stress and the immune system, and infectious agents.The use of medications to treat mental illness (psychopharmacology)is related to these neurobiologic theories.These medications directly affect the central nervous system(CNS) and, subsequently, behavior, perceptions, thinking,and emotions. This chapter discusses five categories of drugsused to treat mental illness, including their mechanisms ofaction, their side effects, and the roles of the nurse in administrationand client teaching. Although pharmacologicinterventions are the most effective treatment for many psychiatricdisorders, adjunctive therapies, such as cognitiveand behavioral therapies, family therapy, and psychotherapy,greatly enhance the success of treatment and the client’s outcome.Chapter 3 discusses these psychosocial modalities.THE NERVOUS SYSTEM AND HOW IT WORKSCentral Nervous SystemThe CNS is composed of the brain, the spinal cord, andassociated nerves that control voluntary acts. Structurally,the brain consists of the cerebrum, cerebellum, brain stem,and limbic system. Figures 2.1 and 2.2 show the locationsof brain structures.CerebrumThe cerebrum is divided into two hemispheres; all lobesand structures are found in both halves except for thepineal body, or gland, which is located between the hemispheres.The pineal body is an endocrine gland thatinfluences the activities of the pituitary gland, islets ofLangerhans, parathyroids, adrenals, and gonads. The corpuscallosum is a pathway connecting the two hemispheresand coordinating their functions. The left hemispherecontrols the right side of the body and is the center forlogical reasoning and analytic functions such as reading,writing, and mathematical tasks. The right hemispherecontrols the left side of the body and is the center for creativethinking, intuition, and artistic abilities.The cerebral hemispheres are divided into four lobes:frontal, parietal, temporal, and occipital. Some functionsof the lobes are distinct; others are integrated. The frontallobes control the organization of thought, body movement,memories, emotions, and moral behavior. The integrationof all this information regulates arousal, focusesattention, and enables problem-solving and decision making.Abnormalities in the frontal lobes are associated withschizophrenia, attention deficit hyperactivity disorder(ADHD), and dementia. The parietal lobes interpret sensationsof taste and touch and assist in spatial orientation.The temporal lobes are centers for the senses of smell andhearing and for memory and emotional expression. Theoccipital lobes assist in coordinating language generationand visual interpretation, such as depth perception.CerebellumThe cerebellum is located below the cerebrum and is the centerfor coordination of movements and postural adjustments.Frontal lobeParietal lobeOccipital lobeDiencephalonPituitary glandMidbrainBrain stem PonsMedullaFigure 2.1. Anatomy of the brain.Cerebellum

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 19Motor cortexCentral sulcusSensory area(pain, touch, etc.)Frontal lobeParietal lobeGyriWrittenspeech areaMotorspeech areaLateral sulcusTemporal lobeAuditory receiving areaAuditory association areaPonsMedullaVisualassociationareaOccipitallobeVisualreceivingareaCerebellumSpinal cordFigure 2.2. The brain and its structures.It receives and integrates information from all areas of thebody, such as the muscles, joints, organs, and other componentsof the CNS. Research has shown that inhibitedtransmission of dopamine, a neurotransmitter, in this area isassociated with the lack of smooth coordinated movementsin diseases such as Parkinson’s disease and dementia.Brain StemThe brain stem includes the midbrain, pons, and medullaoblongata and the nuclei for cranial nerves III through XII.The medulla, located at the top of the spinal cord, containsvital centers for respiration and cardiovascular functions.Above the medulla and in front of the cerebrum, the ponsbridges the gap both structurally and functionally, servingas a primary motor pathway. The midbrain connects thepons and cerebellum with the cerebrum. It measures only0.8 inches (2 cm) long and includes most of the reticularactivating system and the extrapyramidal system. Thereticular activating system influences motor activity, sleep,consciousness, and awareness. The extrapyramidal systemrelays information about movement and coordinationfrom the brain to the spinal nerves. The locus ceruleus, asmall group of norepinephrine-producing neurons in thebrain stem, is associated with stress, anxiety, and impulsivebehavior.Limbic SystemThe limbic system is an area of the brain located above thebrain stem that includes the thalamus, hypothalamus, hippocampus,and amygdala (although some sources differregarding the structures this system includes). The thalamusregulates activity, sensation, and emotion. The hypothalamusis involved in temperature regulation, appetitecontrol, endocrine function, sexual drive, and impulsivebehavior associated with feelings of anger, rage, or excitement.The hippocampus and amygdala are involved inemotional arousal and memory. Disturbances in the limbicsystem have been implicated in a variety of mental illnesses,such as the memory loss that accompanies dementiaand the poorly controlled emotions and impulses seenwith psychotic or manic behavior.NeurotransmittersApproximately 100 billion brain cells form groups of neurons,or nerve cells, that are arranged in networks. Theseneurons communicate information with one another bysending electrochemical messages from neuron to neuron,a process called neurotransmission. These electrochemicalmessages pass from the dendrites (projections from thecell body), through the soma or cell body, down the axon(long extended structures), and across the synapses (gapsbetween cells) to the dendrites of the next neuron. In thenervous system, the electrochemical messages cross thesynapses between neural cells by way of special chemicalmessengers called neurotransmitters.Neurotransmitters are the chemical substances manufacturedin the neuron that aid in the transmission of informationthroughout the body. They either excite or stimulatean action in the cells (excitatory) or inhibit or stop an action(inhibitory). These neurotransmitters fit into specific receptorcells embedded in the membrane of the dendrite, justlike a certain key shape fits into a lock. After neurotransmittersare released into the synapse and relay the message tothe receptor cells, they are either transported back from thesynapse to the axon to be stored for later use (reuptake) or

20UNIT 1 • CURRENT THEORIES AND PRACTICEPresynapticneuronPresynapticreceptorMajor neurotransmitters have been found to play a rolein psychiatric illnesses as well as in the actions and sideeffects of psychotropic drugs. Table 2.1 lists the major neurotransmittersand their actions and effects. Dopamine andserotonin have received the most attention in terms of thestudy and treatment of psychiatric disorders (Tecott &Smart, 2005). The following sections discuss the majorneurotransmitters associated with mental disorders.MetaboliteEnzyme3b1PostsynapticneuronT243aReuptake3cPostsynapticreceptorFigure 2.3. Schematic illustration of (1) neurotransmitter(T) release; (2) binding of transmitter to postsynapticreceptor; termination of transmitter action by (3a) reuptakeof transmitter into the presynaptic terminal, (3b) enzymaticdegradation, or (3c) diffusion away from the synapse; and(4) binding of transmitter to presynaptic receptors forfeedback regulation of transmitter release.metabolized and inactivated by enzymes, primarily monoamineoxidase (MAO) (Figure 2.3).These neurotransmitters are necessary in just the rightproportions to relay messages across the synapses. Studiesare beginning to show differences in the amount of someneurotransmitters available in the brains of people withcertain mental disorders compared with people who haveno signs of mental illness (Figure 2.4).DopamineDopamine, a neurotransmitter located primarily in thebrain stem, has been found to be involved in the control ofcomplex movements, motivation, cognition, and regulationof emotional responses. It is generally excitatory andis synthesized from tyrosine, a dietary amino acid. Dopamineis implicated in schizophrenia and other psychosesas well as in movement disorders such as Parkinson’s disease.Antipsychotic medications work by blocking dopaminereceptors and reducing dopamine activity.Norepinephrine and EpinephrineNorepinephrine, the most prevalent neurotransmitter inthe nervous system, is located primarily in the brain stemand plays a role in changes in attention, learning andmemory, sleep and wakefulness, and mood regulation.Norepinephrine and its derivative, epinephrine, are alsoknown as noradrenaline and adrenaline, respectively.Excess norepinephrine has been implicated in several anxietydisorders; deficits may contribute to memory loss,social withdrawal, and depression. Some antidepressantsblock the reuptake of norepinephrine, whereas othersinhibit MAO from metabolizing it. Epinephrine has limiteddistribution in the brain but controls the fight-orflightresponse in the peripheral nervous system.DopamineDopaminereceptorA Deficient neurotransmitterC Excess neurotransmitterB Deficient receptorsD Excess receptorsFigure 2.4. Abnormal neurotransmission causing some mental disorders because of excess transmission or excessresponsiveness of receptors.

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 21Table 2.1MAJOR NEUROTRANSMITTERSType Mechanism of Action Physiologic EffectsDopamine Excitatory Controls complex movements, motivation, cognition;regulates emotional responseNorepinephrine(noradrenaline)ExcitatoryCauses changes in attention, learning and memory, sleepand wakefulness, moodEpinephrineExcitatoryControls fight-or-flight response(adrenaline)Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperatureregulation, pain control, sexual behaviors, regulation of emotionsHistamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheralallergic responsesAcetylcholine Excitatory or inhibitory Controls sleep and wakefulness cycle; signals muscles to become alertNeuropeptides Neuromodulators Enhance, prolong, inhibit, or limit the effects of principalneurotransmittersGlutamate Excitatory Results in neurotoxicity if levels are too highGamma-aminobutyricacid (GABA)InhibitoryModulates other neurotransmittersSerotoninSerotonin, a neurotransmitter found only in the brain, isderived from tryptophan, a dietary amino acid. The functionof serotonin is mostly inhibitory, and it is involved in thecontrol of food intake, sleep and wakefulness, temperatureregulation, pain control, sexual behavior, and regulation ofemotions. Serotonin plays an important role in anxiety andmood disorders and schizophrenia. It has been found to contributeto the delusions, hallucinations, and withdrawnbehavior seen in schizophrenia. Some antidepressants blockserotonin reuptake, thus leaving it available longer in thesynapse, which results in improved mood.HistamineThe role of histamine in mental illness is under investigation.It is involved in peripheral allergic responses, controlof gastric secretions, cardiac stimulation, and alertness.Some psychotropic drugs block histamine, resulting inweight gain, sedation, and hypotension.AcetylcholineAcetylcholine is a neurotransmitter found in the brain,spinal cord, and peripheral nervous system, particularly atthe neuromuscular junction of skeletal muscle. It can beexcitatory or inhibitory. It is synthesized from dietary cholinefound in red meat and vegetables and has been foundto affect the sleep–wake cycle and to signal muscles tobecome active. Studies have shown that people withAlzheimer’s disease have decreased acetylcholine-secretingneurons, and people with myasthenia gravis (a musculardisorder in which impulses fail to pass the myoneuraljunction, which causes muscle weakness) have reducedacetylcholine receptors.GlutamateGlutamate is an excitatory amino acid that at high levelscan have major neurotoxic effects. It has been implicatedin the brain damage caused by stroke, hypoglycemia, sustainedhypoxia or ischemia, and some degenerative diseasessuch as Huntington’s or Alzheimer’s.Gamma-Aminobutyric AcidGamma-aminobutyric acid (γ-aminobutyric acid, orGABA), an amino acid, is the major inhibitory neurotransmitterin the brain and has been found to modulate otherneurotransmitter systems rather than to provide a directstimulus (Plata-Salaman, Shank, & Smith-Swintosky,2005). Drugs that increase GABA function, such as benzodiazepines,are used to treat anxiety and to induce sleep.BRAIN IMAGING TECHNIQUESAt one time, the brain could be studied only through surgeryor autopsy. During the past 25 years, however, severalbrain imaging techniques have been developed that nowallow visualization of the brain’s structure and function.These techniques are useful for diagnosing some disordersof the brain and have helped to correlate certain areas ofthe brain with specific functions. Brain imaging techniquesare also useful in research to find the causes of mental

22UNIT 1 • CURRENT THEORIES AND PRACTICETable 2.2BRAIN IMAGING TECHNOLOGYProcedure Imaging Method Results DurationComputed tomography (CT) Serial x-rays of brain Structural image 20–40 minutesMagnetic resonance imaging (MRI) Radio waves from brain detected from magnet Structural image 45 minutesPositron emission tomography (PET) Radioactive tracer injected into bloodstream Functional 2–3 hoursand monitored as client performs activitiesSingle photon emission computedtomography (SPECT)Same as PET Functional 1–2 hoursdisorders. Table 2.2 describes and compares several ofthese diagnostic techniques.Types of Brain Imaging TechniquesComputed tomography (CT), also called computed axialtomography (CAT), is a procedure in which a precise x-raybeam takes cross-sectional images (slices) layer by layer. Acomputer reconstructs the images on a monitor and alsostores the images on magnetic tape or film. CT can visualizethe brain’s soft tissues, so it is used to diagnose primarytumors, metastases, and effusions and to determine the sizeof the ventricles of the brain. Some people with schizophreniahave been shown to have enlarged ventricles; this findingis associated with a poorer prognosis and marked negativesymptoms (Figure 2.5; see Chapter 14). The person undergoingCT must lie motionless on a stretcher-like table forabout 20 to 40 minutes as the stretcher passes through atunnel-like “ring” while the serial x-rays are taken.In magnetic resonance imaging (MRI), a type of bodyscan, an energy field is created with a huge magnet andradio waves. The energy field is converted to a visual imageor scan. MRI produces more tissue detail and contrast thanCT and can show blood flow patterns and tissue changessuch as edema. It also can be used to measure the size andthickness of brain structures; persons with schizophreniacan have as much as 7% reduction in cortical thickness.The person undergoing an MRI must lie in a small, closedchamber and remain motionless during the procedure,which takes about 45 minutes. Those who feel claustrophobicor have increased anxiety may require sedationbefore the procedure. Clients with pacemakers or metalimplants, such as heart valves or orthopedic devices, cannotundergo MRI.More advanced imaging techniques, such as positronemission tomography (PET) and single photon emissioncomputed tomography (SPECT), are used to examine thefunction of the brain. Radioactive substances are injectedinto the blood; the flow of those substances in the brain ismonitored as the client performs cognitive activities asinstructed by the operator. PET uses two photons simultaneously;SPECT uses a single photon. PET providesFigure 2.5. Example of computed tomography of the brain of a patient with schizophrenia(right) compared with a normal control (left).

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 23• Researchers are finding that many of the changes in disorderssuch as schizophrenia are at the molecular andchemical levels and cannot be detected with currentimaging techniques (Fujita et al., 2005; Vythilingamet al., 2005).Figure 2.6. Example of axial (horizontal) positron emissiontomography of a male patient with Alzheimer’s disease,showing defects (arrowheads) in metabolism in the regionsof the cerebral cortex of brain.better resolution with sharper and clearer pictures andtakes about 2 to 3 hours; SPECT takes 1 to 2 hours. PETand SPECT are used primarily for research, not for thediagnosis and treatment of clients with mental disorders(Fujita, Kugaya, & Innis, 2005; Vythilingam et al., 2005)(Figure 2.6). A recent breakthrough is the use of thechemical marker FDDNP with PET to identify the amyloidplaques and tangles of Alzheimer’s disease in livingclients; these conditions previously could be diagnosedonly through autopsy. These scans have shown that clientswith Alzheimer’s disease have decreased glucosemetabolism in the brain and decreased cerebral bloodflow. Some persons with schizophrenia also demonstratedecreased cerebral blood flow.Limitations of Brain Imaging TechniquesAlthough imaging techniques such as PET and SPECThave helped bring about tremendous advances in the studyof brain diseases, they have some limitations:• The use of radioactive substances in PET and SPECTlimits the number of times a person can undergo thesetests. There is the risk that the client will have an allergicreaction to the substances. Some clients may findreceiving intravenous doses of radioactive materialfrightening or unacceptable.• Imaging equipment is expensive to purchase and maintain,so availability can be limited. A PET camera costs about$2.5 million; a SPECT camera costs about $500,000.• Some persons cannot tolerate these procedures becauseof fear or claustrophobia.NEUROBIOLOGIC CAUSESOF MENTAL ILLNESSGenetics and HeredityUnlike many physical illnesses that have been found to behereditary, such as cystic fibrosis, Huntington’s disease,and Duchenne’s muscular dystrophy, the origins of mentaldisorders do not seem to be that simple. Current theoriesand studies indicate that several mental disorders may belinked to a specific gene or combination of genes but thatthe source is not solely genetic; nongenetic factors alsoplay important roles.To date, one of the most promising discoveries is theidentification in 2007 of variations in the gene SORL1 thatmay be a factor in late-onset Alzheimer’s disease. Researchis continuing in an attempt to find genetic links to otherdiseases such as schizophrenia and mood disorders. This isthe focus of the ongoing research in the Human GenomeProject, funded by the National Institutes of Health (NIH)and the U.S. Department of Energy. This internationalresearch project, started in 1988, is the largest of its kind. Ithas identified all human DNA and continues with researchto discover the human characteristics and diseases eachgene is related to (encoding). In addition, the project alsoaddresses the ethical, legal, and social implications ofhuman genetics research. This program (known as ELSI)focuses on privacy and fairness in the use and interpretationof genetic information, clinical integration of newgenetic technologies, issues surrounding genetics research,and professional and public education (NIH, 2007). Theresearchers publish their results in the journal Science; furtherinformation can be obtained at www.genome.gov.Three types of studies are commonly conducted toinvestigate the genetic basis of mental illness:1. Twin studies are used to compare the rates of certainmental illnesses or traits in monozygotic (identical)twins, who have an identical genetic makeup, and dizygotic(fraternal) twins, who have a different geneticmakeup. Fraternal twins have the same genetic similaritiesand differences as nontwin siblings.2. Adoption studies are used to determine a trait amongbiologic versus adoptive family members.3. Family studies are used to compare whether a trait ismore common among first-degree relatives (parents,siblings, and children) than among more distant relativesor the general population.Although some genetic links have been found in certainmental disorders, studies have not shown that these illnesses

24UNIT 1 • CURRENT THEORIES AND PRACTICEare solely genetically linked. Investigation continues aboutthe influence of inherited traits versus the influence of theenvironment—the “nature versus nurture” debate. Theinfluence of environmental or psychosocial factors is discussedin Chapter 3.Stress and the Immune System(Psychoimmunology)Researchers are following many avenues to discover possiblecauses of mental illness. Psychoimmunology, a relativelynew field of study, examines the effect of psychosocialstressors on the body’s immune system. Acompromised immune system could contribute to thedevelopment of a variety of illnesses, particularly in populationsalready genetically at risk. So far, efforts to linka specific stressor with a specific disease have beenunsuccessful.Infection as a Possible CauseSome researchers are focusing on infection as a cause ofmental illness. Most studies involving viral theories havefocused on schizophrenia, but so far none has providedspecific or conclusive evidence. Theories that are beingdeveloped and tested include the existence of a virus thathas an affinity for tissues of the CNS, the possibility that avirus may actually alter human genes, and maternal exposureto a virus during critical fetal development of the nervoussystem.Swedo and Grant (2005) studied the relation of streptococcalbacteria and obsessive–compulsive disorder(OCD) and tics. They found enlarged basal ganglia, indicatinga possible autoimmune response to streptococcalinfection. When blood plasma (high in streptococcal antibodies)was replaced by transfusion with healthy donorplasma, the incidence of tics decreased by 50%, and otherOCD symptoms were reduced by 60%. Studies such asthis are promising in discovering a link between infectionand mental illness.THE NURSE’S ROLE IN RESEARCHAND EDUCATIONAmid all the reports of research in these areas of neurobiology,genetics, and heredity, the implications for clientsand their families are still not clear or specific. Often,reports in the media regarding new research and studiesare confusing, contradictory, or difficult for clients andtheir families to understand. The nurse must ensure thatclients and families are well informed about progress inthese areas and must also help them to distinguish betweenfacts and hypotheses. The nurse can explain if or how newresearch may affect a client’s treatment or prognosis. Thenurse is a good resource for providing information andanswering questions.Keeping clients informedPSYCHOPHARMACOLOGYMedication management is a crucial issue that greatlyinfluences the outcomes of treatment for many clientswith mental disorders. The following sections discuss severalcategories of drugs used to treat mental disorders(psychotropic drugs): antipsychotics, antidepressants,mood stabilizers, anxiolytics, and stimulants. Nursesshould understand how these drugs work; their sideeffects, contraindications, and interactions; and the nursinginterventions required to help clients manage medicationregimens.Several terms used in discussions of drugs and drugtherapy are important for nurses to know. Efficacy refersto the maximal therapeutic effect that a drug can achieve.Potency describes the amount of the drug needed toachieve that maximum effect; low-potency drugs requirehigher dosages to achieve efficacy, whereas high-potencydrugs achieve efficacy at lower dosages. Half-life is thetime it takes for half of the drug to be removed from thebloodstream. Drugs with a shorter half-life may need to begiven three or four times a day, but drugs with a longerhalf-life may be given once a day. The time that a drugneeds to leave the body completely after it has been discontinuedis about five times its half-life.The U.S. Food and Drug Administration (FDA) isresponsible for supervising the testing and marketing of

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 25medications for public safety. These activities include clinicaldrug trials for new drugs and monitoring the effectivenessand side effects of medications. The FDA approveseach drug for use in a particular population and for specificdiseases. At times, a drug will prove effective for a diseasethat differs from the one involved in original testing andFDA approval. This is called off-label use. An example issome anticonvulsant drugs (approved to prevent seizures)that are prescribed for their effects in stabilizing the moodsof clients with bipolar disorder (off-label use). The FDAalso monitors the occurrence and severity of drug sideeffects. When a drug is found to have serious or lifethreateningside effects, even if such side effects are rare,the FDA may issue a black box warning. This means thatpackage inserts must have a highlighted box, separate fromthe text, which contains a warning about the serious or lifethreateningside effects. Several psychotropic medicationsdiscussed later in this chapter carry black box warnings.Principles That Guide PharmacologicTreatmentThe following are several principles that guide the use ofmedications to treat psychiatric disorders:• A medication is selected based on its effect on the client’starget symptoms such as delusional thinking,panic attacks, or hallucinations. The medication’s effectivenessis evaluated largely by its ability to diminish oreliminate the target symptoms.• Many psychotropic drugs must be given in adequate dosagesfor some time before their full effect is realized. Forexample, tricyclic antidepressants can require 4 to 6 weeksbefore the client experiences optimal therapeutic benefit.• The dosage of medication often is adjusted to the lowesteffective dosage for the client. Sometimes a clientmay need higher dosages to stabilize his or her targetsymptoms, whereas lower dosages can be used to sustainthose effects over time.• As a rule, older adults require lower dosages of medicationsthan do younger clients to experience therapeuticeffects. It also may take longer for a drug to achieve itsfull therapeutic effect in older adults.• Psychotropic medications often are decreased gradually(tapering) rather than abruptly. This is because ofpotential problems with rebound (temporary return ofsymptoms), recurrence of the original symptoms, orwithdrawal (new symptoms resulting from discontinuationof the drug).• Follow-up care is essential to ensure compliance withthe medication regimen, to make needed adjustmentsin dosage, and to manage side effects.• Compliance with the medication regimen often is enhancedwhen the regimen is as simple as possible interms of both the number of medications prescribedand the number of daily doses.Antipsychotic DrugsAntipsychotic drugs, also known as neuroleptics, are usedto treat the symptoms of psychosis, such as the delusionsand hallucinations seen in schizophrenia, schizoaffectivedisorder, and the manic phase of bipolar disorder. Off-labeluses of antipsychotics include treatment of anxiety andinsomnia; aggressive behavior; and delusions, hallucinations,and other disruptive behaviors that sometimesaccompany Alzheimer’s disease. Antipsychotic drugs workby blocking receptors of the neurotransmitter dopamine.They have been in clinical use since the 1950s. They arethe primary medical treatment for schizophrenia and alsoare used in psychotic episodes of acute mania, psychoticdepression, and drug-induced psychosis. Clients withdementia who have psychotic symptoms sometimesrespond to low dosages of conventional antipsychotics.Atypical antipsychotics can increase mortality rates inelderly clients with dementia-related psychosis. Shorttermtherapy with antipsychotics may be useful for transientpsychotic symptoms such as those seen in someclients with borderline personality disorder.Table 2.3 lists available dosage forms, usual daily oral dosages,and extreme dosage ranges for conventional and atypicalantipsychotic drugs. The low end of the extreme rangetypically is used with older adults or children with psychoses,aggression, or extreme behavior management problems.Mechanism of ActionThe major action of all antipsychotics in the nervous systemis to block receptors for the neurotransmitter dopamine;however, the therapeutic mechanism of action is only partiallyunderstood. Dopamine receptors are classified intosubcategories (D1, D2, D3, D4, and D5), and D2, D3, andD4 have been associated with mental illness. The typicalantipsychotic drugs are potent antagonists (blockers) of D2,D3, and D4. This makes them effective in treating targetsymptoms but also produces many extrapyramidal sideeffects (discussion to follow) because of the blocking of theD2 receptors. Newer, atypical antipsychotic drugs, such asclozapine (Clozaril), are relatively weak blockers of D2,which may account for the lower incidence of extrapyramidalside effects. In addition, atypical antipsychotics inhibitthe reuptake of serotonin, as do some of the antidepressants,increasing their effectiveness in treating the depressiveaspects of schizophrenia. Paliperidone (Invega) is the newestatypical antipsychotic, gaining approval for distributionin the United States in January 2007. It is chemically similarto risperidone (Risperdal); however, it is an extended-releasepreparation. This means the client can take one daily dose inmost cases, which may be a factor in increased compliance.A new generation of antipsychotics, called dopaminesystem stabilizers, is being developed. These drugs arethought to stabilize dopamine output; that is, they preserveor enhance dopaminergic transmission when it is too lowand reduce it when it is too high. This results in control of

26UNIT 1 • CURRENT THEORIES AND PRACTICETable 2.3ANTIPSYCHOTIC DRUGSGeneric (Trade) Name Forms Daily Dosage∗ Extreme Dosage Ranges∗Conventional AntipsychoticsPhenothiazinesChlorpromazine (Thorazine) T, L, INJ 200–1,600 25–2,000Perphenazine (Trilafon) T, L, INJ 16–32 4–64Fluphenazine (Prolixin) T, L, INJ 2.5–20 1–60Thioridazine (Mellaril) T, L 200–600 40–800Mesoridazine (Serentil) T, L, INJ 75–300 30–400Trifluoperazine (Stelazine) T, L, INJ 6–50 2–80ThioxantheneThiothixene (Navane) C, L, INJ 6–30 6–60ButyrophenonesHaloperidol (Haldol) T, L, INJ 2–20 1–100Droperidol (Inapsine) INJ 2.5DibenzazepineLoxapine (Loxitane) C, L, INJ 60–100 30–250DihydroindoloneMolindone (Moban) T, L 50–100 15–250Atypical AntipsychoticsClozapine (Clozaril) T 150–500 75–700Fazclo (clozapine) DT 150–500 75–700Risperidone (Risperdal) T, L, DT 2–8 1–16Olanzapine (Zyprexa) T 5–15 5–20Quetiapine (Seroquel) T 300–600 200–750Ziprasidone (Geodon) C, INJ 40–160 20–200Paliperidone (Invega) T 6 3–12New Generation AntipsychoticAripiprazole (Abilify) T 15–30 10–40∗Values are in milligrams per day for oral doses only.T, tablet; C, capsule; L, liquid for oral use; INJ, injection for IM (usually PRN) use; DT, orally disintegrating tablet.symptoms without some of the side effects of other antipsychoticmedications. Aripiprazole (Abilify), the first drug ofthis type, was approved for use in November 2002. In clinicaltrials, the most common side effects were headache,anxiety, and nausea.Four antipsychotics are available in depot injection, a timereleaseform of medication for maintenance therapy. Two conventionalantipsychotics use sesame oil as the vehicle for theseinjections, so the medication is absorbed slowly over time;thus, less frequent administration is needed to maintain thedesired therapeutic effects. Prolixin (decanoate fluphenazine)has a duration of 7 to 28 days, and Haldol (decanoate haloperidol)has a duration of 4 weeks. After the client’s condition isstabilized with oral doses of these medications, administrationby depot injection is required every 2 to 4 weeks to maintainthe therapeutic effect. Risperidone (Risperdal Consta) Paliperidone(Invega Sustenna), atypical antipsychotics, encapsulatesactive medication into polymer-based microspheres thatdegrade slowly in the body, gradually releasing the drug at acontrolled rate. Risperdal Consta, 25 mg, is given every 2 weeks.Paliperidone (Invega Sustenna) 117mg is given every 4 weeks.WARNINGAtypical AntipsychoticsElderly patients with dementia-related psychosistreated with atypical antipsychotic drugs are at anincreased risk for death. Causes of death were varied,but most of the deaths appeared to be either cardiovascularor infectious in nature.Side EffectsExtrapyramidal Side Effects. Extrapyramidal symptoms(EPS), serious neurologic symptoms, are the major sideeffects of antipsychotic drugs. They include acute dystonia,pseudoparkinsonism, and akathisia. Although oftencollectively referred to as EPS, each of these reactions hasdistinct features. One client can experience all the reactionsin the same course of therapy, which makes distinguishingamong them difficult. Blockade of D2 receptors in themidbrain region of the brain stem is responsible for thedevelopment of EPS. Conventional antipsychotic drugscause a greater incidence of EPS than do atypical

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 27antipsychotic drugs, with ziprasidone (Geodon) rarelycausing EPS (Daniel, Copeland, & Tamminga, 2006).WARNINGGeodonContraindicated in patients with a known history ofQT prolongation, recent myocardial infarction, oruncompensated heart failure, it should not be usedwith other QT-prolonging drugs.Therapies for acute dystonia, pseudoparkinsonism, andakathisia are similar and include lowering the dosage ofthe antipsychotic, changing to a different antipsychotic, oradministering anticholinergic medication (discussion tofollow). Whereas anticholinergic drugs also produce sideeffects, atypical antipsychotic medications are often prescribedbecause the incidence of EPS side effects associatedwith them is decreased.Acute dystonia includes acute muscular rigidity andcramping, a stiff or thick tongue with difficulty swallowing,and, in severe cases, laryngospasm and respiratory difficulties.Dystonia is most likely to occur in the first weekof treatment, in clients younger than 40 years, in males,and in those receiving high-potency drugs such as haloperidoland thiothixene. Spasms or stiffness in musclegroups can produce torticollis (twisted head and neck),opisthotonus (tightness in the entire body with the headback and an arched neck), or oculogyric crisis (eyes rolledback in a locked position). Acute dystonic reactions can bepainful and frightening for the client. Immediate treatmentwith anticholinergic drugs, such as intramuscular benztropinemesylate (Cogentin) or intramuscular or intravenousdiphenhydramine (Benadryl), usually brings rapid relief.Table 2.4 lists the drugs, and their routes and dosages,used to treat EPS. The addition of a regularly scheduledoral anticholinergic such as benztropine may allow theclient to continue taking the antipsychotic drug with nofurther dystonia. Recurrent dystonic reactions wouldnecessitate a lower dosage or a change in the antipsychoticdrug. Assessment of EPS using the Simpson–Angus ratingscale is discussed further in Chapter 14.Drug-induced parkinsonism, or pseudoparkinsonism, isoften referred to by the generic label of EPS. Symptomsresemble those of Parkinson’s disease and include a stiff,stooped posture; mask-like facies; decreased arm swing; ashuffling, festinating gait (with small steps); cogwheel rigidity(ratchet-like movements of joints); drooling; tremor;bradycardia; and coarse pill-rolling movements of thethumb and fingers while at rest. Parkinsonism is treated bychanging to an antipsychotic medication that has a lowerincidence of EPS or by adding an oral anticholinergic agentor amantadine, which is a dopamine agonist that increasestransmission of dopamine blocked by the antipsychoticdrug.Akathisia is reported by the client as an intense need tomove about. The client appears restless or anxious andagitated, often with a rigid posture or gait and a lack ofspontaneous gestures. This feeling of internal restlessnessand the inability to sit still or rest often leads clients todiscontinue their antipsychotic medication. Akathisia canbe treated by a change in antipsychotic medication or bythe addition of an oral agent such as a beta-blocker, anticholinergic,or benzodiazepine.Neuroleptic Malignant Syndrome. Neuroleptic malignantsyndrome (NMS) is a potentially fatal idiosyncratic reactionto an antipsychotic (or neuroleptic) drug. Althoughthe Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision (American Psychiatric Association,2000) notes that the death rate from this syndromehas been reported at 10% to 20%, those figures may haveresulted from biased reporting; the reported rates are nowdecreasing. The major symptoms of NMS are rigidity; highfever; autonomic instability such as unstable blood pressure,diaphoresis, and pallor; delirium; and elevated levelsof enzymes, particularly creatine phosphokinase. Clientswith NMS usually are confused and often mute; they mayfluctuate from agitation to stupor. All antipsychotics seemto have the potential to cause NMS, but high dosages ofTable 2.4DRUGS USED TO TREAT EXTRAPYRAMIDAL SIDE EFFECTSGeneric (Trade) Name Oral Dosages (mg) IM/IV Doses (mg) Drug ClassAmantadine (Symmetrel) 100 bid or tid — DopaminergicagonistBenztropine (Cogentin) 1–3 bid 1–2 AnticholinergicBiperiden (Akineton) 2 tid–qid 2 AnticholinergicDiazepam (Valium) 5 tid 5–10 BenzodiazepineDiphenhydramine (Benadryl) 25–50 tid or qid 25–50 AntihistamineLorazepam (Ativan) 1–2 tid — BenzodiazepineProcyclidine (Kemadrin) 2.5–5 tid — AnticholinergicPropranolol (Inderal) 10–20 tid; up to 40 qid — Beta-blockerTrihexyphenidyl (Artane) 2–5 tid — Anticholinergic

28UNIT 1 • CURRENT THEORIES AND PRACTICEAkathisiahigh-potency drugs increase the risk. NMS most oftenoccurs in the first 2 weeks of therapy or after an increasein dosage, but it can occur at any time.Dehydration, poor nutrition, and concurrent medicalillness all increase the risk for NMS. Treatment includesimmediate discontinuance of all antipsychotic medicationsand the institution of supportive medical care totreat dehydration and hyperthermia until the client’sphysical condition stabilizes. After NMS, the decision totreat the client with other antipsychotic drugs requiresfull discussion between the client and the physician toweigh the relative risks against the potential benefits oftherapy.Tardive Dyskinesia. Tardive dyskinesia (TD), a syndro meof permanent involuntary movements, is most commonlycaused by the long-term use of conventional antipsychoticdrugs. About 20% to 30% of patients on long-term treatmentdevelop symptoms of TD (Sadock & Sadock, 2008). Thepathophysiology is still unclear, and no effective treatmenthas been approved for general use. However, Woods, Saksa,Baker, Cohen, and Tek (2008) report success in treatingTD with levetiracetam in clinical trials. The symptomsof TD include involuntary movements of the tongue,facial and neck muscles, upper and lower extremities, andtruncal musculature. Tongue thrusting and protruding, lipsmacking, blinking, grimacing, and other excessive unnecessaryfacial movements are characteristic. After it has developed,TD is irreversible, although decreasing or discontinuingantipsychotic medications can arrest its progression. Unfortunately,antipsychotic medications can mask the beginningsymptoms of TD; that is, increased dosages of the antipsychoticmedication cause the initial symptoms to disappeartemporarily. As the symptoms of TD worsen, however, they“break through” the effect of the antipsychotic drug.Preventing TD is one goal when administering antipsychotics.This can be done by keeping maintenance dosagesas low as possible, changing medications, and monitoringthe client periodically for initial signs of TD using a standardizedassessment tool such as the Abnormal InvoluntaryMovement Scale (see Chapter 14). Clients who havealready developed signs of TD but still need to take anantipsychotic medication often are given one of the atypicalantipsychotic drugs that have not yet been found tocause or, therefore, worsen TD.Anticholinergic Side Effects. Anticholinergic side effectsoften occur with the use of antipsychotics and includeorthostatic hypotension, dry mouth, constipation, urinaryhesitance or retention, blurred near vision, dry eyes, photophobia,nasal congestion, and decreased memory. Theseside effects usually decrease within 3 to 4 weeks but do notentirely remit. The client taking anticholinergic agents forEPS may have increased problems with anticholinergicside effects. Using calorie-free beverages or hard candymay alleviate dry mouth; stool softeners, adequate fluidintake, and the inclusion of grains and fruit in the diet mayprevent constipation.Other Side Effects. Antipsychotic drugs also increaseblood prolactin levels. Elevated prolactin may cause breastenlargement and tenderness in men and women; diminishedlibido, erectile and orgasmic dysfunction, and menstrualirregularities; and increased risk for breast cancer,and may contribute to weight gain.Weight gain can accompany most antipsychotic medications,but it is most likely with the atypical antipsychoticdrugs, with ziprasidone (Geodon) being theexception. Weight increases are most significant withclozapine (Clozaril) and olanzapine (Zyprexa). Since2004, the FDA has made it mandatory for drug manufacturersthat atypical antipsychotics carry a warning of theincreased risk for hyperglycemia and diabetes. Thoughthe exact mechanism of this weight gain is unknown, it isassociated with increased appetite, binge eating, carbohydratecraving, food preference changes, and decreasedsatiety in some clients. In addition, clients with a geneticpredisposition for weight gain are at greater risk (Muller& Kennedy, 2006). Prolactin elevation may stimulatefeeding centers, histamine antagonism stimulates appetite,and there may be an as yet undetermined interplayof multiple neurotransmitter and receptor interactions withresultant changes in appetite, energy intake, and feeding

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 29behavior. Obesity is common in clients with schizophrenia,further increasing the risk for type 2 diabetes mellitusand cardiovascular disease (Newcomer & Haupt,2006). In addition, clients with schizophrenia are lesslikely to exercise or eat low-fat nutritionally balanceddiets; this pattern decreases the likelihood that they canminimize potential weight gain or lose excess weight. Itis recommended that clients taking antipsychotics beinvolved in an educational program to control weightand decrease body mass index.Most antipsychotic drugs cause relatively minor cardiovascularadverse effects such as postural hypotension, palpitations,and tachycardia. Certain antipsychotic drugs, suchas thioridazine (Mellaril), droperidol (Inapsine), andmesoridazine (Serentil), also can cause a lengthening of theQT interval. A QT interval longer than 500 ms is consideredWARNINGDroperidol, Thioridazine, MesoridazineMay lengthen the QT interval, leading to potentiallylife-threatening cardiac dysrhythmias or cardiacarrest.dangerous and is associated with life-threatening dysrhythmiasand sudden death. Though rare, the lengthened QTinterval can cause torsade de pointes, a rapid heart rhythm of150 to 250 beats per minute, resulting in a “twisted” appearanceon the electrocardiogram; hence the name torsade depointes (Glassman, 2005). Thioridazine and mesoridazineare used to treat psychosis; droperidol is most often used asan adjunct to anesthesia or to produce sedation. Sertindole(Serlect) was never approved in the United States to treatpsychosis, but was used in Europe and was subsequentlywithdrawn from the market because of the number ofcardiac dysrhythmias and deaths that it caused.Clozapine produces fewer traditional side effects thando most antipsychotic drugs, but it has the potentially fatalside effect of agranulocytosis. This develops suddenly andis characterized by fever, malaise, ulcerative sore throat,and leukopenia. This side effect may not be manifestedimmediately and can occur up to 24 weeks after the initiationof therapy. Initially, clients needed to have a weeklywhite blood cell count (WBC) above 3,500 per mm 3to obtain the next week’s supply of clozapine. Currently,all clients must have weekly WBCs drawn for the first6 months. If the WBC is 3,500 per mm 3 and the absoluteneutrophil count (ANC) is 2,000 per mm 3 , the client mayhave these labs monitored every 2 weeks for 6 months,and then every 4 weeks. This decreased monitoring isdependent on continuous therapy with clozapine. Anyinterruption in therapy requires a return to more frequentmonitoring for a specified period of time. After clozapinehas been discontinued, weekly monitoring of the WBCand ANC is required for 4 weeks.WARNINGClozapineMay cause agranulocytosis, a potentially life-threateningevent. Clients who are being treated with clozapinemust have a baseline WBC count and differential beforeinitiation of treatment and a WBC count every weekthroughout treatment and for 4 weeks after discontinuationof clozapine.Client TeachingThe nurse informs clients taking antipsychotic medicationabout the types of side effects that may occur and encouragesclients to report such problems to the physician insteadof discontinuing the medication. The nurse teaches the clientmethods of managing or avoiding unpleasant sideeffects and maintaining the medication regimen. Drinkingsugar-free fluids and eating sugar-free hard candy ease drymouth. The client should avoid calorie-laden beveragesand candy because they promote dental caries, contributeto weight gain, and do little to relieve dry mouth. Methodsto prevent or relieve constipation include exercising andincreasing water and bulk-forming foods in the diet. Stoolsofteners are permissible, but the client should avoidlaxatives. The use of sunscreen is recommended becausephotosensitivity can cause the client to sunburn easily.Clients should monitor the amount of sleepiness ordrowsiness they feel. They should avoid driving and performingother potentially dangerous activities until theirresponse times and reflexes seem normal.If the client forgets a dose of antipsychotic medication,he or she can take the missed dose if it is only 3 or 4 hourslate. If the dose is more than 4 hours overdue or the nextdose is due, the client can omit the forgotten dose. Thenurse encourages clients who have difficulty rememberingto take their medication to use a chart and to record doseswhen taken or to use a pillbox that can be prefilled withaccurate doses for the day or week.Antidepressant DrugsAntidepressant drugs are primarily used in the treatmentof major depressive illness, anxiety disorders, the depressedphase of bipolar disorder, and psychotic depression. Offlabeluses of antidepressants include the treatment ofchronic pain, migraine headaches, peripheral and diabeticneuropathies, sleep apnea, dermatologic disorders, panicdisorder, and eating disorders. Although the mechanism ofaction is not completely understood, antidepressantssomehow interact with the two neurotransmitters, norepinephrineand serotonin, that regulate mood, arousal,attention, sensory processing, and appetite.Antidepressants are divided into four groups:1. Tricyclic and the related cyclic antidepressants2. Selective serotonin reuptake inhibitors (SSRIs)3. MAO inhibitors (MAOIs)

30UNIT 1 • CURRENT THEORIES AND PRACTICE4. Other antidepressants such as venlafaxine desvenlafaxine(Pristiq) (Effexor), bupropion (Wellbutrin), duloxetine(Cymbalta), trazodone (Desyrel), and nefazodone (Serzone).Table 2.5 lists the dosage forms, usual daily dosages,and extreme dosage ranges.The cyclic compounds became available in the 1950sand for years were the first choice of drugs to treat depressioneven though they cause varying degrees of sedation,orthostatic hypotension (drop in blood pressure on rising),and anticholinergic side effects. In addition, cyclic antidepressantsare potentially lethal if taken in an overdose.During that same period, the MAOIs were discovered tohave a positive effect on people with depression. Althoughthe MAOIs have a low incidence of sedation and anticholinergiceffects, they must be used with extreme cautionfor several reasons:• A life-threatening side effect, hypertensive crisis, mayoccur if the client ingests foods containing tyramine(an amino acid) while taking MAOIs.• Because of the risk for potentially fatal drug interactions,MAOIs cannot be given in combination with otherMAOIs, tricyclic antidepressants, meperidine (Demerol),CNS depressants, many antihypertensives, or generalanesthetics.• MAOIs are potentially lethal in overdose and pose apotential risk in clients with depression who may beconsidering suicide.The SSRIs, first available in 1987 with the release offluoxetine (Prozac), have replaced the cyclic drugs asthe first choice in treating depression because they areequal in efficacy and produce fewer troublesome sideeffects. The SSRIs and clomipramine are effective in thetreatment of OCD as well. Prozac Weekly is the first andonly medication that can be given once a week as maintenancetherapy for depression after the client has beenstabilized on fluoxetine. It contains 90 mg of fluoxetinewith an enteric coating that delays release into thebloodstream.Table 2.5ANTIDEPRESSANT DRUGSGeneric (Trade) Name Forms Usual Daily Dosages* Extreme Dosage Ranges*Selective Serotonin Reuptake InhibitorsFluoxetine (Prozac) C, L 20–60 10–80Fluvoxamine (Luvox) T 150–200 50–300Paroxetine (Paxil) T 20–40 10–50Sertraline (Zoloft) T 100–150 50–200Citalopram (Celexa) T, L 20–40 20–60Escitalopram (Lexapro) T 10–20 5–30Cyclic CompoundsImipramine (Tofranil) T, C, INJ 150–200 50–300Desipramine (Norpramin) T, C 150–200 50–300Amitriptyline (Elavil) T, INJ 150–200 50–300Nortriptyline (Pamelor) C, L 75–100 25–150Doxepin (Sinequan) C, L 150–200 25–300Trimipramine (Surmontil) C 150–200 50–300Protriptyline (Vivactil) T 15–40 10–60Maprotiline (Ludiomil) T 100–150 50–200Mirtazapine (Remeron) T 15–45 15–60Amoxapine (Asendin) T 150–200 50–250Clomipramine (Anafranil) C, INJ 150–200 50–250Other CompoundsBupropion (Wellbutrin) T 200–300 100–450Venlafaxine (Effexor) T, C 75–225 75–375Desvenlafaxine (Pristiq) T 50–100 50 every other day-400Trazodone (Desyrel) T 200–300 100–600Nefazodone (Serzone) T 300–600 100–600Duloxetine (Cymbalta) C 60 30–90Monoamine Oxidase InhibitorsPhenelzine (Nardil) T 45–60 15–90Tranylcypromine (Parnate) T 30–50 10–90Isocarboxazid (Marplan) T 20–40 10–60*Values are in milligrams per day for oral doses only.C, capsule; T, tablet; L, liquid; INJ, injection for IM use.

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 31Preferred Drugs for Clients at HighRisk for SuicideSuicide is always a primary consideration when treatingclients with depression. SSRIs, venlafaxine, nefazodone,and bupropion are often better choices for those who arepotentially suicidal or highly impulsive because they carryno risk of lethal overdose, in contrast to the cyclic compoundsand the MAOIs. However, SSRIs are effective onlyfor mild and moderate depression. Evaluation of the riskfor suicide must continue even after treatment with antidepressantsis initiated. The client may feel more energizedbut still have suicidal thoughts, which increases the likelihoodof a suicide attempt. Also, because it often takesweeks before the medications have a full therapeutic effect,clients may become discouraged and tired of waiting tofeel better, which can result in suicidal behavior. There isan FDA-required warning for SSRIs and increased suicidalrisk in children and adolescents.Mechanism of ActionThe precise mechanism by which antidepressants producetheir therapeutic effects is not known, but much is knownabout their action on the CNS. The major interaction iswith the monoamine neurotransmitter systems in thebrain, particularly norepinephrine and serotonin. Both ofthese neurotransmitters are released throughout the brainand help to regulate arousal, vigilance, attention, mood,sensory processing, and appetite. Norepinephrine, serotonin,and dopamine are removed from the synapses afterrelease by reuptake into presynaptic neurons. Afterreuptake, these three neurotransmitters are reloaded forsubsequent release or metabolized by the enzyme MAO.The SSRIs block the reuptake of serotonin, the cyclic antidepressantsand venlafaxine block the reuptake of norepinephrineprimarily and block serotonin to some degree,and the MAOIs interfere with enzyme metabolism. This isnot the complete explanation, however; the blockade ofserotonin and norepinephrine reuptake and the inhibitionof MAO occur in a matter of hours, whereas antidepressantsare rarely effective until taken for several weeks. Thecyclic compounds may take 4 to 6 weeks to be effective,MAOIs need 2 to 4 weeks for effectiveness, and SSRIs maybe effective in 2 to 3 weeks. Researchers believe that theactions of these drugs are an “initiating event” and thateventual therapeutic effectiveness results when neuronsrespond more slowly, making serotonin available at thesynapses (Lehne, 2006).Side Effects of Selective SerotoninReuptake InhibitorsSSRIs have fewer side effects compared with the cycliccompounds. Enhanced serotonin transmission can lead toseveral common side effects such as anxiety, agitation,akathisia (motor restlessness), nausea, insomnia, and sexualdysfunction, specifically diminished sexual drive ordifficulty achieving an erection or orgasm. In addition,weight gain is both an initial and ongoing problem duringantidepressant therapy, although SSRIs cause less weightgain than other antidepressants. Taking medications withfood usually can minimize nausea. Akathisia usually istreated with a beta-blocker such as propranolol (Inderal)or a benzodiazepine. Insomnia may continue to be a problemeven if the client takes the medication in the morning;a sedative-hypnotic or low-dosage trazodone may beneeded.Less common side effects include sedation (particularlywith paroxetine [Paxil]), sweating, diarrhea, hand tremor,and headaches. Diarrhea and headaches usually can bemanaged with symptomatic treatment. Sweating and continuedsedation most likely indicate the need for a changeto another antidepressant.Side Effects of Cyclic AntidepressantsCyclic compounds have more side effects than do SSRIsand the newer miscellaneous compounds. The individualmedications in this category vary in terms of the intensityof side effects, but generally side effects fall into the samecategories. The cyclic antidepressants block cholinergicreceptors, resulting in anticholinergic effects such as drymouth, constipation, urinary hesitancy or retention, drynasal passages, and blurred near vision. More severe anticholinergiceffects such as agitation, delirium, and ileusmay occur, particularly in older adults. Other commonside effects include orthostatic hypotension, sedation,weight gain, and tachycardia. Clients may develop toleranceto anticholinergic effects, but these side effects arecommon reasons that clients discontinue drug therapy.Clients taking cyclic compounds frequently report sexualdysfunction similar to problems experienced with SSRIs.Both weight gain and sexual dysfunction are cited as commonreasons for noncompliance (Stahl, 2006).Side Effects of MonoamineOxidase InhibitorsThe most common side effects of MAOIs include daytimesedation, insomnia, weight gain, dry mouth, orthostatichypotension, and sexual dysfunction. The sedation andinsomnia are difficult to treat and may necessitate a changein medication. Of particular concern with MAOIs is thepotential for a life-threatening hypertensive crisis if theclient ingests food that contains tyramine or takessympathomimetic drugs. Because the enzyme MAO isnecessary to break down the tyramine in certain foods, itsinhibition results in increased serum tyramine levels,causing severe hypertension, hyperpyrexia, tachycardia,diaphoresis, tremulousness, and cardiac dysrhythmias.Drugs that may cause potentially fatal interactionswith MAOIs include SSRIs, certain cyclic compounds,buspirone (BuSpar), dextromethorphan, and opiate derivativessuch as meperidine. The client must be able tofollow a tyramine-free diet; Box 2.1 lists the foods to avoid.

32UNIT 1 • CURRENT THEORIES AND PRACTICEBox 2.1 FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MAOIS• Mature or aged cheeses or dishes made with cheese,such as lasagna or pizza. All cheese is considered agedexcept cottage cheese, cream cheese, ricotta cheese,and processed cheese slices.• Aged meats such as pepperoni, salami, mortadella, summersausage, beef logs, meat extracts, and similar products.Make sure meat and chicken are fresh and havebeen properly refrigerated.• Italian broad beans (fava), bean curd (tofu), banana peel,overripe fruit, and avocado.• All tap beers and microbrewery beer. Drink no more thantwo cans or bottles of beer (including nonalcoholic beer)or 4 ounces of wine per day.• Sauerkraut, soy sauce or soybean condiments, or marmite(concentrated yeast).• Yogurt, sour cream, peanuts, Brewer’s yeast, and monosodiumglutamate (MSG).Adapted from University of North Carolina Clinical Research Center (2004).Studies are currently underway to determine whether aselegiline transdermal patch would be effective in treatingdepression without the risks of dietary tyramine andorally ingested MAOIs.Side Effects of Other AntidepressantsOf the other or novel antidepressant medications, nefazodone,trazodone, and mirtazapine commonly cause sedation.Both nefazodone and trazodone commonly causeheadaches. Nefazodone also can cause dry mouth and nausea.Bupropion and venlafaxine desvenlafaxine may causeloss of appetite, nausea, agitation, and insomnia. Venlafaxinealso may cause dizziness, sweating, or sedation. Sexualdysfunction is much less common with the novel antidepressants,with one notable exception: Trazodone can causepriapism (a sustained and painful erection that necessitatesimmediate treatment and discontinuation of the drug).Priapism also may result in impotence.WARNINGNefazodoneMay cause rare but potentially life-threatening liverdamage, which could lead to liver failure.WARNINGBupropionCan cause seizures at a rate four times that of otherantidepressants. The risk for seizures increases whendoses exceed 450 mg/day (400 mg SR); dose increasesare sudden or in large increments; the client has ahistory of seizures, cranial trauma, excessive use ofor withdrawal from alcohol, or addiction to opiates,cocaine, or stimulants; the client uses OTC stimulantsor anorectics; or the client has diabetes being treatedwith oral hypoglycemics or insulin.Drug InteractionsAn uncommon but potentially serious drug interaction,called serotonin syndrome (or serotonergic syndrome),can result from taking an MAOI and an SSRI at the sametime. It also can occur if the client takes one of these drugstoo close to the end of therapy with the other. In otherwords, one drug must clear the person’s system before initiationof therapy with the other. Symptoms include agitation,sweating, fever, tachycardia, hypotension, rigidity,hyperreflexia, and, in extreme reactions, even coma anddeath (Krishnan, 2006). These symptoms are similar tothose seen with an SSRI overdose.Client TeachingClients should take SSRIs first thing in the morning unlesssedation is a problem; generally, paroxetine most oftencauses sedation. If the client forgets a dose of an SSRI, heor she can take it up to 8 hours after the missed dose. Tominimize side effects, clients generally should take cycliccompounds at night in a single daily dose when possible.If the client forgets a dose of a cyclic compound, he or sheshould take it within 3 hours of the missed dose or omitthe dose for that day. Clients should exercise caution whendriving or performing activities requiring sharp, alertreflexes until sedative effects can be determined.Clients taking MAOIs need to be aware that a lifethreateninghyperadrenergic crisis can occur if they do notobserve certain dietary restrictions. They should receive awritten list of foods to avoid while taking MAOIs. Thenurse should make clients aware of the risk for serious oreven fatal drug interactions when taking MAOIs andinstruct them not to take any additional medication,including over-the-counter preparations, without checkingwith the physician or pharmacist.Mood-Stabilizing DrugsMood-stabilizing drugs are used to treat bipolar disorderby stabilizing the client’s mood, preventing or minimizingthe highs and lows that characterize bipolar illness, andtreating acute episodes of mania. Lithium is the mostestablished mood stabilizer; some anticonvulsant drugs,particularly carbamazepine (Tegretol) and valproic acid

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 33(Depakote, Depakene), are effective mood stabilizers.Other anticonvulsants, such as gabapentin (Neurontin),topiramate (Topamax), oxcarbazepine (Trileptal), andlamotrigine (Lamictal), are also used for mood stabilization.Occasionally, clonazepam (Klonopin) also is used to treatacute mania. Clonazepam is included in the discussion ofantianxiety agents.WARNINGLamotrigineCan cause serious rashes requiring hospitalization,including Stevens–Johnson syndrome and, rarely,life-threatening toxic epidermal necrolysis. The riskfor serious rashes is greater in children younger than16 years.Mechanism of ActionAlthough lithium has many neurobiologic effects, itsmechanism of action in bipolar illness is poorly understood.Lithium normalizes the reuptake of certainneurotransmitters such as serotonin, norepinephrine, acetylcholine,and dopamine. It also reduces the release ofnorepinephrine through competition with calcium andproduces its effects intracellularly rather than within neuronalsynapses; it acts directly on G proteins and certainenzyme subsystems such as cyclic adenosine monophosphatesand phosphatidylinositol. Lithium is considered afirst-line agent in the treatment of bipolar disorder(Howland, 2007).The mechanism of action for anticonvulsants is not clearbecause it relates to their off-label use as mood stabilizers.Valproic acid and topiramate are known to increase levelsof the inhibitory neurotransmitter GABA. Both valproicacid and carbamazepine are thought to stabilize mood byinhibiting the kindling process. This can be described asthe snowball-like effect seen when minor seizure activityseems to build up into more frequent and severe seizures.In seizure management, anticonvulsants raise the level ofthe threshold to prevent these minor seizures. It is suspectedthat this same kindling process also may occur inthe development of full-blown mania with stimulation bymore frequent, minor episodes. This may explain why anticonvulsantsare effective in the treatment and prevention ofmania as well (Plata-Salaman et al., 2005).DosageLithium is available in tablets, capsules, liquid, and asustained-released form; no parenteral forms are available.The effective dosage of lithium is determined by monitoringserum lithium levels and assessing the client’s clinicalresponse to the drug. Daily dosages generally range from900 to 3,600 mg; more importantly, the serum lithiumlevel should be about 1.0 mEq/L. Serum lithium levels ofless than 0.5 mEq/L are rarely therapeutic, and levels ofmore than 1.5 mEq/L are usually considered toxic. Thelithium level should be monitored every 2 to 3 days whilethe therapeutic dosage is being determined; then, it shouldbe monitored weekly. When the client’s condition is stable,the level may need to be checked once a month or lessfrequently.WARNINGLithiumToxicity is closely related to serum lithium levels andcan occur at therapeutic doses. Facilities for serumlithium determinations are required to monitortherapy.Carbamazepine is available in liquid, tablet, and chewabletablet forms. Dosages usually range from 800 to 1,200 mg/day; the extreme dosage range is 200 to 2,000 mg/day.Valproic acid is available in liquid, tablet, and capsuleforms and as sprinkles with dosages ranging from 1,000 to1,500 mg/day; the extreme dosage range is 750 to 3,000 mg/day. Serum drug levels, obtained 12 hours after the lastdose of the medication, are monitored for therapeuticlevels of both these anticonvulsants.Side EffectsCommon side effects of lithium therapy include mild nauseaor diarrhea, anorexia, fine hand tremor, polydipsia,polyuria, a metallic taste in the mouth, and fatigue or lethargy.Weight gain and acne are side effects that occur laterin lithium therapy; both are distressing for clients. Takingthe medication with food may help with nausea, and theuse of propranolol often improves the fine tremor. Lethargyand weight gain are difficult to manage or minimizeand frequently lead to noncompliance.Toxic effects of lithium are severe diarrhea, vomiting,drowsiness, muscle weakness, and lack of coordination.Untreated, these symptoms worsen and can lead to renalfailure, coma, and death. When toxic signs occur, the drugshould be discontinued immediately. If lithium levelsexceed 3.0 mEq/L, dialysis may be indicated.Side effects of carbamazepine and valproic acid includedrowsiness, sedation, dry mouth, and blurred vision. InWARNINGValproic Acid and Its DerivativesCan cause hepatic failure, resulting in fatality. Liverfunction tests should be performed before therapyand at frequent intervals thereafter, especially for thefirst 6 months. Can produce teratogenic effects suchas neural tube defects (e.g., spina bifida). Can causelife-threatening pancreatitis in both children andadults. Can occur shortly after initiation or after yearsof therapy.addition, carbamazepine may cause rashes and orthostatichypotension, and valproic acid may cause weight gain,alopecia, and hand tremor. Topiramate causes dizziness,

34UNIT 1 • CURRENT THEORIES AND PRACTICEsedation, weight loss (rather than gain), and increasedincidence of renal calculi (Stahl, 2006).WARNINGClient TeachingFor clients taking lithium and the anticonvulsants, monitoringblood levels periodically is important. The time ofthe last dose must be accurate so that plasma levels can bechecked 12 hours after the last dose has been taken. Takingthese medications with meals minimizes nausea. Theclient should not attempt to drive until dizziness, lethargy,fatigue, or blurred vision has subsided.Antianxiety Drugs (Anxiolytics)Antianxiety drugs, or anxiolytic drugs, are used totreat anxiety and anxiety disorders, insomnia, OCD,depression, posttraumatic stress disorder, and alcoholwithdrawal. Antianxiety drugs are among the most widelyprescribed medications today. A wide variety of drugs fromPeriodic blood levelsCarbamazepineCan cause aplastic anemia and agranulocytosis ata rate five to eight times greater than the generalpopulation. Pretreatment hematologic baselinedata should be obtained and monitored periodicallythroughout therapy to discover lowered WBC orplatelet counts.different classifications have been used in the treatment ofanxiety and insomnia. Benzodiazepines have proved to bethe most effective in relieving anxiety and are the drugsmost frequently prescribed. Benzodiazepines also may beprescribed for their anticonvulsant and muscle relaxanteffects. Buspirone is a nonbenzodiazepine often used forthe relief of anxiety and therefore is included in this section.Other drugs such as propranolol, clonidine (Catapres), andhydroxyzine (Vistaril) that may be used to relieve anxietyare much less effective and are not included in thisdiscussion.Mechanism of ActionBenzodiazepines mediate the actions of the amino acidGABA, the major inhibitory neurotransmitter in the brain.Because GABA receptor channels selectively admit theanion chloride into neurons, activation of GABA receptorshyperpolarizes neurons and thus is inhibitory. Benzodiazepinesproduce their effects by binding to a specific site onthe GABA receptor. Buspirone is believed to exert its anxiolyticeffect by acting as a partial agonist at serotoninreceptors, which decreases serotonin turnover (Arniel &Mathew, 2007).The benzodiazepines vary in terms of their half-lives,the means by which they are metabolized, and their effectivenessin treating anxiety and insomnia. Table 2.6 listsdosages, half-lives, and speed of onset after a single dose.Drugs with a longer half-life require less frequent dosingand produce fewer rebound effects between doses; however,they can accumulate in the body and produce “nextdaysedation” effects. Conversely, drugs with a shorterhalf-life do not accumulate in the body or cause next-daysedation, but they do have rebound effects and requiremore frequent dosing.Temazepam (Restoril), triazolam (Halcion), and flurazepam(Dalmane) are most often prescribed for sleeprather than for relief of anxiety. Diazepam (Valium),chlordiazepoxide (Librium), and clonazepam often areused to manage alcohol withdrawal as well as to relieveanxiety.Side EffectsAlthough not a side effect in the true sense, one chief problemencountered with the use of benzodiazepines is theirtendency to cause physical dependence. Significant discontinuationsymptoms occur when the drug is stopped;these symptoms often resemble the original symptoms forwhich the client sought treatment. This is especially aproblem for clients with long-term benzodiazepine use,such as those with panic disorder or generalized anxietydisorder. Psychological dependence on benzodiazepines iscommon: Clients fear the return of anxiety symptoms orbelieve they are incapable of handling anxiety withoutthe drugs. This can lead to overuse or abuse of thesedrugs. Buspirone does not cause this type of physicaldependence.

36UNIT 1 • CURRENT THEORIES AND PRACTICE(Dexedrine) has been widely abused to produce a high orto remain awake for long periods. Today, the primary useof stimulants is for ADHD in children and adolescents,residual attention deficit disorder in adults, and narcolepsy(attacks of unwanted but irresistible daytime sleepinessthat disrupt the person’s life).WARNINGAmphetaminesPotential for abuse is high. Administration for prolongedperiods may lead to drug dependence.The primary stimulant drugs used to treat ADHD aremethylphenidate (Ritalin), amphetamine (Adderall), anddextroamphetamine (Dexedrine). Pemoline (Cylert) isinfrequently used for ADHD because of the potential forliver problems. Of these drugs, methylphenidate accountsfor 90% of the stimulant medication given to children forADHD (Stahl, 2006). About 10% to 30% of clients withADHD who do not respond adequately to the stimulantmedications have been treated with antidepressants. In2003, atomoxetine (Strattera), a selective norepinephrinereuptake inhibitor, was approved for the treatment ofADHD, becoming the first nonstimulant medication specificallydesigned and tested for ADHD.WARNINGMethylphenidateUse with caution in emotionally unstable clients such asthose with alcohol or drug dependence because theymay increase the dosage on their own. Chronic abusecan lead to marked tolerance and psychic dependence.WARNINGPemolineCan cause life-threatening liver failure, which can resultin death or require liver transplantation in 4 weeks fromthe onset of symptoms. The physician should obtainwritten consent before the initiation of this drug.Mechanism of ActionAmphetamines and methylphenidate are often termedindirectly acting amines because they act by causing releaseof the neurotransmitters (norepinephrine, dopamine, andserotonin) from presynaptic nerve terminals as opposed tohaving direct agonist effects on the postsynaptic receptors.They also block the reuptake of these neurotransmitters.Methylphenidate produces milder CNS stimulation thanamphetamines; pemoline primarily affects dopamine andtherefore has less effect on the sympathetic nervous system.It was originally thought that the use of methylphenidateand pemoline to treat ADHD in children produced thereverse effect of most stimulants—a calming or slowing ofactivity in the brain. However, this is not the case; theinhibitory centers in the brain are stimulated, so the childhas greater abilities to filter out distractions and managehis or her own behavior. Atomoxetine helps to block thereuptake of norepinephrine into neurons, thereby leavingmore of the neurotransmitter in the synapse to help conveyelectrical impulses in the brain.DosageFor the treatment of narcolepsy in adults, both dextroamphetamineand methylphenidate are given in divided dosestotaling 20 to 200 mg/day. The higher dosages may beneeded because adults with narcolepsy develop toleranceto the stimulants and so require more medication to sustainimprovement. Stimulant medications are also available insustained-release preparations so that once-a-day dosing ispossible. Tolerance is not seen in persons with ADHD.The dosages used to treat ADHD in children vary widelydepending on the physician; the age, weight, and behaviorof the child; and the tolerance of the family for the child’sbehavior. Table 2.7 lists the usual dosage ranges for thesestimulants. Arrangements must be made for the schoolnurse or another authorized adult to administer the stimulantsto the child at school. Sustained-released preparationseliminate the need for additional dosing at school.Side EffectsThe most common side effects of stimulants are anorexia,weight loss, nausea, and irritability. The client should avoidcaffeine, sugar, and chocolate, which may worsen thesesymptoms. Less common side effects include dizziness, drymouth, blurred vision, and palpitations. The most commonlong-term problem with stimulants is the growth andweight suppression that occurs in some children. This canusually be prevented by taking “drug holidays” on weekendsand holidays or during summer vacation, which helps torestore normal eating and growth patterns. Atomoxetinecan cause decreased appetite, nausea, vomiting, fatigue, orupset stomach.Client TeachingThe potential for abuse exists with stimulants, but this isseldom a problem in children. Taking doses of stimulantsafter meals may minimize anorexia and nausea. Caffeine-freebeverages are suggested; clients should avoid chocolate andexcessive sugar. Most important is to keep the medicationout of the child’s reach because as little as a 10-day supplycan be fatal.Disulfiram (Antabuse)Disulfiram is a sensitizing agent that causes an adversereaction when mixed with alcohol in the body. Thisagent’s only use is as a deterrent to drinking alcohol inpersons receiving treatment for alcoholism. It is useful for

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 37Table 2.7DRUGS USED TO TREAT ATTENTION DEFICIT HYPERACTIVITY DISORDERGeneric (Trade) NameStimulantsMethylphenidate (Ritalin)Sustained release (Ritalin-SR, Concerta,Metadate-CD)Transdermal patch (Daytrana)Dextroamphetamine (Dexedrine)Sustained release (Dexedrine-SR)Amphetamine (Adderall)Sustained release (Adderall-SR)Pemoline (Cylert)Selective Norepinephrine Reuptake InhibitorAtomoxetine (Strattera)DosageAdults: 20–200 mg/day, orally, in divided dosesChildren: 10–60 mg/day, orally, in 2–4 divided doses20–60 mg/day, orally, single doseAdults and Children: 15 mg patch worn for 9 hours per dayAdults: 20–200 mg/day, orally, in divided dosesChildren: 5–40 mg/day, orally, in 2 or 3 divided doses10–30 mg/day, orally, single dose5–40 mg/day, orally, in divided doses10–30 mg/day, orally, single doseChildren: 37.5–112.5 mg/day, orally, single dose in the morning0.5–1.5 mg/kg/day, orally, single dosepersons who are motivated to abstain from drinking andwho are not impulsive. Five to ten minutes after a persontaking disulfiram ingests alcohol, symptoms begin toappear: facial and body flushing from vasodilation, a throbbingheadache, sweating, dry mouth, nausea, vomiting,dizziness, and weakness. In severe cases, there may bechest pain, dyspnea, severe hypotension, confusion, andeven death. Symptoms progress rapidly and last from 30minutes to 2 hours. Because the liver metabolizes disulfiram,it is most effective in persons whose liver enzymelevels are within or close to normal range.Disulfiram inhibits the enzyme aldehyde dehydrogenase,which is involved in the metabolism of ethanol.Acetaldehyde levels are then increased from 5 to 10 timeshigher than normal, resulting in the disulfiram–alcoholreaction. This reaction is potentiated by decreased levelsof epinephrine and norepinephrine in the sympatheticnervous system caused by inhibition of dopaminebeta-hydroxylase (dopamine -hydroxylase) (Cornish,McNicholas, & O’Brien, 2006).Education is extremely important for the client takingdisulfiram. Many common products such as shavingcream, aftershave lotion, cologne, and deodorant andover-the-counter medications such as cough preparationscontain alcohol; when used by the client taking disulfiram,these products can produce the same reaction as drinkingalcohol. The client must read product labels carefully andselect items that are alcohol free.WARNINGDisulfiramNever give to a client in a state of alcohol intoxication orwithout the client’s full knowledge. Instruct the client’srelatives accordingly.Other side effects reported by persons taking disulfiraminclude fatigue, drowsiness, halitosis, tremor, and impotence.Disulfiram also can interfere with the metabolismof other drugs the client is taking, such as phenytoin(Dilantin), isoniazid, warfarin (Coumadin), barbiturates,and long-acting benzodiazepines such as diazepam andchlordiazepoxide.Acamprosate (Campral) is sometimes prescribed forpersons in recovery from alcohol abuse or dependence. Ithelps reduce the physical and emotional discomfortencountered during the first weeks or months of sobriety,such as sweating, anxiety, and sleep disturbances. The dosageis two tablets (333 mg each) three times a day. Personswith renal impairments cannot take this drug. Side effectsare reported as mild and include diarrhea, nausea, flatulence,and pruritus.CULTURAL CONSIDERATIONSStudies have shown that people from different ethnic backgroundsrespond differently to certain drugs used to treatmental disorders. The nurse should be familiar with thesecultural differences. Studies have also shown that AfricanAmericans respond more rapidly to antipsychotic medicationsand tricyclic antidepressants than do whites. Also,African Americans have a greater risk for developing sideeffects from both these classes of drugs than do whites.Asians metabolize antipsychotics and tricyclic antidepressantsmore slowly than do whites and therefore requirelower dosages to achieve the same effects. Hispanics alsorequire lower dosages of antidepressants than do whites toachieve the desired results (Woods et al., 2003).Asians respond therapeutically to lower dosages of lithiumthan do whites. African Americans have higher blood

38UNIT 1 • CURRENT THEORIES AND PRACTICElevels of lithium than whites when given the same dosage,and they also experience more side effects. This suggests thatAfrican Americans require lower dosages of lithium than dowhites to produce desired effects (Chen et al., 2002).Herbal medicines have been used for hundreds of yearsin many countries and are now being used with increasingfrequency in the United States. St. John’s wort is used totreat depression and is the second most commonly purchasedherbal product in the United States (Malaty, 2005).Kava is used to treat anxiety and can potentiate the effectsof alcohol, benzodiazepines, and other sedative–hypnoticagents. Valerian helps produce sleep and is sometimesused to relieve stress and anxiety. Ginkgo biloba is primarilyused to improve memory but is also taken for fatigue,anxiety, and depression.It is essential for the nurse to ask clients specifically ifthey use any herbal preparations. Clients may not considerthese products as “medicine” or may be reluctant to admittheir use for fear of censure by health professionals. Herbalmedicines are often chemically complex and are not standardizedor regulated for use in treating illnesses. Combiningherbal preparations with other medicines can lead tounwanted interactions, so it is essential to assess the clients’use of these products.SELF-AWARENESS ISSUESNurses must examine their own beliefs andfeelings about mental disorders as illnesses andthe role of drugs in treating mental disorders.Some nurses may be skeptical about some mentaldisorders and may believe that clients could gain controlof their lives if they would just put forth enough effort.Nurses who work with clients with mental disorders cometo understand that many disorders are similar to chronicphysical illnesses such as asthma or diabetes, which requirelifelong medication to maintain health. Without propermedication management, clients with certain mental disorders,such as schizophrenia or bipolar affective disorder, cannotsurvive in and cope with the world around them. Thenurse must explain to the client and family that this is anillness that requires continuous medication managementand follow-up, just like a chronic physical illness.It is also important for the nurse to know about currentbiologic theories and treatments. Many clients and theirfamilies will have questions about reports in the news aboutresearch or discoveries. The nurse can help them distinguishbetween what is factual and what is experimental.Also, it is important to keep discoveries and theories inperspective.Clients and families need more than factual informationto deal with mental illness and its effect on their lives. Manyclients do not understand the nature of their illness andask, “Why is this happening to me?” They need simple butthorough explanations about the nature of the illness andhow they can manage it. The nurse must learn to give outenough information about the illness while providing thecare and support needed by all those confronting mentalillness.Points to Consider When Workingon Self-Awareness• Chronic mental illness has periods of remission and exacerbationjust like chronic physical illness. A recurrenceof symptoms is not the client’s fault, nor is it afailure of treatment or nursing care.• Research regarding the neurobiologic causes of mentaldisorders is still in its infancy. Do not dismiss new ideasjust because they may not yet help in the treatment ofthese illnesses.• Often, when clients stop taking medication or takemedication improperly, it is not because they intend to;rather, it is the result of faulty thinking and reasoning,which is part of the illness.Critical Thinking Questions1. It is possible to identify a gene associated with increasedrisk for the late onset of Alzheimer’s disease.Should this test be available to anyone who requestsit? Why or why not? What dilemmas might arisefrom having such knowledge?2. What are the implications for nursing if it becomespossible to predict certain illnesses such as schizophreniathrough the identification of genes responsiblefor or linked to the disease? Should thisinfluence whether people who carry such genesshould have children? Who should make that decision,given that many people with chronic mentalillness depend on government programs for financialsupport?3. Drug companies research and develop new drugs.Much more money and effort are expended to producenew drugs for common disorders rather thandrugs (often called “orphan drugs”) needed to treatrare disorders such as Tourette’s syndrome. What arethe ethical and financial dilemmas associated withresearch designed to produce new drugs?KEY POINTS• Neurobiologic research is constantlyexpanding our knowledge in the field ofpsychiatry and is significantly affectingclinical practice.• The cerebrum is the center for coordination and integrationof all information needed to interpret and respondto the environment.

CHAPTER 2 • NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY 39INTERNET RESOURCESRESOURCES• Clinical Pharmacology Online• Research Project Relating to DNA, Genetics,and Mental Disorders• U.S. Food and Drug AdministrationINTERNET ADDRESSwww.clinicalpharmacology.comNimh.nih.govhttp://www.fda.gov• The cerebellum is the center for coordination of movementsand postural adjustments.• The brain stem contains centers that control cardiovascularand respiratory functions, sleep, consciousness,and impulses.• The limbic system regulates body temperature, appetite,sensations, memory, and emotional arousal.• Neurotransmitters are the chemical substances manufacturedin the neuron that aid in the transmission of informationfrom the brain throughout the body. Severalimportant neurotransmitters including dopamine, norepinephrine,serotonin, histamine, acetylcholine, GABA,and glutamate have been found to play a role in mentaldisorders and are targets of pharmacologic treatment.• Researchers continue to examine the roles of genetics,heredity, and viruses in the development of mental illness.• Pharmacologic treatment is based on the ability of medicationsto eliminate or minimize identified targetsymptoms.• The following factors must be considered in the selectionof medications to treat mental disorders: the efficacy,potency, and half-life of the drug; the age and raceof the client; other medications the client is taking; andthe side effects of the drugs.• Antipsychotic drugs are the primary treatment for psychoticdisorders such as schizophrenia, but they producea host of side effects that also may requirepharmacologic intervention. Neurologic side effects,which can be treated with anticholinergic medications,are called EPS and include acute dystonia, akathisia,and pseudoparkinsonism. Some of the more seriousneurologic side effects include TD (permanent involuntarymovements) and NMS, which can be fatal.• Because of the serious side effects of antipsychotic medications,clients must be well educated regarding theirmedications, medication compliance, and side effects.Health-care professionals must closely supervise theregimen.• Antidepressant medications include cyclic compounds,SSRIs, MAOIs, and a group of newer drugs.• The nurse must carefully instruct clients receivingMAOIs to avoid foods containing tyramine because thecombination produces a hypertensive crisis that canbecome life threatening.• The risk for suicide may increase as clients begin takingantidepressants. Although suicidal thoughts arestill present, the medication may increase the client’senergy, which may allow the client to carry out a suicideplan.• Lithium and selected anticonvulsants are used to stabilizemood, particularly in bipolar affective disorder.• The nurse must monitor serum lithium levels regularlyto ensure the level is in the therapeutic range and toavoid lithium toxicity. Symptoms of toxicity includesevere diarrhea and vomiting, drowsiness, muscle weakness,and loss of coordination. Untreated, lithium toxicityleads to coma and death.• Benzodiazepines are used to treat a wide variety of problemsrelated to anxiety and insomnia. Clients takingthem should avoid alcohol, which increases the effectsof benzodiazepines.• The primary use of stimulants such as methylphenidate(Ritalin) is the treatment of children with ADHD. Methylphenidatehas been proved successful in allowingthese children to slow down their activity and focus onthe tasks at hand and their schoolwork. Its exact mechanismof action is unknown.• Clients from various cultures may metabolize medicationsat different rates and therefore require alterationsin standard dosages.• Assessing use of herbal preparations is essential for allclients.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Arniel, J. M., & Mathew, S. J. (2007). Glutamate and anxiety disorders.Current Psychiatry Reports, 9(4), 278–282.Chen, J. P., Barron, C., Lin, K. M., et al. (2002). Prescribing medicationfor Asians with mental disorders. Western Journal of Medicine, 176(4),271–275.Cornish, J. W., McNicholas, L. F., & O’Brien, C. P. (2006). Treatment ofsubstance-related disorders. In A. F. Schatzberg & C. B. Nemeroff(Eds.), Essentials of clinical pharmacology (2nd ed., pp. 647–667).Washington, DC: American Psychiatric Publishing.

40UNIT 1 • CURRENT THEORIES AND PRACTICEDaniel, D. G., Copeland, L. F., & Tamminga, C. (2006). Ziprasidone. InA. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials of clinical pharmacology(2nd ed., pp. 297–305). Washington, DC: American PsychiatricPublishing.Fujita, M., Kugaya, A., & Innis, R. B. (2005). Radiotracer imaging: Basicprinciples and exemplary findings in neuropsychiatric disorders. InB. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 222–236). Philadelphia: LippincottWilliams & Wilkins.Glassman, A. H. (2005). Schizophrenia, antipsychotic drugs, and cardiovasculardisease. Journal of Clinical Psychiatry, 66(Suppl. 6), 5–10.Howland, R. H. (2007). Lithium: Underappreciated and underused?Journal of Psychosocial Nursing, 45(8), 13–17.Krishnan, K. R. R. (2006). Monoamine oxidase inhibitors. In A. F.Schatzberg & C. B. Nemeroff (Eds.), Essentials of clinical pharmacology(2nd ed., pp. 113–125). Washington, DC: American PsychiatricPublishing.Lehne, R. A. (2006). Pharmacology for nursing care (6th ed.). Philadelphia:W. B. Saunders.Malaty, W. (2005). St. John’s wort for depression. American FamilyPhysician, 71(7), 1375–1376.Muller, D. J., & Kennedy, J. L. (2006). Genetics of antipsychotic treatmentemergent weight gain in schizophrenia. Pharmacogenomics,7(6), 863–887.National Institutes of Health. (2007). About ELSI. Retrieved February 3,2002, from http://www.nhgri.nhi.gov/ELSI.Newcomer, J. N., & Haupt, D. W. (2006). The metabolic effects of antipsychoticmedications. Canadian Journal of Psychiatry, 51(8), 480–491.Plata-Salaman, C. R., Shank, R. P., & Smith-Swintosky, V. L. (2005).Amino acid neurotransmitters. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 60–72).Philadelphia: Lippincott Williams & Wilkins.Sadock, B. J., & Sadock, V. A. (2008). Kaplan & Sadock’s concise textbookof clinical psychiatry (3rd ed.). Philadelphia: Lippincott Williams &Wilkins/Wolters Kluwer.Stahl, S. M. (2006). Essential psychopharmacology: The prescriber’s guide.Cambridge: Cambridge University Press.Swedo, S. E., & Grant, P. J. (2005). Annotation: PANDAS: A model forhuman autoimmune disease. Journal of Child Psychology andPsychiatry, and Allied Disciplines, 46(3), 227–234.Tecott, L. H., & Smart, S. L. (2005). Monoamine transmitters. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 49–60). Philadelphia: Lippincott Williams &Wilkins.Vythilingam, M., Shen, J., Drevets, W. C., et al. (2005). Nuclear magneticresonance imaging: Basic principles and recent findings inneuropsychiatric disorders. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 201–222).Philadelphia: Lippincott Williams & Wilkins.Woods, S. W., Saksa, J. R., Baker, C. B., Cohen, S. J., & Tek, C. (2008).Effects of levetiracetam on tardive dyskinesia: A randomized, doubleblind,placebo-controlled study. Journal of Clinical Psychiatry, 69(4),546–554.Woods, S. W., Sullivan, M. C., Neuse, E. C., et al. (2003). Racial andethnic effects on antipsychotic prescribing practices in a communitymental health center. Psychiatric Services, 54(2), 177–179.ADDITIONAL READINGSJanicak, P. G., & Beedle, D. (2005). Medication-induced movement disorders.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbookof psychiatry (Vol. 2, 8th ed., pp. 2712–2718). Philadelphia: LippincottWilliams & Wilkins.Mathews, C. A., & Friemer, N. B. (2005). Genetic linkage analysis of thepsychiatric disorders. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 252–272).Philadelphia: Lippincott Williams & Wilkins.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The nurse is teaching a client taking an MAOI aboutfoods with tyramine that he or she should avoid. Whichof the following statement indicates that the client needsfurther teaching?a. “I’m so glad I can have pizza as long as I don’t orderpepperoni.”b. “I will be able to eat cottage cheese without worrying.”c. “I will have to avoid drinking nonalcoholic beer.”d. “I can eat green beans on this diet.”2. A client who has been depressed and suicidal startedtaking a tricyclic antidepressant 2 weeks ago and is nowready to leave the hospital to go home. Which of thefollowing is a concern for the nurse as discharge plansare finalized?a. The client may need a prescription for diphenhydramine(Benadryl) to use for side effects.b. The nurse will evaluate the risk for suicide by overdoseof the tricyclic antidepressant.c. The nurse will need to include teaching regardingthe signs of neuroleptic malignant syndrome.d. The client will need regular laboratory work to monitortherapeutic drug levels.3. The signs of lithium toxicity include which of thefollowing?a. Sedation, fever, restlessnessb. Psychomotor agitation, insomnia, increased thirstc. Elevated white blood cell count, sweating, confusiond. Severe vomiting, diarrhea, weakness4. Which of the following is a concern for children takingstimulants for ADHD for several years?a. Dependence on the drugb. Insomniac. Growth suppressiond. Weight gain5. The nurse is caring for a client with schizophrenia whois taking haloperidol (Haldol). The client complains ofrestlessness, cannot sit still, and has muscle stiffness. Ofthe following PRN medications, which would the nurseadminister?a. Haloperidol (Haldol), 5 mg POb. Benztropine (Cogentin), 2 mg POc. Propranolol (Inderal), 20 mg POd. Trazodone, 50 mg PO6. Client teaching for lamotrigine (Lamictal) should includewhich of the following?a. Eat a well-balanced diet to avoid weight gain.b. Report any rashes to your doctor immediately.c. Take each dose with food to avoid nausea.d. This drug may cause psychological dependence.7. Which of the following physician orders would thenurse question for a client who has stated “I’m allergicto phenothiazines”?a. Haldol, 5 mg PO bidb. Navane, 10 mg PO bidc. Prolixin, 5 mg PO tidd. Risperdal, 2 mg bid8. Clients taking which of the following types of psychotropicmedications need close monitoring of their cardiacstatus?a. Antidepressantsb. Antipsychoticsc. Mood stabilizersd. StimulantsFILL-IN-THE-BLANK QUESTIONSIdentify the drug classification for each of the following medications.______________________________________________________________________________________________________________________________________________________________________________________________1. Clozapine (Clozaril)2. Fluoxetine (Prozac)3. Amitriptyline (Elavil)4. Benztropine (Cogentin)5. Methylphenidate (Ritalin)41

42 UNIT 1 • CURRENT THEORIES AND PRACTICE__________________________________________________________________________________________________________________6. Carbamazepine (Tegretol)7. Clonazepam (Klonopin)8. Quetiapine (Seroquel)SHORT-ANSWER QUESTIONS1. Explain the rationale for tapering psychotropic medication doses before the client discontinuesthe drug.2. Describe the teaching needed for a client who is scheduled for PET.3. Explain the kindling process as it relates to the manic episodes of bipolar affectivedisorder.

3Psychosocial Theoriesand TherapyLearning ObjectivesAfter reading this chapter, you should be able toKey Terms• alternative medicine• behavior modification• behaviorism• client-centered therapy• closed groups• cognitive therapy• complementary medicine• countertransference• crisis• crisis intervention• dream analysis• education group• ego• ego defense mechanisms• family therapy• free association• group therapy• hierarchy of needs• humanism• id• individual psychotherapy• integrative medicine• milieu therapy• negative reinforcement1. Explain the basic beliefs and approaches of the following psychosocialtheories: psychoanalytic, developmental, interpersonal, humanistic,behavioral, existential, and crisis intervention.2. Describe the following psychosocial treatment modalities: individualpsychotherapy, group psychotherapy, family therapy, behavior modification,systematic desensitization, token economy, self-help groups, supportgroups, education groups, cognitive therapy, milieu therapy, and psychiatricrehabilitation.3. Identify the psychosocial theory on which each treatment strategy is based.4. Identify how several of the theoretical perspectives have influenced currentnursing practice.• open groups• operant conditioning• parataxic mode• participant observer• positive reinforcement• prototaxic mode• psychiatric rehabilitation• psychoanalysis• psychosocial interventions• psychotherapy group• self-actualization• self-help group• subconscious• superego• support groups• syntaxic mode• systematic desensitization• therapeutic community ormilieu• therapeutic nurse–patientrelationship• transferenceVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!43

44UNIT 1 • CURRENT THEORIES AND PRACTICETODAY’S MENTAL HEALTH TREATMENT has an eclectic approach,meaning one that incorporates concepts and strategiesfrom a variety of sources. This chapter presents an overviewof major psychosocial theories, highlights the ideasand concepts in current practice, and explains the variouspsychosocial treatment modalities. The psychosocial theorieshave produced many models currently used in individualand group therapy and various treatment settings.The medical model of treatment is based on the neurobiologictheories discussed in Chapter 2.PSYCHOSOCIAL THEORIESMany theories attempt to explain human behavior, health,and mental illness. Each theory suggests how normaldevelopment occurs based on the theorist’s beliefs, assumptions,and view of the world. These theories suggest strategiesthat the clinician can use to work with clients. Manytheories discussed in this chapter were not based onempirical or research evidence; rather, they evolved fromindividual experiences and might more appropriately becalled conceptual models or frameworks.This chapter discusses the following types of psychosocialtheories:• Psychoanalytic• Developmental• Interpersonal• Humanistic• Behavioral• ExistentialPsychoanalytic TheoriesSigmund Freud: The Father of PsychoanalysisSigmund Freud (1856–1939; Figure 3.1) developedpsychoanalytic theory in the late 19th and early 20th centuriesin Vienna, where he spent most of his life. Severalother noted psychoanalysts and theorists have contributedto this body of knowledge, but Freud is its undisputedfounder. Many clinicians and theorists did not agree withmuch of Freud’s psychoanalytic theory and later developedtheir own theories and styles of treatment.Psychoanalytic theory supports the notion that allhuman behavior is caused and can be explained (deterministictheory). Freud believed that repressed (drivenfrom conscious awareness) sexual impulses and desiresmotivate much human behavior. He developed his initialideas and explanations of human behavior from his experienceswith a few clients, all of them women who displayedunusual behaviors such as disturbances of sightand speech, inability to eat, and paralysis of limbs. Thesesymptoms had no physiological basis, so Freud consideredthem to be the “hysterical” or neurotic behavior of women.After several years of working with these women, Freudconcluded that many of their problems resulted fromFigure 3-1. Sigmund Freud: The father of psychoanalysis.childhood trauma or failure to complete tasks of psychosexualdevelopment. These women repressed their unmetneeds and sexual feelings as well as traumatic events. The“hysterical” or neurotic behaviors resulted from theseunresolved conflicts.Personality Components: Id, Ego, and Superego. Freud conceptualizedpersonality structure as having three components:id, ego, and superego (Freud, 1923/1962). The id isthe part of one’s nature that reflects basic or innate desiressuch as pleasure-seeking behavior, aggression, and sexualimpulses. The id seeks instant gratification, causes impulsiveunthinking behavior, and has no regard for rules orsocial convention. The superego is the part of a person’snature that reflects moral and ethical concepts, values, andparental and social expectations; therefore, it is in directopposition to the id. The third component, the ego, is thebalancing or mediating force between the id and the superego.The ego represents mature and adaptive behavior thatallows a person to function successfully in the world.Freud believed that anxiety resulted from the ego’s attemptsto balance the impulsive instincts of the id with thestringent rules of the superego. The accompanying drawingdemonstrates the relationship of these personalitystructures.Behavior Motivated by Subconscious Thoughts and Feelings.Freud believed that the human personality functions atthree levels of awareness: conscious, preconscious, andunconscious (Freud, 1923/1962). Conscious refers to theperceptions, thoughts, and emotions that exist in the person’sawareness, such as being aware of happy feelings orthinking about a loved one. Preconscious thoughts andemotions are not currently in the person’s awareness, but

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 45Freud’s components of personalityhe or she can recall them with some effort—for example,an adult remembering what he or she did, thought, or feltas a child. The unconscious is the realm of thoughts andfeelings that motivate a person even though he or she istotally unaware of them. This realm includes most defensemechanisms (see discussion to follow) and some instinctualdrives or motivations. According to Freud’s theories,the person represses into the unconscious the memory oftraumatic events that are too painful to remember.Freud believed that much of what we do and say ismotivated by our subconscious thoughts or feelings (thosein the preconscious or unconscious level of awareness). AFreudian slip is a term we commonly use to describe slipsof the tongue—for example, saying “You look portlytoday” to an overweight friend instead of “You look prettytoday.” Freud believed these slips are not accidents orcoincidences but rather are indications of subconsciousfeelings or thoughts that accidentally emerge in casualday-to-day conversation.Freud’s Dream Analysis. Freud believed that a person’sdreams reflect his or her subconscious and have significantmeaning, although sometimes the meaning is hiddenor symbolic. Dream analysis, a primary technique used inpsychoanalysis, involves discussing a client’s dreams todiscover their true meaning and significance. For example,a client might report having recurrent frightening dreamsabout snakes chasing her. Freud’s interpretation might bethat the woman fears intimacy with men; he would viewthe snake as a phallic symbol, representing the penis.Another method used to gain access to subconsciousthoughts and feelings is free association, in which thetherapist tries to uncover the client’s true thoughts andfeelings by saying a word and asking the client to respondquickly with the first thing that comes to mind. Freudbelieved that such quick responses would be likely touncover subconscious or repressed thoughts or feelings.Ego Defense Mechanisms. Freud believed the self, or ego,uses ego defense mechanisms, which are methods ofattempting to protect the self and cope with basic drives oremotionally painful thoughts, feelings, or events. Defensemechanisms are explained in Table 3.1. For example, aperson who has been diagnosed with cancer and told hehas 6 months to live but refuses to talk about his illness isusing the defense mechanism of denial, or refusal to acceptthe reality of the situation. If a person dying of cancerexhibits continuously cheerful behavior, he could be usingthe defense mechanism of reaction formation to protecthis emotions. Most defense mechanisms operate at the unconsciouslevel of awareness, so people are not aware ofwhat they are doing and often need help to see the reality.Five Stages of Psychosexual Development. Freud based histheory of childhood development on the belief that sexualenergy, termed libido, was the driving force of humanbehavior. He proposed that children progress throughfive stages of psychosexual development: oral (birthto 18 months), anal (18 to 36 months), phallic/oedipal(3 to 5 years), latency (5 to 11 or 13 years), and genital(11 to 13 years). Table 3.2 describes these stages and theaccompanying developmental tasks. Psychopathologyresults when a person has difficulty making the transitionfrom one stage to the next or when a person remains stalledat a particular stage or regresses to an earlier stage. Freud’sopen discussion of sexual impulses, particularly in children,was considered shocking for his time (Freud,1923/1962).Transference and Countertransference. Freud developedthe concepts of transference and countertransference.Transference occurs when the client displaces onto thetherapist attitudes and feelings that the client originallyexperienced in other relationships (Freud, 1923/1962).Transference patterns are automatic and unconscious inthe therapeutic relationship. For example, an adolescentfemale client working with a nurse who is about the sameage as the teen’s parents might react to the nurse like shereacts to her parents. She might experience intense feelingsof rebellion or make sarcastic remarks; these reactionsare actually based on her experiences with her parents, notthe nurse.Countertransference occurs when the therapist displacesonto the client attitudes or feelings from his or herpast. For example, a female nurse who has teenage childrenand who is experiencing extreme frustration with anadolescent client may respond by adopting a parental or

46UNIT 1 • CURRENT THEORIES AND PRACTICETable 3.1EGO DEFENSE MECHANISMSCompensationConversionDenialDisplacementDissociationFixationIdentificationIntellectualizationIntrojectionProjectionRationalizationReaction formationRegressionRepressionResistanceSublimationOverachievement in one area to offset real or perceived deficiencies in another area• Napoleon complex: diminutive man becoming emperor.• Nurse with low self-esteem working double shifts so her supervisor will like herExpression of an emotional conflict through the development of a physical symptom, usuallys ensorimotor in nature• Teenager forbidden to see X-rated movies is tempted to do so by friends and developsblindness, and the teenager is unconcerned about the loss of sight.Failure to acknowledge an unbearable condition; failure to admit the reality of a situation or howone enables the problem to continue• Diabetic person eating chocolate candy• Spending money freely when broke• Waiting 3 days to seek help for severe abdominal painVentilation of intense feelings toward persons less threatening than the one who aroused thosefeelings• Person who is mad at the boss yells at his or her spouse.• Child who is harassed by a bully at school mistreats a younger sibling.Dealing with emotional conflict by a temporary alteration in consciousness or identity• Amnesia that prevents recall of yesterday’s auto accident• Adult remembers nothing of childhood sexual abuse.Immobilization of a portion of the personality resulting from unsuccessful completion of tasks ina developmental stage• Never learning to delay gratification• Lack of a clear sense of identity as an adultModeling actions and opinions of influential others while searching for identity, or aspiring toreach a personal, social, or occupational goal• Nursing student becoming a critical care nurse because this is the specialty of an instructorshe admiresSeparation of the emotions of a painful event or situation from the facts involved; acknowledgingthe facts but not the emotions• Person shows no emotional expression when discussing serious car accident.Accepting another person’s attitudes, beliefs, and values as one’s own• Person who dislikes guns becomes an avid hunter, just like a best friend.Unconscious blaming of unacceptable inclinations or thoughts on an external object• Man who has thought about same-gender sexual relationship, but never had one, beats aman who is gay.• Person with many prejudices loudly identifies others as bigots.Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect• Student blames failure on teacher being mean.• Man says he beats his wife because she doesn’t listen to him.Acting the opposite of what one thinks or feels• Woman who never wanted to have children becomes a supermom.• Person who despises the boss tells everyone what a great boss she is.Moving back to a previous developmental stage to feel safe or have needs met• Five-year-old asks for a bottle when new baby brother is being fed.• Man pouts like a 4-year-old if he is not the center of his girlfriend’s attention.Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness• Woman has no memory of the mugging she suffered yesterday.• Woman has no memory before age 7, when she was removed from abusive parents.Overt or covert antagonism toward remembering or processing anxiety-producing information• Nurse is too busy with tasks to spend time talking to a dying patient.• Person attends court-ordered treatment for alcoholism but refuses to participate.Substituting a socially acceptable activity for an impulse that is unacceptable• Person who has quit smoking sucks on hard candy when the urge to smoke arises.• Person goes for a 15-minute walk when tempted to eat junk food.

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 47Table 3.1EGO DEFENSE MECHANISMS ContinuedSubstitutionSuppressionUndoingReplacing the desired gratification with one that is more readily available• Woman who would like to have her own children opens a day care center.Conscious exclusion of unacceptable thoughts and feelings from conscious awareness• Student decides not to think about a parent’s illness to study for a test.• Woman tells a friend she cannot think about her son’s death right now.Exhibiting acceptable behavior to make up for or negate unacceptable behavior• Person who cheats on a spouse brings the spouse a bouquet of roses.• Man who is ruthless in business donates large amounts of money to charity.Table 3.2FREUD’S DEVELOPMENTAL STAGESPhase Age FocusOral Birth to 18 months Major site of tension and gratification is the mouth, lips, and tongue; includesbiting and sucking activities.Id is present at birth.Ego develops gradually from rudimentary structure present at birth.Anal 18–36 months Anus and surrounding area are major source of interest.Voluntary sphincter control (toilet training) is acquired.Phallic/oedipal 3–5 years Genital is the focus of interest, stimulation, and excitement.Penis is organ of interest for both sexes.Masturbation is common.Penis envy (wish to possess penis) is seen in girls; oedipal complex (wish tomarry opposite-sex parent and be rid of same-sex parent) is seen in boysand girls.Latency 5–11 or 13 years Resolution of oedipal complexSexual drive channeled into socially appropriate activities such as school workand sportsFormation of the superegoFinal stage of psychosexual developmentGenital 11–13 years Begins with puberty and the biologic capacity for orgasm; involves the capacityfor true intimacy.Adapted from Freud, S. (1962). The ego and the id (The standard edition of the complete psychological works of Sigmund Freud) (J. Strachey, Trans.).New York: W. W. Norton & Company.chastising tone. The nurse is countertransfering her ownattitudes and feelings toward her children onto the client.Nurses can deal with countertransference by examiningtheir own feelings and responses, using self-awareness,and talking with colleagues.Current Psychoanalytic PracticePsychoanalysis focuses on discovering the causes of theclient’s unconscious and repressed thoughts, feelings, andconflicts believed to cause anxiety and on helping the clientto gain insight into and resolve these conflicts andanxieties. The analytic therapist uses the techniques offree association, dream analysis, and interpretation ofbehavior.Psychoanalysis is still practiced today but on a verylimited basis. Analysis is lengthy, with weekly or morefrequent sessions for several years. It is costly and notcovered by conventional health insurance programs;thus, it has become known as “therapy for the wealthy.”Developmental TheoriesErik Erikson and Psychosocial Stages ofDevelopmentErik Erikson (1902–1994) was a German-born psychoanalystwho extended Freud’s work on personality developmentacross the life span while focusing on social andpsychological development in the life stages. In 1950,

48UNIT 1 • CURRENT THEORIES AND PRACTICETable 3.3ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENTStage Virtue TaskTrust vs. mistrust (infant) Hope Viewing the world as safe and reliable; relationships as nurturing,stable, and dependableAutonomy vs. shame and doubt WillAchieving a sense of control and free will(toddler)Initiative vs. guilt (preschool) Purpose Beginning development of a conscience; learning to manage conflictand anxietyIndustry vs. inferiority (schoolage)Competence Emerging confidence in own abilities; taking pleasure inaccomplishmentsIdentity vs. role confusion Fidelity Formulating a sense of self and belonging(adolescence)Intimacy vs. isolation (youngadult)LoveForming adult, loving relationships and meaningful attachmentsto othersGenerativity vs. stagnation CareBeing creative and productive; establishing the next generation(middle adult)Ego integrity vs. despair(maturity)Wisdom Accepting responsibility for one’s self and lifeErikson published Childhood and Society, in which hedescribed eight psychosocial stages of development. Ineach stage, the person must complete a life task that isessential to his or her well-being and mental health. Thesetasks allow the person to achieve life’s virtues: hope, purpose,fidelity, love, caring, and wisdom. The stages, lifetasks, and virtues are described in Table 3.3.Erikson’s eight psychosocial stages of development arestill used in a variety of disciplines. In his view, psychosocialgrowth occurs in sequential phases, and each stage isdependent on completion of the previous stage and lifetask. For example, in the infant stage (birth to 18 months),trust versus mistrust, the infant must learn to develop basictrust (the positive outcome) such as that he or she will befed and taken care of. The formation of trust is essential:mistrust, the negative outcome of this stage, will impair theperson’s development throughout his or her life.Jean Piaget and Cognitive Stages ofDevelopmentJean Piaget (1896–1980) explored how intelligence andcognitive functioning develop in children. He believedthat human intelligence progresses through a series ofstages based on age, with the child at each successive stagedemonstrating a higher level of functioning than at previousstages. In his schema, Piaget strongly believed thatbiologic changes and maturation were responsible for cognitivedevelopment.Piaget’s four stages of cognitive development are asfollows:1. Sensorimotor—birth to 2 years: The child develops asense of self as separate from the environment and theconcept of object permanence; that is, tangible objectsdo not cease to exist just because they are out of sight.He or she begins to form mental images.2. Preoperational—2 to 6 years: The child develops theability to express self with language, understands themeaning of symbolic gestures, and begins to classifyobjects.3. Concrete operations—6 to 12 years: The child begins toapply logic to thinking, understands spatiality and reversibility,and is increasingly social and able to applyrules; however, thinking is still concrete.4. Formal operations—12 to 15 years and beyond: Thechild learns to think and reason in abstract terms, furtherdevelops logical thinking and reasoning, andachieves cognitive maturity.Piaget’s theory suggests that individuals reach cognitivematurity by middle to late adolescence. Some critics ofPiaget believe that cognitive development is less rigid andmore individualized than his theory suggests. Piaget’s theoryis useful when working with children. The nurse maybetter understand what the child means if the nurse isaware of his or her level of cognitive development. Also,teaching for children is often structured with their cognitivedevelopment in mind.Interpersonal TheoriesHarry Stack Sullivan: Interpersonal Relationshipsand Milieu TherapyHarry Stack Sullivan (1892–1949) was an American psychiatristwho extended the theory of personality

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 49Table 3.4SULLIVAN’S LIFE STAGESStage Ages FocusInfancyChildhoodBirth to onsetof languageLanguage to5 yearsPrimary need exists for bodily contact and tenderness.Prototaxic mode dominates (no relation between experiences).Primary zones are oral and anal.If needs are met, infant has sense of well-being; unmet needs lead to dreadand anxiety.Parents are viewed as source of praise and acceptance.Shift to parataxic mode: experiences are connected in sequence to each other.Primary zone is anal.Gratification leads to positive self-esteem.Moderate anxiety leads to uncertainty and insecurity; severe anxiety resultsin self-defeating patterns of behavior.Juvenile 5–8 years Shift to the syntaxic mode begins (thinking about self and others based onanalysis of experiences in a variety of situations).Opportunities for approval and acceptance of othersLearn to negotiate own needs.Severe anxiety may result in a need to control or in restrictive, prejudicial attitudes.Preadolescence 8–12 years Move to genuine intimacy with friend of the same sex.Move away from family as source of satisfaction in relationships.Major shift to syntaxic mode occurs.Capacity for attachment, love, and collaboration emerges or fails to develop.AdolescencePuberty toadulthoodLust is added to interpersonal equation.Need for special sharing relationship shifts to the opposite sex.New opportunities for social experimentation lead to the consolidationof self-esteem or self-ridicule.If the self-system is intact, areas of concern expand to include values, ideals,career decisions, and social concerns.Adapted from Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W. W. Norton & Company.development to include the significance of interpersonalrelationships. Sullivan believed that one’s personalityinvolves more than individual characteristics, particularlyhow one interacts with others. He thought that inadequateor nonsatisfying relationships produce anxiety, which hesaw as the basis for all emotional problems (Sullivan,1953). The importance and significance of interpersonalrelationships in one’s life is probably Sullivan’s greatestcontribution to the field of mental health.Five Life Stages. Sullivan established five life stages ofdevelopment—infancy, childhood, juvenile, preadolescence,and adolescence, each focusing on various interpersonalrelationships (Table 3.4). He also described threedevelopmental cognitive modes of experience and believedthat mental disorders are related to the persistence of oneof the early modes. The prototaxic mode, characteristic ofinfancy and childhood, involves brief, unconnected experiencesthat have no relationship to one another. Adults withschizophrenia exhibit persistent prototaxic experiences.The parataxic mode begins in early childhood as the childbegins to connect experiences in sequence. The child maynot make logical sense of the experiences and may see themas coincidence or chance events. The child seeks to relieveanxiety by repeating familiar experiences, although he orshe may not understand what he or she is doing. Sullivanexplained paranoid ideas and slips of the tongue as a personoperating in the parataxic mode. In the syntaxic mode,which begins to appear in school-aged children and becomesmore predominant in preadolescence, the personbegins to perceive himself or herself and the world withinthe context of the environment and can analyze experiencesin a variety of settings. Maturity may be defined aspredominance of the syntaxic mode (Sullivan, 1953).Therapeutic Community or Milieu. Sullivan envisioned thegoal of treatment as the establishment of satisfying interpersonalrelationships. The therapist provides a correctiveinterpersonal relationship for the client. Sullivan coinedthe term participant observer for the therapist’s role,meaning that the therapist both participates in and observesthe progress of the relationship.Sullivan is also credited with developing the firsttherapeutic community or milieu with young men with

50UNIT 1 • CURRENT THEORIES AND PRACTICEschizophrenia in 1929 (although the term therapeutic communitywas not used extensively until Maxwell Jones publishedThe Therapeutic Community in 1953). In the conceptof therapeutic community or milieu, the interaction amongclients is seen as beneficial, and treatment emphasizes therole of this client-to-client interaction. Until this time, itwas believed that the interaction between the client andthe psychiatrist was the one essential component to theclient’s treatment. Sullivan and later Jones observed thatinteractions among clients in a safe, therapeutic settingprovided great benefits to clients. The concept of milieutherapy, originally developed by Sullivan, involved clients’interactions with one another, including practicing interpersonalrelationship skills, giving one another feedbackabout behavior, and working cooperatively as a group tosolve day-to-day problems.Milieu therapy was one of the primary modes of treatmentin the acute hospital setting. In today’s health-careenvironment, however, inpatient hospital stays are oftentoo short for clients to develop meaningful relationshipswith one another. Therefore, the concept of milieu therapyreceives little attention. Management of the milieu, orenvironment, is still a primary role for the nurse in termsof providing safety and protection for all clients and promotingsocial interaction.Hildegard Peplau: TherapeuticNurse–Patient RelationshipHildegard Peplau (1909–1999; Figure 3.2) was a nursing theoristand clinician who built on Sullivan’s interpersonalFigure 3-2. Hildegard Peplau, who developed the phases ofthe nurse–client therapeutic relationship, which has madegreat contributions to the foundation of nursing practicetoday.theories and also saw the role of the nurse as a participantobserver. Peplau developed the concept of the therapeuticnurse– patient relationship, which includes four phases:orientation, identification, exploitation, and resolution(Table 3.5).Table 3.5PEPLAU’S STAGES AND TASKS OF RELATIONSHIPSStageOrientationIdentificationExploitationResolutionTasksPatient’s problems and needs are clarified.Patient asks questions.Hospital routines and expectations are explained.Patient harnesses energy toward meeting problems.Patient’s full participation is elicited.Patient responds to persons he or she perceives as helpful.Patient feels stronger.Patient expresses feelings.Interdependent work with the nurse occurs.Roles of both patient and nurse are clarified.Patient makes full use of available services.Goals such as going home and returning to work emerge.Patient’s behaviors fluctuate between dependence and independence.Patient gives up dependent behavior.Services are no longer needed by patient.Patient assumes power to meet own needs, set new goals, and so forth.Adapted from Peplau, H. (1952). Interpersonal relations in nursing. New York: G. P. Putnam’s Sons.

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 51During these phases, the client accomplishes certaintasks and makes relationship changes that help the healingprocess (Peplau, 1952).1. The orientation phase is directed by the nurse and involvesengaging the client in treatment, providing explanationsand information, and answering questions.2. The identification phase begins when the client worksinterdependently with the nurse, expresses feelings,and begins to feel stronger.3. In the exploitation phase, the client makes full use of theservices offered.4. In the resolution phase, the client no longer needs professionalservices and gives up dependent behavior. Therelationship ends.Peplau’s concept of the nurse–client relationship, withtasks and behaviors characteristic of each stage, has beenmodified but remains in use today (see Chapter 5).Roles of the Nurse in the Therapeutic Relationship. Peplaualso wrote about the roles of the nurse in the therapeuticrelationship and how these roles help meet the client’sneeds. The primary roles she identified are as follows:• Stranger––offering the client the same acceptance andcourtesy that the nurse would to any stranger;• Resource person––providing specific answers to questionswithin a larger context;• Teacher––helping the client to learn formally orinformally;• Leader––offering direction to the client or group;• Surrogate––serving as a substitute for another such as aparent or sibling;• Counselor––promoting experiences leading to healthfor the client such as expression of feelings.Peplau also believed that the nurse could take on manyother roles, including consultant, tutor, safety agent, mediator,administrator, observer, and researcher. These werenot defined in detail but were “left to the intelligence andimagination of the readers” (Peplau, 1952, p. 70).Four Levels of Anxiety. Peplau defined anxiety as the initialresponse to a psychic threat. She described four levelsof anxiety: mild, moderate, severe, and panic (Table 3.6).These serve as the foundation for working with clientswith anxiety in a variety of contexts (see Chapter 13).1. Mild anxiety is a positive state of heightened awarenessand sharpened senses, allowing the person to learn newbehaviors and solve problems. The person can take inall available stimuli (perceptual field).2. Moderate anxiety involves a decreased perceptual field(focus on immediate task only); the person can learnnew behavior or solve problems only with assistance.Another person can redirect the person to the task.Table 3.6ANXIETY LEVELSMild Moderate Severe PanicSharpened sensesIncreased motivationAlertEnlarged perceptual fieldCan solve problemsLearning is effectiveRestlessGastrointestinal “butterflies”SleeplessIrritableHypersensitive to noiseSelectively attentivePerceptual field limited tothe immediate taskCan be redirectedCannot connect thoughtsor events independentlyMuscle tensionDiaphoresisPounding pulseHeadacheDry mouthHigher voice pitchIncreased rate of speechGastrointestinal upsetFrequent urinationIncreased automatisms(nervous mannerisms)Perceptual field reduced toone detail or scattereddetailsCannot complete tasksCannot solve problems orlearn effectivelyBehavior geared towardanxiety relief and is usuallyineffectiveFeels awe, dread, or horrorDoesn’t respond toredirectionSevere headacheNausea, vomiting, diarrheaTremblingRigid stanceVertigoPaleTachycardiaChest painCryingRitualistic (purposeless,repetitive) behaviorPerceptual field reducedto focus on selfCannot processenvironmental stimuliDistorted perceptionsLoss of rational thoughtPersonality disorganizationDoesn’t recognize dangerPossibly suicidalDelusions or hallucinationpossibleCan’t communicate verballyEither cannot sit (may boltand run) or is totallymute and immobileAdapted from Peplau, H. (1952). Interpersonal relations in nursing. New York: G. P. Putnam’s Sons.

52UNIT 1 • CURRENT THEORIES AND PRACTICE3. Severe anxiety involves feelings of dread or terror. Theperson cannot be redirected to a task; he or she focusesonly on scattered details and has physiological symptomsof tachycardia, diaphoresis, and chest pain. A personwith severe anxiety may go to an emergency department,believing he or she is having a heart attack.4. Panic anxiety can involve loss of rational thought, delusions,hallucinations, and complete physical immobilityand muteness. The person may bolt and runaimlessly, often exposing himself or herself to injury.Humanistic TheoriesHumanism represents a significant shift away from thepsychoanalytic view of the individual as a neurotic,impulse-driven person with repressed psychic problemsand away from the focus on and examination of the client’spast experiences. Humanism focuses on a person’s positivequalities, his or her capacity to change (human potential),and the promotion of self-esteem. Humanists do considerthe person’s past experiences, but they direct more attentiontoward the present and future.Abraham Maslow: Hierarchy of NeedsAbraham Maslow (1921–1970) was an American psychologistwho studied the needs or motivations of theindividual. He differed from previous theorists in that hefocused on the total person, not just on one facet of theMaslow’s hierarchy of needsperson, and emphasized health instead of simply illnessand problems. Maslow (1954) formulated the hierarchyof needs, in which he used a pyramid to arrange andillustrate the basic drives or needs that motivate people.The most basic needs—the physiological needs of food,water, sleep, shelter, sexual expression, and freedom frompain—must be met first. The second level involves safetyand security needs, which include protection, security,and freedom from harm or threatened deprivation. Thethird level is love and belonging needs, which includeenduring intimacy, friendship, and acceptance. Thefourth level involves esteem needs, which include theneed for self-respect and esteem from others. The highestlevel is self-actualization, the need for beauty, truth, andjustice.Maslow hypothesized that the basic needs at the bottomof the pyramid would dominate the person’s behavioruntil those needs were met, at which time the next level ofneeds would become dominant. For example, if needs forfood and shelter are not met, they become the overridingconcern in life: the hungry person risks danger and socialostracism to find food.Maslow used the term self-actualization to describe aperson who has achieved all the needs of the hierarchy andhas developed his or her fullest potential in life. Few peopleever become fully self-actualized.Maslow’s theory explains individual differences interms of a person’s motivation, which is not necessarilystable throughout life. Traumatic life circumstances orcompromised health can cause a person to regress to alower level of motivation. For example, if a 35-year-oldwoman who is functioning at the “love and belonging”level discovers she has cancer, she may regress to the“safety” level to undergo treatment for the cancer and preserveher own health. This theory helps nurses understandhow clients’ motivations and behaviors change duringlife crises (see Chapter 7).Carl Rogers: Client-Centered TherapyCarl Rogers (1902–1987) was a humanistic Americanpsychologist who focused on the therapeutic relationshipand developed a new method of client-centered therapy.Rogers was one of the first to use the term client ratherthan patient. Client-centered therapy focuses on the roleof the client, rather than the therapist, as the key to thehealing process. Rogers believed that each person experiencesthe world differently and knows his or her ownexperience best (Rogers, 1961). According to Rogers, clientsdo “the work of healing,” and within a supportive andnurturing client–therapist relationship, clients can curethemselves. Clients are in the best position to know theirown experiences and make sense of them, to regain theirself-esteem, and to progress toward self-actualization.The therapist takes a person-centered approach, a supportiverole, rather than a directive or expert role, becauseRogers viewed the client as the expert on his or her life.

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 53The therapist must promote the client’s self-esteem asmuch as possible through three central concepts:• Unconditional positive regard—a nonjudgmental caringfor the client that is not dependent on the client’sbehavior• Genuineness—realness or congruence between what thetherapist feels and what he or she says to the client• Empathetic understanding—in which the therapist sensesthe feelings and personal meaning from the client andcommunicates this understanding to the client.Unconditional positive regard promotes the client’sself-esteem and decreases his or her need for defensivebehavior. As the client’s self-acceptance grows, the naturalself-actualization process can continue.Rogers also believed that the basic nature of humansis to become self-actualized, or to move toward selfimprovementand constructive change. We are all bornwith a positive self-regard and a natural inclination tobecome self-actualized. If relationships with others aresupportive and nurturing, the person retains feelings ofself-worth and progresses toward self-actualization, whichis healthy. If the person encounters repeated conflicts withothers or is in nonsupportive relationships, he or she losesself-esteem, becomes defensive, and is no longer inclinedtoward self-actualization; this is not healthy.Behavioral TheoriesBehaviorism grew out of a reaction to introspection modelsthat focused on the contents and operations of themind. Behaviorism is a school of psychology that focuseson observable behaviors and what one can do externally tobring about behavior changes. It does not attempt toexplain how the mind works.Behaviorists believe that behavior can be changedthrough a system of rewards and punishments. For adults,receiving a regular paycheck is a constant positive reinforcerthat motivates people to continue to go to workevery day and to try to do a good job. It helps motivatepositive behavior in the workplace. If someone stops receivinga paycheck, he or she is most likely to stop working.If a motorist consistently speeds (negative behavior)and does not get caught, he or she is likely to continue tospeed. If the driver receives a speeding ticket (a negativereinforcer), he or she is likely to slow down. However, ifthe motorist does not get caught for speeding for the next4 weeks (negative reinforcer is removed), he or she islikely to resume speeding.Ivan Pavlov: Classical ConditioningLaboratory experiments with dogs provided the basis forthe development of Ivan Pavlov’s theory of classical conditioning:Behavior can be changed through conditioningwith external or environmental conditions or stimuli.Pavlov’s experiment with dogs involved his observationthat dogs naturally began to salivate (response) when theysaw or smelled food (stimulus). Pavlov (1849–1936) setout to change this salivating response or behavior throughconditioning. He would ring a bell (new stimulus), thenproduce the food, and the dogs would salivate (the desiredresponse). Pavlov repeated this ringing of the bell alongwith the presentation of food many times. Eventually hecould ring the bell and the dogs would salivate withoutseeing or smelling food. The dogs had been “conditioned,”or had learned a new response—to salivate when theyheard the bell. Their behavior had been modified throughclassical conditioning, or a conditioned response.B. F. Skinner: Operant ConditioningOne of the most influential behaviorists was B. F. Skinner(1904–1990), an American psychologist. He developedthe theory of operant conditioning, which says peoplelearn their behavior from their history or past experiences,particularly those experiences that were repeatedly reinforced.Although some criticize his theories for not consideringthe role that thoughts, feelings, or needs play inmotivating behavior, his work has provided several importantprinciples still used today. Skinner did not deny theexistence of feelings and needs in motivation; however, heviewed behavior as only that which could be observed,studied, and learned or unlearned. He maintained that ifthe behavior could be changed, then so too could theaccompanying thoughts or feelings. Changing the behaviorwas what was important.The following principles of operant conditioningdescribed by Skinner (1974) form the basis for behaviortechniques in use today:1. All behavior is learned.2. Consequences result from behavior—broadly speaking,reward and punishment.3. Behavior that is rewarded with reinforcers tends torecur.4. Positive reinforcers that follow a behavior increase thelikelihood that the behavior will recur.5. Negative reinforcers that are removed after a behaviorincrease the likelihood that the behavior will recur.6. Continuous reinforcement (a reward every time thebehavior occurs) is the fastest way to increase thatbehavior, but the behavior will not last long after thereward ceases.7. Random intermittent reinforcement (an occasionalreward for the desired behavior) is slower to producean increase in behavior, but the behavior continuesafter the reward ceases.These behavioral principles of rewarding or reinforcingbehaviors are used to help people change their behaviorsin a therapy known as behavior modification, which is amethod of attempting to strengthen a desired behavior orresponse by reinforcement, either positive or negative. For

54UNIT 1 • CURRENT THEORIES AND PRACTICEexample, if the desired behavior is assertiveness, wheneverthe client uses assertiveness skills in a communicationgroup, the group leader provides positive reinforcementby giving the client attention and positive feedback. Negativereinforcement involves removing a stimulus immediatelyafter a behavior occurs so that the behavior is morelikely to occur again. For example, if a client becomes anxiouswhen waiting to talk in a group, he or she may volunteerto speak first to avoid the anxiety.In a group home setting, operant principles may comeinto play in a token economy, a way to involve residents inperforming activities of daily living. A chart of desiredbehaviors, such as getting up on time, taking a shower,and getting dressed, is kept for each resident. Each day thechart is marked when the desired behavior occurs. At theend of the day or the week, the resident gets a reward ortoken for each time each of the desired behaviors occurred.The resident can redeem the tokens for items such assnacks, TV time, or a relaxed curfew.Conditioned responses, such as fears or phobias, can betreated with behavioral techniques. Systematic desensitizationcan be used to help clients overcome irrational fearsand anxiety associated with phobias. The client is asked tomake a list of situations involving the phobic object, fromthe least to the most anxiety provoking. The client learnsand practices relaxation techniques to decrease and manageanxiety. He or she is then exposed to the least anxietyprovokingsituation and uses the relaxation techniques tomanage the resulting anxiety. The client is graduallyexposed to more and more anxiety-provoking situationsuntil he or she can manage the most anxiety-provokingsituation.Behavioral techniques can be used for a variety of problems.In the treatment of anorexia nervosa, the goal isweight gain. A behavioral contract between the client andthe therapist or physician is initiated when treatmentbegins. Initially, the client has little unsupervised time andis restricted to the hospital unit. The contract may specifythat if the client gains a certain amount of weight, such as0.2 kg/day, in return he or she will get increased unsupervisedtime or time off the unit as long as the weight gainprogresses. When working with children with attentiondeficit hyperactivity disorder, goals include task completionfor homework, hygiene tasks, turn-taking when talking,and so forth. The child is given a “star” or stickerwhen tasks are completed. Upon reaching a specified numbersof stars, the child receives a reward.Existential TheoriesExistential theorists believe that behavioral deviationsresult when a person is out of touch with himself or herselfor the environment. The person who is self-alienatedis lonely and sad and feels helpless. Lack of self-awareness,coupled with harsh self-criticism, prevents the personfrom participating in satisfying relationships. The personis not free to choose from all possible alternatives becauseof self-imposed restrictions. Existential theorists believethat the person is avoiding personal responsibility and givingin to the wishes or demands of others.All existential therapies have the goal of helping theperson discover an authentic sense of self. They emphasizepersonal responsibility for one’s self, feelings, behaviors,and choices. These therapies encourage the person to livefully in the present and to look forward to the future. CarlRogers is sometimes grouped with existential therapists.Table 3.7 summarizes existential therapies.Cognitive TherapyMany existential therapists use cognitive therapy, whichfocuses on immediate thought processing—how a personperceives or interprets his or her experience and determineshow he or she feels and behaves. For example, if a personinterprets a situation as dangerous, he or she experiencesanxiety and tries to escape. Basic emotions of sadness, elation,anxiety, and anger are reactions to perceptions of loss,Table 3.7EXISTENTIAL THERAPIESTherapy Therapist Therapeutic ProcessRational emotive therapy Albert Ellis A cognitive therapy using confrontation of “irrational beliefs” thatprevent the individual from accepting responsibility for self andbehaviorLogotherapy Viktor E. Frankl A therapy designed to help individuals assume personal responsibility(the search for meaning (logos) in life is a central theme)Gestalt therapy Frederick S. Perls A therapy focusing on the identification of feelings in the here andnow, which leads to self-acceptanceReality therapy William Glasser Therapeutic focus is need for identity through responsible behavior;individuals are challenged to examine ways in which their behaviorthwarts their attempts to achieve life goals

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 55gain, danger, and wrongdoing by others (Beck & Newman,2005). Aaron Beck is credited with pioneering cognitivetherapy in persons with depression.Rational Emotive TherapyAlbert Ellis, founder of rational emotive therapy, identified11 “irrational beliefs” that people use to make themselvesunhappy. An example of an irrational belief is “If I lovesomeone, he or she must love me back just as much.” Ellisclaimed that continuing to believe this patently untruestatement will make the person utterly unhappy, but he orshe will blame it on the person who does not return his orher love. Ellis also believes that people have “automaticthoughts” that cause them unhappiness in certain situations.He used the ABC technique to help people identifythese automatic thoughts: A is the activating stimulus orevent, C is the excessive inappropriate response, and B isthe blank in the person’s mind that he or she must fill in byidentifying the automatic thought.Viktor Frankl and LogotherapyViktor Frankl based his beliefs in his observations of peoplein Nazi concentration camps during World War II. Hiscuriosity about why some survived and others did not ledhim to conclude that survivors were able to find meaningin their lives even under miserable conditions. Hence, thesearch for meaning (logos) is the central theme in logotherapy.Counselors and therapists who work with clientsin spirituality and grief counseling often use the conceptsthat Frankl developed.Gestalt TherapyGestalt therapy, founded by Frederick “Fritz” Perls,emphasizes identifying the person’s feelings and thoughtsin the here and now. Perls believed that self-awarenessleads to self-acceptance and responsibility for one’s ownthoughts and feelings. Therapists often use gestalt therapyto increase clients’ self-awareness by having them writeand read letters, keep journals, and perform other activitiesdesigned to put the past to rest and focus on thepresent.Reality TherapyWilliam Glasser devised an approach called reality therapythat focuses on the person’s behavior and how that behaviorkeeps him or her from achieving life goals. He developedthis approach while working with persons withdelinquent behavior, unsuccessful school performance,and emotional problems. He believed that persons whowere unsuccessful often blamed their problems on otherpeople, the system, or the society. He believed they neededto find their own identities through responsible behavior.Reality therapy challenges clients to examine the ways inwhich their own behavior thwarts their attempts to achievelife goals.Crisis InterventionA crisis is a turning point in an individual’s life that producesan overwhelming emotional response. Individualsexperience a crisis when they confront some life circumstanceor stressor that they cannot effectively managethrough use of their customary coping skills. Caplan (1964)identified the stages of crisis: (1) the person is exposed to astressor, experiences anxiety, and tries to cope in a customaryfashion; (2) anxiety increases when customary copingskills are ineffective; (3) the person makes all possibleefforts to deal with the stressor, including attempts at newmethods of coping; and (4) when coping attempts fail, theperson experiences disequilibrium and significant distress.Crises occur in response to a variety of life situationsand events and fall into three categories:• Maturational crises, sometimes called developmentalcrises, are predictable events in the normal course oflife, such as leaving home for the first time, getting married,having a baby, and beginning a career.• Situational crises are unanticipated or sudden eventsthat threaten the individual’s integrity, such as the deathof a loved one, loss of a job, and physical or emotionalillness in the individual or family member.• Adventitious crises, sometimes called social crises,include natural disasters like floods, earthquakes, orhurricanes; war; terrorist attacks; riots; and violentcrimes such as rape or murder.Note that not all events that result in crisis are “negative”in nature. Events like marriage, retirement, andchildbirth are often desirable for the individual but maystill present overwhelming challenges. Aguilera (1998)identified three factors that influence whether or not anindividual experiences a crisis: the individual’s perceptionof the event, the availability of emotional supports, andthe availability of adequate coping mechanisms. When theperson in crisis seeks assistance, these three factors representa guide for effective intervention. The person can beassisted to view the event or issue from a different perspective,for example, as an opportunity for growth or changerather than as a threat. Assisting the person to use existingsupports or helping the individual find new sources ofsupport can decrease the feelings of being alone or overwhelmed.Finally, assisting the person to learn new methodsof coping will help to resolve the current crisis andgive him or her new coping skills to use in the future.Crisis is described as self-limiting; that is, the crisis doesnot last indefinitely but usually exists for 4 to 6 weeks. Atthe end of that time, the crisis is resolved in one of threeways. In the first two, the person either returns to his or herpre-crisis level of functioning or begins to function at ahigher level; both are positive outcomes for the individual.The third resolution is that the person’s functioning stabilizesat a level lower than pre-crisis functioning, which is anegative outcome for the individual. Positive outcomes are

56UNIT 1 • CURRENT THEORIES AND PRACTICEmore likely when the problem (crisis response and precipitatingevent or issue) is clearly and thoroughly defined.Likewise, early intervention is associated with betteroutcomes.Persons experiencing a crisis usually are distressed andlikely to seek help for their distress. They are ready to learnand even eager to try new coping skills as a way to relievetheir distress. This is an ideal time for intervention thatis likely to be successful. Crisis intervention includes avariety of techniques based on the assessment of the individual.Directive interventions are designed to assess theperson’s health status and promote problem-solving, suchas offering the person new information, knowledge, ormeaning; raising the person’s self-awareness by providingfeedback about behavior; and directing the person’s behaviorby offering suggestions or courses of action. Supportiveinterventions aim at dealing with the person’s needs forempathetic understanding, such as encouraging the personto identify and discuss feelings, serving as a soundingboard for the person, and affirming the person’s self-worth.Techniques and strategies that include a balance of thesedifferent types of intervention are the most effective.CULTURAL CONSIDERATIONSThe major psychosocial theorists were white and born inEurope or the United States, as were many of the peoplewhom they treated. What they considered normal or typicalmay not apply equally well to people with differentracial, ethnic, or cultural backgrounds. For example,Erikson’s developmental stages focus on autonomy andindependence for toddlers, but this focus may not beappropriate for people from other cultures in which earlyindividual independence is not a developmental milestone.Therefore, it is important that the nurse avoids reachingfaulty conclusions when working with clients and familiesfrom other cultures. Chapter 7 discusses cultural factors indepth.TREATMENT MODALITIESBenefits of Community MentalHealth TreatmentRecent changes in health care and reimbursement haveaffected mental health treatment, as they have all areas ofmedicine, nursing, and related health disciplines (seeChapter 4). Inpatient treatment is often the last, ratherthan the first, mode of treatment for mental illness. Currenttreatment reflects the belief that it is more beneficialand certainly more cost-effective for clients to remain inthe community and receive outpatient treatment wheneverpossible. The client can often continue to work andcan stay connected to family, friends, and other supportsystems while participating in therapy. Outpatient therapyalso takes into account that a person’s personality orbehavior patterns, such as coping skills, styles of communication,and level of self-esteem, gradually develop overthe course of a lifetime and cannot be changed in a relativelyshort inpatient course of treatment. Hospital admissionis indicated when the person is severely depressedand suicidal, severely psychotic, experiencing alcohol ordrug withdrawal, or exhibiting behaviors that require closesupervision in a safe, supportive environment. This sectionbriefly describes the treatment modalities currentlyused in both inpatient and outpatient settings.Individual PsychotherapyIndividual psychotherapy is a method of bringing aboutchange in a person by exploring his or her feelings, attitudes,thinking, and behavior. It involves a one-to-onerelationship between the therapist and the client. Peoplegenerally seek this kind of therapy based on their desire tounderstand themselves and their behavior, to make personalchanges, to improve interpersonal relationships, orto get relief from emotional pain or unhappiness. Therelationship between the client and the therapist proceedsthrough stages similar to those of the nurse–clientrelationship: introduction, working, and termination.Cost-containment measures mandated by health maintenanceorganizations and other insurers may necessitatemoving into the working phase rapidly so the client canget the maximum benefit possible from therapy.The therapist–client relationship is key to the successof this type of therapy. The client and the therapist must becompatible for therapy to be effective. Therapists vary intheir formal credentials, experience, and model of practice.Selecting a therapist is extremely important in termsof successful outcomes for the client. The client mustselect a therapist whose theoretical beliefs and style oftherapy are congruent with the client’s needs and expectationsof therapy. The client also may have to try differenttherapists to find a good match.A therapist’s theoretical beliefs strongly influence his orher style of therapy (discussed earlier in this chapter). Forexample, a therapist grounded in interpersonal theoryemphasizes relationships, whereas an existential therapistfocuses on the client’s self-responsibility.The nurse or other health-care provider who is familiarwith the client may be in a position to recommend a therapistor a choice of therapists. He or she also may help theclient understand what different therapists have to offer.The client should select a therapist carefully and shouldask about the therapist’s treatment approach and area ofspecialization. State laws regulate the practice and licensingof therapists; thus, from state to state, the qualificationsto practice psychotherapy, the requirements forlicensure, or even the need for a license can vary. A fewtherapists have little or no formal education, credentials,or experience but still practice entirely within the legallimits of their states. A client can verify a therapist’s legal

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 57credentials with the state licensing board; state governmentlistings are in the local phone book. The Better BusinessBureau can inform consumers if a particular therapisthas been reported to them for investigation. Calling thelocal mental health services agency or contacting the primarycare provider is another way for a client to check atherapist’s credentials and ethical practices.GroupsA group is a number of persons who gather in a face-tofacesetting to accomplish tasks that require cooperation,collaboration, or working together. Each person in a groupis in a position to influence and to be influenced by othergroup members. Group content refers to what is said inthe context of the group, including educational material,feelings and emotions, or discussions of the project to becompleted. Group process refers to the behavior of thegroup and its individual members, including seatingarrangements, tone of voice, who speaks to whom, who isquiet, and so forth. Content and process occur continuouslythroughout the life of the group.Stages of Group DevelopmentA group may be established to serve a particular purposein a specified period such as a work group to complete anassigned project or a therapy group that meets with thesame members to explore ways to deal with depression.These groups develop in observable stages. In the pregroupstages, members are selected, the purpose or work of thegroup is identified, and group structure is addressed.Group structure includes where and how often the groupwill meet, identification of a group leader, and the rules ofthe group—for example, whether individuals can join thegroup after it begins, how to handle absences, and expectationsfor group members.The beginning stage of group development, or the initialstage, commences as soon as the group begins to meet.Members introduce themselves, a leader can be selected (ifnot done previously), the group purpose is discussed, andrules and expectations for group participation are reviewed.Group members begin to “check out” one another and theleader as they determine their levels of comfort in thegroup setting.The working stage of group development begins asmembers begin to focus their attention on the purpose ortask the group is trying to accomplish. This may happenrelatively quickly in a work group with a specific assignedproject but may take two or three sessions in a therapygroup because members must develop some level of trustbefore sharing personal feelings or difficult situations.During this phase, several group characteristics may beseen. Group cohesiveness is the degree to which memberswork together cooperatively to accomplish the purpose.Cohesiveness is a desirable group characteristic and isassociated with positive group outcomes. It is evidencedwhen members value one another’s contributions to thegroup; members think of themselves as “we” and shareresponsibility for the work of the group. When a group iscohesive, members feel free to express all opinions, positiveand negative, with little fear of rejection or retribution.If a group is “overly cohesive,” in that uniformity andagreement become the group’s implicit goals, there may bea negative effect on the group outcome. In a therapy group,members do not give one another needed feedback if thegroup is overly cohesive. In a work group, critical thinkingand creative problem-solving are unlikely, which maymake the work of the group less meaningful.Some groups exhibit competition, or rivalry, amonggroup members. This may positively affect the outcome ofthe group if the competition leads to compromise,improved group performance, and growth for individualmembers. Many times, however, competition can bedestructive for the group; when conflicts are not resolved,members become hostile, or the group’s energy is divertedfrom accomplishing its purpose to bickering and powerstruggles.The final stage, or termination, of the group occursbefore the group disbands. The work of the group isreviewed, with the focus on group accomplishments orgrowth of group members or both, depending on the purposeof the group.Observing the stages of group development in groupsthat are ongoing is difficult with members joining andleaving the group at various times. Rather, the groupinvolvement of new members as they join the groupevolves as they feel accepted by the group, take a moreactive role, and join in the work of the group. An exampleof this type of group would be Alcoholics Anonymous, aself-help group with stated purposes. Members may attendAlcoholics Anonymous meetings as often or infrequentlyas they choose; group cohesiveness or competition canstill be observed in ongoing groups.Group LeadershipGroups often have an identified or formal leader— someonedesignated to lead the group. In therapy groups and educationgroups, a formal leader is usually identified basedon his or her education, qualifications, and experience.Some work groups have formal leaders appointed inadvance, whereas other work groups select a leader at theinitial meeting. Support groups and self-help groups usuallydo not have identified formal leaders; all members areseen as equals. An informal leader may emerge from a“leaderless” group or from a group that has an identifiedformal leader. Informal leaders are generally members recognizedby others as having the knowledge, experience, orcharacteristics that members admire and value.Effective group leaders focus on group process as wellas on group content. Tasks of the group leader include givingfeedback and suggestions; encouraging participationfrom all members (eliciting responses from quiet members

58UNIT 1 • CURRENT THEORIES AND PRACTICEand placing limits on members who may monopolize thegroup’s time); clarifying thoughts, feelings, and ideas;summarizing progress and accomplishments; and facilitatingprogress through the stages of group development.Group RolesRoles are the parts that members play within the group.Not all members are aware of their “role behavior,” andchanges in members’ behavior may be a topic that thegroup will need to address. Some roles facilitate the workof the group, whereas others can negatively affect the processor outcome of the group. Growth-producing rolesinclude the information seeker, opinion seeker, informationgiver, energizer, coordinator, harmonizer, encourager,and elaborator. Growth-inhibiting roles include themonopolizer, aggressor, dominator, critic, recognitionseeker, and passive follower.Group TherapyIn group therapy, clients participate in sessions with agroup of people. The members share a common purposeand are expected to contribute to the group to benefit othersand receive benefit from others in return. Group rulesare established, which all members must observe. Theserules vary according to the type of group. Being a memberof a group allows the client to learn new ways of looking atGroup therapya problem or ways of coping with or solving problems andalso helps him or her to learn important interpersonalskills. For example, by interacting with other members,clients often receive feedback on how others perceive andreact to them and their behavior. This is extremely importantinformation for many clients with mental disorders,who often have difficulty with interpersonal skills.The therapeutic results of group therapy (Yalom, 1995)include the following:• Gaining new information, or learning• Gaining inspiration or hope• Interacting with others• Feeling acceptance and belonging• Becoming aware that one is not alone and that othersshare the same problems• Gaining insight into one’s problems and behaviors andhow they affect others• Giving of oneself for the benefit of others (altruism).Therapy groups vary with different purposes, degrees offormality, and structures. Our discussion includes psychotherapygroups, family therapy, family education, educationgroups, support groups, and self-help groups.Psychotherapy Groups. The goal of a psychotherapygroup is for members to learn about their behavior and tomake positive changes in their behavior by interacting andcommunicating with others as a member of a group.Groups may be organized around a specific medical diagnosis,such as depression, or a particular issue, such asimproving interpersonal skills or managing anxiety. Grouptechniques and processes are used to help group memberslearn about their behavior with other people and how itrelates to core personality traits. Members also learn theyhave responsibilities to others and can help other membersachieve their goals.Psychotherapy groups are often formal in structure,with one or two therapists as the group leaders. One taskof the group leader or the entire group is to establish therules for the group. These rules deal with confidentiality,punctuality, attendance, and social contact between membersoutside of group time.There are two types of groups: open groups and closedgroups. Open groups are ongoing and run indefinitely,allowing members to join or leave the group as they needto. Closed groups are structured to keep the same membersin the group for a specified number of sessions. If thegroup is closed, the members decide how to handle memberswho wish to leave the group and the possible additionof new group members (Yalom, 1995).Family Therapy. Family therapy is a form of group therapyin which the client and his or her family members participate.The goals include understanding how family dynamics contributeto the client’s psychopathology, mobilizing the family’sinherent strengths and functional resources, restructuringmaladaptive family behavioral styles, and strengtheningfamily problem-solving behaviors (Sadock & Sadock, 2008).

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 59Family therapy can be used both to assess and to treat variouspsychiatric disorders. Although one family member usuallyis identified initially as the one who has problems andneeds help, it often becomes evident through the therapeuticprocess that other family members also have emotionalproblems and difficulties.Family Education. The National Alliance for the MentallyIll (NAMI) developed a unique 12-week Family-to-FamilyEducation Course taught by trained family members. Thecurriculum focuses on schizophrenia, bipolar disorder, clinicaldepression, panic disorder, and obsessive–compulsivedisorder. The course discusses the clinical treatment of theseillnesses and teaches the knowledge and skills that familymembers need to cope more effectively. The specific featuresof this education program include emphasis on emotionalunderstanding and healing in the personal realm and onpower and action in the social realm. NAMI also conductsProvider Education Programs taught by two consumers,two family members, and a mental health professional whois also a family member or consumer. This course is designedto help providers realize the hardships that familiesand consumers endure and to appreciate the courage andpersistence it takes to live with and recover from mental illness(NAMI, 2008).Education Groups. The goal of an education group is toprovide information to members on a specific issue—forinstance, stress management, medication management, orassertiveness training. The group leader has expertise inthe subject area and may be a nurse, therapist, or otherhealth professional. Education groups usually are scheduledfor a specific number of sessions and retain the samemembers for the duration of the group. Typically, theleader presents the information and then members can askquestions or practice new techniques.In a medication management group, the leader may discussmedication regimens and possible side effects, screenclients for side effects, and in some instances, actuallyadminister the medication (e.g., depot injections of haloperidol[Haldol] decanoate or fluphenazine [Prolixin]decanoate).Support Groups. Support groups are organized to helpmembers who share a common problem to cope with it.The group leader explores members’ thoughts and feelingsand creates an atmosphere of acceptance so that membersfeel comfortable expressing themselves. Support groupsoften provide a safe place for group members to expresstheir feelings of frustration, boredom, or unhappiness andalso to discuss common problems and potential solutions.Rules for support groups differ from those in psychotherapyin that members are allowed—in fact, encouraged—tocontact one another and socialize outside the sessions.Confidentiality may be a rule for some groups; the membersdecide this. Support groups tend to be open groups inwhich members can join or leave as their needs dictate.Common support groups include those for cancer orstroke victims, persons with AIDS, and family members ofsomeone who has committed suicide. One national supportgroup, Mothers Against Drunk Driving (MADD), isfor family members of someone killed in a car accidentcaused by a drunk driver.Self-Help Groups. In a self-help group, members share acommon experience, but the group is not a formal orstructured therapy group. Although professionals organizesome self-help groups, many are run by members and donot have a formally identified leader. Various self-helpgroups are available. Some are locally organized andannounce their meetings in local newspapers. Others arenationally organized, such as Alcoholics Anonymous,Parents Without Partners, Gamblers Anonymous, andAl-Anon (a group for spouses and partners of alcoholics),and have national headquarters and Internet websites (seeInternet Resources).Most self-help groups have a rule of confidentiality: whoeveris seen and whatever is said at the meetings cannot bedivulged to others or discussed outside the group. In many12-step programs, such as Alcoholics Anonymous andGamblers Anonymous, people use only their first names sotheir identities are not divulged (although in some settings,group members do know one another’s names).Complementary and Alternative TherapiesThe National Center for Complementary and AlternativeMedicine (NCCAM) is a federal government agency forscientific research on complementary and alternativemedicine (CAM). This agency is part of the National Institutesof Health in the Department of Health and HumanServices. Complementary medicine includes therapiesused with conventional medicine practices (the medicalmodel). Alternative medicine includes therapies used inplace of conventional treatment. NCCAM conducts clinicalresearch to help determine the safety and efficacy ofthese practices (NCCAM, 2006). Studying the use ofSt. John’s wort to treat depression (instead of using antidepressantmedication) would be an example of researchingalternative medicine. Conducting research on the use ofchiropractic massage and antidepressant medication totreat depression is an example of complementary medicineresearch. Integrative medicine combines conventionalmedical therapy and CAM therapies that have scientificevidence supporting their safety and effectiveness.NCCAM studies a wide variety of complementary andalternative therapies:• Alternative medical systems include homeopathic medicineand naturopathic medicine in Western cultures,and traditional Chinese medicine, which includesherbal and nutritional therapy, restorative physicalexercises (yoga and Tai chi), meditation, acupuncture,and remedial massage.• Mind–body interventions include meditation, prayer,mental healing, and creative therapies that use art,music, or dance.

60UNIT 1 • CURRENT THEORIES AND PRACTICE• Biologically based therapies use substances found in nature,such as herbs, food, and vitamins. Dietary supplements,herbal products, medicinal teas, aromatherapy,and a variety of diets are included.• Manipulative and body-based therapies are based on manipulationor movement of one or more parts of thebody, such as therapeutic massage and chiropractic orosteopathic manipulation.• Energy therapies include two types of therapy: biofieldtherapies, intended to affect energy fields that are believedto surround and penetrate the body, such as therapeutictouch, qi gong, and Reiki, and bioelectric-basedtherapies involving the unconventional use of electromagneticfields, such as pulsed fields, magnetic fields,and AC or DC fields. Qi gong is part of Chinese medicinethat combines movement, meditation, and regulatedbreathing to enhance the flow of vital energy andpromote healing. Reiki (which in Japanese meansuniversal life energy) is based on the belief that whenspiritual energy is channeled through a Reiki practitioner,the patient’s spirit and body are healed.Clients may be reluctant to tell the psychiatrist or primarycare provider about the use of CAM. Therefore, it is importantthat the nurse ask clients specifically about use ofherbs, vitamins, or other health practices in a nonjudgmentalway.Psychiatric RehabilitationPsychiatric rehabilitation involves providing services topeople with severe and persistent mental illness to helpthem to live in the community. These programs are oftencalled community support services or community supportprograms. Psychiatric rehabilitation focuses on the client’sstrengths, not just on his or her illness. The client activelyparticipates in program planning. The programs aredesigned to help the client manage the illness and symptoms,gain access to needed services, and live successfullyin the community.These programs assist clients with activities of daily livingsuch as transportation, shopping, food preparation,money management, and hygiene. Social support andinterpersonal relationships are recognized as a primaryneed for successful community living. Psychiatric rehabilitationprograms provide opportunities for socialization,such as drop-in centers and places where clients cango to be with others in a safe, supportive environment.Vocational referral, training, job coaching, and support areavailable for clients who want to seek and maintainemployment. Community support programs also provideeducation about the client’s illness and treatment and helpthe client to obtain health care when needed.Lecomte, Wallace, Perreault, and Caron (2005) emphasizethe importance of including the client in identifyingrehabilitation goals. There is often a disparity betweenwhat health-care professionals view as the client’s needsand what the client perceives as valuable. Offering servicesthat meet each client’s most important goals can significantlyimprove his or her quality of life and promote recoveryand well-being.THE NURSE AND PSYCHOSOCIALINTERVENTIONSIntervention is a crucial component of the nursing process.Psychosocial interventions are nursing activities thatenhance the client’s social and psychological functioningand improve social skills, interpersonal relationships, andcommunication. Nurses often use psychosocial interventionsto help meet clients’ needs and achieve outcomes inall practice settings, not just mental health. For example, amedical-surgical nurse might need to use interventionsthat incorporate behavioral principles such as setting limitswith manipulative behavior or giving positive feedback.For example, a client with diabetes tells the nurse,“I promise to have just one bite of cake. Please! It’smy grandson’s birthday cake.” (manipulativebehavior)The nurse might use behavioral limit-setting by saying,“I can’t give you permission to eat the cake. Yourblood glucose level will go up if you do, andyour insulin can’t be adjusted properly.”When a client first attempts to change a colostomy bag butneeds some assistance, the nurse might say,“You gave it a good effort. You were able tocomplete the task with a little assistance.”(giving positive feedback)Understanding the theories and treatment modalitiespresented in this chapter can help the nurse selectappropriate and effective intervention strategies. In laterchapters that present particular mental disorders or problems,specific psychosocial interventions that the nursemight use are described.SELF-AWARENESS ISSUESThe nurse must examine his or her beliefsabout the theories of psychosocial developmentand realize that many treatmentapproaches are available. Different treatmentsmay work for different clients: no one approach works foreveryone. Sometimes the nurse’s personal opinions maynot agree with those of the client, but the nurse must make

CHAPTER 3 • PSYCHOSOCIAL THEORIES AND THERAPY 61sure that those beliefs do not inadvertently affect the therapeuticprocess. For example, an overweight client may beworking on accepting herself as being overweight ratherthan trying to lose weight, but the nurse believes the clientreally just needs to lose weight. The nurse’s responsibilityis to support the client’s needs and goals, not to promotethe nurse’s own ideas about what the client should do.Hence, the nurse must support the client’s decision towork on self-acceptance. For the nurse who believes thatbeing overweight is simply a lack of will power, it might bedifficult to support a client’s participation in a self-helpweight-loss group, such as Overeaters Anonymous, thatemphasizes overeating as a disease and accepting oneself.Points to Consider When Workingon Self-AwarenessPoints to consider regarding psychosocial theories andtreatment:• No one theory explains all human behavior. No one approachwill work with all clients.• Becoming familiar with the variety of psychosocial approachesfor working with clients will increase thenurse’s effectiveness in promoting the client’s healthand well-being.• The client’s feelings and perceptions about his or hersituation are the most influential factors in determininghis or her response to therapeutic interventions, ratherthan what the nurse believes the client should do.Critical Thinking Questions1. Can sound parenting and nurturing in a loving environmentovercome a genetic or biologic predispositionto mental illness?2. Which of the theories in this chapter fit with yourbeliefs about psychosocial development? Mentalhealth and illness? Effective treatment? Explain why.KEY POINTS• Psychosocial theories help to explainhuman behavior—both mental health andmental illness. There are several types ofpsychosocial theories, including psychoanalytictheories, interpersonal theories, humanistictheories, behavioral theories, and existential theories.• Freud believed that human behavior is motivated by repressedsexual impulses and desires and that childhooddevelopment is based on sexual energy (libido) as thedriving force.• Erik Erikson’s theories focused on both social andpsychological developments across the life span. Heproposed eight stages of psychosocial development;each stage includes a developmental task and a virtue tobe achieved (hope, will, purpose, fidelity, love, caring,and wisdom). Erikson’s theories remain in wide usetoday.• Jean Piaget described four stages of cognitive development:sensorimotor, preoperational, concrete operations,and formal operations.• Harry Stack Sullivan’s theories focused on developmentin terms of interpersonal relationships. He viewed thetherapist’s role (termed participant observer) as key tothe client’s treatment.• Hildegard Peplau is a nursing theorist whose theoriesformed much of the foundation of modern nursingpractice, including the therapeutic nurse–patient relationship,the role of the nurse in the relationship, andthe four anxiety levels.• Abraham Maslow developed a hierarchy of needs statingthat people are motivated by progressive levels of needs;each level must be satisfied before the person can progressto the next level. The levels begin with physiologicalneeds and then proceed to safety and securityneeds, belonging needs, esteem needs, and finally selfactualizationneeds.• Carl Rogers developed client-centered therapy in whichthe therapist plays a supportive role, demonstrating unconditionalpositive regard, genuineness, and empatheticunderstanding to the client.• Behaviorism focuses on the client’s observable performanceand behaviors and external influences that canbring about behavior changes rather than focusing onfeelings and thoughts.• Systematic desensitization is an example of conditioningin which a person who has an excessive fear ofsomething, such as frogs or snakes, learns to manage hisor her anxiety response through being exposed to thefeared object.• B. F. Skinner was a behaviorist who developed the theoryof operant conditioning in which people are motivatedto learn or change behavior with a system ofrewards or reinforcement.• Existential theorists believe that problems result whenthe person is out of touch with the self or the environment.The person has self-imposed restrictions, criticizeshimself or herself harshly, and does not participatein satisfying interpersonal relationships.• Founders of existentialism include Albert Ellis (rationalemotive therapy), Viktor Frankl (logotherapy),Frederick Perls (gestalt therapy), and William Glasser(reality therapy).• All existential therapies have the goal of returning theperson to an authentic sense of self through emphasizingpersonal responsibility for oneself and one’s feelings,behavior, and choices.

62UNIT 1 • CURRENT THEORIES AND PRACTICEINTERNET RESOURCESRESOURCES• Albert Ellis Institute (Rational Emotive Behavior Therapy)• Alcoholics Anonymous• American Group Psychotherapy Association• Beck Institute for Cognitive Therapy and Research• Gamblers Anonymous• NAMI Family-to-Family Education Program• National Association of Cognitive–Behavioral TherapistsINTERNET ADDRESShttp://www.rebt.orghttp://www.alcoholics-anonymous.orghttp://www.agpa.orghttp://www.beckinstitute.orghttp://www.gamblersanonymous.orghttp://www.nami.org/familyhttp://www.nacbt.org• A crisis is a turning point in an individual’s life that producesan overwhelming response. Crises may be maturational,situational, or adventitious. Effective crisisintervention includes assessment of the person in crisis,promotion of problem-solving, and provision of empatheticunderstanding.• Cognitive therapy is based on the premise that how aperson thinks about or interprets life experiences determineshow he or she will feel or behave. It seeks to helpthe person change how he or she thinks about things tobring about an improvement in mood and behavior.• Treatment of mental disorders and emotional problemscan include one or more of the following: individualpsychotherapy, group psychotherapy, family therapy,family education, psychiatric rehabilitation, self-helpgroups, support groups, education groups, and otherpsychosocial interventions such as setting limits or givingpositive feedback.• An understanding of psychosocial theories and treatmentmodalities can help the nurse select appropriateand effective intervention strategies to use with clients.REFERENCESAguilera, D. C. (1998). Crisis intervention: Theory and methodology(7th ed.). St. Louis: Mosby.Beck, A. T., & Newman, C. F. (2005). Cognitive therapy. In B. J. Sadock &V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 2, 8thed., pp. 2595–2610). Philadelphia: Lippincott Williams & Wilkins.Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: Norton.Freud, S. (1962). The ego and the id (The standard edition of the completepsychological works of Sigmund Freud) (J. Strachey, Trans.). NewYork: W. W. Norton & Company. (Original work published 1923.)Lecomte, T., Wallace, C. J., Perreault, M., & Caron, J. (2005). Consumer’sgoals in psychiatric rehabilitation and their concordance with existingservices. Psychiatric Services, 56(2), 209–211.Maslow, A. H. (1954). Motivation and personality. New York: Harper &Row.National Alliance for the Mentally Ill (NAMI). (2008). Education, training& peer support center. Retrieved October 11, 2008, fromhttp//:www.nami.org.National Center for Complementary and Alternative Medicine. (2006).What is complementary and alternative medicine? Available at: http://nccam.nih.gov/health.Peplau, H. (1952). Interpersonal relations in nursing. New York: G. P.Putnam’s Sons.Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy.Boston: Houghton Mifflin.Sadock, B. J., & Sadock, V. A. (2008). Concise textbook of clinical psychiatry(3rd ed.). Philadelphia: Lippincott Williams & Wilkins.Skinner, B. F. (1974). About behaviorism. New York: Alfred A. Knopf,Inc.Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York:Norton.Yalom, I. D. (1995). The theory and practice of group psychotherapy. NewYork: Basic Books.ADDITIONAL READINGSBeck, A. T. (1976). Cognitive therapy and the emotional disorders. NewYork: New American Library, Inc.Berne, E. (1964). Games people play. New York: Grove Press.Caplan, G. (1964). Principles of preventive psychiatry. New York: BasicBooks.Crain, W. C. (1980). Theories of development: Concepts and application.Englewood Cliffs, NJ: Prentice Hall, Inc.Frankl, V. E. (1959). Man’s search for meaning: An introduction to logotherapy.New York: Beacon Press.Glasser, W. (1965). Reality therapy: A new approach to psychiatry. NewYork: Harper & Row.Miller, P. H. (1983). Theories of developmental psychology. San Francisco:W. H. Freeman & Co.Millon, T. (Ed.). (1967). Theories of psychopathology. Philadelphia: W. B.Saunders.Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy:Excitement and growth in the human personality. New York: DellPublishing Co., Inc.Sugarman, L. (1986). Life-span development: Concepts, theories and interventions.London: Methuen & Co., Ltd.Szasz, T. (1961). The myth of mental illness. New York: Hoeber-Harper.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following theorists believed that a correctiveinterpersonal relationship with the therapist wasthe primary mode of treatment?a. Sigmund Freudb. William Glasserc. Hildegard Peplaud. Harry Stack Sullivan2. Dream analysis and free association are techniques inwhich of the following?a. Client-centered therapyb. Gestalt therapyc. Logotherapyd. Psychoanalysis3. Four levels of anxiety were described bya. Erik Eriksonb. Sigmund Freudc. Hildegard Peplaud. Carl Rogers4. Correcting how one thinks about the world and oneselfis the focus ofa. Behaviorismb. Cognitive therapyc. Psychoanalysisd. Reality therapy5. The personality structures of id, ego, and superego weredescribed bya. Sigmund Freudb. Hildegard Peplauc. Frederick Perlsd. Harry Stack Sullivan6. The nursing role that involves being a substitute foranother, such as a parent, is calleda. Counselorb. Resource personc. Surrogated. Teacher7. Psychiatric rehabilitation focuses ona. Client’s strengthsb. Medication compliancec. Social skills deficitsd. Symptom reduction8. When a nurse develops feelings toward a client that arebased on the nurse’s past experience, it is calleda. Countertransferenceb. Role reversalc. Transferenced. Unconditional regard9. A group that was designed to meet weekly for 10 sessionsto deal with feelings of depression would be a(n)a. Closed groupb. Educational groupc. Open groupd. Support groupFILL-IN-THE-BLANK QUESTIONSWrite the name of the appropriate theorist beside the statement or theory. Names may be used more than once.1. The client is the key to his or her own healing. _____________________________2. Social and psychological factors influence development. _____________________________3. Behavior change occurs through conditioning with environmental stimuli. _______________4. People make themselves unhappy by clinging to irrational beliefs. _____________________5. Behavior is learned from past experience that is reinforcing. __________________________63

64 UNIT 1 • CURRENT THEORIES AND PRACTICE6. Client-centered therapy _______________________________________________________7. Gestalt therapy ______________________________________________________________8. Hierarchy of needs ___________________________________________________________9. Logotherapy ________________________________________________________________10. Rational emotive therapy ______________________________________________________11. Reality therapy ______________________________________________________________SHORT-ANSWER QUESTIONSDescribe each of the following types of groups, and give an example.1. Group psychotherapy2. Education group3. Support group4. Self-help group

4Treatment Settingsand TherapeuticProgramsLearning ObjectivesAfter reading this chapter, you should be able to1. Discuss traditional treatment settings.Key Terms• Access to Community Care andEffective Services and Support(ACCESS) Demonstration Project• assertive community treatment(ACT)• case management• clubhouse model• criminalization of mental illness• day treatment• evolving consumer household• interdisciplinary(multidisciplinary) team• partial hospitalization programs(PHPs)• residential treatment settings2. Describe different types of residential treatment settings and the servicesthey provide.3. Describe community treatment programs that provide services to peoplewith mental illness.4. Identify barriers to effective treatment for homeless people with mental illness.5. Discuss the issues related to people with mental illness in the criminal justicesystem.6. Describe the roles of different members of a multidisciplinary mentalhealth-care team.7. Identify the different roles of the nurse in varied treatment settings andprograms.MENTAL HEALTH CARE HAS UNDERGONE profound changes in the past 50 years.Before the 1950s, humane treatment in large state facilities was the bestavailable strategy for people with chronic and persistent mental illness,many of whom stayed in such facilities for months or years. The introductionof psychotropic medications in the 1950s offered the first hope ofsuccessfully treating the symptoms of mental illness in a meaningful way.By the 1970s, focus on client rights and changes in commitment laws ledto deinstitutionalization and a new era of treatment. Institutions could nolonger hold clients with mental illness indefinitely, and treatment in the“least restrictive environment” became a guiding principle and right. Largestate hospitals emptied. Treatment in the community was intended to replacemuch of state hospital inpatient care. Adequate funding, however,has not kept pace with the need for community programs and treatment(see Chapter 1).Today, people with mental illness receive treatment in a variety of settings.This chapter describes the range of treatment settings available forthose with mental illness and the psychiatric rehabilitation programs thatVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!65

66UNIT 1 • CURRENT THEORIES AND PRACTICEhave been developed to meet their needs. Both of thesesections discuss the challenges of integrating people withmental illness into the community. The chapter alsoaddresses two populations who are receiving inadequatetreatment because they are not connected with needed services:homeless clients and clients who are in jail. In addition,the chapter describes the multidisciplinary team,including the role of the nurse as a member. Finally, itbriefly discusses psychosocial nursing in public health andhome care.TREATMENT SETTINGSInpatient Hospital TreatmentIn the 1980s, inpatient psychiatric care was still a primarymode of treatment for people with mental illness. A typicalpsychiatric unit emphasized talk therapy, or one-on-oneinteractions between residents and staff, and milieu therapy,meaning the total environment and its effect on theclient’s treatment. Individual and group interactionsfocused on trust, self-disclosure by clients to staff and oneanother, and active participation in groups. Effectivemilieu therapy required long lengths of stay because clientswith more stable conditions helped to provide structureand support for newly admitted clients with more acuteconditions.By the 1990s, the economics of health care began tochange dramatically, and the lengths of stay in hospitalsdecreased to just a few days. Today, most Americans areinsured under some form of managed care. Managed careexerts cost-control measures such as recertification ofadmissions, utilization review, and case management—allof which have altered inpatient treatment significantly.The growth of managed care has been associated withdeclining admissions, shorter lengths of stay, reducedreimbursement, and increased acuity of inpatients. Therefore,clients are sicker when they are admitted and do notstay as long in the hospital.Today, inpatient units must provide rapid assessment,stabilization of symptoms, and discharge planning, and theymust accomplish goals quickly. A client-centered multidisciplinaryapproach to a brief stay is essential. Clinicianshelp clients recognize symptoms, identify coping skills, andchoose discharge supports. When the client is safe andstable, the clinicians and the client identify long-term issuesfor the client to pursue in outpatient therapy.Some inpatient units have a locked entrance door,requiring staff with keys to let persons in or out of theunit. This situation has both advantages and disadvantages(Haglund, von Knorring, & von Essen, 2006). Nursesidentify the advantages of providing protection against the“outside world” in a safe and secure environment as wellas the primary disadvantages of making clients feel confinedor dependent, and emphasizing the staff members’power over them.Short Inpatient StaysAlwan, Johnstone, and Zolese (2008) found that plannedshort hospital stays were as effective as longer hospitalizations.Patients spending fewer days in the hospital were morelikely to attend post-discharge day programming and morelikely to be employed after 2 years than patients with longerhospitalizations. Patients with planned shorter stays did nothave more frequent subsequent admissions to the hospital.The Department of Veterans Affairs (VA) hospitalsystem has piloted a variety of alternatives to inpatienthospital admission that occurs when the client’s conditionhas worsened or a crisis has developed. Scheduled, intermittenthospital stays did not lessen veterans’ days in thehospital, but did improve their self-esteem and feelings ofself-control. Another alternative available to veterans, theshort-term acute residential treatment (START) program(Hawthorne et al., 2005), is based in San Diego and isavailable at six facilities, all of which are non-hospitalbasedresidential treatment centers. Over a 2-year period,veterans treated in the START program had the sameimprovement in symptoms and functioning as thosetreated at a VA hospital, but were significantly more satisfiedwith the services. The cost of treatment in a STARTprogram was 65% lower than treatment in the hospital.Long-Stay ClientsLong-stay clients are people with severe and persistentmental illness who continue to require acute care servicesdespite the current emphasis on decreased hospital stays.This population includes clients who were hospitalizedbefore deinstitutionalization and remain hospitalizeddespite efforts at community placement. It also includesclients who have been hospitalized consistently for longperiods despite efforts to minimize their hospital stays.Community placement of clients with problematic behaviorsstill meets resistance from the public, creating a barrierto successful placement in community settings.One approach to working with long-stay clients is a“hospital hostel,” a unit within a hospital that is designedto be more homelike and less institutional. Hostel projectshave been established that provide access to communityfacilities and focus on “normal expectations,” such ascooking, cleaning, and doing housework. Clients reportedimproved functioning, had fewer aggressive episodes, andwere more satisfied with their care. Some clients remainedin the hostel setting, whereas others were eventually resettledin the community. (Bartusch, et al., 2007)The concept of a “crisis hostel” has been successful in arural community–based program in Colorado (Knight, 2004).The only criterion for using the service is the client’s perceptionof being in crisis and needing a more structured environment.Knight believed that if the client does not have to exhibit anycertain “symptoms” to gain access to the hostel, he or she ismore likely to perceive his or her situation more accurately, feelbetter about asking for help, and avoid rehospitalization.

CHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 67Lunsky and colleagues (2006) studied more than12,000 long-stay clients in the tertiary mental health-caresystem in Ontario. They found that 1 in 8 clients had adual diagnosis of a major mental illness and mental retardation.These clients required, but did not often receive, ahigher level of care with more intensive services and supervisionthan clients with a mental illness and normal intellectualfunctioning. As a group, the clients with a dualdiagnosis had more severe symptoms, more instances ofaggressive behavior, and a greater lack of financial andhealth-care resources. The authors suggested that reformin the tertiary mental health-care system should addressthe needs of clients with a dual diagnosis, which oftenexceed current available services.Case ManagementCase management, or management of care on a case-bycasebasis, is an important concept in both inpatient andcommunity settings. Inpatient case managers are usuallynurses or social workers who follow the client from admissionto discharge and serve as liaisons between the clientand community resources, home care, and third-party payers.In the community, the case manager works with clientson a broad range of issues, from accessing needed medicaland psychiatric services to carrying out tasks of daily livingsuch as using public transportation, managing money,and buying groceries.Case managerDischarge PlanningAn important concept in any inpatient treatment setting isdischarge planning. Environmental supports, such as housingand transportation, and access to community resourcesand services are crucial to successful discharge planning. Infact, the adequacy of discharge plans is a better predictor ofhow long the person could remain in the community thanare clinical indicators such as psychiatric diagnoses.Impediments to successful discharge planning includealcohol and drug abuse, criminal or violent behavior, noncompliancewith medication regimens, and suicidal ideation.For example, optimal housing often is not availableto people with a recent history of drug or alcohol abuse orcriminal behavior. Also, clients who have suicidal ideasor a history of noncompliance with medication regimensmay be ineligible for some treatment programs or services.Therefore, clients with these impediments to successfuldischarge planning may have a marginal discharge plan inplace because optimal services or plans are not availableto them. Consequently, people discharged with marginalplans are readmitted more quickly and more frequentlythan those who have better discharge plans.However, discharge plans cannot be successful if clientsdo not follow through with the established plan. Clientsdo not keep follow-up appointments or referrals if theydon’t feel connected to the outpatient services or if theseservices aren’t perceived as helpful or valuable. Attentionto psychosocial factors that address the client’s well-being,his or her preference for follow-up services, inclusion ofthe family, and familiarity with outpatient providers is criticalto the success of a discharge plan.Prince (2006) found that three types of intervention aresignificant in preventing rehospitalization for individualswith four or more prior inpatient stays. These interventionsare symptom education, service continuity, andestablishment of daily structure. Clients who can recognizesigns of impending relapse and seek help, participatein outpatient appointments and services, and have a dailyplan of activities and responsibilities are least likely torequire rehospitalization.Creating successful discharge plans that offer optimalservices and housing is essential if people with mental illnessare to be integrated into the community. A holisticapproach to reintegrating persons into the community isthe best way to prevent repeated hospital admissions andimprove quality of life for clients. Community programsafter discharge from the hospital should include socialservices, day treatment, and housing programs, all gearedtoward survival in the community, compliance with treatmentrecommendations, rehabilitation, and independentliving. Assertive community treatment (ACT) programsprovide many of the services that are necessary to stop therevolving door of repeated hospital admissions punctuatedby unsuccessful attempts at community living. ACTprograms are discussed in detail later in this chapter.

68UNIT 1 • CURRENT THEORIES AND PRACTICEBox 1.2 NUMBERED BOX TITLE WOULD LOOK LIKEBox 4.1PARTIAL HOSPITALIZATIONPROGRAM GOALSBox 4.2 RESIDENTIAL SETTINGS• Stabilizing psychiatric symptoms• Monitoring drug effectiveness• Stabilizing living environment• Improving activities of daily living• Learning to structure time• Developing social skills• Obtaining meaningful work, paid employment, or avolunteer position• Providing follow-up of any health concernsPartial Hospitalization ProgramsPartial hospitalization programs (PHPs) are designed tohelp clients make a gradual transition from being inpatientsto living independently and to prevent repeat admissions.In day treatment programs, clients return home atnight; evening programs are just the reverse. The servicesthat different PHPs offer vary, but most programs includegroups for building communication and social skills, solvingproblems, monitoring medications, and learning copingstrategies and skills for daily living. Individual sessionsare available in some PHPs, as are vocational assistanceand occupational and recreation therapies.Each client has an individualized treatment plan andgoals, which the client develops with the case managerand other members of the treatment team. Eight broad categoriesof goals usually addressed in PHPs are summarizedin Box 4.1.Clients in PHPs may complete the program after aninpatient hospital stay, which is usually too short to addressanything other than stabilization of symptoms and medicationeffectiveness. Other clients may come to a PHP totreat problems before they really start, thus avoiding acostly and unwanted hospital stay. Others may make thetransition from a PHP to longer-term outpatient therapy.Randall and Finkelstein (2007) found that usingcognitive–behavioral therapy in a day treatment settingwas beneficial for clients with severe and persistent mentalillness to achieve program goals of relapse prevention,improved community functioning, and increased socialadjustment. Participants also experienced increased selfesteem,feelings of hope, and a sense of empowerment.Residential SettingsPersons with mental illness may live in community residentialtreatment settings that vary according to structure,level of supervision, and services provided (Box 4.2). Somesettings are designed as transitional housing with the expectationthat residents will progress to more independentGroup homesSupervised apartmentsBoard and care homesAdult foster careRespite/crisis housingliving. Other residential programs serve clients for as longas the need exists, sometimes years. Board and care homesoften provide a room, bathroom, laundry facilities, and onecommon meal each day. Adult foster homes may care forone to three clients in a family-like atmosphere, includingmeals and social activities with the family. Halfway housesusually serve as temporary placements that provide supportas the clients prepare for independence. Group homes house6 to 10 residents, who take turns cooking meals and sharinghousehold chores under the supervision of one or two staffpersons. Independent living programs are often housed inapartment complexes, where clients share apartments. Staffmembers are available for crisis intervention, transportation,assistance with daily living tasks, and, sometimes, drugmonitoring. In addition to on-site staff, many residentialsettings provide case management services for clients andput them in touch with other programs (e.g., vocationalrehabilitation; medical, dental, and psychiatric care; andpsychosocial rehabilitation programs or services) asneeded.Some agencies provide respite housing, or crisis housingservices, for clients in need of short-term temporary shelter.These clients may live in group homes or independentlymost of the time but have a need for “respite” from theirusual residences. This usually occurs when clients experiencea crisis, feel overwhelmed, or cannot cope with problemsor emotions. Respite services often provide increasedemotional support and assistance with problem-solving in asetting away from the source of the clients’ distress.A client’s living environment affects his or her level offunctioning, rate of reinstitutionalization, and duration ofremaining in the community setting. In fact, the livingenvironment is often more predictive of the client’s successthan the characteristics of his or her illness. A client witha poor living environment often leaves the community oris readmitted to the hospital. Finding quality living situationsfor clients is a difficult task. Many clients live incrime-ridden or commercial, rather than residential, areas(Forchuk, Nelson, & Hall, 2006).The evolving consumer household is a group-livingsituation in which the residents make the transition froma traditional group home to a residence where they fulfilltheir own responsibilities and function without on-sitesupervision from paid staff. One of the problems with

THISCHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 69housing for people with mental illness is that they mayhave to move many times, from one type of setting toanother, as their independence increases. This continualmoving necessitates readjustment in each setting, makingit difficult for clients to sustain their gains in independence.Because the evolving consumer household is a permanentliving arrangement, it eliminates the problem ofrelocation.Frequently, residents oppose plans to establish a grouphome or residential facility in their neighborhood. Theyargue that having a group home will decrease their propertyvalues, and they may believe that people with mentalillness are violent, will act bizarrely in public, or will be amenace to their children. These people have stronglyingrained stereotypes and a great deal of misinformation.Local residents must be given the facts so that safe, affordable,and desirable housing can be established for personsneeding residential care. Nurses are in a position to advocatefor clients by educating members of the community.Transitional CareIn Canada and Scotland, the transitional discharge model(Forchuk, Reynolds, Sharkey, Martin, & Jensen, 2007) hasproved successful. Patients who were discharged to thecommunity after long hospitalizations received intensiveservices to facilitate their transition to successful communityliving and functioning. Two essential components ofthis model are peer support and bridging staff. Peer supportis provided by a consumer now living successfully inthe community. Bridging staff refers to an overlap betweenhospital and community care—hospital staff do not terminatetheir therapeutic relationship with the client untila therapeutic relationship has been established with thecommunity care provider. This model requires collaboration,administrative support, and adequate funding toeffectively promote the patient’s health and well-being andprevent relapse and rehospitalization.Poverty among people with mental illness is a significantbarrier to maintaining housing. Residents often relyon government entitlements, such as Social Security Insuranceor Social Security Disability Insurance, for theirincome, which averages $400 to $450 per month. Althoughmany clients express the desire to work, many cannot doso consistently. Even with vocational services, the jobsavailable tend to be unskilled and part-time, resulting inincome that is inadequate to maintain independent living.In addition, the Social Security Insurance system is often adisincentive to making the transition to paid employment:the client would have to trade a reliable source of incomeand much-needed health insurance for a poorly paying,relatively insecure job that is unlikely to include fringebenefits. Both psychiatric rehabilitation programs andsociety must address poverty among people with mentalillness to remove this barrier to independent living andself-sufficiency (Perese, 2007).PSYCHIATRIC REHABILITATIONPROGRAMSPsychiatric rehabilitation, sometimes called psychosocialrehabilitation, refers to services designed to promote therecovery process for clients with mental illness (Box 4.3).This recovery goes beyond symptom control and medicationmanagement to include personal growth, reintegrationinto the community, empowerment, increased independence,and improved quality of life. Communitysupport programs and services provide psychiatric rehabilitationto varying degrees, often depending on theresources and funding available. Some programs focus primarilyon reducing hospital readmissions through symptomcontrol and medication management, whereas othersinclude social and recreation services. Too few programsare available nationwide to meet the needs of people withmental illnesses.Psychiatric rehabilitation has improved client outcomesby providing community support services to decrease hospitalreadmission rates and increase community integration.At the same time, managed care has reduced the“medically necessary” services that are funded. For example,because skills training was found to be successful inassisting clients in the community, managed care organizationsdefined psychiatric rehabilitation as only skills trainingand did not fund other aspects of rehabilitation suchas socialization or environmental supports. Clients andproviders identified poverty, lack of jobs, and inadequatevocational skills as barriers to community integration, butbecause these barriers were not included in the “medicallynecessary” definition of psychiatric rehabilitation by managedcare, services to overcome these barriers were notfunded.Box 4.3GOALS OF PSYCHIATRICREHABILITATION• Recovery from mental illness• Personal growth• Quality of life• Community reintegration• Empowerment• Increased independence• Decreased hospital admissions• Improved social functioning• Improved vocational functioning• Continuous treatment• Increased involvement in treatment decisions• Improved physical health• Recovered sense of self

70UNIT 1 • CURRENT THEORIES AND PRACTICEClubhouse ModelIn 1948, Fountain House pioneered the clubhouse modelof community-based rehabilitation in New York City. As of2008, more than 400 such clubhouses have been establishedin 32 countries throughout the world by Fountain House.Fountain House is an “intentional community” based onthe belief that men and women with serious and persistentpsychiatric disabilities can and will achieve normal life goalswhen given opportunity, time, support, and fellowship. Theessence of membership in the clubhouse is based on thefour guaranteed rights of members:• A place to come to• Meaningful work• Meaningful relationships• A place to return to (lifetime membership)The clubhouse model provides members with manyopportunities, including daytime work activities focusedon the care, maintenance, and productivity of the clubhouse;evening, weekend, and holiday leisure activities;transitional and independent employment support andefforts; and housing options. Members are encouraged andassisted to use psychiatric services, which are usually localclinics or private practitioners.The clubhouse model recognizes the physician–clientrelationship as a key to successful treatment and rehabilitationwhile acknowledging that brief encounters that focuson symptom management are not sufficient to promoterehabilitation efforts. The “rehabilitation alliance” refers tothe network of relationships that must develop over time tosupport people with psychiatric disabilities and includesthe client, family, friends, clinicians, and even landlords,employers, and neighbors. The rehabilitation alliance needscommunity support, opportunities for success, coordinationof service providers, and member involvement tomaintain a positive focus on life goals, strengths, creativity,and hope as the members pursue recovery. The clubhousemodel exists to promote the rehabilitation alliance as apositive force in the members’ lives.The clubhouse focus is on health, not illness. Takingprescribed drugs, for example, is not a condition of participationin the clubhouse. Members, not staff, must ultimatelymake decisions about treatment, such as whetheror not they need hospital admission. Clubhouse staff supportsmembers, helps them to obtain needed assistance,and most of all allows them to make the decisions thatultimately affect all aspects of their lives. This approach topsychiatric rehabilitation is the cornerstone and thestrength of the clubhouse model.Assertive Community Treatment (1973)One of the most effective approaches to community-basedtreatment for people with mental illness is ACT (Box 4.4).Marx, Test, and Stein (1973) conceived this idea in 1973 inMadison, Wisconsin, while working at Mendota State Hospital.They believed that skills training, support, and teachingshould be done in the community where it was neededrather than in the hospital. Their program was first knownas the Madison model, then “training in community living,”and, finally, ACT, or the program for assertive treatment.The mobile outreach and continuous treatment programs oftoday all have their roots in the Madison model.An ACT program has a problem-solving orientation:Staff members attend to specific life issues, no matter howBOX 4.4 COMPONENTS OF AN ACT PROGRAM• Having a multidisciplinary team that includes a psychiatrist,psychiatric–mental health nurse, vocational rehabilitationspecialist, and social worker for each 100 clients(low staff-to-client ratio)• Identifying a fixed point of responsibility for clients witha primary provider of services• Ameliorating or eliminating the debilitating symptoms ofmental illness• Improving client functioning in adult social and employmentroles and activities• Decreasing the family’s burden of care by providing opportunitiesfor clients to learn skills in real-life situations• Implementing an individualized, ongoing treatment programdefined by clients’ needs• Involving all needed support systems for holistic treatmentof clients• Promoting mental health through the use of a vast arrayof resources and treatment modalities• Emphasizing and promoting client independence• Using daily team meetings to discuss strategies toimprove the care of clients• Providing services 24 hours a day that would includerespite care to deflect unnecessary hospitalization andcrisis intervention to prevent destabilization with unnecessaryemergency department visits• Measuring client outcomes on the following aspects:symptomatology; social, psychological, and familial functioning;gainful employment; client independence; clientempowerment; use of ancillary services; client, family,and societal satisfaction; hospital use; agency use; rehospitalization;quality of life; and costs

CHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 71mundane. ACT programs provide most services directlyrather than relying on referrals to other programs or agencies,and they implement the services in the clients’ homesor communities, not in offices. The ACT services are alsointense; three or more face-to-face contacts with clientsare tailored to meet clients’ needs. The team approachallows all staff to be equally familiar with all clients, soclients do not have to wait for an assigned person. ACTprograms also make a long-term commitment to clients,providing services for as long as the need persists and withno time constraints (Coldwell & Bender, 2007).ACT programs were developed and flourished in urbansettings. They have also been effective in rural areas, wheretraditional psychiatric services are more limited, fragmented,and difficult to obtain than in cities. Rural areashave less money to fund services, and social stigma aboutmental illness is greater in rural areas, as are negative attitudesabout public service programs. Rural ACT programshave resulted in fewer hospital admissions, greater housingstability, improved quality of life, and improved psychiatricsymptoms. This success occurred even thoughcertain modifications of traditional ACT programs wererequired, such as two-person teams, fewer and shortercontacts with clients, and minimal participation fromsome disciplines.ACT programs have also been successful in Canada andAustralia (Latimer, 2005; Udechuku et al., 2005) indecreasing hospital admissions and fostering communityintegration for persons with mental illness. In New York,ACT services have been modified to include servicesdesigned to prevent arrest and incarceration of adults withsevere mental illness who have been involved in the criminaljustice system. This special population is discussedlater in the chapter.SPECIAL POPULATIONS OF CLIENTSWITH MENTAL ILLNESSHomeless PopulationHomeless people with mental illness have been the focusof recent studies. For this population, shelters, rehabilitationprograms, and prisons may serve as makeshift alternativesto inpatient care or supportive housing. Frequentshifts between the street, programs, and institutionsworsen the marginal existence of this population. Comparedwith homeless people without mental illness, mentallyill homeless people are homeless longer, spend moretime in shelters, have fewer contacts with family, spendmore time in jail, and face greater barriers to employment(National Resource and Training Center on Homelessnessand Mental Illness, 2006). For this population, professionalssupersede families as the primary source of help.Providing housing alone does not significantly alter theprognosis of homelessness for persons with mental illness.Psychosocial rehabilitation services, peer support, vocationaltraining, and daily living skill training are all importantcomponents for decreasing homelessness and improvingquality of life. In the early 1990s, the federal governmentauthorized a grant program to address the needs of peoplewho are homeless and have mental illness. The programProjects for Assistance in Transition from Homelessness(PATH) funds community-based outreach, mental health,substance abuse, case management, and other supportservices. Some limited housing services are available, butPATH works primarily with existing housing services inthe given community (Substance Abuse and Mental HealthServices Administration, 2006).The Center for Mental Health Services initiated the Accessto Community Care and Effective Services and Support(ACCESS) Demonstration Project in 1994 to assess whethermore integrated systems of service delivery enhance thequality of life of homeless people with serious mental disabilitiesthrough the use of services and outreach. ACCESSwas a 5-year demonstration program located within 15 U.S.cities in nine states that represented most geographic areas ofthe continental United States. Each site provided outreachand intensive case management to 100 homeless people withsevere mental illnesses every year.Participants in the first 2 years of the ACCESS demonstrationproject were surveyed to determine whether theyhad formed a relationship with their assigned case managersand what, if any, differences they experienced in termsof homelessness, symptom management, and use of substances.A total of 2,798 participants completed the surveyprocess. Only 48% reported having relationships or personalconnections with their case managers, underscoringthe difficulty in establishing therapeutic relationships withhomeless mentally ill clients. Clients reporting such relationshipsdescribed more social support, received morepublic support and education, were less psychotic, werehomeless fewer days, and were intoxicated fewer days thanparticipants who reported having no relationship withtheir assigned case managers. Although engaging this populationin therapeutic relationships is difficult, results arepositive when those relationships are established.The most recent report from the ACCESS project foundthat participants reported multiple factors that influencetheir quality of life; managing psychiatric symptoms andreceiving social support were most important. The datafrom this report suggest that focusing treatment on the multipleindependent domains of psychiatric illness, social supportnetworks, work and income, housing, and increasedservice use is necessary to maximally improve clients’ selfassessedquality of life and decrease the number of homelessdays. These positive outcomes were maintained after terminationof the intervention (Rothbard, Min, Kuno, & Wong,2004). Desai and Rosenheck (2005) studied persons in theACCESS project in terms of unmet physical health needs.They found that collaborative case management played animportant role in improving the physical health of participantsby linking them to appropriate medical services.

72UNIT 1 • CURRENT THEORIES AND PRACTICEPrisonersThe rate of mental illness in the jailed population is 13%,compared with 2% in the general population. Offenders generallyhave acute and chronic mental illness and poor functioning,and many are homeless. Factors cited as reasonsthat mentally ill people are placed in the criminal justice systeminclude deinstitutionalization, more rigid criteria forcivil commitment, lack of adequate community support,economizing on treatment for mental illness, and the attitudesof police and society (Gostin, 2008). Criminalizationof mental illness refers to the practice of arresting and prosecutingmentally ill offenders, even for misdemeanors, at arate four times that of the general population in an effort tocontain them in some type of institution where they mightreceive needed treatment. However, if offenders with mentalillness had obtained needed treatment, some might not haveengaged in criminal activity.The public concern about the potential danger of peoplewith mental illness is fueled by the media attentionthat surrounds any violent criminal act committed by amentally ill person. Although it is true that people withmajor mental illnesses who do not take prescribed medicationare at increased risk for being violent, most peoplewith mental illness do not represent a significant danger toothers. This fact, however, does not keep citizens fromclinging to stereotypes of the mentally ill as people to befeared, avoided, and institutionalized. If such people cannotbe confined in mental hospitals for any period, thereseems to be public support for arresting and incarceratingthem instead. In fact, people with a mental illness are morelikely to be the victims of violence, both in prisons and inthe community (Blitz, Wolf, & Shi, 2008).People with mental illness who are in the criminal justicesystem face several barriers to successful communityreintegration:• Poverty• Homelessness• Substance use• Violence• Victimization, rape, and trauma• Self-harmSome communities have mobile crisis services linked totheir police departments. These professionals are called tothe scene (after the situation is stabilized) when policeofficers believe mental health issues are involved. Frequently,the mentally ill individual can be diverted to crisiscounseling services or to the hospital, if needed, instead ofbeing arrested and going to jail. Often, these same professionalsprovide education to police to help them recognizemental illness and perhaps change their attitude aboutmentally ill offenders.Steadman and associates (2005) piloted the Brief JailMental Health Screen (BJMHS) at Cook County jail inChicago. This is an eight-item questionnaire that can beadministered in 2.5 minutes. Each detainee was given thequestionnaire to see if further evaluation or referral formental health services was indicated. The BJMHS correctlyclassified 73.5% of males, but only 61.6% of females. Thisled the authors to suggest that this brief screening toolwould increase effective identification and referral of maledetainees and, therefore, could be useful as a standard partof jail admission.INTERDISCIPLINARY TEAMRegardless of the treatment setting, rehabilitation program,or population, an interdisciplinary (multidisciplinary)team approach is most useful in dealing with the multifacetedproblems of clients with mental illness. Differentmembers of the team have expertise in specific areas. Bycollaborating, they can meet clients’ needs more effectively.Members of the interdisciplinary team include the pharmacist,psychiatrist, psychologist, psychiatric nurse, psychiatricsocial worker, occupational therapist, recreationtherapist, and vocational rehabilitation specialist. Theirprimary roles are described in Box 4.5. Not all settingshave a full-time member from each discipline on theirteam; the programs and services that the team offers determineits composition in any setting.Functioning as an effective team member requires thedevelopment and practice of several core skill areas:• Interpersonal skills, such as tolerance, patience, andunderstanding• Humanity, such as warmth, acceptance, empathy, genuineness,and nonjudgmental attitude• Knowledge base about mental disorders, symptoms,and behavior• Communication skills• Personal qualities, such as consistency, assertiveness,and problem-solving abilities• Teamwork skills, such as collaborating, sharing, andintegrating• Risk assessment and risk management skillsThe role of the case manager has become increasinglyimportant with the proliferation of managed care and thevariety of services that clients need. No standard formaleducational program to become a case manager exists,however, and people from many different backgroundsmay fill this role. In some settings, a social worker or psychiatricnurse may be the case manager. In other settings,people who work in psychosocial rehabilitation settingsmay take on the role of case manager with a baccalaureatedegree in a related field, such as psychology, or by virtue oftheir experience and demonstrated skills. Effective casemanagers need to have clinical skills, relationship skills,and liaison and advocacy skills to be most successful withtheir clients. Clinical skills include treatment planning,

CHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 73Box 4.5 INTERDISCIPLINARY TEAM PRIMARY ROLES• Pharmacist: The registered pharmacist is a member ofthe interdisciplinary team when medications, managementof side effects, and/or interactions with nonpsychiatricmedications are complex. Clients with refractorysymptoms may also benefit from the pharmacist’s knowledgeof chemical structure and actions of medications.• Psychiatrist: The psychiatrist is a physician certified inpsychiatry by the American Board of Psychiatry and Neurology,which requires a 3-year residency, 2 years of clinicalpractice, and completion of an examination. Theprimary function of the psychiatrist is diagnosis of mentaldisorders and prescription of medical treatments.• Psychologist: The clinical psychologist has a doctorate(Ph.D.) in clinical psychology and is prepared to practicetherapy, conduct research, and interpret psychologicaltests. Psychologists may also participate in the design oftherapy programs for groups of individuals.• Psychiatric nurse: The registered nurse gains experiencein working with clients with psychiatric disorders aftergraduation from an accredited program of nursing andcompletion of the licensure examination. The nurse has asolid foundation in health promotion, illness prevention,and rehabilitation in all areas, allowing him or her to viewthe client holistically. The nurse is also an essential teammember in evaluating the effectiveness of medical treatment,particularly medications. Registered nurses whoobtain master’s degrees in mental health may be certifiedas clinical specialists or licensed as advanced practitioners,depending on individual state nurse practice acts.Advanced practice nurses are certified to prescribe drugsin many states.• Psychiatric social worker: Most psychiatric social workersare prepared at the master’s level, and they are licensedin some states. Social workers may practicetherapy and often have the primary responsibility forworking with families, community support, and referral.• Occupational therapist: Occupational therapists mayhave an associate degree (certified occupational therapyassistant) or a baccalaureate degree (certified occupationaltherapist). Occupational therapy focuses on thefunctional abilities of the client and ways to improve clientfunctioning, such as working with arts and crafts andfocusing on psychomotor skills.• Recreation therapist: Many recreation therapists completea baccalaureate degree, but in some instances personswith experience fulfill these roles. The recreationtherapist helps the client to achieve a balance of workand play in his or her life and provides activities that promoteconstructive use of leisure or unstructured time.• Vocational rehabilitation specialist: Vocational rehabilitationincludes determining clients’ interests and abilitiesand matching them with vocational choices. Clientsare also assisted in job-seeking and job-retention skills aswell as in pursuit of further education, if that is neededand desired. Vocational rehabilitation specialists can beprepared at the baccalaureate or master’s level and mayhave different levels of autonomy and program supervisionbased on their education.symptom and functional assessment, and skills training.Relationship skills include the ability to establish andmaintain collaborative, respectful, and therapeutic allianceswith a wide variety of clients. Liaison and advocacyskills are necessary to develop and maintain effective interagencycontacts for housing, financial entitlements, andvocational rehabilitation.As clients’ needs become more varied and complex, thepsychiatric nurse is in an ideal position to fulfill the role ofcase manager. In 1994, the American Nurses Associationstated that the psychiatric nurse can assess, monitor, andrefer clients for general medical problems as well as psychiatricproblems; administer drugs; monitor for drug sideeffects; provide drug and client and family health education;and monitor for general medical disorders that havepsychological and physiological components. Registerednurses bring unique nursing knowledge and skills to themultidisciplinary team.PSYCHOSOCIAL NURSING IN PUBLICHEALTH AND HOME CAREPsychosocial nursing is an important area of public healthnursing practice and home care. Public health nurses workingin the community provide mental health prevention servicesto reduce risks to the mental health of persons, families,and communities. Examples include primary prevention,such as stress management education; secondary prevention,such as early identification of potential mental healthproblems; and tertiary prevention, such as monitoring andcoordinating rehabilitation services for the mentally ill.The clinical practice of public health and home carenurses includes caring for clients and families with issuessuch as substance abuse, domestic violence, child abuse,grief, and depression. In addition, public health nursescare for children in schools and teach health-related subjectsto community groups and agencies. Mental health

74UNIT 1 • CURRENT THEORIES AND PRACTICEservices that public health and home care nurses providecan reduce the suffering that many people experience as aresult of physical disease, mental disorders, social andemotional disadvantages, and other vulnerabilities.SELF-AWARENESS ISSUESPsychiatric–mental health nursing is evolvingas changes continue in health care. The focusis shifting from traditional hospital-based goalsof symptom and medication management tomore client-centered goals, which include improved qualityof life and recovery from mental illness. Therefore, the nursealso must expand his or her repertoire of skills and abilitiesto assist clients in their efforts. These challenges may overwhelmthe nurse at times, and he or she may feel underpreparedor ill-equipped to meet them.Mental health services are moving into some nontraditionalsettings such as jails and homeless shelters. As nursingroles expand in these alternative settings, the nursedoes not have the array of backup services found in hospitalsor clinics, such as on-site physicians and colleagues,medical services, and so forth. This requires the nurse topractice in a more autonomous and independent manner,which can be unsettling.Empowering clients to make their own decisions abouttreatment is an essential part of full recovery. This differsfrom the model of the psychiatrist or treatment team as theauthority on what is the best course for the client to follow.It is a challenge for the nurse to be supportive of the clientwhen the nurse believes the client has made choices thatare less than ideal.The nurse may experience frustration when workingwith mentally ill adults who are homeless or incarceratedor both. Typically, these clients are difficult to engage intherapeutic relationships and may present great challengesto the nurse. The nurse may feel rejected by clients who donot engage readily in a relationship, or the nurse may feelinadequate in attempts to engage these clients.Points to Consider When Workingin Community-Based Settings• The client can make mistakes, survive them, and learnfrom them. Mistakes are a part of normal life for everyone,and it is not the nurse’s role to protect clients fromsuch experiences.• The nurse will not always have the answer to solve aclient’s problems or resolve a difficult situation.• As clients move toward recovery, they need support tomake decisions and follow a course of action, even ifthe nurse thinks the client is making decisions that areunlikely to be successful.• Working with clients in community settings is a morecollaborative relationship than the traditional role ofcaring for the client. The nurse may be more familiarand comfortable with the latter.Critical Thinking Questions1. Discuss the role of the nurse in advocating for social orlegislative policy changes needed to provide psychiatricrehabilitation services for clients in all settings.2. How much input should the residents in a neighborhoodhave about the location of a group home orhalfway house in their area?KEY POINTS• People with mental illness are treated in avariety of settings, and some are not intouch with needed services at all.• Shortened inpatient hospital stays necessitatechanges in the ways hospitals deliver services toclients.• Adequate discharge planning is a good indicator of howsuccessful the client’s community placement will be.• Impediments to successful discharge planning includealcohol and drug abuse, criminal or violent behavior,noncompliance with medications, and suicidal ideation.• PHPs usually address the client’s psychiatric symptoms,medication use, living environment, activities of daily living,leisure time, social skills, work, and health concerns.• Community residential settings vary in terms of structure,level of supervision, and services provided. Someresidential settings are transitional, with the expectationthat clients will progress to independent living; othersserve the client for as long as he or she needs.• Types of residential settings include board and care homes,adult foster homes, halfway houses, group homes, andindependent living programs.• A client’s ability to remain in the community is closelyrelated to the quality and adequacy of his or her livingenvironment.• Poverty among persons with mental illness is a significantbarrier to maintaining housing in the communityand is seldom addressed in psychiatric rehabilitation.• Psychiatric rehabilitation refers to services designed topromote the recovery process for clients with mental illness.This recovery goes beyond symptom control andmedication management to include personal growth,reintegration into the community, empowerment, increasedindependence, and improved quality of life.• The clubhouse model of psychosocial rehabilitation isan intentional community based on the belief that menand women with mental illness can and will achievenormal life goals when provided time, opportunity, support,and fellowship.• ACT is one of the most effective approaches to communitybasedtreatment. It includes 24-hour-a-day services, lowstaff-to-client ratios, in-home or community services, intenseand frequent contact, and unlimited length ofservice.

CHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS 75INTERNET RESOURCESRESOURCES• Fountain House (clubhouse model)• National Association for Home Care and Hospice• National Law Center on Homelessness and Poverty• National Mental Health Association• National Mental Health Information Center• National Rehabilitation Information CenterINTERNET ADDRESShttp://www.fountainhouse.orghttp://www.nahc.orghttp://www.nlchp.orghttp://www.nmha.orghttp://www.mentalhealth.orghttp://www.naric.com• Psychiatric rehabilitation services such as ACT must beprovided along with stable housing to produce positiveoutcomes for mentally ill adults who are homeless.• Adults with mental illness may be placed in the criminaljustice system more frequently because of deinstitutionalization,rigid criteria for civil commitment, lack of adequatecommunity support, economizing on treatment for mentalillness, and the attitudes of police and society.• Barriers to community reintegration for mentally ill personswho have been incarcerated include poverty, homelessness,substance abuse, violence, victimization, rape,trauma, and self-harm.• The multidisciplinary team includes the psychiatrist,psychologist, psychiatric nurse, psychiatric social worker,occupational therapist, recreation therapist, vocationalrehabilitation specialist, and sometimes pharmacist.• The psychiatric nurse is in an ideal position to fulfill therole of case manager. The nurse can assess, monitor, andrefer clients for general medical and psychiatric problems;administer drugs; monitor for drug side effects;provide drug and patient and family health education;and monitor for general medical disorders that havepsychological and physiological components.• Empowering clients to pursue full recovery requirescollaborative working relationships with clients ratherthan the traditional approach of caring for clients.REFERENCESAlwan, N. A., Johnstone, P., & Zolese, G. (2008). Length of hospitalisationfor people with severe mental illness. Cochrane Database ofSystematic Reviews, 1, CD0000384.Bartusch, S. M., Bruggemann, B. R., Elgeti, H., Zeigenbein, M., & Machleidt,W. (2007). Hannover study on long-stay hospitalization—part II:Characteristics and care conditions of long-stay hospitalization in casesof chronic mental illness. Clinical Practice and Epidemiology in MentalHealth, 3, 27.Blitz, C. L., Wolff, N., & Shi, J. (2008). Physical victimization in prison: Therole of mental illness. International Journal of Law and Psychiatry, 31(5),385–393.Coldwell, C. M., & Bender, W. S. (2007). The effectiveness of assertivecommunity treatment for homeless populations with severe mentalillness: A meta-analysis. American Journal of Psychiatry, 164(3),393–399.Desai, M. M., & Rosenheck, R. A. (2005). Unmet need for medical careamong homeless adults with serious mental illness. General HospitalPsychiatry, 27(6), 418–425.Forchuk, C., Nelson, G., & Hall, G. B. (2006). “It’s important to be proudof the place you live in”: Housing problems and preferences of psychiatricsurvivors. Perspectives in Psychiatric Care, 42(1), 42–52.Forchuk, C., Reynolds, W., Sharkey, S., Martin, M. L., & Jensen, E.(2007). The transitional discharge model. Journal of PsychosocialNursing, 45(11), 31–38.Gostin, L. O. (2008). Old and new institutions for persons with mentalillness: Treatment, punishment, or preventive confinement? PublicHealth, 122(9), 906–913.Haglund, K, von Knorring, L., & von Essen, L. (2006). Psychiatric wardswith locked doors: Advantages and disadvantages according tonurses and mental health assistants. Journal of Clinical Nursing,15(4), 387–394.Hawthorne, W. B., Green, E. E., Gilmer, T., et al. (2005). A randomizedtrial of short-term acute residential treatment for veterans. PsychiatricServices, 56(11), 1379–1386.Knight, E. L. (2004). Exempary rural mental health service delivery.Behavioral Health Care Tomorrow, 13(3), 20–24.Latimer, E. (2005). Economic considerations associated with assertive communitytreatment and supported employment for people with severemental illness. Journal of Psychiatry and Neuroscience, 30(5), 355–359.Lunsky, Y., Bradley, E., Durbin, J., et al. (2006). The clinical profile andservice needs of hospitalized adults with mental retardation and apsychiatric diagnosis. Psychiatric Services, 57(1), 77–83.Marx, A. J., Test, M. A., & Stein, L. I. (1973). Extrohospital managementof severe mental illness: Feasibility and effects of social functioning.Archives of General Psychiatry, 29(4), 505–511.National Resource and Training Center on Homelessness and MentalIllness. (2006). Why are so many people with mental illness homeless?Available at: http://www.nrchmi.sanhsa.gov/facts.Perese, E. F. (2007). Stigma, poverty, and victimization: Roadblocks torecovery for individuals with severe mental illness. Journal of theAmerican Psychiatric Nurses Association, 13(5), 285–295.Prince, J. D. (2006). Practices preventing rehospitalization of individualswith schizophrenia. Journal of Nervous and Mental Disease, 194(6),397–403.Randall, M., & Finkelstein, S. H. (2007). Integration of cognitive behavioraltherapy into psychiatric rehabilitation day programming.Psychiatric Rehabilitation Journal, 30(3), 199–206.Rothbard, A. B., Min, S. Y., Kuno, E., & Wong, Y. L. (2004). Long-termeffectiveness of the ACCESS program in linking community mentalhealth services to homeless persons with serious mental illness.Journal of Behavioral Health Services and Research, 31(4), 441–449.Steadman, H. J., Scott, J. E., Osher, F., et al. (2005). Validation of the briefjail mental health screen. Psychiatric Services, 56(7), 816–822.Substance Abuse and Mental Health Services Administration (SAMHSA).(2006). PATH: Overview of the program. Available at: http://mentalhealth.samhsa.gov/cmhs/homelessness/about.asp.Udechuku, A., Oliver, J., Hallam, K., et al. (2005). Assertive communitytreatment of the mentally ill: Service model and effectiveness.Australasian Psychiatry, 13(2), 129–134.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. All the following are characteristics of ACT excepta. Services are provided in the home or community.b. Services are provided by the client’s case manager.c. There are no time limitations on ACT services.d. All needed support systems are involved in ACT.2. Research shows that scheduled intermittent hospitaladmissions result in which of the following?a. Fewer inpatient hospital staysb. Increased sense of control for the clientc. Feelings of failure when hospitalizedd. Shorter hospital stays3. Inpatient psychiatric care focuses on all the followingexcepta. Brief interventionsb. Discharge planningc. Independent living skillsd. Symptom management4. How many persons in the state prison population havesevere mental illness?a. Less than 9%b. 16%c. 33%d. More than 45%5. Which of the following interventions is an example of primaryprevention implemented by a public health nurse?a. Reporting suspected child abuseb. Monitoring compliance with medications for a clientwith schizophreniac. Teaching effective problem-solving skills to highschool studentsd. Helping a client to apply for disability benefits6. The primary purpose of psychiatric rehabilitation is toa. Control psychiatric symptomsb. Manage clients’ medicationsc. Promote the recovery processd. Reduce hospital readmissions7. Managed care provides funding for psychiatric rehabilitationprograms toa. Develop vocational skillsb. Improve medication compliancec. Provide community skills trainingd. Teach social skills8. The mentally ill homeless population benefits most froma. Case management servicesb. Outpatient psychiatric care to manage psychiatricsymptomsc. Stable housing in a residential neighborhoodd. A combination of housing, rehabilitation services,and community supportFILL-IN-THE-BLANK QUESTIONSIdentify the interdisciplinary team member responsible for the functions listed below.____________________________________________________________________________________________________________________________________________________________________________Works with families, community supports, and referralsFocuses on functional abilities and work using arts and craftsMakes diagnoses and prescribes treatmentEmphasizes job-seeking and job-retention skills76

CHAPTER 4 • TREATMENT SETTINGS AND THERAPEUTIC PROGRAMS77SHORT-ANSWER QUESTIONS1. Identify three barriers to community reintegration faced by mentally ill offenders.2. Discuss the concept of evolving consumer households.3. List factors that have caused an increased number of persons with mental illness to bedetained in jails.

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BUILDING THENURSE–CLIENTRELATIONSHIPUnit 2Chapter 5 Therapeutic RelationshipsChapter 6 Therapeutic CommunicationChapter 7 Client’s Response to IllnessChapter 8 Assessment

5TherapeuticRelationshipsLearning ObjectivesAfter reading this chapter, you should be able toKey Terms• acceptance• advocacy• attitudes• beliefs• confidentiality• congruence• countertransference• duty to warn• empathy• exploitation• genuine interest• intimate relationship• orientation phase• patterns of knowing• positive regard• preconceptions• problem identification• self-awareness• self-disclosure• social relationship• termination or resolution phase• therapeutic relationship• therapeutic use of self• transference• unknowing• values• working phase801. Describe how the nurse uses the necessary components involved in buildingand enhancing the nurse–client relationship (trust, genuine interest,empathy, acceptance, and positive regard).2. Explain the importance of values, beliefs, and attitudes in the developmentof the nurse–client relationship.3. Describe the importance of self-awareness and therapeutic use of self inthe nurse–client relationship.4. Identify self-awareness issues that can enhance or hinder the nurse–clientrelationship.5. Define Carper’s four patterns of knowing and give examples of each.6. Describe the differences between social, intimate, and therapeuticrelationships.7. Describe and implement the phases of the nurse–client relationship asoutlined by Hildegard Peplau.8. Explain the negative behaviors that can hinder or diminish the nurse–clientrelationship.9. Explain the various possible roles of the nurse (teacher, caregiver, advocate,and parent surrogate) in the nurse–client relationship.THE ABILITY TO ESTABLISH THERAPEUTIC relationships with clients is one of themost important skills a nurse can develop. Although important in all nursingspecialties, the therapeutic relationship is especially crucial to the successof interventions with clients requiring psychiatric care because thetherapeutic relationship and the communication within it serve as the underpinningfor treatment and success.This chapter examines the crucial components involved in establishingappropriate therapeutic nurse–client relationships: trust, genuine interest,acceptance, positive regard, self-awareness, and therapeutic use of self. Itexplores the tasks that should be accomplished in each phase of the nurse–client relationship and the techniques the nurse can use to help do so.Visit http://thePoint.lww.com for NCLEX-style questions, journal articles, andmore.

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 81It also discusses each of the therapeutic roles of the nurse:teacher, caregiver, advocate, and parent surrogate.COMPONENTS OF A THERAPEUTICRELATIONSHIPMany factors can enhance the nurse–client relationship,and it is the nurse’s responsibility to develop them. Thesefactors promote communication and enhance relationshipsin all aspects of the nurse’s life.TrustThe nurse–client relationship requires trust. Trust buildswhen the client is confident in the nurse and when thenurse’s presence conveys integrity and reliability. Trustdevelops when the client believes that the nurse will beconsistent in his or her words and actions and can be reliedon to do what he or she says. Some behaviors the nursecan exhibit to help build the client’s trust include caring,interest, understanding, consistency, honesty, keepingpromises, and listening to the client (Box 5.1). A caringtherapeutic nurse–client relationship enables trust todevelop so that the client can accept the assistance beingoffered (Warelow, Edward, & Vinek, 2008).Congruence occurs when words and actions match. Forexample, the nurse says to the client, “I have to leave now togo to a clinical conference, but I will be back at 2 PM,” andindeed returns at 2 PM to see the client. The nurse needs toexhibit congruent behaviors to build trust with the client.Trust erodes when a client sees inconsistency betweenwhat the nurse says and does. Inconsistent or incongruentbehaviors include making verbal commitments andnot following through on them. For example, the nursetells the client she will work with him every Tuesday at10 AM, but the very next week she has a conflict with herconference schedule and does not show up. Anotherexample of incongruent behavior is when the nurse’svoice or body language is inconsistent with the words heor she speaks. For example, an angry client confronts anurse and accuses her of not liking her. The nurseresponds by saying, “Of course I like you, Nancy! I amhere to help you.” But as she says these words, the nurseBox 5.1 TRUSTING BEHAVIORSTrust is built in the nurse–client relationship when thenurse exhibits the following behaviors:• Caring• Openness• Objectivity• Respect• Interest• Understanding• Consistency• Treating the client as a human being• Suggesting without telling• Approachability• Listening• Keeping promises• Honestybacks away from Nancy and looks over her shoulder:the verbal and nonverbal components of the message donot match.When working with a client with psychiatric problems,some of the symptoms of the disorder, such as paranoia,low self-esteem, and anxiety, may make trust difficult toestablish. For example, a client with depression has littlepsychic energy to listen to or comprehend what the nurseis saying. Likewise, a client with panic disorder may be tooanxious to focus on the nurse’s communication. Althoughclients with mental disorders frequently give incongruentmessages because of their illness, the nurse must continueto provide consistent congruent messages. Examiningone’s own behavior and doing one’s best to make messagesclear, simple, and congruent help to facilitate trust betweenthe nurse and the client.Genuine InterestWhen the nurse is comfortable with himself or herself,aware of his or her strengths and limitations, and clearlyCLINICAL VIGNETTE: THERAPEUTIC RELATIONSHIPSTwelve nursing students have arrived for their first day onthe psychiatric unit. They are apprehensive, uncertain whatto expect, and standing in a row just inside the locked doors.They are not at all sure how to react to these clients and arefearful of what to say at the first meeting. Suddenly theyhear one of the clients shout, “Oh look, the students arehere. Now we can have some fun!” Another client replies,“Not me, I just want to be left alone.” A third client says,“I want to talk to the good-looking one.” And so, thesestudents’ nurse–client relationships have just begun—notquite in the best or textbook circumstances.

82UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPfocused, the client perceives a genuine person showinggenuine interest. A client with mental illness can detectwhen someone is exhibiting dishonest or artificial behaviorsuch as asking a question and then not waiting forthe answer, talking over him or her, or assuring him orher everything will be all right. The nurse should beopen and honest and display congruent behavior. Sometimes,however, responding with truth and honesty alonedoes not provide the best professional response. In suchcases, the nurse may choose to disclose to the client apersonal experience related to the client’s current concerns.It is essential, however, that the nurse is veryselective about personal examples. These examplesshould be from the nurse’s past experience, not a currentproblem the nurse is still trying to resolve, or a recent,still painful experience. Self-disclosure examples aremost helpful to the client when they represent commonday-to-day experiences and do not involve value-ladentopics. For example, the nurse might share an experienceof being frustrated with a coworker’s tardiness orbeing worried when a child failed an exam at school. Itis rarely helpful to share personal experiences such asgoing through a divorce or the infidelity of a spouse orpartner. Self-disclosure can be helpful on occasion, butthe nurse must not shift emphasis to his or her ownproblems rather than the client’s.EmpathyEmpathy is the ability of the nurse to perceive the meaningsand feelings of the client and to communicate thatunderstanding to the client. It is considered one of theessential skills a nurse must develop. Being able to puthimself or herself in the client’s shoes does not mean thatthe nurse has had the exact experiences as the client.Nevertheless, by listening and sensing the importance ofthe situation to the client, the nurse can imagine the client’sfeelings about the experience. Both the client andthe nurse give a “gift of self” when empathy occurs—theclient by feeling safe enough to share feelings and thenurse by listening closely enough to understand. Empathyhas been shown to positively influence clientoutcomes. Clients tend to feel better about themselvesand more understood when the nurse is empathetic(Welch, 2005).Several therapeutic communication techniques, such asreflection, restatement, and clarification, help the nurse tosend empathetic messages to the client. For example, a clientsays,“You’re confused because your son asked for thesafety deposit key?”The nurse, using clarification, responds,“Are you confused about the purpose of yourson’s visit?”From these empathetic moments, a bond can be establishedto serve as the foundation for the nurse–client relationship.More examples of therapeutic communicationtechniques are found in Chapter 6.The nurse must understand the difference betweenempathy and sympathy (feelings of concern or compassionone shows for another). By expressing sympathy, the nursemay project his or her personal concerns onto the client,thus inhibiting the client’s expression of feelings. In theabove example, the nurse using sympathy would haveresponded, “I know how confusing sons can be. My sonconfuses me, too, and I know how bad that makes youfeel.” The nurse’s feelings of sadness or even pity couldinfluence the relationship and hinder the nurse’s abilitiesto focus on the client’s needs. Sympathy often shifts theemphasis to the nurse’s feelings, hindering the nurse’sability to view the client’s needs objectively.“I’m so confused! My son just visited and wantsto know where the safety deposit box key is.”Using reflection, the nurse responds,Empathy vs. sympathy

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 83AcceptanceThe nurse who does not become upset or respond negativelyto a client’s outbursts, anger, or acting out conveysacceptance to the client. Avoiding judgments of the person,no matter what the behavior, is acceptance. Thisdoes not mean acceptance of inappropriate behavior butacceptance of the person as worthy. The nurse must setboundaries for behavior in the nurse–client relationship.By being clear and firm without anger or judgment, thenurse allows the client to feel intact while still conveyingthat certain behavior is unacceptable. For example, a clientputs his arm around the nurse’s waist. An appropriateresponse would be for the nurse to remove his handand say,“John, do not place your hand on me. We areworking on your relationship with your girlfriendand that does not require you to touchme. Now, let’s continue.”An inappropriate response would be,“John, stop that! What’s gotten into you? I amleaving, and maybe I’ll return tomorrow.”Leaving and threatening not to return punish the clientwhile failing to clearly address the inappropriate behavior.Positive RegardThe nurse who appreciates the client as a unique worthwhilehuman being can respect the client regardless of hisor her behavior, background, or lifestyle. This unconditionalnonjudgmental attitude is known as positive regardand implies respect. Calling the client by name, spendingtime with the client, and listening and responding openlyare measures by which the nurse conveys respect and positiveregard to the client. The nurse also conveys positiveregard by considering the client’s ideas and preferenceswhen planning care. Doing so shows that the nurse believesthe client has the ability to make positive and meaningfulcontributions to his or her own plan of care. The nurserelies on presence, or attending, which is using nonverbaland verbal communication techniques to make the clientaware that he or she is receiving full attention. Nonverbaltechniques that create an atmosphere of presence includeleaning toward the client, maintaining eye contact, beingrelaxed, having arms resting at the sides, and having aninterested but neutral attitude. Verbally attending meansthat the nurse avoids communicating value judgmentsabout the client’s behavior. For example, the client maysay, “I was so mad, I yelled and screamed at my mother foran hour.” If the nurse responds with, “Well, that didn’thelp, did it?” or “I can’t believe you did that,” the nurse iscommunicating a value judgment that the client was“wrong” or “bad.” A better response would be “What happenedthen?” or “You must have been really upset.” Thenurse maintains attention on the client and avoids communicatingnegative opinions or value judgments aboutthe client’s behavior.Self-Awareness and TherapeuticUse of SelfBefore he or she can begin to understand clients, the nursemust first know himself or herself. Self-awareness is theprocess of developing an understanding of one’s own values,beliefs, thoughts, feelings, attitudes, motivations,prejudices, strengths, and limitations and how these qualitiesaffect others. It allows the nurse to observe, pay attentionto, and understand the subtle responses and reactionsof clients when interacting with them.Values are abstract standards that give a person a senseof right and wrong and establish a code of conduct for living.Sample values include hard work, honesty, sincerity,cleanliness, and orderliness. To gain insight into oneselfand personal values, the values clarification process ishelpful.The values clarification process has three steps: choosing,prizing, and acting. Choosing is when the person considersa range of possibilities and freely chooses the valueValues clarification process

84UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPthat feels right. Prizing is when the person considers thevalue, cherishes it, and publicly attaches it to himself orherself. Acting is when the person puts the value intoaction. For example, a clean and orderly student has beenassigned to live with another student who leaves clothesand food all over their room. At first the orderly student isunsure why she hesitates to return to the room and feelstense around her roommate. As she examines the situation,she realizes that they view the use of personal spacedifferently (choosing). Next she discusses her conflict andchoices with her adviser and friends (prizing). Finally, shedecides to negotiate with her roommate for a compromise(acting).Beliefs are ideas that one holds to be true, for example,“All old people are hard of hearing,” “If the sun isshining, it will be a good day,” or “Peas should be plantedon St. Patrick’s Day.” Some beliefs have objective evidenceto substantiate them. For example, people who believe inevolution have accepted the evidence that supports thisexplanation for the origins of life. Other beliefs are irrationaland may persist, despite these beliefs having nosupportive evidence or the existence of contradictoryempirical evidence. For example, many people harborirrational beliefs about cultures different from their ownthat they developed simply from others’ comments orfear of the unknown, not from any evidence to supportsuch beliefs.Attitudes are general feelings or a frame of referencearound which a person organizes knowledge about theworld. Attitudes, such as hopeful, optimistic, pessimistic,positive, and negative, color how we look at the worldand people. A positive mental attitude occurs when aperson chooses to put a positive spin on an experience, acomment, or a judgment. For example, in a crowded groceryline, the person at the front pays with change, slowlycounting it out. The person waiting in line who has apositive attitude would be thankful for the extra minutesand would begin to use them to do deep-breathing exercisesand to relax. A negative attitude also colors how oneviews the world and other people. For example, a personwho has had an unpleasant experience with a rude waitermay develop a negative attitude toward all waiters. Sucha negative attitude might cause the person to behaveimpolitely and unpleasantly with every waiter he or sheencounters.The nurse should reevaluate and readjust beliefs andattitudes periodically as he or she gains experience andwisdom. Ongoing self-awareness allows the nurse to acceptvalues, attitudes, and beliefs of others that may differ fromhis or her own. Box 5.2 lists questions designed to increasethe nurse’s cultural awareness. A person who does notassess personal attitudes and beliefs may hold a prejudiceor bias toward a group of people because of preconceivedideas or stereotypical images of that group. It is not uncommonfor a person to be ethnocentric about his or her ownculture (believing one’s own culture to be superior toBox 5.2CULTURAL AWARENESSQUESTIONSACKNOWLEDGING YOUR CULTURALHERITAGE• To what ethnic group, socioeconomic class, religion,age group, and community do you belong?• What experiences have you had with people fromethnic groups, socioeconomic classes, religions, agegroups, or communities different from your own?• What were those experiences like? How did you feelabout them?• When you were growing up, what did your parentsand significant others say about people who were differentfrom your family?• What about your ethnic group, socioeconomic class,religion, age, or community do you find embarrassingor wish you could change? Why?• What sociocultural factors in your background mightcontribute to being rejected by members of othercultures?• What personal qualities do you have that will helpyou establish interpersonal relationships with peoplefrom other cultural groups? What personal qualitiesmay be detrimental?others), particularly when the person has no experiencewith any culture than his or her own. (See Chapter 7 forfurther discussion of cultural competence.) Box 5.3 providesan example of a value clarification exercise that canassist nurses to become aware of their own beliefs andthoughts about other cultures.Therapeutic Use of SelfBy developing self-awareness and beginning to understandhis or her attitudes, the nurse can begin to use aspects ofhis or her personality, experiences, values, feelings, intelligence,needs, coping skills, and perceptions to establishrelationships with clients. This is called therapeutic use ofself. Nurses use themselves as a therapeutic tool to establishtherapeutic relationships with clients and to help clientsgrow, change, and heal. Peplau (1952), who describedthis therapeutic use of self in the nurse–client relationship,believed that nurses must clearly understand themselvesto promote their clients’ growth and to avoid limiting clients’choices to those that nurses value.The nurse’s personal actions arise from conscious andunconscious responses that are formed by life experiencesand educational, spiritual, and cultural values. Nurses(and all people) tend to use many automatic responses orbehaviors just because they are familiar. They need to

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 85Box 5.3 VALUES CLARIFICATION EXERCISEVALUES CLARIFICATIONYour values are your ideas about what is most important toyou in your life—what you want to live by and live for. Theyare the silent forces behind many of your actions and decisions.The goal of “values clarification” is for their influenceto become fully conscious, for you to explore and honestlyacknowledge what you truly value at this time. You can bemore self-directed and effective when you know which valuesyou really choose to keep and live by as an adult andwhich ones will get priority over others. Identify your valuesfirst, and then rank your top three or five values.■ Being with people■ Being loved■ Being married■ Having a special partner■ Having companionship■ Loving someone■ Taking care of others■ Having someone’s help■ Having a close family■ Having good friends■ Being liked■ Being popular■ Getting someone’sapproval■ Being appreciated■ Being treated fairly■ Being admired■ Being independent■ Being courageous■ Having things incontrol■ Having self-control■ Being emotionally stable■ Having self-acceptance■ Having pride or dignity■ Being well organized■ Being competent■ Learning and knowinga lot■ Achieving highly■ Being productively busy■ Having enjoyable work■ Having an importantposition■ Making money■ Striving for perfection■ Making a contributionto the world■ Fighting injustice■ Living ethically■ Being a good parent(or child)■ Being a spiritual person■ Having a relationshipwith God■ Having peace andquiet■ Making a home■ Preserving your roots■ Having financial security■ Holding on to what youhave■ Being safe physically■ Being free from pain■ Not getting takenadvantage of■ Having it easy■ Being comfortable■ Avoiding boredom■ Having fun■ Enjoying sensualpleasures■ Looking good■ Being physically fit■ Being healthy■ Having prized possessions■ Being a creative person■ Having deep feelings■ Growing as a person■ Living fully■ “Smelling the flowers”■ Having a purposeSource: Joyce Sichel. From Bernard, M. E., & Wolfe, J. L. (Eds.) (2000). The RET resource book for practitioners. New York: Albert Ellis Institute.examine such accepted ways of responding or behavingand evaluate how they help or hinder the therapeuticrelationship.One tool that is useful in learning more about oneself isthe Johari window (Luft, 1970), which creates a “wordportrait” of a person in four areas and indicates how wellthat person knows himself or herself and communicateswith others. The four areas evaluated are as follows:• Quadrant 1: Open/public self—qualities one knowsabout oneself and others also know.• Quadrant 2: Blind/unaware self—qualities known onlyto others.• Quadrant 3: Hidden/private self—qualities known onlyto oneself.• Quadrant 4: Unknown—an empty quadrant to symbolizequalities as yet undiscovered by oneself or others.In creating a Johari window, the first step is for thenurse to appraise his or her own qualities by creating a listof them: values, attitudes, feelings, strengths, behaviors,accomplishments, needs, desires, and thoughts. The secondstep is to find out others’ perceptions by interviewingthem and asking them to identify qualities, both positiveand negative, they see in the nurse. To learn from thisexercise, the opinions given must be honest; there must beno sanctions taken against those who list negative qualities.The third step is to compare lists and assign qualitiesto the appropriate quadrant.If quadrant 1 is the longest list, this indicates that thenurse is open to others; a smaller quadrant 1 means thatthe nurse shares little about himself or herself with others.If quadrants 1 and 3 are both small, the person demonstrateslittle insight. Any change in one quadrant isreflected by changes in other quadrants. The goal is towork toward moving qualities from quadrants 2, 3, and 4into quadrant 1 (qualities known to self and others). Doingso indicates that the nurse is gaining self-knowledge andawareness. See the accompanying figure for an example ofa Johari window.Patterns of KnowingNurse theorist Hildegard Peplau (1952) identified preconceptions,or ways one person expects another tobehave or speak, as a roadblock to the formation of an

86UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPwork with him. Both men are missing the opportunity todo some important work together because of incorrectpreconceptions.Carper (1978) identified four patterns of knowing innursing: empirical knowing (derived from the science ofnursing), personal knowing (derived from life experiences),ethical knowing (derived from moral knowledgeof nursing), and aesthetic knowing (derived from the artof nursing). These patterns provide the nurse with a clearmethod of observing and understanding every client interaction.Understanding where knowledge comes from andhow it affects behavior helps the nurse become more selfaware(Table 5.1). Munhall (1993) added another patternthat she called unknowing: For the nurse to admit she orhe does not know the client or the client’s subjective worldopens the way for a truly authentic encounter. The nursein a state of unknowing is open to seeing and hearing theclient’s views without imposing any of his or her values orviewpoints. In psychiatric nursing, negative preconceptionson the nurse’s part can adversely affect the therapeuticrelationship; thus, it is especially important for thenurse to work on developing this openness and acceptancetoward the client.Johari windowauthentic relationship. Preconceptions often prevent peoplefrom getting to know one another. Preconceptions anddifferent or conflicting personal beliefs and values mayprevent the nurse from developing a therapeutic relationshipwith a client. Here is an example of preconceptionsthat interfere with a therapeutic relationship: Mr. Lopez, aclient, has the preconceived stereotypical idea that allmale nurses are homosexual and refuses to have Samuel,a male nurse, take care of him. Samuel has a preconceivedstereotypical notion that all Hispanic men use switchblades,so he is relieved that Mr. Lopez has refused toTYPES OF RELATIONSHIPSEach relationship is unique because of the various combinationsof traits and characteristics of and circumstancesrelated to the people involved. Although every relationshipis different, all relationships may be categorized intothree major types: social, intimate, and therapeutic.Social RelationshipA social relationship is primarily initiated for the purposeof friendship, socialization, companionship, or accomplishmentof a task. Communication, which may be superficial,usually focuses on sharing ideas, feelings, and experiencesand meets the basic need for people to interact.Table 5.1CARPER’S PATTERNS OF NURSING KNOWLEDGEPatternExampleEmpirical knowing (obtained from the science of nursing)Personal knowing (obtained from life experience)Ethical knowing (obtained from the moral knowledgeof nursing)Aesthetic knowing (obtained from the art of nursing)Client with panic disorder begins to have an attack. Panic attackwill raise pulse rate.Client’s face shows the panic.Although the nurse’s shift has ended, she remains with theclient.Although the client shows outward signals now, the nurse hassensed previously the client’s jumpiness and subtle differencesin the client’s demeanor and behavior.Adapted from Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Sciences, 1(1),13–23.

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 87Advice is often given. Roles may shift during social interactions.Outcomes of this kind of relationship are rarelyassessed. When a nurse greets a client and chats about theweather or a sports event or engages in small talk or socializing,this is a social interaction. This is acceptable in nursing,but for the nurse–client relationship to accomplishthe goals that have been decided on, social interactionmust be limited. If the relationship becomes more socialthan therapeutic, serious work that moves the client forwardwill not be done.Intimate RelationshipA healthy intimate relationship involves two people whoare emotionally committed to each other. Both parties areconcerned about having their individual needs met andhelping each other to meet needs as well. The relationshipmay include sexual or emotional intimacy as well as sharingof mutual goals. Evaluation of the interaction may beongoing or not. The intimate relationship has no place inthe nurse–client interaction.Therapeutic RelationshipThe therapeutic relationship differs from the social orintimate relationship in many ways because it focuses onthe needs, experiences, feelings, and ideas of the clientonly. The nurse and client agree about the areas to work onand evaluate the outcomes. The nurse uses communicationskills, personal strengths, and understanding ofhuman behavior to interact with the client. In the therapeuticrelationship the parameters are clear: the focus isthe client’s needs, not the nurse’s. The nurse should not beconcerned about whether or not the client likes him or heror is grateful. Such concern is a signal that the nurse isfocusing on a personal need to be liked or needed. Thenurse must guard against allowing the therapeutic relationshipto slip into a more social relationship and mustconstantly focus on the client’s needs, not his or her own.The nurse’s level of self-awareness can either benefit orhamper the therapeutic relationship. For example, if thenurse is nervous around the client, the relationship is moreapt to stay social because superficiality is safer. If the nurseis aware of his or her fears, he or she can discuss them withthe instructor, paving the way for a more therapeutic relationshipto develop.ESTABLISHING THE THERAPEUTICRELATIONSHIPThe nurse who has self-confidence rooted in self- awarenessis ready to establish appropriate therapeutic relationshipswith clients. Because personal growth is ongoing over one’slifetime, the nurse cannot expect to have complete selfknowledge.Awareness of his or her strengths and limitationsat any particular moment, however, is a good start.Phases of nurse–client relationshipPhasesPeplau studied and wrote about the interpersonal processesand the phases of the nurse–client relationship for35 years. Her work provides the nursing profession with amodel that can be used to understand and document progresswith interpersonal interactions. Peplau’s model (1952)has three phases: orientation, working, and resolution ortermination (Table 5.2). In real life, these phases are notthat clear-cut; they overlap and interlock.OrientationThe orientation phase begins when the nurse and clientmeet and ends when the client begins to identify problemsto examine. During the orientation phase, the nurse establishesroles, the purpose of meeting, and the parameters ofsubsequent meetings; identifies the client’s problems; andclarifies expectations.Before meeting the client, the nurse has important workto do. The nurse reads background materials available onthe client, becomes familiar with any medications the clientis taking, gathers necessary paperwork, and arrangesfor a quiet, private, and comfortable setting. This is thetime for self-assessment. The nurse should consider his orher personal strengths and limitations in working withthis client. Are there any areas that might signal difficultybecause of past experiences? For example, if this client is

88UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 5.2PHASES OF THE NURSE–CLIENT RELATIONSHIPWorkingOrientation Identification Exploitation TerminationClient• Seeks assistance• Conveys needs• Asks questions• Shares preconceptionsand expectations ofnurse based on pastexperienceNurse• Responds to client• Gives parameters ofmeetings• Explains roles• Gathers data• Helps client identifyproblem• Helps client plan use ofcommunity resourcesand services• Reduces anxiety andtension• Practices active listening• Focuses client’s energies• Clarifies preconceptionsand expectations ofnurse• Participates in identifyingproblems• Begins to be aware of time• Responds to help• Identifies with nurse• Recognizes nurse as a person• Explores feelings• Fluctuates dependence,independence, andinterdependence inrelationship with nurse• Increases focal attention• Changes appearance (forbetter or worse)• Understands continuitybetween sessions (process andcontent)• Testing maneuvers decrease• Maintains separate identity• Exhibits ability to edit speechor control focal attention• Shows unconditionalacceptance• Helps express needs andfeelings• Assesses and adjusts to needs• Provides information• Provides experiences thatdiminish feelings ofhelplessness• Does not allow anxiety tooverwhelm client• Helps client focus on cues• Helps client develop responsesto cues• Uses word stimuli• Makes full use of services• Identifies new goals• Attempts to attain newgoals• Rapid shifts in behavior:dependent andindependent• Exploitative behavior• Self-directing• Develops skill in interpersonalrelationships andproblem-solving• Displays changes in mannerof communication (moreopen, flexible)• Continues assessment• Meets needs as theyemerge• Understands reason forshifts in behavior• Initiates rehabilitative plans• Reduces anxiety• Identifies positive factors• Helps plan for total needs• Facilitates forward movementof personality• Deals with therapeuticimpasse• Abandons old needs• Aspires to new goals• Becomes independentof helping person• Applies new problemsolvingskills• Maintains changes instyle of communicationand interaction• Shows positive changesin view of self• Integrates illness• Exhibits ability to standalone• Sustains relationship aslong as client feelsnecessary• Promotes family interactionto assist with goalplanning• Teaches preventivemeasures• Uses communityagencies• Teaches self-care• Terminates nurse–clientrelationshipAdapted from Forchuck, C., & Brown, B. (1989). Establishing a nurse–client relationship. Journal of Psychosocial Nursing, 27(2), 30–34.a spouse batterer and the nurse’s father was also one, thenurse needs to consider the situation: How does it makehim or her feel? What memories does it prompt, and canhe or she work with the client without these memoriesinterfering? The nurse must examine preconceptionsabout the client and ensure that he or she can put themaside and get to know the real person. The nurse mustcome to each client without preconceptions or prejudices.It may be useful for the nurse to discuss all potential problemareas with the instructor.During the orientation phase, the nurse begins tobuild trust with the client. It is the nurse’s responsibilityto establish a therapeutic environment that fosters trustand understanding (Table 5.3). The nurse should shareappropriate information about himself or herself at thistime, including name, reason for being on the unit, andlevel of schooling: For example, “Hello, James. My nameis Miss Ames and I will be your nurse for the next sixTuesdays. I am a senior nursing student at the Universityof Mississippi.”

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 89Table 5.3COMMUNICATION DURING THE PHASES OF THE NURSE–CLIENT RELATIONSHIPPhase of Relationship Sample Conversation Communication SkillOrientationOrientationOrientationWorkingWorkingWorkingTerminationNurse: “Hello, Mr. O’Hare. I am Sally Fourth, anursing student from Orange County CommunityCollege. I will be coming to the hospitalfor the next six Mondays. I would like to meetwith you each time I am here to help supportyou as you work on your treatment goals.”Nurse: “Mr. O’Hare, we will meet every Monday fromJune 1 to July 15 at 11 AM in conference room 2.We can use that time to work on your feelings ofloss since the death of your twin sister.”Nurse: “Mr. O’Hare, it is important that I tell you Iwill be sharing some of what we talk aboutwith my instructor, peers, and staff at clinicalconference. I will not be sharing any informationwith your wife or children without yourpermission. If I feel a piece of information maybe helpful, I will ask you first if I may share itwith your wife.”Client: “Nurse, I miss my sister Eileen so much.”Nurse: “Mr. O’Hare, how long have you beenwithout your sister?”Client: “Without my twin, I am not half theperson I was.”Nurse: “Mr. O’Hare, let’s look at the strengthsyou have.”Client: “Oh, why talk about me. I’m nothingwithout my twin.”Nurse: “Mr. O’Hare, you are a person in your ownright. I believe working together we can identifystrengths you have. Will you try with me?”Nurse: “Well, Mr. O’Hare, as you know I onlyhave 1 week left to meet with you.”Client: “I am going to miss you. I feel betterwhen you are here.”Nurse: “I will miss you also, Mr. O’Hare.”Establishing trust; placing boundaries onthe relationship and first mention oftermination in 6 weeksEstablishing specifics of the relationshiptime, date, place, and duration of meetings(can be written as a formal contractor stated as an informal contract)Establishing confidentialityGathering dataPromoting self-esteemOvercoming resistanceSharing of the termination experience withthe client demonstrates the partnershipand the caring of the relationshipThe nurse needs to listen closely to the client’s history,perceptions, and misconceptions. He or she needs to conveyempathy and understanding. If the relationship getsoff to a positive start, it is more likely to succeed and tomeet established goals.At the first meeting, the client may be distrustful if previousrelationships with nurses have been unsatisfactory.The client may use rambling speech, act out, or exaggerateepisodes as ploys to avoid discussing the real problems. Itmay take several sessions until the client believes that heor she can trust the nurse.Nurse–Client Contracts. Although many clients have hadprior experiences in the mental health system, the nursemust once again outline the responsibilities of the nurseand the client. At the outset, both nurse and client shouldagree on these responsibilities in an informal or verbalcontract. In some instances, a formal or written contractmay be appropriate; examples include if a written contracthas been necessary in the past with the client or if the client“forgets” the agreed-on verbal contract.The contract should state the following:• Time, place, and length of sessions• When sessions will terminate• Who will be involved in the treatment plan (familymembers or health team members)

90UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIP• Client responsibilities (arrive on time and end ontime)• Nurse’s responsibilities (arrive on time, end on time,maintain confidentiality at all times, evaluate progresswith client, and document sessions).Confidentiality. Confidentiality means respecting theclient’s right to keep private any information about his orher mental and physical health and related care. It meansallowing only those dealing with the client’s care to haveaccess to the information that the client divulges. Onlyunder precisely defined conditions can third parties haveaccess to this information; for example, in many statesthe law requires that staff report suspected child andelder abuse.Adult clients can decide which family members, if any,may be involved in treatment and may have access toclinical information. Ideally, the people close to the clientand responsible for his or her care are involved. The clientmust decide, however, who will be included. For theclient to feel safe, boundaries must be clear. The nursemust clearly state information about who will have accessto client assessment data and progress evaluations. He orshe should tell the client that members of the mentalhealth team share appropriate information among themselvesto provide consistent care and that only with theclient’s permission will they include a family member. Ifthe client has an appointed guardian, that person canreview client information and make treatment decisionsthat are in the client’s best interest. For a child, the parentor appointed guardian is allowed access to informationand can make treatment decisions as outlined by thehealth-care team.The nurse must be alert if a client asks him or her tokeep a secret because this information may relate to theclient’s harming himself or herself or others. The nursemust avoid any promises to keep secrets. If the nurse haspromised not to tell before hearing the message, he or shecould be jeopardizing the client’s trust. In most cases, evenwhen the nurse refuses to agree to keep information secret,the client continues to relate issues anyway. The followingis an example of a good response to a client who is suicidalbut requests secrecy:Client: “I am going to jump off the 14th floor ofmy apartment building tonight, but please don’ttell anyone.”Nurse: “I cannot keep such a promise, especiallyif it involves your safety. I sense you arefeeling frightened. The staff and I will help you stay safe.”The Tarasoff vs. Regents of the University of California(1976) decision releases professionals from privilegedcommunication with their clients should a client make ahomicidal threat. The decision requires the nurse to notifyintended victims and police of such a threat. In this circumstance,the nurse must report the homicidal threat tothe nursing supervisor and attending physician so thatboth the police and the intended victim can be notified.This is called a duty to warn and is discussed more fully inChapter 9.The nurse documents the client’s problems with plannedinterventions. The client must understand that the nursewill collect data about him or her that helps in making adiagnosis, planning health care (including medications),and protecting the client’s civil rights. The client needs toknow the limits of confidentiality in nurse–client interactionsand how the nurse will use and share this informationwith professionals involved in client care.Self-Disclosure. Self-disclosure means revealing personalinformation such as biographical information andpersonal ideas, thoughts, and feelings about oneself to clients.Traditionally, conventional wisdom held that nursesshould share only their name and give a general idea abouttheir residence, such as “I live in Ocean County.” Now,however, it is believed that some purposeful, well-planned,self-disclosure can improve rapport between the nurse andthe client. The nurse can use self-disclosure to conveysupport, educate clients, and demonstrate that a client’sanxiety is normal and that many people deal with stressand problems in their lives.Self-disclosure may help the client feel more comfortableand more willing to share thoughts and feelings, orhelp the client gain insight into his or her situation.When using self-disclosure, the nurse must also considercultural factors. Some clients may deem self-disclosureinappropriate or too personal, causing the client discomfort.Disclosing personal information to a client can beharmful and inappropriate, so it must be planned andconsidered thoughtfully in advance. Spontaneously selfdisclosingpersonal information can have negative results.For example, when working with a client whose parentsare getting a divorce, the nurse says, “My parents got adivorce when I was 12 and it was a horrible time for me.”The nurse has shifted the focus away from the client andhas given the client the idea that this experience will behorrible for the client. Although the nurse may havemeant to communicate empathy, the result can be quitethe opposite.WorkingThe working phase of the nurse–client relationship isusually divided into two subphases: During problemidentification, the client identifies the issues or concernscausing problems. During exploitation, the nurse guidesthe client to examine feelings and responses and todevelop better coping skills and a more positive selfimage;this encourages behavior change and developsindependence. (Note that Peplau’s use of the word exploitationhad a very different meaning than current usage,which involves unfairly using or taking advantage of aperson or situation. For that reason, this phase is better

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 91conceptualized as intense exploration and elaboration onearlier themes that the client discussed.) The trust establishedbetween nurse and client at this point allows themto examine the problems and to work on them within thesecurity of the relationship. The client must believe thatthe nurse will not turn away or be upset when the clientreveals experiences, issues, behaviors, and problems.Sometimes the client will use outrageous stories or acting-outbehaviors to test the nurse. Testing behavior challengesthe nurse to stay focused and not to react or to bedistracted. Often when the client becomes uncomfortablebecause he or she is getting too close to the truth, he orshe will use testing behaviors to avoid the subject. Thenurse may respond by saying, “It seems as if we have hitan uncomfortable spot for you. Would you like to let it gofor now?” This statement focuses on the issue at hand anddiverts attention from the testing behavior.The nurse must remember that it is the client whoexamines and explores problem situations and relationships.The nurse must be nonjudgmental and refrain fromgiving advice; the nurse should allow the client to analyzesituations. The nurse can guide the client to observe patternsof behavior and whether or not the expected responseoccurs. For example, a client who suffers from depressioncomplains to the nurse about the lack of concern her childrenshow her. With the assistance and guidance of thenurse, the client can explore how she communicates withher children and may discover that her communicationinvolves complaining and criticizing. The nurse can thenhelp the client explore more effective ways of communicatingin the future. The specific tasks of the workingphase include the following:• Maintaining the relationship• Gathering more data• Exploring perceptions of reality• Developing positive coping mechanisms• Promoting a positive self-concept• Encouraging verbalization of feelings• Facilitating behavior change• Working through resistance• Evaluating progress and redefining goals as appropriate• Providing opportunities for the client to practice newbehaviors• Promoting independence.As the nurse and client work together, it is common forthe client unconsciously to transfer to the nurse feelingshe or she has for significant others. This is called transference.For example, if the client has had negative experienceswith authority figures, such as a parent or teachersor principals, he or she may display similar reactions ofnegativity and resistance to the nurse, who also is viewedas an authority. A similar process can occur when the nurseresponds to the client based on personal unconsciousneeds and conflicts; this is called countertransference. Forexample, if the nurse is the youngest in her family andoften felt as if no one listened to her when she was a child,she may respond with anger to a client who does not listenor resists her help. Again, self-awareness is important sothat the nurse can identify when transference and countertransferencemight occur. By being aware of such “hotspots,” the nurse has a better chance of responding appropriatelyrather than letting old unresolved conflicts interferewith the relationship.TerminationThe termination or resolution phase is the final stage inthe nurse–client relationship. It begins when the problemsare resolved, and it ends when the relationship isended. Both nurse and client usually have feelings aboutending the relationship; the client especially may feel thetermination as an impending loss. Often clients try toavoid termination by acting angry or as if the problem hasnot been resolved. The nurse can acknowledge the client’sangry feelings and assure the client that this response isnormal to ending a relationship. If the client tries toreopen and discuss old resolved issues, the nurse mustavoid feeling as if the sessions were unsuccessful; instead,he or she should identify the client’s stalling maneuversand refocus the client on newly learned behaviors andskills to handle the problem. It is appropriate to tell theclient that the nurse enjoyed the time spent with the clientand will remember him or her, but it is inappropriatefor the nurse to agree to see the client outside the therapeuticrelationship.Nurse Jones comes to see Mrs. O’Shea for the last time.Mrs. O’Shea is weeping quietly.Mrs. O’Shea: “Oh, Ms. Jones, you have been sohelpful to me. I just know I will go back to myold self without you here to help me.”Nurse Jones: “Mrs. O’Shea, I think we’vehad a very productive time together. You havelearned so many new ways to have better relationships withyour children, and I know you will go home and be able touse those skills. When you come back for your follow-upvisit, I will want to hear all about how things have changedat home.”AVOIDING BEHAVIORS THAT DIMINISHTHE THERAPEUTIC RELATIONSHIPThe nurse has power over the client by virtue of his or herprofessional role. That power can be abused if excessivefamiliarity or an intimate relationship occurs or if confidentialityis breached.Inappropriate BoundariesAll staff members, both new and veteran, are at risk forallowing a therapeutic relationship to expand into an inappropriaterelationship. Self-awareness is extremely important:

92UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPThe nurse who is in touch with his or her feelings and awareof his or her influence over others can help maintain theboundaries of the professional relationship. The nurse mustmaintain professional boundaries to ensure the best therapeuticoutcomes. It is the nurse’s responsibility to define theboundaries of the relationship clearly in the orientation phaseand to ensure those boundaries are maintained throughoutthe relationship. The nurse must act warmly and empatheticallybut must not try to be friends with the client. Socialinteractions that continue beyond the first few minutes of ameeting contribute to the conversation staying on the surface.This lack of focus on the problems that have been agreedon for discussion erodes the professional relationship.If a client is attracted to a nurse or vice versa, it is up tothe nurse to maintain professional boundaries. Acceptinggifts or giving a client one’s home address or phone numberwould be considered a breach of ethical conduct.Nurses must continually assess themselves and ensurethey keep their feelings in check and focus on the clients’interests and needs. Nurses can assess their behavior byusing the Nursing Boundary Index in Table 5.4. A full discussionof ethical dilemmas encountered in relationshipsis found in Chapter 9.Feelings of Sympathy and EncouragingClient DependencyThe nurse must not let feelings of empathy turn into sympathyfor the client. Unlike the therapeutic use of empathy, thenurse who feels sorry for the client often tries to compensateby trying to please him or her. When the nurse’s behavior isrooted in sympathy, the client finds it easier to manipulatethe nurse’s feelings. This discourages the client from exploringhis or her problems, thoughts, and feelings; discouragesclient growth; and often leads to client dependency.The client may make increased requests of the nurse forhelp and assistance or may regress and act as if he or shecannot carry out tasks previously done. These can be signalsthat the nurse has been “overdoing” for the client andmay be contributing to the client’s dependency. Clientsoften test the nurse to see how much the nurse is willingto do. If the client cooperates only when the nurse is inattendance and does not carry out agreed-on behavior inthe nurse’s absence, the client has become too dependent.In any of these instances, the nurse needs to reassess his orher professional behavior and refocus on the client’s needsand therapeutic goals.Table 5.4NURSING BOUNDARY INDEXPlease rate yourself according to the frequency that the following statements reflect your behavior, thoughts, orfeelings within the past 2 years while providing patient care.1. Have you ever received any feedback about your behavior for being Never Rarely Sometimes Oftenoverly intrusive with patients or their families?2. Do you ever have difficulty setting limits with patients? Never Rarely Sometimes Often3. Do you arrive early or stay late to be with your patient for a longer Never Rarely Sometimes Oftenperiod of time?4. Do you ever find yourself relating to patients or peers as you might Never Rarely Sometimes Oftento a family member?5. Have you ever acted on sexual feelings you have for a patient? Never Rarely Sometimes Often6. Do you feel that you are the only one who understands the patient? Never Rarely Sometimes Often7. Have you ever received feedback that you get “too involved” with Never Rarely Sometimes Oftenpatients or families?8. Do you derive conscious satisfaction from patients’ praise,Never Rarely Sometimes Oftenappreciation, or affection?9. Do you ever feel that other staff members are too critical of “your” Never Rarely Sometimes Oftenpatient?10. Do you ever feel that other staff members are jealous of yourNever Rarely Sometimes Oftenrelationship with a patient?11. Have you ever tried to “match-make” a patient with one of your Never Rarely Sometimes Oftenfriends?12. Do you find it difficult to handle patients’ unreasonablerequests for assistance, verbal abuse, or sexual language?Never Rarely Sometimes OftenAny item that is responded to with a “sometimes” or “often” should alert the nurse to a possible area of vulnerability. If theitem is responded to with a “rarely,” the nurse should determine whether it was an isolated event or a possible pattern ofbehavior.Source: Pilette, P., Berck, C., & Achber, L. (1995). Therapeutic management. Journal of Psychosocial Nursing, 33(1), 45.

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 93Nonacceptance and AvoidanceThe nurse–client relationship can be jeopardized if thenurse finds the client’s behavior unacceptable or distastefuland allows those feelings to show by avoiding the clientor making verbal responses or facial expressions ofannoyance or turning away from the client. The nurseshould be aware of the client’s behavior and backgroundbefore beginning the relationship; if the nurse believesthere may be conflict, he or she must explore this possibilitywith a colleague. If the nurse is aware of a prejudicethat would place the client in an unfavorable light, he orshe must explore this issue as well. Sometimes by talkingabout and confronting these feelings, the nurse can acceptthe client and not let a prejudice hinder the relationship.If the nurse cannot resolve such negative feelings, however,he or she should consider requesting another assignment.It is the nurse’s responsibility to treat each clientwith acceptance and positive regard, regardless of the client’shistory. Part of the nurse’s responsibility is to continueto become more self-aware and to confront andresolve any prejudices that threaten to hinder the nurse–client relationship (Box 5.4).ROLES OF THE NURSE IN A THERAPEUTICRELATIONSHIPAs when working with clients in any other nursing setting,the psychiatric nurse uses various roles to provide neededcare to the client. The nurse understands the importanceof assuming the appropriate role for the work that he orshe is doing with the client.TeacherThe teacher role is inherent in most aspects of client care.During the working phase of the nurse–client relationship,the nurse may teach the client new methods of coping andsolving problems. He or she may instruct about themedication regimen and available community resources.To be a good teacher, the nurse must feel confident aboutthe knowledge he or she has and must know the limitationsof that knowledge base. The nurse should be familiarwith the resources in the health-care setting and communityand on the Internet, which can provide needed informationfor clients. The nurse must be honest about whatinformation he or she can provide and when and where torefer clients for further information. This behavior andhonesty build trust in clients.CaregiverThe primary caregiving role in mental health settings isthe implementation of the therapeutic relationship tobuild trust, explore feelings, assist the client in problemsolving,and help the client meet psychosocial needs. If theclient also requires physical nursing care, the nurse mayneed to explain to the client the need for touch while performingphysical care. Some clients may confuse physicalcare with intimacy and sexual interest, which can erodethe therapeutic relationship. The nurse must consider therelationship boundaries and parameters that have beenestablished and must repeat the goals that were establishedtogether at the beginning of the relationship.AdvocateIn the advocate role, the nurse informs the client and thensupports him or her in whatever decision he or she makes(Edd, Fox, & Burns, 2005). In psychiatric–mental healthnursing, advocacy is a bit different from medical-surgical settingsbecause of the nature of the client’s illness. For example,the nurse cannot support a client’s decision to hurt himself orherself or another person. Advocacy is the process of actingon the client’s behalf when he or she cannot do so. Thisincludes ensuring privacy and dignity, promoting informedconsent, preventing unnecessary examinations and procedures,accessing needed services and benefits, and ensuringBox 5.4POSSIBLE WARNINGS OR SIGNALS OF ABUSE OF THE NURSE–CLIENTRELATIONSHIP• Secrets; reluctance to talk to others about the work beingdone with clients• Sudden increase in phone calls between nurse and clientor calls outside clinical hours• Nurse making more exceptions for client than normal• Inappropriate gift-giving between client and nurse• Loaning, trading, or selling goods or possessions• Nurse disclosure of personal issues or information• Inappropriate touching, comforting, or physical contact• Overdoing, overprotecting, or overidentifying with client• Change in nurse’s body language, dress, or appearance(with no other satisfactory explanation)• Extended one-on-one sessions or home visits• Spending off-duty time with the client• Thinking about the client frequently when awayfrom work• Becoming defensive if another person questions thenurses’s care of the client• Ignoring agency policies

94UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPBox 5.5METHODS TO AVOID INAPPROPRIATE RELATIONSHIPS BETWEEN NURSESAND CLIENTS• Realize that all staff members, whether male or female,junior or senior, or from any discipline, are at risk forover-involvement and loss of boundaries.• Assume that boundary violations will occur. Supervisorsshould recognize potential “problem” clients and regularlyraise the issue of sexual feelings or boundary losswith staff members.• Provide opportunities for staff members to discuss theirdilemmas and effective ways of dealing with them.• Develop orientation programs to include how to set limits,how to recognize clues that the relationship is losing boundaries,what the institution expects of the professional, clearlydefined consequences, case studies, how to develop skillsto maintain boundaries, and recommended reading.• Provide resources for confidential and nonjudgmentalassistance.• Hold regular meetings to discuss inappropriate relationshipsand feelings toward clients.• Provide senior staff to lead groups and model effectivetherapeutic interventions with difficult clients.• Use clinical vignettes for training.• Use situations that reflect not only sexual dilemmas butalso other boundary violations, including problems withabuse of authority and power.safety from abuse and exploitation by a health professional orauthority figure. For example, if a physician begins to examinea client without closing the curtains and the nurse stepsin and properly drapes the client and closes the curtains, thenurse has just acted as the client’s advocate.Being an advocate has risks. In the previous example,the physician may be embarrassed and angry and make acomment to the nurse. The nurse needs to stay focused onthe appropriateness of his or her behavior and not beintimidated.The role of advocate also requires the nurse to be observantof other health-care professionals. At times, staff membersmay be reluctant to see what is happening or becomeinvolved when a colleague violates the boundaries of a professionalrelationship. Nurses must take action by talking tothe colleague or a supervisor when they observe boundaryviolations. State nurse practice acts include the nurse’s legalresponsibility to report boundary violations and unethicalconduct on the part of other health-care providers. There isa full discussion of ethical conduct in Chapter 9.There is debate about the role of nurse as advocate.There are times when the nurse does not advocate for theclient’s autonomy or right to self-determination, such asby supporting involuntary hospitalization for a suicidalclient. At these times, acting in the client’s best interest(keeping the client safe) is in direct opposition to the client’swishes. Some critics view this as paternalism andinterference with the true role of advocacy. In addition,they do not see advocacy as a role exclusive to nursing butalso relevant to the domains of physicians, social workers,and other health-care professionals.Parent SurrogateWhen a client exhibits child-like behavior or when a nurseis required to provide personal care such as feeding orbathing, the nurse may be tempted to assume the parentalrole as evidenced in choice of words and nonverbal communication.The nurse may begin to sound authoritativewith an attitude of “I know what’s best for you.” Often, theclient responds by acting more child-like and stubborn.Neither party realizes they have fallen from adult–adultcommunication to parent–child communication. It is easyfor the client to view the nurse in such circumstances as aparent surrogate. In such situations, the nurse must beclear and firm and set limits or reiterate the previously setlimits. By retaining an open, easygoing, nonjudgmentalattitude, the nurse can continue to nurture the client whileestablishing boundaries. The nurse must ensure the relationshipremains therapeutic and does not become socialor intimate (Box 5.5).SELF-AWARENESS ISSUESSelf-awareness is crucial in establishing therapeuticnurse–client relationships. For example,a nurse who is prejudiced against people from acertain culture or religion but is not consciouslyaware of it may have difficulty relating to a client from thatculture or religion. If the nurse is aware of, acknowledges,and is open to reassessing the prejudice, the relationship hasa better chance of being authentic. If the nurse has certainbeliefs and attitudes that he or she will not change, it may bebest for another nurse to care for the client. Examining personalstrengths and weaknesses helps one gain a strong senseof self. Understanding oneself helps one understand andaccept others who may have different ideas and values. Thenurse must continue on a path of self-discovery to becomemore self-aware and more effective in caring for clients.Nurses also need to learn to “care for themselves.” Thismeans balancing work with leisure time, building satisfyingpersonal relationships with friends, and taking time to

CHAPTER 5 • THERAPEUTIC RELATIONSHIPS 95Critical Thinking Questions1. When is it appropriate to accept a gift from a client?What types of gifts are acceptable? Under what circumstancesshould the nurse accept a gift from aclient?2. What relationship-building behaviors would thenurse use with a client who is very distrustful of thehealth-care system?3. Is it ever appropriate for the nurse to provide professionalnursing services to family? Friends? Acquaintances?How should these situations be handled?relax and pamper oneself. Nurses who are overly committedto work become burned out, never find time to relax orsee friends, and sacrifice their personal lives in the process.When this happens, the nurse is more prone toboundary violations with clients (e.g., sharing frustrationsor responding to the client’s personal interest in the nurse).In addition, the nurse who is stressed or overwhelmedtends to lose the objectivity that comes with self-awarenessand personal growth activities. In the end, nurses who failto take good care of themselves also cannot take good careof clients and families.Points to Consider When BuildingTherapeutic Relationships• Attend workshops about values clarification, beliefs, andattitudes to help you assess and learn about yourself.• Keep a journal of thoughts, feelings, and lessons learnedto provide self-insight.• Listen to feedback from colleagues about your relationshipswith clients.• Participate in group discussions on self-growth at thelocal library or health center to aid self-understanding.• Develop a continually changing care plan for self-growth.• Read books on topics that support the strengths you haveidentified and help to develop your areas of weakness.KEY POINTS• Factors that enhance the nurse–client relationshipinclude trust and congruence,genuine interest, empathy, acceptance, andpositive regard.• Self-awareness is crucial in the therapeutic relationship.The nurse’s values, beliefs, and attitudes all come intoplay as he or she forms a relationship with a client.• Carper identified four patterns of knowing: empirical,aesthetic, personal, and ethical.• Munhall established the pattern of unknowing as anopenness that the nurse brings to the relationship thatprevents preconceptions from clouding his or her viewof the client.• The three types of relationships are social, intimate, andtherapeutic. The nurse–client relationship should betherapeutic, not social or intimate.• Nurse theorist Hildegard Peplau developed the phasesof the nurse–client relationship: orientation, working(with subphases of problem identification and exploitation),and termination or resolution. These phases areongoing and overlapping.• The orientation phase begins when the nurse and clientmeet and ends when the client begins to identify problemsto examine.• Tasks of the working phase include maintaining the relationship,gathering more data, exploring perceptions ofreality, developing positive coping mechanisms, promotinga positive self-concept, encouraging verbalization offeelings that facilitate behavior change, working throughresistance, evaluating progress and redefining goals asappropriate, providing opportunities for the client topractice new behaviors, and promoting independence.• Termination begins when the problems are resolved andends when the relationship is ended.• Factors that diminish the nurse–client relationship includeloss of, or unclear, boundaries, intimacy, andabuse of power.• Therapeutic roles of the nurse in the nurse–client relationshipinclude teacher, caregiver, advocate, and parentsurrogate.INTERNET RESOURCESRESOURCE• American Psychological Association Brochure AboutSexual Relationships in Therapy• Summary of the Work of Hildegard Peplau• Managing the Boundaries of the Therapeutic Nurse–Client RelationshipINTERNET ADDRESShttp://www.apa.org/pi/therapy.htmlhttp://www.enursescribe.com/Peplau.htmhttp://www.nanb.nb.ca/PDF/practice/Standards_for_the_therapeutic_Nurse-Client_Relationship_English.pdf

96UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPREFERENCESCarper, B. (1978). Fundamental patterns of knowing in nursing.Advances in Nursing Science, 1(1), 13–23.Edd, J. R., Fox, P. G., & Burns, K. (2005). Advocating for the rights ofthe mentally ill: A global issue. International Journal of PsychiatricNursing Research, 11(1), 1211–1217.Luft, J. (1970). Group processes: An introduction in group dynamics. PaloAlto, CA: National Press Books.Munhall, P. (1993). Unknowing: Toward another pattern of knowing innursing. Nursing Outlook, 41(3), 125–128.Peplau, H. E. (1952). Interpersonal relations in nursing. New York: G. P.Putnam’s Sons.Warelow, P., Edward, K. L., & Vinek, J. (2008). Care: What nurses sayand what nurses do. Holistic Nursing Practice, 22(3), 146–153.Welch, M. (2005). Pivotal moments in the therapeutic relationship.International Journal of Mental Health Nursing, 14(3), 161–165.ADDITIONAL READINGSMcNeill, C., Shattell, M., Rossen, E., & Bartlett, R. (2008). Relationshipskills building with older adults. Journal so Nursing Education, 47(6),269–271.Shattell, M. M., Starr, S. S., & Thomas, S. P. (2007). Take my hand, helpme out: Mental health service recipients’ experience of the therapeuticrelationship. International Journal of Mental Health Nursing, 16(4),274–284.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Building trust is important ina. The orientation phase of the relationshipb. The problem identification subphase of the relationshipc. All phases of the relationshipd. The exploitation subphase of the relationship2. Abstract standards that provide a person with his or hercode of conduct area. Valuesb. Attitudesc. Beliefsd. Personal philosophy3. Ideas that one holds as true area. Valuesb. Attitudesc. Beliefsd. Personal philosophy4. The emotional frame of reference by which one sees theworld is created bya. Valuesb. Attitudesc. Beliefsd. Personal philosophyMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Which of the following are specific tasks of the workingphase of a therapeutic relationship?a. Begin planning for terminationb. Build trustc. Encourage expression of feelingsd. Establish a nurse–client contracte. Facilitate behavior changef. Promote self-esteem2. Confidentiality means respecting the client’s right tokeep his or her information private. When can thenurse share information about the client?a. The client threatens to harm a family member.b. Sharing the information is in the client’s bestinterest.c. The client gives written permission.d. The client’s legal guardian asks for information.e. The client is discharged to the parent’s care.f. The client admits to domestic abuse.CLINICAL EXAMPLEMr. Johnson is a suspicious client who doesn’t want to be in the hospital. The nurseapproaches him for the first time to introduce herself. Mr. Johnson says, “There’s nothing Ineed from you! Why should I talk to you?” How should the nurse proceed? What couldthe nurse say to Mr. Johnson?97

6TherapeuticCommunicationLearning ObjectivesAfter reading this chapter, you should be able to1. Describe the goals of therapeutic communication.Key Terms• abstract messages• active listening• active observation• assertive communication• body language• circumstantiality• closed body positions• communication• concrete messages• congruent message• content• context• cues (overt and covert)• directive role• distance zones• eye contact• incongruent message• intimate zone• nondirective role• nonverbal communication• personal zone• process• proxemics• public zone• social zone• spirituality• therapeutic communication• verbal communication982. Identify therapeutic and nontherapeutic verbal communication skills.3. Discuss nonverbal communication skills such as facial expression, body language,vocal cues, eye contact, and understanding of levels of meaningand context.4. Discuss boundaries in therapeutic communication with respect to distanceand use of touch.5. Distinguish between concrete and abstract messages.6. Given a hypothetical situation, select an effective therapeutic response tothe client.COMMUNICATION IS THE PROCESS that people use to exchange information.Messages are simultaneously sent and received on two levels: verballythrough the use of words and nonverbally by behaviors that accompanythe words (DeVito, 2008). Verbal communication consists of the words aperson uses to speak to one or more listeners. Words represent the objectsand concepts being discussed. Placement of words into phrases and sentencesthat are understandable to both speaker and listeners gives an orderand a meaning to these symbols. In verbal communication, content is theliteral words that a person speaks. Context is the environment in whichcommunication occurs and can include the time and the physical, social,emotional, and cultural environments. Context includes the situation orcircumstances that clarify the meaning of the content of the message. It isdiscussed in more detail throughout this chapter.Nonverbal communication is the behavior that accompanies verbal contentsuch as body language, eye contact, facial expression, tone of voice,speed and hesitations in speech, grunts and groans, and distance from thelisteners. Nonverbal communication can indicate the speaker’s thoughts,feelings, needs, and values that he or she acts out mostly unconsciously.Process denotes all nonverbal messages that the speaker uses to givemeaning and context to the message. The process component ofVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 6 • THERAPEUTIC COMMUNICATION 99communication requires the listeners to observe the behaviorsand sounds that accent the words and to interpret thespeaker’s nonverbal behaviors to assess whether they agreeor disagree with the verbal content. A congruent messageis conveyed when content and process agree. For example,a client says, “I know I haven’t been myself. I need help.”She has a sad facial expression and a genuine and sincerevoice tone. The process validates the content as being true.But when the content and process disagree—when whatthe speaker says and what he or she does do not agree—the speaker is giving an incongruent message. For example,if the client says, “I’m here to get help,” but has a rigidposture, clenched fists, an agitated and frowning facialexpression, and snarls the words through clenched teeth,the message is incongruent. The process or observedbehavior invalidates what the speaker says (content).Nonverbal process represents a more accurate messagethan does verbal content. “I’m sorry I yelled and screamedat you” is readily believable when the speaker has aslumped posture, a resigned voice tone, downcast eyes,and a shameful facial expression because the content andprocess are congruent. The same sentence said in a loudvoice and with raised eyebrows, a piercing gaze, an insultedfacial expression, hands on hips, and outraged body languageinvalidates the words (incongruent message). Themessage conveyed is “I’m apologizing because I think Ihave to. I’m not really sorry.”WHAT IS THERAPEUTICCOMMUNICATION?Therapeutic communication is an interpersonal interactionbetween the nurse and the client during which the nursefocuses on the client’s specific needs to promote an effectiveexchange of information. Skilled use of therapeutic communicationtechniques helps the nurse understand andempathize with the client’s experience. All nurses need skillsin therapeutic communication to effectively apply the nursingprocess and to meet standards of care for their clients.Therapeutic communication can help nurses to accomplishmany goals:• Establish a therapeutic nurse–client relationship.• Identify the most important client concern at that moment(the client-centered goal).• Assess the client’s perception of the problem as it unfolds.This includes detailed actions (behaviors and messages)of the people involved and the client’s thoughts and feelingsabout the situation, others, and self.• Facilitate the client’s expression of emotions.• Teach the client and family necessary self-care skills.• Recognize the client’s needs.• Implement interventions designed to address theclient’s needs.• Guide the client toward identifying a plan of action to asatisfying and socially acceptable resolution.Establishing a therapeutic relationship is one of themost important responsibilities of the nurse when workingwith clients. Communication is the means by which atherapeutic relationship is initiated, maintained, and terminated.The therapeutic relationship is discussed indepth in Chapter 5, including confidentiality, selfdisclosure,and therapeutic use of self. To have effectivetherapeutic communication, the nurse also must considerprivacy and respect of boundaries, use of touch, and activelistening and observation.Privacy and Respecting BoundariesPrivacy is desirable but not always possible in therapeuticcommunication. An interview or a conference room isoptimal if the nurse believes this setting is not too isolativefor the interaction. The nurse also can talk with the clientat the end of the hall or in a quiet corner of the day roomor lobby, depending on the physical layout of the setting.The nurse needs to evaluate whether interacting in the client’sroom is therapeutic. For example, if the client hasdifficulty maintaining boundaries or has been making sexualcomments, then the client’s room is not the best setting.A more formal setting would be desirable.Proxemics is the study of distance zones between peopleduring communication. People feel more comfortablewith smaller distances when communicating with someonethey know rather than with strangers (DeVito, 2008).People from the United States, Canada, and many EasternEuropean nations generally observe four distance zones:• Intimate zone (0 to 18 inches between people): Thisamount of space is comfortable for parents with youngchildren, people who mutually desire personal contact,or people whispering. Invasion of this intimate zone byanyone else is threatening and produces anxiety.• Personal zone (18 to 36 inches): This distance is comfortablebetween family and friends who are talking.• Social zone (4 to 12 feet): This distance is acceptablefor communication in social, work, and businesssettings.• Public zone (12 to 25 feet): This is an acceptable distancebetween a speaker and an audience, small groups,and other informal functions (Hall, 1963).People from some cultures (e.g., Hispanic, Mediterranean,East Indian, Asian, and Middle Eastern) are morecomfortable with less than 4 to 12 feet of space betweenthem while talking. The nurse of European American orAfrican American heritage may feel uncomfortable if clientsfrom these cultures stand close when talking. Conversely,clients from these backgrounds may perceive thenurse as remote and indifferent (Andrews & Boyle, 2007).Both the client and the nurse can feel threatened if oneinvades the other’s personal or intimate zone, which canresult in tension, irritability, fidgeting, or even flight. Whenthe nurse must invade the intimate or personal zone, he or

100UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPCLINICAL VIGNETTE: PERSONAL BOUNDARIES BETWEENNURSE AND CLIENTSaying he wanted to discuss his wife’s condition, a manaccompanied the nurse down the narrow hallway of hishouse but did not move away when they reached the parlor.He was 12 inches from the nurse. The nurse was uncomfortablewith his closeness, but she did not perceive any physicalthreat from him. Because this was the first visit to this home,the nurse indicated two easy chairs and said, “Let’s sit overhere, Mr. Barrett” (offering collaboration). If sitting downwere not an option and Mr. Barrett moved in to compensatefor the nurse’s backing up, the nurse could neutrally say, “Ifeel uncomfortable when anyone invades my personalspace, Mr. Barrett. Please back up at least 12 inches” (settinglimits). In this message, the nurse has taken the blameinstead of shaming the other person and has gently givenan order for a specific distance between herself and Mr.Barrett. If Mr. Barrett were to move closer to the nurse again,the nurse would note the behavior and ask the client aboutit—for example, “You have moved in again very close tome, Mr. Barrett. What is that about?” (encouraging evaluation).The use of an open-ended question provides an opportunityfor the client to address his behavior. He may havedifficulty hearing the nurse, want to keep this discussionconfidential so his wife will not hear it, come from a culturein which 12 inches is an appropriate distance for a conversation,or be using his closeness as a manipulative behavior(ensure attention, threat, or sexual invitation). After discussingMr. Barrett’s response and understanding that he canhear adequately, the nurse can add, “We can speak just finefrom 2 or 3 feet apart, Mr. Barrett. Otherwise, I will leave orwe can continue this discussion in your wife’s room” (settinglimits). If Mr. Barrett again moves closer, the nurse will leaveor move to the wife’s room to continue the interview.she always should ask the client’s permission. For example,if a nurse performing an assessment in a community settingneeds to take the client’s blood pressure, he or she shouldsay, “Mr. Smith, to take your blood pressure I will wrap thiscuff around your arm and listen with my stethoscope. Isthis acceptable to you?” He or she should ask permission ina yes/no format so the client’s response is clear. This is oneof the times when yes/no questions are appropriate.The therapeutic communication interaction is mostcomfortable when the nurse and client are 3 to 6 feet apart.If a client invades the nurse’s intimate space (0 to18 inches), the nurse should set limits gradually, dependingon how often the client has invaded the nurse’s spaceand the safety of the situation.TouchAs intimacy increases, the need for distance decreases.Knapp (1980) identified five types of touch:• Functional-professional touch is used in examinations orprocedures such as when the nurse touches a client toassess skin turgor or a masseuse performs a massage.• Social-polite touch is used in greeting, such as a handshakeand the “air kisses” some women use to greetacquaintances, or when a gentle hand guides someonein the correct direction.• Friendship-warmth touch involves a hug in greeting, anarm thrown around the shoulder of a good friend, or thebackslapping some men use to greet friends and relatives.• Love-intimacy touch involves tight hugs and kissesbetween lovers or close relatives.• Sexual-arousal touch is used by lovers.Touching a client can be comforting and supportivewhen it is welcome and permitted. The nurse shouldobserve the client for cues that show whether touch isdesired or indicated. For example, holding the hand ofa sobbing mother whose child is ill is appropriate andtherapeutic. If the mother pulls her hand away, however,she signals to the nurse that she feels uncomfortablebeing touched. The nurse also can ask the clientabout touching (e.g., “Would it help you to squeeze myhand?”).Although touch can be comforting and therapeutic, itis an invasion of intimate and personal space. Some clientswith mental illness have difficulty understandingthe concept of personal boundaries or knowing whentouch is or is not appropriate. Consequently, most psychiatricinpatient, outpatient, and ambulatory care unitshave policies against clients touching one another orstaff. Unless they need to get close to a client to performsome nursing care, staff members should serve as rolemodels and refrain from invading clients’ personal andintimate space. When a staff member is going to touch aclient while performing nursing care, he or she must verballyprepare the client before starting the procedure. Aclient with paranoia may interpret being touched as athreat and may attempt to protect himself or herself bystriking the staff person.Active Listening and ObservationTo receive the sender’s simultaneous messages, the nursemust use active listening and active observation. Activelistening means refraining from other internal mental

CHAPTER 6 • THERAPEUTIC COMMUNICATION 101activities and concentrating exclusively on what the clientsays. Active observation means watching the speaker’snonverbal actions as he or she communicates.Peplau (1952) used observation as the first step in thetherapeutic interaction. The nurse observes the client’sbehavior and guides him or her in giving detaileddescriptions of that behavior. The nurse also documentsthese details. To help the client develop insight into hisor her interpersonal skills, the nurse analyzes the informationobtained, determines the underlying needs thatrelate to the behavior, and connects pieces of information(makes links between various sections of theconversation).A common misconception by students learning theart of therapeutic communication is that they alwaysmust be ready with questions the instant the client hasfinished speaking. Hence, they are constantly thinkingahead regarding the next question rather than activelylistening to what the client is saying. The result can bethat the nurse does not understand the client’s concerns,and the conversation is vague, superficial, and frustratingto both participants. When a superficial conversationoccurs, the nurse may complain that the client isnot cooperating, is repeating things, or is not takingresponsibility for getting better. Superficiality, however,can be the result of the nurse’s failure to listen to cues inthe client’s responses and repeatedly asking the samequestion. The nurse does not get details and works fromhis or her assumptions rather than from the client’s truesituation.While listening to a client’s story, it is almost impossiblefor the nurse not to make assumptions. A person’s lifeexperiences, knowledge base, values, and prejudices oftencolor the interpretation of a message. In therapeutic communication,the nurse must ask specific questions to getthe entire story from the client’s perspective, to clarifyassumptions, and to develop empathy with the client.Empathy is the ability to place oneself into the experienceof another for a moment in time. Nurses develop empathyby gathering as much information about an issue as possibledirectly from the client to avoid interjecting theirpersonal experiences and interpretations of the situation.The nurse asks as many questions as needed to gain aclear understanding of the client’s perceptions of an eventor issue.Active listening and observation help the nurse to• Recognize the issue that is most important to the clientat this time.• Know what further questions to ask the client.• Use additional therapeutic communication techniquesto guide the client to describe his or her perceptionsfully.• Understand the client’s perceptions of the issue insteadof jumping to conclusions.• Interpret and respond to the message objectively.VERBAL COMMUNICATION SKILLSUsing Concrete MessagesWhen speaking to the client the nurse should use wordsthat are as clear as possible so that the client can understandthe message. Anxious people lose cognitive processingskills—the higher the anxiety, the less the ability to processconcepts—so concrete messages are important for accurateinformation exchange. In a concrete message, the words areexplicit and need no interpretation; the speaker uses nounsinstead of pronouns—for example, “What health symptomscaused you to come to the hospital today?” or “When wasthe last time you took your antidepressant medications?”Concrete questions are clear, direct, and easy to understand.They elicit more accurate responses and avoid the need togo back and rephrase unclear questions, which interruptsthe flow of a therapeutic interaction.Abstract messages, in contrast, are unclear patterns ofwords that often contain figures of speech that are difficultto interpret. They require the listener to interpret what thespeaker is asking. For example, a nurse who wants toknow why a client was admitted to the unit asks, “How didyou get here?” This is an abstract message: the terms howand here are vague. An anxious client might not be awareof where he or she is and might reply, “Where am I?” ormight interpret this as a question about how he or she wasconveyed to the hospital and respond, “The ambulancebrought me.” Clients who are anxious, from different cultures,cognitively impaired, or suffering from some mentaldisorders often function at a concrete level of comprehensionand have difficulty answering abstract questions. Thenurse must be sure that statements and questions are clearand concrete.The following are examples of abstract and concretemessages:Abstract (unclear): “Get the stuff from him.”Concrete (clear): “John will be home todayat 5 pm, and you can pick up your clothes at thattime.”Abstract (unclear): “Your clinical performancehas to improve.”Concrete (clear): “To administer medications tomorrow,you’ll have to be able to calculate dosages correctly by the endof today’s class.”Using Therapeutic CommunicationTechniquesThe nurse can use many therapeutic communication techniquesto interact with clients. The choice of techniquedepends on the intent of the interaction and the client’sability to communicate verbally. Overall, the nurse selectstechniques that facilitate the interaction and enhance communicationbetween client and nurse. Table 6.1 lists thesetechniques and gives examples. Techniques such as

102UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 6.1THERAPEUTIC COMMUNICATION TECHNIQUESTherapeuticCommunication Technique Examples RationaleAccepting—indicatingreceptionBroad openings—allowingthe client to take the initiativein introducing thetopicConsensual validation—searching for mutual understanding,for accord inthe meaning of the wordsEncouragingcomparison—askingthat similarities anddifferences be notedEncouraging descriptionof perceptions—askingthe client to verbalizewhat he or she perceivesEncouraging expression—asking the client to appraisethe quality of his orher experiencesExploring—delving furtherinto a subject or an ideaFocusing—concentratingon a single pointFormulating a plan ofaction—asking the clientto consider kinds ofbehavior likely to beappropriate in futuresituationsGeneral leads—givingencouragement tocontinue“Yes.”“I follow what you said.”Nodding“Is there something you’d liketo talk about?”“Where would you like tobegin?”“Tell me whether my understandingof it agrees withyours.”“Are you using this word toconvey that…?”“Was it something like…?”“Have you had similarexperiences?”“Tell me when you feelanxious.”“What is happening?”“What does the voice seemto be saying?”“What are your feelings inregard to…?”“Does this contribute to yourdistress?”“Tell me more about that.”“Would you describe it morefully?”“What kind of work?”“This point seems worthlooking at more closely.”“Of all the concerns you’vementioned, which is mosttroublesome?”“What could you do to let youranger out harmlessly?”“Next time this comes up, whatmight you do to handle it?”“Go on.”“And then?”“Tell me about it.”An accepting response indicates the nurse has heard andfollowed the train of thought. It does not indicateagreement but is nonjudgmental. Facial expression,tone of voice, and so forth also must convey acceptanceor the words lose their meaning.Broad openings make explicit that the client has the leadin the interaction. For the client who is hesitant abouttalking, broad openings may stimulate him or her totake the initiative.For verbal communication to be meaningful, it is essentialthat the words being used have the same meaningfor both (all) participants. Sometimes, words, phrases,or slang terms have different meanings and can beeasily misunderstood.Comparing ideas, experiences, or relationships bringsout many recurring themes. The client benefits frommaking these comparisons because he or she mightrecall past coping strategies that were effective orremember that he or she has survived a similarsituation.To understand the client, the nurse must see thingsfrom his or her perspective. Encouraging the clientto describe ideas fully may relieve the tension theclient is feeling, and he or she might be less likelyto take action on ideas that are harmful orfrightening.The nurse asks the client to consider people and eventsin light of his or her own values. Doing so encouragesthe client to make his or her own appraisal rather thanto accept the opinion of others.When clients deal with topics superficially, exploring canhelp them examine the issue more fully. Any problemor concern can be better understood if explored indepth. If the client expresses an unwillingness to explorea subject, however, the nurse must respect his orher wishes.The nurse encourages the client to concentrate his or herenergies on a single point, which may prevent a multitudeof factors or problems from overwhelming theclient. It is also a useful technique when a client jumpsfrom one topic to another.It may be helpful for the client to plan in advance whathe or she might do in future similar situations. Makingdefinite plans increases the likelihood that the clientwill cope more effectively in a similar situation.General leads indicate that the nurse is listening and followingwhat the client is saying without taking awaythe initiative for the interaction. They also encouragethe client to continue if he or she is hesitant or uncomfortableabout the topic.

CHAPTER 6 • THERAPEUTIC COMMUNICATION 103Table 6.1THERAPEUTIC COMMUNICATION TECHNIQUES (Continued)TherapeuticCommunication Technique Examples RationaleGiving information—making available the factsthat the client needsGiving recognition—acknowledging, indicatingawarenessMaking observations—verbalizing what the nurseperceivesOffering self—making oneselfavailablePlacing event in time orsequence—clarifying therelationship of events intimePresenting reality—offering for considerationthat which is realReflecting—directing clientactions, thoughts, andfeelings back to clientRestating—repeating themain idea expressed“My name is….”“Visiting hours are….”“My purpose in being hereis….”“Good morning, Mr. S.….”“You’ve finished your list ofthings to do.”“I notice that you’ve combedyour hair.”“You appear tense.”“Are you uncomfortablewhen…?”“I notice that you’re bitingyour lip.”“I’ll sit with you awhile.”“I’ll stay here with you.”“I’m interested in what youthink.”“What seemed to lead upto…?”“Was this before or after…?”“When did this happen?”“I see no one else in the room.”“That sound was a carbackfiring.”“Your mother is not here; I ama nurse.”Client: “Do you think I shouldtell the doctor…?”Nurse: “Do you think youshould?”Client: “My brother spends allmy money and then has nerveto ask for more.”Nurse: “This causes you to feelangry?”Client: “I can’t sleep. I stayawake all night.”Nurse: “You have difficultysleeping.”Client: “I’m really mad, I’m reallyupset.”Nurse: “You’re really mad andupset.”Informing the client of facts increases his or herknowledge about a topic or lets the client know whatto expect. The nurse is functioning as a resourceperson. Giving information also builds trust withthe client.Greeting the client by name, indicating awareness ofchange, or noting efforts the client has made all showthat the nurse recognizes the client as a person, as anindividual. Such recognition does not carry the notionof value, that is, of being “good” or “bad.”Sometimes clients cannot verbalize or make themselvesunderstood. Or the client may not be ready to talk.The nurse can offer his or her presence, interest, anddesire to understand. It is important that this offer isunconditional; that is, the client does not have torespond verbally to get the nurse’s attention.Putting events in proper sequence helps both thenurse and the client to see them in perspective. Theclient may gain insight into cause-and-effect behaviorand consequences, or the client may be able to seethat perhaps some things are not related. Thenurse may gain information about recurrentpatterns or themes in the client’s behavior orrelationships.When it is obvious that the client is misinterpreting reality,the nurse can indicate what is real. The nurse doesthis by calmly and quietly expressing his or her perceptionsor the facts, not by way of arguing with the clientor belittling his or her experience. The intent is toindicate an alternative line of thought for the client toconsider, not to “convince” the client that he or she iswrong.Reflection encourages the client to recognize and accepthis or her own feelings. The nurse indicates that theclient’s point of view has value and that the client hasthe right to have opinions, make decisions, and thinkindependently.The nurse repeats what the client has said in approximatelyor nearly the same words the client has used.This restatement lets the client know that he or shecommunicated the idea effectively. This encouragesthe client to continue. Or if the client has been misunderstood,he or she can clarify his or her thoughts.(continued)

104UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 6.1THERAPEUTIC COMMUNICATION TECHNIQUES (Continued)TherapeuticCommunication Technique Examples RationaleSeeking information—seeking to make clear thatwhich is not meaningful orthat which is vagueSilence—absence of verbalcommunication, whichprovides time for the clientto put thoughts or feelingsinto words, to regain composure,or to continuetalkingSuggesting collaboration—offering to share, to strive,and to work with the clientfor his or her benefitSummarizing—organizingand summing up thatwhich has gone beforeTranslating into feelings—seeking to verbalize client’sfeelings that he orshe expresses onlyindirectlyVerbalizing the implied—voicing what the client hashinted at or suggestedVoicing doubt—expressinguncertainty about the realityof the client’sperceptions“I’m not sure that I follow.”“Have I heard you correctly?”Nurse says nothing but continuesto maintain eye contactand conveys interest.“Perhaps you and I can discussand discover the triggers foryour anxiety.”“Let’s go to your room, and I’llhelp you find what you’relooking for.”“Have I got this straight?”“You’ve said that….”“During the past hour, you and Ihave discussed….”Client: “I’m dead.”Nurse: “Are you suggesting thatyou feel lifeless?”Client: “I’m way out in theocean.”Nurse: “You seem to feel lonelyor deserted.”Client: “I can’t talk to you oranyone. It’s a waste of time.”Nurse: “Do you feel that no oneunderstands?”“Isn’t that unusual?”“Really?”“That’s hard to believe.”The nurse should seek clarification throughout interactionswith clients. Doing so can help the nurse to avoidmaking assumptions that understanding has occurredwhen it has not. It helps the client to articulatethoughts, feelings, and ideas more clearly.Silence often encourages the client to verbalize, providedthat it is interested and expectant. Silence gives the clienttime to organize thoughts, direct the topic of interaction,or focus on issues that are most important.Much nonverbal behavior takes place during silence,and the nurse needs to be aware of the client and hisor her own nonverbal behavior.The nurse seeks to offer a relationship in which the clientcan identify problems in living with others, grow emotionally,and improve the ability to form satisfactory relationships.The nurse offers to do things with, ratherthan for, the client.Summarization seeks to bring out the important pointsof the discussion and to increase the awareness andunderstanding of both participants. It omits the irrelevantand organizes the pertinent aspects of the interaction.It allows both client and nurse to depart withthe same ideas and provides a sense of closure at thecompletion of each discussion.Often what the client says, when taken literally, seemsmeaningless or far removed from reality. To understand,the nurse must concentrate on what the clientmight be feeling to express himself or herself this way.Putting into words what the client has implied or said indirectlytends to make the discussion less obscure. Thenurse should be as direct as possible without being unfeelinglyblunt or obtuse. The client may have difficultycommunicating directly. The nurse should take care toexpress only what is fairly obvious; otherwise, thenurse may be jumping to conclusions or interpretingthe client’s communication.Another means of responding to distortions of reality isto express doubt. Such expression permits the client tobecome aware that others do not necessarily perceiveevents in the same way or draw the same conclusions.This does not mean the client will alter his or her pointof view, but at least the nurse will encourage the clientto reconsider or reevaluate what has happened. Thenurse neither agreed nor disagreed; however, he orshe has not let the misperceptions and distortions passwithout comment.Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New York: Macmillan Press.

CHAPTER 6 • THERAPEUTIC COMMUNICATION 105exploring, focusing, restating, and reflecting encourage theclient to discuss his or her feelings or concerns in moredepth. Other techniques help focus or clarify what is beingsaid. The nurse may give the client feedback using techniquessuch as making an observation or presenting reality.Avoiding Nontherapeutic CommunicationIn contrast, there are many nontherapeutic techniquesthat nurses should avoid (Table 6.2). These responses cutoff communication and make it more difficult for the interactionto continue. Responses such as “Everything willwork out” or “Maybe tomorrow will be a better day” maybe intended to comfort the client, but instead may impedethe communication process. Asking “why” questions (inan effort to gain information) may be perceived as criticismby the client, conveying a negative judgment fromthe nurse. Many of these responses are common in socialinteraction. Therefore, it takes practice for the nurse toavoid making these types of comments.Table 6.2NONTHERAPEUTIC COMMUNICATION TECHNIQUESTechniques Examples RationaleAdvising—telling theclient what to doAgreeing—indicatingaccord with the clientBelittling feelingsexpressed—misjudgingthe degree of the client’sdiscomfortChallenging—demandingproof from the clientDefending—attemptingto protect someone orsomething from verbalattack?Disagreeing—opposingthe client’s ideasDisapproving—denouncingthe client’s behavioror ideasGiving approval—sanctioning the client’sbehavior or ideasGiving literalresponses—respondingto a figurative commentas though it were astatement of fact“I think you should….”“Why don’t you….”“That’s right.”“I agree.”Client: “I have nothing to livefor… I wish I was dead.”Nurse: “Everybody gets downin the dumps,” or “I’ve feltthat way myself.”“But how can you be presidentof the United States?”“If you’re dead, why is yourheart beating?”“This hospital has a finereputation.”“I’m sure your doctor hasyour best interests inmind.”“That’s wrong.”“I definitely disagree with….”“I don’t believe that.”“That’s bad.”“I’d rather you wouldn’t….”“That’s good.”“I’m glad that….”Client: “They’re looking in myhead with a televisioncamera.”Nurse: “Try not to watch television”or “What channel?”Giving advice implies that only the nurse knows what is bestfor the client.Approval indicates the client is “right” rather than “wrong.”This gives the client the impression that he or she is “right”because of agreement with the nurse. Opinions and conclusionsshould be exclusively the client’s. When the nurseagrees with the client, there is no opportunity for the clientto change his or her mind without being “wrong.”When the nurse tries to equate the intense and overwhelmingfeelings the client has expressed to “everybody” or to thenurse’s own feelings, the nurse implies that thediscomfort is temporary, mild, self-limiting, or not veryimportant. The client is focused on his or her own worriesand feelings; hearing the problems or feelings of others isnot helpful.Often the nurse believes that if he or she can challenge theclient to prove unrealistic ideas, the client will realize thereis no “proof” and then will recognize reality. Actually, challengingcauses the client to defend the delusions or misperceptionsmore strongly than before.Defending what the client has criticized implies that he or shehas no right to express impressions, opinions, or feelings.Telling the client that his or her criticism is unjust or unfoundeddoes not change the client’s feelings but onlyserves to block further communication.Disagreeing implies the client is “wrong.” Consequently, theclient feels defensive about his or her point of view orideas.Disapproval implies that the nurse has the right to pass judgmenton the client’s thoughts or actions. It further impliesthat the client is expected to please the nurse.Saying what the client thinks or feels is “good” implies thatthe opposite is “bad.” Approval, then, tends to limit theclient’s freedom to think, speak, or act in a certain way.This can lead to the client’s acting in a particular way justto please the nurse.Often the client is at a loss to describe his or her feelings, sosuch comments are the best he or she can do. Usually, it ishelpful for the nurse to focus on the client’s feelings inresponse to such statements.(continued)

106UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 6.2NONTHERAPEUTIC COMMUNICATION TECHNIQUES (Continued)Techniques Examples RationaleIndicating the existenceof an external source—attributing the source ofthoughts, feelings, andbehavior to others or tooutside influencesInterpreting—asking tomake conscious thatwhich is unconscious;telling the client themeaning of his or herexperienceIntroducing an unrelatedtopic—changingthe subjectMaking stereotypedcomments—offeringmeaningless clichés ortrite commentsProbing—persistent questioningof the clientReassuring—indicatingthere is no reason foranxiety or other feelingsof discomfortRejecting—refusing toconsider or showingcontempt for the client’sideas or behaviorsRequesting anexplanation—askingthe client to providereasons for thoughts,feelings, behaviors,eventsTesting—appraising theclient’s degree of insightUsing denial—refusing toadmit that a problemexists“What makes you say that?”“What made you do that?”“Who told you that you werea prophet?”“What you really mean is….”“Unconsciously you’resaying….”Client: “I’d like to die.”Nurse: “Did you have visitorslast evening?”“It’s for your own good.”“Keep your chin up.”“Just have a positive attitudeand you’ll be better in notime.”“Now tell me about this problem.You know I have tofind out.”“Tell me your psychiatrichistory.”“I wouldn’t worry aboutthat.”“Everything will be all right.”“You’re coming along justfine.”“Let’s not discuss….”“I don’t want to hearabout….”“Why do you think that?”“Why do you feel that way?”“Do you know what kind ofhospital this is?”“Do you still have the ideathat…?”Client: “I’m nothing.”Nurse: “Of course you’resomething—everybody’ssomething.”Client: “I’m dead.”Nurse: “Don’t be silly.”The nurse can ask, “What happened?” or “What events ledyou to draw such a conclusion?” But to question, “Whatmade you think that?” implies that the client was made orcompelled to think in a certain way. Usually, the nurse doesnot intend to suggest that the source is external, but that isoften what the client thinks.The client’s thoughts and feelings are his or her own, not tobe interpreted by the nurse for hidden meaning. Only theclient can identify or confirm the presence of feelings.The nurse takes the initiative for the interaction away fromthe client. This usually happens because the nurse is uncomfortable,doesn’t know how to respond, or has a topiche or she would rather discuss.Social conversation contains many clichés and much meaninglesschitchat. Such comments are of no value in thenurse–client relationship. Any automatic responses lack thenurse’s consideration or thoughtfulness.Probing tends to make the client feel used or invaded. Clientshave the right not to talk about issues or concerns if theychoose. Pushing and probing by the nurse will not encouragethe client to talk.Attempts to dispel the client’s anxiety by implying that thereis not sufficient reason for concern completely devalue theclient’s feelings. Vague reassurances without accompanyingfacts are meaningless to the client.When the nurse rejects any topic, he or she closes it off fromexploration. In turn, the client may feel personally rejectedalong with his or her ideas.There is a difference between asking the client to describewhat is occurring or has taken place and asking him to explainwhy. Usually, a “why” question is intimidating. In addition,the client is unlikely to know “why” and maybecome defensive trying to explain himself or herself.These types of questions force the client to try to recognizehis or her problems. The client’s acknowledgment that heor she doesn’t know these things may meet the nurse’sneeds but is not helpful for the client.The nurse denies the client’s feelings or the seriousness of thesituation by dismissing his or her comments without attemptingto discover the feelings or meaning behind them.Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New York: Macmillan Press.

CHAPTER 6 • THERAPEUTIC COMMUNICATION 107Interpreting Signals or CuesTo understand what a client means, the nurse watches andlistens carefully for cues. Cues (overt and covert) are verbalor nonverbal messages that signal key words or issuesfor the client. Finding cues is a function of active listening.Cues can be buried in what a client says or can be actedout in the process of communication. Often, cue wordsintroduced by the client can help the nurse to know whatto ask next or how to respond to the client. The nursebuilds his or her responses on these cue words or concepts.Understanding this can relieve pressure on studentswho are worried and anxious about what question to asknext. The following example illustrates questions thenurse might ask when responding to a client’s cue:Client: “I had a boyfriend when I was younger.”Nurse: “You had a boyfriend?” (reflecting)“Tell me about you and your boyfriend.”(encouraging description)“How old were you when you had this boyfriend?”(placing events in time or sequence)If a client has difficulty attending to a conversation anddrifts into a rambling discussion or a flight of ideas, thenurse listens carefully for a theme or a topic around whichthe client composes his or her words. Using the theme, thenurse can assess the nonverbal behaviors that accompanythe client’s words and build responses based on these cues.In the following examples, the underlined words arethemes and cues to help the nurse formulate furthercommunication.Theme of sadness:Client: “Oh, hi, nurse.” (face is sad; eyes lookteary; voice is low, with little inflection)Nurse: “You seem sad today, Mrs. Venezia.”Client: “Yes, it is the anniversary of myhusband’s death.”Nurse: “How long ago did your husband die?” (Or thenurse can use the other cue.)Nurse: “Tell me about your husband’s death, Mrs.Venezia.”Theme of loss of control:Client: “I had a fender bender this morning. I’mokay. I lost my wallet, and I have to go to thebank to cover a check I wrote last night. I can’tget in contact with my husband at work. I don’tknow where to start.”Nurse: “I sense you feel out of control” (translating intofeelings).Clients may use many word patterns to cue the listenerto their intent. Overt cues are clear, direct statements ofintent, such as “I want to die.” The message is clear thatthe client is thinking of suicide or self-harm. Covert cuesare vague or indirect messages that need interpretationand exploration—for example, if a client says, “Nothingcan help me.” The nurse is unsure, but it sounds as if theclient might be saying he feels so hopeless and helplessthat he plans to commit suicide. The nurse can explorethis covert cue to clarify the client’s intent and to protectthe client. Most suicidal people are ambivalent aboutwhether to live or die and often admit their plan whendirectly asked about it. When the nurse suspects self-harmor suicide, he or she uses a yes/no question to elicit a clearresponse.Theme of hopelessness and suicidal ideation:Client: “Life is hard. I want it to be done. Thereis no rest. Sleep, sleep is good . . . forever.”Nurse: “I hear you saying things seem hopeless.I wonder if you are planning to kill yourself”(verbalizing the implied).Other word patterns that need further clarification formeaning include metaphors, proverbs, and clichés. When aclient uses these figures of speech, the nurse must followup with questions to clarify what the client is trying to say.A metaphor is a phrase that describes an object or asituation by comparing it to something else familiar.Client: “My son’s bedroom looks like a bombwent off.”Nurse: “You’re saying your son is not veryneat” (verbalizing the implied).Client: “My mind is like mashed potatoes.”Nurse: “I sense you find it difficult to put thoughts together”(translating into feelings).Proverbs are old accepted sayings with generallyaccepted meanings.Client: “People who live in glass houses shouldn’tthrow stones.”Nurse: “Who do you believe is criticizing youbut actually has similar problems?” (encouragingdescription of perception)A cliché is an expression that has become trite and generallyconveys a stereotype. For example, if a client says,“she has more guts than brains,” the implication is that thespeaker believes the woman to whom he or she refers isnot smart, acts before thinking, or has no common sense.The nurse can clarify what the client means by saying,“Give me one example of how you see Mary as havingmore guts than brains” (focusing).NONVERBAL COMMUNICATION SKILLSNonverbal communication is the behavior a person exhibitswhile delivering verbal content. It includes facialexpression, eye contact, space, time, boundaries, and bodymovements. Nonverbal communication is as important as,if not more so than, verbal communication. It is estimatedthat one third of meaning is transmitted by words and two

108UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPthirds is communicated nonverbally. The speaker may verbalizewhat he or she believes the listener wants to hear,whereas nonverbal communication conveys the speaker’sactual meaning. Nonverbal communication involves theunconscious mind acting out emotions related to the verbalcontent, the situation, the environment, and the relationshipbetween the speaker and the listener.Knapp and Hall (2009) listed the ways in which nonverbalmessages accompany verbal messages:• Accent: using flashing eyes or hand movements• Complement: giving quizzical looks, nodding• Contradict: rolling eyes to demonstrate that the meaningis the opposite of what one is saying• Regulate: taking a deep breath to demonstrate readinessto speak, using “and uh” to signal the wish to continuespeaking• Repeat: using nonverbal behaviors to augment the verbalmessage, such as shrugging after saying “Whoknows?”• Substitute: using culturally determined body movementsthat stand in for words, such as pumping the armup and down with a closed fist to indicate successFacial ExpressionThe human face produces the most visible, complex, andsometimes confusing nonverbal messages. Facial movementsconnect with words to illustrate meaning; this connectiondemonstrates the speaker’s internal dialogue.Facial expressions can be categorized into expressive,impassive, and confusing:• An expressive face portrays the person’s moment-bymomentthoughts, feelings, and needs. These expressionsmay be evident even when the person does notwant to reveal his or her emotions.• An impassive face is frozen into an emotionless deadpanexpression similar to a mask.• A confusing facial expression is one that is the oppositeof what the person wants to convey. A person who isverbally expressing sad or angry feelings while smilingis exhibiting a confusing facial expression.Facial expressions often can affect the listener’s response.Strong and emotional facial expressions can persuade thelistener to believe the message. For example, by appearingperplexed and confused, a client could manipulate the nurseinto staying longer than scheduled. Facial expressions suchas happy, sad, embarrassed, or angry usually have the samemeaning across cultures, but the nurse should identify thefacial expression and ask the client to validate the nurse’sinterpretation of it—for instance, “You’re smiling, but Isense you are very angry” (Sheldon, 2008).Frowns, smiles, puzzlement, relief, fear, surprise, andanger are common facial communication signals. Lookingaway, not meeting the speaker’s eyes, and yawning indicatethat the listener is disinterested, lying, or bored. To ensurethe accuracy of information, the nurse identifies the nonverbalcommunication and checks its congruency with thecontent (Sheldon, 2008). An example is “Mr. Jones, yousaid everything is fine today, yet you frowned as you spoke.I sense that everything is not really fine” (verbalizing theimplied).Body LanguageBody language (gestures, postures, movements, and bodypositions) is a nonverbal form of communication. Closedbody positions, such as crossed legs or arms folded acrossthe chest, indicate that the interaction might threaten thelistener who is defensive or not accepting. A better, moreaccepting body position is to sit facing the client with bothfeet on the floor, knees parallel, hands at the side of thebody, and legs uncrossed or crossed only at the ankle. Thisopen posture demonstrates unconditional positive regard,trust, care, and acceptance. The nurse indicates interest inand acceptance of the client by facing and slightly leaningtoward him or her while maintaining nonthreatening eyecontact.Hand gestures add meaning to the content. A slight liftof the hand from the arm of a chair can punctuate orstrengthen the meaning of words. Holding both handswith palms up while shrugging the shoulders often means“I don’t know.” Some people use many hand gestures todemonstrate or act out what they are saying, whereasothers use very few gestures.Closed body position

CHAPTER 6 • THERAPEUTIC COMMUNICATION 109tedious descriptions is called circumstantiality. It canindicate the client is confused about what is important oris a poor historian. Slow, hesitant responses can indicatethat the person is depressed, confused and searching forthe correct words, having difficulty finding the rightwords to describe an incident, or reminiscing. It is importantfor the nurse to validate these nonverbal indicatorsrather than to assume that he or she knows what the clientis thinking or feeling (e.g., “Mr. Smith, you sound anxious.Is that how you’re feeling?”).Eye ContactThe eyes have been called the mirror of the soul becausethey often reflect our emotions. Messages that the eyesgive include humor, interest, puzzlement, hatred, happiness,sadness, horror, warning, and pleading. Eye contact,looking into the other person’s eyes during communication,is used to assess the other person and the environmentand to indicate whose turn it is to speak; it increasesduring listening but decreases while speaking (DeVito,2008). Although maintaining good eye contact is usuallydesirable, it is important that the nurse doesn’t “stare” atthe client.Accepting body positionThe positioning of the nurse and client in relation toeach other is also important. Sitting beside or across fromthe client can put the client at ease, whereas sitting behinda desk (creating a physical barrier) can increase the formalityof the setting and may decrease the client’s willingnessto open up and communicate freely. The nurse maywish to create a more formal setting with some clients,however, such as those who have difficulty maintainingboundaries.Vocal CuesVocal cues are nonverbal sound signals transmitted alongwith the content: voice volume, tone, pitch, intensity,emphasis, speed, and pauses augment the sender’s message.Volume, the loudness of the voice, can indicate anger,fear, happiness, or deafness. Tone can indicate whethersomeone is relaxed, agitated, or bored. Pitch varies fromshrill and high to low and threatening. Intensity is thepower, severity, and strength behind the words, indicatingthe importance of the message. Emphasis refers to accentson words or phrases that highlight the subject or giveinsight into the topic. Speed is the number of words spokenper minute. Pauses also contribute to the message,often adding emphasis or feeling.The high-pitched rapid delivery of a message oftenindicates anxiety. The use of extraneous words with long,SilenceSilence or long pauses in communication may indicatemany different things. The client may be depressed andstruggling to find the energy to talk. Sometimes pausesindicate the client is thoughtfully considering the questionbefore responding. At times, the client may seem to be“lost in his or her own thoughts” and not paying attentionto the nurse. It is important to allow the client sufficienttime to respond, even if it seems like a long time. It mayconfuse the client if the nurse “jumps in” with anotherquestion or tries to restate the question differently. Also, insome cultures, verbal communication is slow with manypauses, and the client may believe the nurse is impatientor disrespectful if he or she does not wait for the client’sresponse.UNDERSTANDING THE MEANINGOF COMMUNICATIONFew messages in social and therapeutic communicationhave only one level of meaning; messages often containmore meaning than just the spoken words (DeVito, 2008).The nurse must try to discover all the meaning in the client’scommunication. For example, the client with depressionmight say, “I’m so tired that I just can’t go on.” If thenurse considers only the literal meaning of the words, heor she might assume the client is experiencing the fatiguethat often accompanies depression. However, statementssuch as the previous example often mean the client wishesto die. The nurse would need to further assess the client’s

110UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPstatement to determine whether or not the client issuicidal.It is sometimes easier for clients to act out their emotionsthan to organize their thoughts and feelings intowords to describe feelings and needs. For example, peoplewho outwardly appear dominating and strong and oftenmanipulate and criticize others in reality may have lowself-esteem and feel insecure. They do not verbalize theirtrue feelings but act them out in behavior toward others.Insecurity and low self-esteem often translate into jealousyand mistrust of others and attempts to feel more importantand strong by dominating or criticizing them.UNDERSTANDING CONTEXTUnderstanding the context of communication is extremelyimportant in accurately identifying the meaning of a message.Think of the difference in the meaning of “I’m goingto kill you!” when stated in two different contexts: angerduring an argument and when one friend discovers anotheris planning a surprise party for him or her. Understandingthe context of a situation gives the nurse more informationand reduces the risk for assumptions.To clarify context, the nurse must gather informationfrom verbal and nonverbal sources and validate findingswith the client. For example, if a client says, “I collapsed,”she may mean she fainted or felt weak and had to sit down.Or she could mean she was tired and went to bed. To clarifythese terms and view them in the context of the action,the nurse could say,“What do you mean collapsed?” (seekingclarification)or“Describe where you were and what you weredoing when you collapsed” (placing events intime and sequence).Assessment of context focuses on who was there, whathappened, when it occurred, how the event progressed, andwhy the client believes it happened as it did.UNDERSTANDING SPIRITUALITYSpirituality is a client’s belief about life, health, illness,death, and one’s relationship to the universe. It differs fromreligion, which is an organized system of beliefs about oneor more all-powerful, all-knowing forces that govern theuniverse and offer guidelines for living in harmony withthe universe and others (Andrews & Boyle, 2007). Spiritualand religious beliefs usually are supported by otherswho share them and follow the same rules and rituals fordaily living. Spirituality and religion often provide comfortand hope to people and can greatly affect a person’s healthand health-care practices.The nurse must first assess his or her own spiritual andreligious beliefs. Religion and spirituality are highlysubjective and can be vastly different among people. Thenurse must remain objective and nonjudgmental regardingthe client’s beliefs and must not allow them to alternursing care. The nurse must assess the client’s spiritualand religious needs and guard against imposing his or herown on the client. The nurse must ensure that the client isnot ignored or ridiculed because his or her beliefs and valuesdiffer from those of the staff.As the therapeutic relationship develops, the nursemust be aware of and respect the client’s religious and spiritualbeliefs. Ignoring or being judgmental will quicklyerode trust and could stall the relationship. For example, anurse working with a Native American client could findhim looking up at the sky and talking to “GrandmotherMoon.” If the nurse did not realize that the client’s beliefsembody all things with spirit, including the sun, moon,earth, and trees, the nurse might misinterpret the client’sactions as inappropriate. Chapter 7 gives a more detaileddiscussion on spirituality.CULTURAL CONSIDERATIONSCulture is all the socially learned behaviors, values, beliefs,and customs transmitted down to each generation. Therules about the way in which to conduct communicationvary because they arise from each culture’s specific socialrelationship patterns (Sheldon, 2008). Each culture has itsown rules governing verbal and nonverbal communication.For example, in Western cultures, the handshake is anonverbal greeting used primarily by men often to size upor judge someone they just met. For women, a polite“hello” is an accepted form of greeting. In some Asian cultures,bowing is the accepted form of greeting and departingand a method of designating social status.Because of these differences, cultural assessment is necessarywhen establishing a therapeutic relationship. Thenurse must assess the client’s emotional expression, beliefs,values, and behaviors; modes of emotional expression; andviews about mental health and illness.When caring for people who do not speak English, theservices of a qualified translator who is skilled at obtainingaccurate data are necessary. He or she should be able totranslate technical words into another language whileretaining the original intent of the message and not injectinghis or her own biases. The nurse is responsible forknowing how to contact a translator, regardless of whetherthe setting is inpatient, outpatient, or in the community.The nurse must understand the differences in how variouscultures communicate. It helps to see how a personfrom another culture acts toward and speaks with others.U.S. and many European cultures are individualistic; theyvalue self-reliance and independence and focus on individualgoals and achievements. Other cultures, such as Chineseand Korean, are collectivistic, valuing the group and observingobligations that enhance the security of the group. Personsfrom these cultures are more private and guarded when

CHAPTER 6 • THERAPEUTIC COMMUNICATION 111speaking to members outside the group and sometimes mayeven ignore outsiders until they are formally introduced tothe group. Cultural differences in greetings, personal space,eye contact, touch, and beliefs about health and illness arediscussed in depth in Chapter 7.THE THERAPEUTIC COMMUNICATIONSESSIONGoalsThe nurse uses all the therapeutic communication techniquesand skills previously described to help achieve thefollowing goals:• Establish rapport with the client by being empathetic,genuine, caring, and unconditionally accepting of theclient regardless of his or her behavior or beliefs.• Actively listen to the client to identify the issues ofconcern and to formulate a client-centered goal for theinteraction.• Gain an in-depth understanding of the client’s perceptionof the issue, and foster empathy in the nurse–clientrelationship.• Explore the client’s thoughts and feelings.• Facilitate the client’s expression of thoughts and feelings.• Guide the client to develop new skills in problemsolving.• Promote the client’s evaluation of solutions.Often the nurse can plan the time and setting for therapeuticcommunication, such as having an in-depth, one-ononeinteraction with an assigned client. The nurse has timeto think about where to meet and what to say and will havea general idea of the topic, such as finding out what theclient sees as his or her major concern or following up oninteraction from a previous encounter. At times, however,a client may approach the nurse saying, “Can I talk to youright now?” Or the nurse may see a client sitting alone,crying, and decide to approach the client for an interaction.In these situations, the nurse may know that he orshe will be trying to find out what is happening with theclient at that moment in time.When meeting the client for the first time, introducingoneself and establishing a contract for the relationship is anappropriate start for therapeutic communication. The nursecan ask the client how he or she prefers to be addressed. Acontract for the relationship includes outlining the care thenurse will give, the times the nurse will be with the client,and acceptance of these conditions by the client.Nurse: “Hello, Mr. Kirk. My name is Joan, andI’ll be your nurse today. I’m here from 7 AM to3:30 PM. Right now I have a few minutes, and Isee you are dressed and ready for the day.I would like to spend some time talking with youif this is convenient.” (giving recognition and introducingself, setting limits of contract)After making the introduction and establishing the contract,the nurse can engage in small talk to break the iceand to help get acquainted with the client if they have notmet before. Then the nurse can use a broad opening questionto guide the client toward identifying the major topicof concern. Broad opening questions are helpful tobegin the therapeutic communication session because theyallow the client to focus on what he or she considersimportant. The following is a good example of how tobegin the therapeutic communication:Nurse: “Hello, Mrs. Nagy. My name is Donna,and I am your nurse today and tomorrow from7 AM to 3:30 PM. What do you like to be called?”(introducing self, establishing limits ofrelationship)Client: “Hi, Donna. You can call me Peggy.”Nurse: “The rain today has been a welcome relief from theheat of the past few days.”Client: “Really? It’s hard to tell what it’s doing outside. Stillseems hot in here to me.”Nurse: “It does get stuffy here sometimes. So tell me, howare you doing today?” (broad opening)Nondirective RoleWhen beginning therapeutic interaction with a client, it isoften the client (not the nurse) who identifies the problemhe or she wants to discuss. The nurse uses active listeningskills to identify the topic of concern. The client identifiesthe goal, and information gathering about this topic focuseson the client. The nurse acts as a guide in this conversation.The therapeutic communication centers on achieving thegoal within the time limits of the conversation.The following are examples of client-centered goals:• Client will discuss her concerns about her 16-year-olddaughter, who is having trouble in school.• Client will describe difficulty she has with side effectsof her medication.• Client will share his distress about son’s drug abuse.• Client will identify the greatest concerns he has aboutbeing a single parent.The nurse is assuming a nondirective role in this typeof therapeutic communication, using broad openings andopen-ended questions to collect information and help theclient to identify and discuss the topic of concern. The clientdoes most of the talking. The nurse guides the clientthrough the interaction, facilitating the client’s expressionof feelings and identification of issues. The following is anexample of the nurse’s nondirective role:Client: “I’m so upset about my family.”Nurse: “You’re so upset?” (reflecting)Client: “Yes, I am. I can’t sleep. My appetiteis poor. I just don’t know what to do.”Nurse: “Go on.” (using a general lead)

112UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPClient: “Well, my husband works long hours and is verytired when he gets home. He barely sees the children beforetheir bedtime.”Nurse: “I see.” (accepting)Client: “I’m busy trying to fix dinner, trying to keep an eyeon the children, but I also want to talk to my husband.”Nurse: “How do you feel when all this is happening?”(encouraging expression)Client: “Like I’m torn in several directions at once. Nothingseems to go right, and I can’t straighten everything out.”Nurse: “It sounds like you’re feeling overwhelmed.”( translating into feelings)Client: “Yes, I am. I can’t do everything at once all bymyself. I think we have to make some changes.”Nurse: “Perhaps you and I can discuss some potentialchanges you’d like to make.” (suggesting collaboration)In some therapeutic interactions, the client wants onlyto talk to an interested listener and feel like he or she hasbeen heard. Often just sharing a distressing event can allowthe client to express thoughts and emotions that he or shehas been holding back. It serves as a way to lighten theemotional load and release feelings without a need to alterthe situation. Other times, the client may need to reminisceand share pleasant memories of past events. Olderadults often find great solace in reminiscing about eventsin their lives such as what was happening in the worldwhen they were growing up, how they met and when theymarried their spouses, and so forth. Reminiscence is discussedfurther in Chapter 21.Directive RoleWhen the client is suicidal, experiencing a crisis, or outof touch with reality, the nurse uses a directive role, askingdirect yes/no questions and using problem-solving tohelp the client develop new coping mechanisms to dealwith present here-and-now issues. The following is anexample of therapeutic communication using a moredirective role:Nurse: “I see you sitting here in the corner of theroom away from everyone else.” (makingobservation)Client: “Yeah, what’s the point?”Nurse: “What’s the point of what?” (seekingclarification)Client: “Of anything”Nurse: “You sound hopeless.” (verbalizing the implied)“Are you thinking about suicide?” (seeking information)Client: “I have been thinking I’d be better off dead.”The nurse uses a very directive role in this example becausethe client’s safety is at issue.As the nurse–client relationship progresses, the nurseuses therapeutic communication to implement manyinterventions in the client’s plan of care. In Unit 4, specificmental illnesses and disorders are discussed, as are specifictherapeutic communication interventions and examples ofhow to use the techniques effectively.How to Phrase QuestionsThe manner in which the nurse phrases questions isimportant. Open-ended questions elicit more descriptiveinformation; yes/no questions yield just an answer. Thenurse asks different types of questions based on the informationthe nurse wishes to obtain. The nurse uses activelistening to build questions based on the cues the clienthas given in his or her responses.In English, people frequently substitute the word feelfor the word think. Emotions differ from the cognitive processof thinking, so using the appropriate term is important.For example, “What do you feel about that test?” is avague question that could elicit several types of answers. Amore specific question is, “How well do you think you didon the test?” The nurse should ask, “What did you thinkabout…?” when discussing cognitive issues and “How didyou feel about…?” when trying to elicit the client’s emotionsand feelings. Box 6.1 lists “feeling” words that arecommonly used to express or describe emotions. The followingare examples of different responses that clientscould give to questions using “think” and “feel”:Nurse: “What did you think about your daughter’srole in her automobile accident?”Client: “I believe she is just not a carefuldriver. She drives too fast.”Box 6.1 “FEELING” WORDSAfraidAlarmedAngryAnxiousAshamedBewilderedCalmCarefreeConfusedDepressedEcstaticEmbarrassedEnragedEnviousExcitedFearfulFrustratedGuiltyHappyHopefulHopelessHorrifiedImpatientIrritatedJealousJoyfulLonelyPleasedPowerlessRelaxedResentfulSadScaredSurprisedTenseTerrifiedThreatenedThrilledUptight

CHAPTER 6 • THERAPEUTIC COMMUNICATION 113Nurse: “How did you feel when you heard about yourdaughter’s automobile accident?”Client: “Relieved that neither she nor anyone else wasinjured.”Using active listening skills, asking many open-endedquestions, and building on the client’s responses help thenurse obtain a complete description of an issue or anevent and understand the client’s experience. Some clientsdo not have the skill or patience to describe how anevent unfolded over time without assistance from thenurse. Clients tend to recount the beginning and the endof a story, leaving out crucial information about their ownbehavior. The nurse can help the client by using techniquessuch as clarification and placing an event in timeor sequence.Asking for ClarificationNurses often believe they always should be able to understandwhat the client is saying. This is not always the case:The client’s thoughts and communications may be unclear.The nurse never should assume that he or she understands;rather, the nurse should ask for clarification if thereis doubt. Asking for clarification to confirm the nurse’sunderstanding of what the client intends to convey is paramountto accurate data collection.If the nurse needs more information or clarification ona previously discussed issue, he or she may need to returnto that issue. The nurse also may need to ask questions insome areas to clarify information. The nurse then can usethe therapeutic technique of consensual validation, orrepeating his or her understanding of the event that theclient just described, to see whether their perceptionsagree. It is important to go back and clarify rather than towork from assumptions.The following is an example of clarifying and focusingtechniques:Client: “I saw it coming. No one else had a cluethis would happen.”Nurse: “What was it that you saw coming?”(seeking information)Client: “We were doing well, and then thefloor dropped out from under us. There was little anyone coulddo but hope for the best.”Nurse: “Help me understand by describing what ‘doingwell’ refers to.” (seeking information)“Who are the ‘we’ you refer to?” (focusing)“How did the floor drop out from under you?” (encouragingdescription of perceptions)“What did you hope would happen when you ‘hoped forthe best’?” (seeking information)Client’s Avoidance of the Anxiety-Producing TopicSometimes clients begin discussing a topic of minimalimportance because it is less threatening than the issuethat is increasing the client’s anxiety. The client is discussinga topic but seems to be focused elsewhere. Active listeningand observing changes in the intensity of the nonverbalprocess help to give the nurse a sense of what isgoing on. Many options can help the nurse to determinewhich topic is more important:1. Ask the client which issue is more important at thistime.2. Go with the new topic because the client has given nonverbalmessages that this is the issue that needs to bediscussed.3. Reflect the client’s behavior, signaling there is a moreimportant issue to be discussed.4. Mentally file the other topic away for later exploration.5. Ignore the new topic because it seems that the client istrying to avoid the original topic.The following example shows how the nurse can try toidentify which issue is most important to the client:Client: “I don’t know whether it is better to tellor not tell my husband that I won’t be able towork anymore. He gets so upset whenever hehears bad news. He has an ulcer, and badnews seems to set off a new bout of ulcer bleedingand pain.”Nurse: “Which issue is more difficult for you to confrontright now: your bad news or your husband’s ulcer?” (encouragingexpression)Guiding the Client in Problem-Solvingand Empowering the Clientto ChangeMany therapeutic situations involve problem-solving. Thenurse is not expected to be an expert or to tell the clientwhat to do to fix his or her problem. Rather, the nurseshould help the client explore possibilities and find solutionsto his or her problem. Often just helping the client todiscuss and explore his or her perceptions of a problemstimulates potential solutions in the client’s mind. Thenurse should introduce the concept of problem-solvingand offer himself or herself in this process.Virginia Satir (1967) explained how important the client’sparticipation is to finding effective and meaningfulsolutions to problems. If someone else tells the clienthow to solve his or her problems and does not allow theclient to participate and develop problem-solving skillsand paths for change, the client may fear growth andchange. The nurse who gives advice or directions aboutthe way to fix a problem does not allow the client to playa role in the process and implies that the client is lessthan competent. This process makes the client feel helplessand not in control and lowers self-esteem. The clientmay even resist the directives in an attempt to regain asense of control.

114UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPWhen a client is more involved in the problem-solvingprocess, he or she is more likely to follow through on thesolutions. The nurse who guides the client to solve his orher own problems helps the client to develop new copingstrategies, maintains or increases the client’s self-esteem,and demonstrates the belief that the client is capable ofchange. These goals encourage the client to expand his orher repertoire of skills and to feel competent; feelingeffective and in control is a comfortable state for anyclient.Problem-solving is frequently used in crisis interventionbut is equally effective for general use. The problemsolvingprocess is used when the client has difficultyfinding ways to solve the problem or when working witha group of people whose divergent viewpoints hinderfinding solutions. It involves several steps:1. Identify the problem.2. Brainstorm all possible solutions.3. Select the best alternative.4. Implement the selected alternative.5. Evaluate the situation.6. If dissatisfied with results, select another alternativeand continue the process.Identifying the problem involves engaging the client intherapeutic communication. The client tells the nurse theproblem and what he or she has tried to do to solve it:Nurse: “I see you frowning. What is going on?”(making observation; broad opening)Client: “I’ve tried to get my husband moreinvolved with the children other than yelling atthem when he comes in from work, but I’ve hadlittle success.”Nurse: “What have you tried that has not worked?”(encouraging expression)Client: “Before my surgery, I tried to involve him in theirhomework. My husband is a math whiz. Then I tried TV timetogether, but the kids like cartoons and he wants to watch stuffabout history, natural science, or travel.”Nurse: “How have you involved your husband in this planfor him to get more involved with the children?” (seekinginformation)Client: “Uh, I haven’t. I mean, he always says he wants tospend more quality time with the kids, but he doesn’t. Do youmean it would be better for him to decide how he wants to dothis—I mean, spend quality time with the kids?”Nurse: “That sounds like a place to start. Perhaps you andyour husband could discuss this issue when he comes to visitand decide what would work for both of you.” (formulating aplan of action)It is important to remember that the nurse is facilitatingthe client’s problem-solving abilities. The nurse may notbelieve the client is choosing the best or most effectivesolution, but it is essential that the nurse supports the client’schoice and assists him or her to implement thechosen alternative. If the client makes a mistake or theselected alternative isn’t successful, the nurse can supportthe client’s efforts and assist the client to try again. Effectiveproblem-solving involves helping the client to resolvehis or her own problems as independently as possible.ASSERTIVE COMMUNICATIONAssertive communication is the ability to express positiveand negative ideas and feelings in an open, honest, anddirect way (Hopkins, 2008). It recognizes the rights ofboth parties, and is useful in a variety of situations, such asresolving conflicts, solving problems, and expressing feelingsor thoughts that are difficult for some people toexpress. Assertive communication can help a person dealwith issues with coworkers, family, or friends. It is particularlyhelpful for people who have difficulty refusing another’srequest, expressing emotions of anger or frustration, ordealing with persons of authority.Nurses can assist clients to learn and practice assertivecommunication skills, as well as using assertive communicationto communicate with other nurses and members ofthe health-care team. It can be used in both personal andprofessional situations.Assertive communication works best when the speakeris calm; makes specific, factual statements; and focuses on“I” statements. For example, one of the nurses on yourunit is always a few minutes late to work, arriving in a rushand disrupting change-of-shift report. There are four typesof responses that coworkers can have to this situation:• Aggressive: After saying nothing for several days, onenurse jumps up and yells, “You’re always late! That is sorude! Why can’t you be on time like everyone else?”Then the nurse stomps out of the room, leaving everyoneuncomfortable.• Passive-aggressive: A coworker says to another nurse,“So nice of her to join us! Aren’t we lucky.” Everyonesits in uncomfortable silence.• Passive: One nurse doesn’t say anything at the time, butlater tells coworkers, “She’s always late. I had to tell herwhat she missed. I have so much work of my own todo.” But this nurse doesn’t say anything to the nursewho was late.• Assertive: After report, one nurse says, “When you arelate, report is disrupted, and I don’t like having to repeatinformation that was already discussed.” Thisnurse has communicated feelings about the specificsituation in a calm manner with no accusations or inflammatorycomments.Using assertive communication does not guarantee thatthe situation will change, but it does allow the speaker toexpress honest feelings in and open and direct way that isstill respectful of the other person. This lets the speakerfeel good about expressing the feelings, and may lead to adiscussion about how to resolve this problem.

CHAPTER 6 • THERAPEUTIC COMMUNICATION 115Sometimes people have difficulty “saying no” or refusingrequests from others. Later, the person may regret sayingyes, and feel overburdened or even resentful. Usingassertive communication can help the person say nopolitely, but firmly, even when the person making therequest is persistent in the request.Nurse 1: “Can you work for me next Saturday?”Nurse 2: “No, I can’t work for you nextSaturday.”Nurse 1: “Oh please, can’t you help me? I havetickets for a concert that I really want to see?”Nurse 2: “I can’t work for you next Saturday.”Nurse 1: “Why not? I heard you say you weren’t doinganything special this weekend. Please, I’ll never ask again.Please? I’ll do something special for you.”Nurse 2: “I can’t work for you next Saturday.”This is called the “broken record technique.” Insteadof responding to additional information, such as concerttickets, not having plans, or emotional pleas, the speakersimply repeats the response without justifying or explainingthe response. In time, the person can become quitecomfortable refusing a request without feeling guilty orcompelled to explain the refusal. In time, this can allowthe person to avoid stress from being overcommitted orresentful from agreeing to a request that is laterresented.Assertive communication takes practice. It is oftenhelpful to “rehearse” statements or responses in advance,especially if expressing feelings or discussing conflict isdifficult. Using assertive communication doesn’t alwaysproduce a positive result, and others may not like theassertive communication style, especially if it is a changefrom a previous style. But the speaker can feel confidentthat he or she communicated thoughts and feelingsopenly and honestly while respecting the rights of bothparties.COMMUNITY-BASED CAREAs community care for people with physical and mentalhealth problems continues to expand, the nurse’s roleexpands as well. The nurse may become the major caregiverand resource person for increasingly high-risk clientstreated in the home and their families and may becomemore responsible for primary prevention in wellness andhealth maintenance. Therapeutic communication techniquesand skills are essential to successful management ofclients in the community.Caring for older adults in the family unit and in communitiestoday is a major nursing concern and responsibility.It is important to assess the relationships of familymembers; identifying their areas of agreement and conflictcan greatly affect the care of clients. To be responsive tothe needs of these clients and their families for supportand caring, the nurse must communicate and relate toclients and establish a therapeutic relationship.When practicing in the community, the nurse needs selfawarenessand knowledge about cultural differences. Whenthe nurse enters the home of a client, the nurse is the outsiderand must learn to negotiate the cultural context of each familyby understanding their beliefs, customs, and practices andnot judging them according to his or her own cultural context.Asking the family for help in learning about their culturedemonstrates the nurse’s unconditional positive regard andgenuineness. Families from other cultural backgrounds oftenrespect nurses and health-care professionals and are quitepatient and forgiving of the cultural mistakes that nursesmight make as they learn different customs and behaviors.Another reason the nurse needs to understand the healthcarepractices of various cultures is to make sure thesepractices do not hinder or alter the prescribed therapeuticregimens. Some cultural healing practices, remedies, andeven dietary practices may alter the client’s immune systemand may enhance or interfere with prescribed medications.The nurse in community care is a member of the healthcareteam and must learn to collaborate with the client andfamily as well as with other health-care providers who areinvolved in the client’s care such as physicians, physicaltherapists, psychologists, and home health aides.Working with several people at one time rather thanjust with the client is the standard in community care.Self-awareness and sensitivity to the beliefs, behaviors,and feelings of others are paramount to the successful careof clients in the community setting.SELF-AWARENESS ISSUESTherapeutic communication is the primaryvehicle that nurses use to apply the nursingprocess in mental health settings. The nurse’sskill in therapeutic communication influencesthe effectiveness of many interventions. Therefore, thenurse must evaluate and improve his or her communicationskills on an ongoing basis. When the nurse examineshis or her personal beliefs, attitudes, and values as theyrelate to communication, he or she is gaining awareness ofthe factors influencing communication. Gaining awarenessof how one communicates is the first step towardimproving communication.The nurse will experience many different emotionalreactions to clients, such as sadness, anger, frustration,and discomfort. The nurse must reflect on these experiencesto determine how emotional responses affect bothverbal and nonverbal communication. When workingwith clients from different cultural or ethnic backgrounds,the nurse needs to know or find out what communicationstyles are comfortable for the client in terms of eye contact,touch, proximity, and so forth. The nurse can thenadapt his or her communication style in ways that are beneficialto the nurse–client relationship.

116UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPPoints to Consider When Workingon Therapeutic Communication Skills• Remember that nonverbal communication is just as importantas the words you speak. Be mindful of yourfacial expression, body posture, and other nonverbalaspects of communication as you work with clients.• Ask colleagues for feedback about your communicationstyle. Ask them how they communicate with clients indifficult or uncomfortable situations.• Examine your communication by asking questionssuch as “How do I relate to men? To women? Toauthority figures? To elderly persons? To people fromcultures different from my own?” or “What types ofclients or situations make me uncomfortable? Sad?Angry? Frustrated?” Use these self-assessment data toimprove your communication skills.Critical Thinking Questions1. Identify a situation in which you felt frustrated withanother person, or angry about something that occurred,but you kept silent about your feelings. Whatled to your silence? What assertive communicationstatements could help you express your feelings andthoughts?2. The nurse is working with a client whose culture includeshonoring one’s parents and being obedient,keeping “private” matters within the family only,and not talking with strangers about family matters.Given this client’s belief system, how will the nurseuse therapeutic communication effectively?KEY POINTS• Communication is the process people useto exchange information through verbal andnonverbal messages. It is composed of boththe literal words or content and all the nonverbalmessages (process), including body language,eye contact, facial expression, tone of voice, rate ofspeech, context, and hesitations that accompany thewords. To communicate effectively, the nurse must beskilled in the analysis of both content and process.• Therapeutic communication is an interpersonal interactionbetween the nurse and the client during which thenurse focuses on the needs of the client to promote aneffective exchange of information between the nurseand the client.• Goals of therapeutic communication include establishingrapport, actively listening, gaining the client’s perspective,exploring the client’s thoughts and feelings,and guiding the client in problem-solving.• The crucial components of therapeutic communicationare confidentiality, privacy, respect for boundaries, selfdisclosure,use of touch, and active listening and observationskills.• Proxemics is concerned with the distance zones betweenpeople when they communicate: intimate, personal,social, and public.• Active listening involves refraining from other internalmental activities and concentrating exclusively on whatthe client is saying.• Verbal messages need to be clear and concrete ratherthan vague and abstract. Abstract messages requiringthe client to make assumptions can be misleading andconfusing. The nurse needs to clarify any areas of confusionso that he or she does not make assumptions basedon his or her own experiences.• Nonverbal communication includes facial expressions,body language, eye contact, proxemics (environmentaldistance), touch, and vocal cues. All are important inunderstanding the speaker’s message.• Understanding the context is important to the accuracyof the message. Assessment of context focuses on thewho, what, when, how, and why of an event.• Spirituality and religion can greatly affect a client’shealth and health care. These beliefs vary widely and arehighly subjective. The nurse must be careful not to imposehis or her beliefs on the client or to allow differencesto erode trust.• Cultural differences can greatly affect the therapeuticcommunication process.INTERNET RESOURCESRESOURCES• Resources for Listening and Communicating• Seven Keys to Listening• Team Communication• Assertive Communication SkillsINTERNET ADDRESShttp://www.allaboutcounseling.comhttp://www.stresscure.com/relation/7keys.htmlhttp://www.yorkteam.com/teamc.htmhttp://stress.about.com/od/relationships/ht/howtoassert.htm

CHAPTER 6 • THERAPEUTIC COMMUNICATION 117• When guiding a client in the problem-solving process, itis important that the client (not the nurse) chooses andimplements solutions.• Therapeutic communication techniques and skills areessential to successful management of clients in thecommunity.• Assertive communication is the ability to express one’sself in an open, direct way. These skills are useful in resolvingconflicts, solving problems, and expressingthoughts and feelings safely.• The greater the nurse’s understanding of his or her ownfeelings and responses, the better the nurse can communicateand understand others.REFERENCESAndrews, M., & Boyle, J. (2007). Transcultural concepts in nursing care(5th ed.). Philadelphia: Lippincott Williams & Wilkins.DeVito, J. A. (2008). The interpersonal communication handbook(12th ed.). Boston: Pearson Education.Hall, E. (1963). Proxemics: The study of man’s spatial relationships.In J. Gladstone (Ed.), Man’s image in medicine and anthropology(pp. 109–120). Philadelphia: Mosby.Hopkins, L. (2008). Assertive communication—6 tips for effective use.Retrieved 12/2/2008 from http://ezinearticles.com.Knapp, M. L. (1980). Essentials of nonverbal communication. New York:Holt, Rinehart & Winston.Knapp, M. L., & Hall, J. A. (2009). Nonverbal behavior in human interaction(7th ed.). New York: Wadsworth.Peplau, H. (1952). Interpersonal relations in nursing. New York: G. P.Putnam.Satir, V. (1967). Conjoint family therapy: A guide to theory and technique(Rev. ed.). Palo Alto, CA: Science and Behavior Books, Inc.Sheldon, L. K. (2008). Communication for nurses: Talking with patients(2nd ed.). Boston: Jones & Bartlett Publishers.ADDITIONAL READINGSHasan, S. (2008). A tool to teach communication skills to pharmacystudents. American Journal of Pharmaceutical Education, 72(15), 67.Yamagashi, M., Kobayashi, T., Nagami, M., Shimazu, A., & Kageyama, T.(2007). Effect of web-based assertion training for stress managementof Japanese nurses. Journal of Nursing Management, 15(6), 603–607.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Client: “I had an accident.”Nurse: “Tell me about your accident.”This is an example of which therapeutic communicationtechnique?a. Making observationsb. Offering selfc. General leadd. Reflection2. “Earlier today you said you were concerned that yourson was still upset with you. When I stopped by yourroom about an hour ago, you and your son seemed relaxedand smiling as you spoke to each other. How didthings go between the two of you?”This is an example of which therapeutic communicationtechnique?a. Consensual validationb. Encouraging comparisonc. Acceptingd. General lead3. “Why do you always complain about the night nurse?She is a nice woman and a fine nurse and has five kidsto support. You’re wrong when you say she is noisy anduncaring.”This example reflects which nontherapeutic technique?a. Requesting an explanationb. Defendingc. Disagreeingd. Advising4. “How does Jerry make you upset?” is a nontherapeuticcommunication technique because ita. Gives a literal responseb. Indicates an external source of the emotionc. Interprets what the client is sayingd. Is just another stereotyped comment5. Client: “I was so upset about my sister ignoring mypain when I broke my leg.”Nurse: “When are you going to your next diabetes educationprogram?”This is a nontherapeutic response because the nursehasa. Used testing to evaluate the client’s insightb. Changed the topicc. Exhibited an egocentric focusd. Advised the client what to do6. When the client says, “I met Joe at the dance last week,”what is the best way for the nurse to ask the client todescribe her relationship with Joe?a. “Joe who?”b. “Tell me about Joe.”c. “Tell me about you and Joe.”d. “Joe, you mean that blond guy with the dark blueeyes?”7. Which of the following is a concrete message?a. “Help me put this pile of books on Marsha’s desk.”b. “Get this out of here.”c. “When is she coming home?”d. “They said it is too early to get in.”MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. The advantages of assertive communication are:a. All persons’ rights are respected.b. It gains approval from others.c. It protects the speaker from being exploited.d. The speaker can say “no” to another person’s request.e. The speaker can safely express thoughts andfeelings.f. The speaker will get their needs met.2. Which of the following are examples of a therapeuticcommunication response?a. “Don’t worry––everybody has a bad day occasionally.”b. “I don’t think your mother will appreciate thatbehavior.”c. “Let’s talk about something else.”d. “Tell me more about your discharge plans.”e. “That sounds like a great idea.”f. “What might you do the next time you’re feelingangry?”118

7Client’s Responseto IllnessLearning ObjectivesAfter reading this chapter, you should be able to1. Discuss the influences of age, growth, and development on a client’sresponse to illness.Key Terms• culturally competent• culture• environmental control• ethnicity• hardiness• race• resilience• resourcefulness• self-efficacy• sense of belonging• social networks• social organization• social support• socioeconomic status• spirituality• time orientation2. Identify the roles that physical health and biologic makeup play in a client’semotional responses.3. Explain the importance of personal characteristics, such as self-efficacy,hardiness, resilience, resourcefulness, and spirituality, in a client’s responseto stressors.4. Explain the influence of interpersonal factors, such as sense of belonging,social networks, and family support, on the client’s response to illness.5. Describe various cultural beliefs and practices that can affect mental healthor illness.6. Explain the cultural factors that the nurse must assess and consider whenworking with clients of different cultural backgrounds.7. Explain the nurse’s role in assessing and working with clients of differentcultural backgrounds.NURSING PHILOSOPHIES OFTEN describe the person or individual as a biopsychosocialbeing who possesses unique characteristics and responds to others andthe world in various and diverse ways. This view of the individual as uniquerequires nurses to assess each person and his or her responses to plan andprovide nursing care that is personally meaningful. This uniqueness ofresponse may partially explain why some people become ill and others donot. Understanding why two people raised in a stressful environment (e.g.,one with neglect or abuse) turn out differently is difficult: one personbecomes reasonably successful and maintains a satisfying marriage andfamily, whereas the other feels isolated, depressed, and lonely; is divorced;and abuses alcohol. Although we do not know exactly what makes the difference,studies have begun to show that certain personal, interpersonal,and cultural factors influence a person’s response.Culture is all the socially learned behaviors, values, beliefs, customs,and ways of thinking of a population that guide its members’ views ofVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!119

120UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPthemselves and the world. This view affects all aspects ofthe person’s being, including health, illness, and treatment.Cultural diversity refers to the vast array of differencesthat exist among populations.This chapter examines some of the personal, interpersonal,and cultural factors that create the unique individualresponse to both illness and treatment. In determining how aperson copes with illness, we cannot single out one or twofactors. Rather, we must consider each person as a combinationof all these overlapping and interacting factors.INDIVIDUAL FACTORSAge, Growth, and DevelopmentA person’s age seems to affect how he or she copes with illness.For instance, the age at onset of schizophrenia is astrong predictor of the prognosis of the disease (Buchanan &Carpenter, 2005). People with a younger age at onset havepoorer outcomes, such as more negative signs (apathy, socialisolation, and lack of volition) and less effective coping skills,than do people with a later age at onset. A possible reason forthis difference is that younger clients have not had experiencesof successful independent living or the opportunity towork and be self-sufficient and have a less well-developedsense of personal identity than older clients.A client’s age also can influence how he or she expressesillness. A young child with attention deficit hyperactivitydisorder may lack the understanding and ability to describehis or her feelings, which may make management of thedisorder more challenging. Nurses must be aware of thechild’s level of language and work to understand the experienceas he or she describes it.Erik Erikson described psychosocial development acrossthe life span in terms of developmental tasks to accomplishat each stage (Table 7.1). Each stage of development dependson the successful completion of the previous stage. In eachstage, the person must complete a critical life task that isessential to well-being and mental health. Failure to completethe critical task results in a negative outcome for thatstage of development and impedes completion of futuretasks. For example, the infancy stage (birth to 18 months)is the stage of “trust versus mistrust,” when infants mustlearn to develop basic trust that their parents or guardianswill take care of them, feed them, change their diapers, lovethem, and keep them safe. If the infant does not developtrust in this stage, he or she may be unable to love and trustothers later in life because the ability to trust others isessential to establishing good relationships. Specific developmentaltasks for adults are summarized in Table 7.2.According to Erikson’s theory, people may get “stuck”at any stage of development. For example, a person whonever completed the developmental task of autonomy maybecome overly dependent on others. Failure to developidentity can result in role confusion or an unclear ideaabout whom one is as a person. Negotiating these developmentaltasks affects how the person responds to stress andillness. Lack of success may result in feelings of inferiority,doubt, lack of confidence, and isolation—all of which canaffect how a person responds to illness.Genetics and Biologic FactorsHeredity and biologic factors are not under voluntary control.We cannot change these factors. Research has identifiedgenetic links to several disorders. For example, somepeople are born with a gene associated with one type ofAlzheimer’s disease. Although specific genetic links havenot been identified for several mental disorders (e.g., bipolardisorder, major depression, and alcoholism), researchhas shown that these disorders tend to appear more frequentlyin families. Genetic makeup tremendously influencesa person’s response to illness and perhaps even toTable 7.1ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENTStageTasksTrust vs. mistrust (infant)Autonomy vs. shame and doubt (toddler)Initiative vs. guilt (preschool)Industry vs. inferiority (school age)Identity vs. role diffusion (adolescence)Intimacy vs. isolation (young adult)Generativity vs. stagnation (middle adult)Ego integrity vs. despair (maturity)Viewing the world as safe and reliableViewing relationships as nurturing, stable, and dependableAchieving a sense of control and free willBeginning to develop a conscienceLearning to manage conflict and anxietyBuilding confidence in own abilitiesTaking pleasure in accomplishmentsFormulating a sense of self and belongingForming adult, loving relationships and meaningful attachment to othersBeing creative and productiveEstablishing the next generationAccepting responsibility for one’s self and life

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 121Table 7.2ADULT GROWTH AND DEVELOPMENT TASKSStageTasksYoung adult (25–45 years of age)Middle adult (45–65 years of age)Older adult (65 years of age and older)Accept self.Stabilize self-image.Establish independence from parental home and financial independence.Establish a career or vocation.Form an intimate bond with another person.Build a congenial social and friendship group.Become an involved citizen.Establish and maintain a home.Express love through more–than-sexual contacts.Maintain healthy life patterns.Develop sense of unity with mate.Help growing and grown children to be responsible adults.Relinquish central role in lives of grown children.Accept children’s mates and friends.Create a comfortable home.Be proud of accomplishments of self and mate/spouse.Reverse roles with aging parents.Achieve mature civic and social responsibility.Adjust to physical changes of middle age.Use leisure time creatively.Cherish old friends and make new ones.Prepare for retirement.Recognize the aging process and its limitations.Adjust to health changes.Decide where to live out remaining years.Continue warm relationship with mate/spouse.Adjust living standards to retirement income.Maintain maximum level of health.Care for self physically and emotionally.Maintain contact with children and relatives.Maintain interest in people outside the family.Find meaning in life after retirement.Adjust to the death of mate/spouse or other loved ones.treatment. Hence, family history and background areessential parts of the nursing assessment.Physical Health and Health PracticesPhysical health also can influence how a person responds topsychosocial stress or illness. The healthier a person is, thebetter he or she can cope with stress or illness. Poor nutritionalstatus, lack of sleep, or a chronic physical illness mayimpair a person’s ability to cope. Unlike genetic factors, howa person lives and takes care of himself or herself can altermany of these factors. For this reason, nurses must assessthe client’s physical health even when the client is seekinghelp for mental health problems.Personal health practices, such as exercise, can influencethe client’s response to illness. Exercising is one self-help interventionthat can diminish the negative effects of depressionand anxiety (Morgan & Jorm, 2008). Further, when individualsparticipated with others in exercise, the members of thegroup reported increased social support and an improved senseof well-being (Carless & Douglas, 2008). This suggests thatcontinued participation in exercise is a positive indicator ofimproved health, whereas cessation from participation in exercisemight indicate declining mental health.Response to DrugsBiologic differences can affect a client’s response to treatment,specifically to psychotropic drugs. Ethnic groupsdiffer in the metabolism and efficacy of psychoactive compounds.Some ethnic groups metabolize drugs more slowly(meaning the serum level of the drug remains higher),which increases the frequency and severity of side effects.Clients who metabolize drugs more slowly generally need

122UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIP• Social persuasion (persuading people to believe inthemselves)• Reducing stress, building physical strength, and learninghow to interpret physical sensations positively (e.g., viewingfatigue as a sign that one has accomplished somethingrather than as a lack of stamina).Cutler (2005) reports a relationship between self-efficacyand the client’s motivation for self-care and follow-up afterdischarge from treatment. Clients returning to the communitywith higher self-efficacy were more confident and hadpositive expectations about their personal success. Cutlersuggests that therapeutic interventions designed to promotethe client’s self-efficacy can have positive effects on interpersonalrelationships and coping on return to the community.Assess client’s physical healthlower doses of a drug to produce the desired effect ( Purnell& Paulanka, 2008). In general, nonwhites treated withWestern dosing protocols have higher serum levels perdose and suffer more side effects. Although many non-Western countries report successful treatment with lowerdosages of psychotropic drugs, Western dosage protocolscontinue to drive prescribing practices in the United States.When evaluating the efficacy of psychotropic medications,the nurse must be alert to side effects and serum drug levelsin clients from different ethnic backgrounds.Self-EfficacySelf-efficacy is a belief that personal abilities and effortsaffect the events in our lives. A person who believes thathis or her behavior makes a difference is more likely to takeaction. People with high self-efficacy set personal goals, areself-motivated, cope effectively with stress, and requestsupport from others when needed. People with low selfefficacyhave low aspirations, experience much self-doubt,and may be plagued by anxiety and depression. It has beensuggested that focusing treatment on developing a client’sskills to take control of his or her life (developing self-efficacy)so that he or she can make life changes could be verybeneficial. Four main ways to do so follow:• Experience of success or mastery in overcoming obstacles• Social modeling (observing successful people instillsthe idea that one can also succeed)HardinessHardiness is the ability to resist illness when under stress.First described by Kobasa (1979), hardiness has threecomponents:1. Commitment: active involvement in life activities2. Control: ability to make appropriate decisions in lifeactivities3. Challenge: ability to perceive change as beneficial ratherthan just stressful.Hardiness has been found to have a moderating or bufferingeffect on people experiencing stress. Kobasa (1979)found that male executives who had high stress but lowoccurrence of illness scored higher on the hardiness scalethan executives with high stress and high occurrence ofillness. Study findings suggested that stressful life eventscaused more harm to people with low hardiness than withhigh hardiness.Personal hardiness is often described as a pattern of attitudesand actions that helps the person turn stressful circumstancesinto opportunities for growth. Maddi (2005)found that persons with high hardiness perceived stressorsmore accurately and were able to problem-solve in the situationmore effectively. Hardiness has been identified as animportant resilience factor for families coping with themental illness of one of their members (Greeff, Vansteenween,& Mieke, 2006).Some believe that the concept of hardiness is vague andindistinct and may not help everyone. Some research onhardiness suggests that its effects are not the same for menand women. In addition, hardiness may be useful only tothose who value individualism, such as people from someWestern cultures. For people and cultures who value relationshipsover individual achievement, hardiness may notbe beneficial.Resilience and ResourcefulnessTwo closely related concepts, resilience and resourcefulness,help people to cope with stress and to minimize the

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 123effects of illness (Edward & Warelow, 2005). Resilience isdefined as having healthy responses to stressful circumstancesor risky situations. This concept helps to explainwhy one person reacts to a slightly stressful event withsevere anxiety, whereas another person does not experiencedistress even when confronting a major disruption.Keyes (2007) found that high resilience was associatedwith promoting and protecting one’s mental health, describedas flourishing. Family resilience refers to the successful copingof family members under stress (Black & Lobo, 2008).Factors that are present in resilient families include positiveoutlook, spirituality, family member accord, flexibility, familycommunication, and support networks. Resilient familiesalso spend time together, share recreational activities, andparticipate in family rituals and routines together.Resourcefulness involves using problem-solving abilitiesand believing that one can cope with adverse or novelsituations. People develop resourcefulness through interactionswith others, that is, through successfully copingwith life experiences. Examples of resourcefulness includeperforming health-seeking behaviors, learning self-care,monitoring one’s thoughts and feelings about stressful situations,and taking action to deal with stressful circumstances.Chang, Zauszniewski, Heinzer, Musil, and Tsai(2007) found building resourcefulness skills to be the keyin reducing depressive symptoms and enhancing adaptivefunctioning among middle school children whose femalecaregivers were depressed.SpiritualitySpirituality involves the essence of a person’s being andhis or her beliefs about the meaning of life and the purposefor living. It may include belief in God or a higher power,the practice of religion, cultural beliefs and practices, and arelationship with the environment. Although many clientswith mental disorders have disturbing religious delusions,for many in the general population, religion and spiritualityare a source of comfort and help in times of stress ortrauma. Studies have shown that spirituality is a genuinehelp to many adults with mental illness, serving as a primarycoping device and a source of meaning and coherencein their lives or helping to provide a social network(Anthony, 2008).Religious activities, such as church attendance andpraying, and associated social support have been shown tobe very important for many people and are linked withbetter health and a sense of well-being. These activitiesalso have been found to help people cope with poor health.Hope and faith have been identified as critical factors inpsychiatric and physical rehabilitation. Chaudry (2008)described patients who depended on their religious faithas significantly less depressed and anxious than those whoare less reliant on their faith. Religion and spirituality canalso be helpful to families who have a relative with mentalillness, providing support and solace to caregivers. BecauseSpiritualityspiritual or religious beliefs and practices help many clientsto cope with stress and illness, the nurse must be particularlysensitive to and accepting of such beliefs and practices.Incorporating those practices into the care of clientscan help them cope with illness and find meaning and purposein the situation. Doing so can also offer a strongsource of support (Huguelet, Mohr, Borras, Gillieron, &Brandt, 2006).INTERPERSONAL FACTORSSense of BelongingA sense of belonging is the feeling of connectedness with orinvolvement in a social system or environment of which aperson feels an integral part. Abraham Maslow described asense of belonging as a basic human psychosocial need thatinvolves feelings of both value and fit. Value refers to feelingneeded and accepted. Fit refers to feeling that one meshes orfits in with the system or environment. This means thatwhen a person belongs to a system or group, he or she feelsvalued and worthwhile within that support system. Examplesof support systems include family, friends, coworkers,clubs or social groups, and even health-care providers.A person’s sense of belonging is closely related to his orher social and psychological functioning. A sense of belongingwas found to promote health, whereas a lack of belongingimpaired health. An increased sense of belonging also

124UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPor talking on the phone. Thus, the primary components ofsatisfactory support are the person’s ability and willingnessto request support when needed and the ability andwillingness of the support system to respond.Two key components are necessary for a support systemto be effective: the client’s perception of the supportsystem and the responsiveness of the support system. Theclient must perceive that the social support system bolstershis or her confidence and self-esteem and providessuch stress-related interpersonal help as offering assistancein solving a problem. The client also must perceive thatthe actions of the support system are consistent with the client’sdesires and expectations—in other words, the supportprovided is what the client wants, not what the supporterbelieves would be good for the client. Also, the supportsystem must be able to provide direct help or materialaid (e.g., providing transportation or making a follow-upappointment). Some people have the capacity to seek helpwhen needed, whereas a lack of well-being may cause othersto withdraw from potential providers of support. Thenurse can help the client to find support people who willbe available and helpful and can teach the client to requestsupport when needed.Sense of belongingwas associated with decreased levels of anxiety. Personswith a sense of belonging are less alienated and isolated,have a sense of purpose, believe they are needed by others,and feel productive socially. Hence, the nurse should focuson interventions that help increase a client’s sense of belonging(Granerud & Severinsson, 2006).Social Networks and Social SupportSocial networks are groups of people whom one knowsand with whom one feels connected. Studies have foundthat having a social network can help reduce stress, diminishillness, and positively influence the ability to cope andto adapt (Chanokruthai, Williams, & Hagerty, 2005).Social support is emotional sustenance that comes fromfriends, family members, and even health-care providerswho help a person when a problem arises. It is differentfrom social contact, which does not always provide emotionalsupport. An example of social contact is the friendlytalk that goes on at parties.Persons who are supported emotionally and functionallyhave been found to be healthier than those who arenot supported (Vanderhorst & McLaren, 2005). Meaningfulsocial relationships with family or friends were found toimprove the health and well-being outcomes for olderadults. An essential element of improved outcomes is thatfamily or friends respond with support when it is requested.In other words, the person must be able to count on thesefriends or family to help or support him or her by visitingFamily SupportFamily as a source of social support can be a key factor inthe recovery of clients with psychiatric illnesses. Althoughfamily members are not always a positive resource in mentalhealth, they are most often an important part of recovery.Health-care professionals cannot totally replace familymembers. The nurse must encourage family members tocontinue to support the client even while he or she is inthe hospital and should identify family strengths, such aslove and caring, as a resource for the client (Reid, Lloyd, &de Groot, 2005).CULTURAL FACTORSAccording to the U.S. Census Bureau, 33% of U.S. residentscurrently are members of nonwhite cultures. By2050, the nonwhite population will more than triple. Thischanging composition of society has implications forhealth-care professionals, who are predominantly whiteand unfamiliar with different cultural beliefs and practices(Purnell & Paulanka, 2008). Culturally competent nursingcare means being sensitive to issues related to culture,race, gender, sexual orientation, social class, economic situation,and other factors.Nurses and other health-care providers must learnabout other cultures and become skilled at providing careto people with cultural backgrounds that are differentfrom their own. Finding out about another’s culturalbeliefs and practices and understanding their meaning isessential to providing holistic and meaningful care to theclient (Table 7.3).

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 125Table 7.3CULTURAL BELIEFS ABOUT HEALTH AND ILLNESSCulture Illness Beliefs: Causes of Mental Illness Concept of HealthAfrican American Lack of spiritual balance Feelings of well-being, able to fulfill role expectations,free of pain or excess stressAmerican Indians Loss of harmony with natural world, breaking Holistic and wellness orientedof taboos, ghostsArab Americans Wrath of God, sudden fears, pretending to beill to manipulate familyGift of God manifested by eating well, meetingsocial obligations, being in a good mood,having no stressors or painCambodians Khmer Rouge brutalities Health as equilibrium, individually maintainedbut influenced by family and communityChinese Lack of harmony of emotions, evil spirits Health maintained by balance of yin and yang,body, mind, and spiritCubans Heredity, extreme stress Fat and rosy-cheeked (traditional); fitness andstaying trim (acculturated)FilipinosDisruption of harmonious function of individualand spirit worldMaintaining balance; good health involvesgood food, strength, and no painHaitians Supernatural causes Maintenance of equilibrium by eating well,paying attention to personal hygiene, prayerand good spiritual habitsJapanese Americans Loss of mental self-control caused by evil spirits,punishment for behavior, not living good lifeBalance and harmony among oneself, society,and universeMexican Americans Humoral, God, spirituality, and interpersonalrelationships all can contributeFeeling well and being able to maintain rolefunctionPuerto Ricans Heredity, follows sufriamientos (suffering) No mental, spiritual, or physical discomforts;being clean and not being too thinRussians Stress and moving into new environment Regular bowel movements and no symptomsSouth Asians Spells cast by enemy, falling prey to evil spirit Balance of digestive fire, bodily humors, andwaste products; senses functioning normally;body, mind, and spirit in harmonyVietnameseDisruption of harmony in individual; ancestralspirit hauntingHarmony and balance within oneselfBeliefs About Causes of IllnessCulture has the most influence on a person’s health beliefsand practices. It has been shown to influence one’s conceptof disease and illness. Two prevalent types of beliefs aboutwhat causes illness in non-Western cultures are natural andunnatural or personal. Unnatural or personal beliefs attributethe cause of illness to the active, purposeful intervention ofan outside agent, spirit, or supernatural force or deity. Thenatural view is rooted in a belief that natural conditions orforces, such as cold, heat, wind, or dampness, are responsiblefor the illness (Giger & Davidhizar, 2007). A sick personwith these beliefs would not see the relationship between hisor her behavior or health practices and the illness. Thus, heor she would try to counteract the negative forces or spiritsusing traditional cultural remedies rather than taking medicationor changing his or her health practices.Factors in Cultural AssessmentGiger and Davidhizar (2007) recommended a modelfor assessing clients using six cultural phenomena:communication, physical distance or space, social organization,time orientation, environmental control,and biologic variations (Box 7.1). Each phenomenon isdiscussed in more detail below and in Table 7.4.Box 7.1CommunicationPhysical distance or spaceSocial organizationTime orientationEnvironmental controlBiologic variationsIMPORTANT FACTORS INCULTURAL ASSESSMENTSource: Giger, J. N., & Davidhizar, R. E. (2007). Transculturalnursing: Assessment and intervention (5th ed.). St. Louis: Mosby.

126UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 7.4CULTURAL ASSESSMENT FACTORS OF VARIOUS CULTURES AFFECTINGRESPONSE TO ILLNESSCulture Communication Space Social Organization Time OrientationAfrican AmericanAmericanIndians/NativeAmericansArab AmericanCambodianChineseCubanFilipinosNonverbal: affectionate,hugging,touching, eyecontactTone: may be loudand animatedNonverbal: respectcommunicated byavoiding eyecontactTone: quiet, reservedNonverbal: expressive,warm, otheroriented, shy, andmodestTone: flowery, loudvoice means messageis importantNonverbal: silencewelcomed ratherthan chatter; eyecontact acceptable,but “polite”women lower theireyesTone: quietNonverbal: eye contactand touchingamong family andfriends; eye contactavoided withauthority figuresTone: expressive andmay appear loudNonverbal: direct eyecontact, outgoing,close contact andtouching withfamily and friendsTone: loud in normalconversation, directcommands orrequests may seemforcefulNonverbal: shy andaffectionate, littledirect eye contactwith authorityfiguresTone: soft spoken,tone changes withemotionRespect privacy,respectful approach,handshakeappropriateLight-touchhandshakePrefer closeness inspace and withsame sexSmall personal spacewith one anotherKeep respectfuldistancePreferences forpersonal space varygreatlyHandshakes notusually practiced,personal spaceconstrictedFamily: nuclear,extended,matriarchal, mayinclude closefriendsFamily: vary; may bematrilineal orpatrilineal clanFamily: nuclear andextended, often insame householdFamily oriented,usually threegenerations in onehouseExtended familiescommon, wifeexpected to be partof husband’s familyFamily oriented,extended familiesin same householdFamily oriented,nuclear andextended, mayhave severalgenerations in onehouseholdFlexible, nonlinear; lifeissues may takepriority over keepingappointmentsFlexible, nonlinear;flow with naturalcycles rather thanscheduled, rigidappointmentsMore past and futurethan presentFlexible attitude,tardiness forappointmentsexpected,emphasis on past(rememberingancestors) but alsoon present becauseactions willdetermine futureBeing on time notvaluedSocial orientation totime varies, on timefor businessappointmentsBoth past and presentorientations; tardyfor social eventsbut on time forbusiness events likeappointments(continued)

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 127Table 7.4CULTURAL ASSESSMENT FACTORS OF VARIOUS CULTURES AFFECTINGRESPONSE TO ILLNESS (Continued )Culture Communication Space Social Organization Time OrientationHaitiansJapaneseAmericanMexicanAmericanPuerto RicansRussiansSouth AsiansVietnameseNonverbal: polite,shy, less eyecontact withauthority figures,smile and nod assign of respectTone: rich andexpressive,increased volumefor emphasisNonverbal: quietand polite, reservedand formal, littleeye contact withauthority figuresTone: soft, conflictavoidedNonverbal: avoiddirect eye contactwith authorityfiguresTone: respectful andpoliteNonverbal: eyecontact variesgreatly, desirewarm and smoothinterpersonalrelationshipsTone: melodic,increased volumefor emphasisNonverbal: directeye contact,nodding meansapprovalTone: sometimesloud even inpleasantconversationsNonverbal: direct eyecontact consideredrude; modesty,humility, shynessemphasizedTone: soft, may bossyounger peopleNonverbal: gentletouch may beaccepted inconversation, noeye contact withauthorityTone: soft spokenVery friendly andclose with family,respectfulhandshake withothersTouching uncommon,small bow, handshakewith youngergenerationTouch by strangersnot appreciated,handshake politeand welcomedSpace close for familyand friends, handshakewith othersSpace close for familyand friends andmore distant forothers untilfamiliarity isestablishedPersonal spaceconstricted;handshakeacceptable for menbut not commonamong womenPersonal space moredistant than inEuropeanAmericansClose, tightly knit,extended familyand nuclear family,matriarchal societyFamily oriented, selfsubordinate tofamily unit; familystructurehierarchical,interdependentMostly nuclearfamilies withextended familyand godparents;family comes firstAll activities,decisions, socialand culturalstandardsconceived aroundfamilyExtended family withstrong family bondsand great respectfor eldersExtended family common,daughterexpected to movein with husband’sfamilyHighly familyoriented, may benuclear orextendedNot committed totime or schedule,everyone andeverything can waitPromptness important,often early forappointmentsPresent oriented, timeviewed as relativeto situationMay be late forappointments orwant more timethan allottedOn time or earlyNot extremely timeconscious in socialsituations, but ontime forappointmentsFashionably late atsocial functions,but understand theimportance ofbeing on time forappointments

128UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPCommunicationVerbal communication can be difficult when the client andnurse do not speak the same language. The nurse should beaware that nonverbal communication has different meaningsin various cultures. For example, some cultures welcometouch and consider it supportive, whereas other cultures findtouch offensive. Some Asian women avoid shaking handswith one another or men. Some Native American tribesbelieve that vigorous handshaking is aggressive, whereas peoplefrom Spain and France consider a firm handshake a signof strength and good character.Although Western cultures view direct eye contact aspositive, Native American and Asian cultures may find itrude, and people from these backgrounds may avoid lookingstrangers in the eye when talking to them. People fromMiddle Eastern cultures can maintain very intense eyecontact, which may appear to be glaring to those from differentcultures. These differences are important to notebecause many people make inferences about a person’sbehavior based on the frequency or duration of eye contact.Chapter 6 provides a detailed discussion of communicationtechniques.Physical Distance or SpaceVarious cultures have different perspectives on what theyconsider a comfortable physical distance from anotherperson during communication. In the United States andmany other Western cultures, 2 to 3 feet is a comfortabledistance. Latin Americans and people from the MiddleEast tend to stand closer to one another than do peoplein Western cultures. People from Asian and Native Americancultures are usually more comfortable with distancesgreater than 2 or 3 feet. The nurse should be conscious ofthese cultural differences in space and should allowenough room for clients to be comfortable (Giger &Davidhizar, 2007).Social OrganizationSocial organization refers to family structure and organization,religious values and beliefs, ethnicity, and culture,all of which affect a person’s role and, therefore, his or herhealth and illness behavior. In Western cultures, peoplemay seek the advice of a friend or family member or maymake most decisions independently. Many Chinese, Mexican,Vietnamese, and Puerto Rican Americans stronglyvalue the role of family in making health-care decisions.People from these backgrounds may delay making decisionsuntil they can consult appropriate family members.Autonomy in health-care decisions is an unfamiliar andundesirable concept because the cultures consider the collectiveto be greater than the individual.Time OrientationTime orientation, or whether one views time as preciseor approximate, differs among cultures. Many Westerncountries focus on the urgency of time, valuing punctualityand precise schedules. Clients from other cultures may notperceive the importance of adhering to specific follow-upappointments or procedures or time-related treatment regimens.Health-care providers can become resentful andangry when these clients miss appointments or fail to followspecific treatment regimens such as taking medicationsat prescribed times. Nurses should not label such clients asnoncompliant when their behavior may be related to a differentcultural orientation to the meaning of time. Whenpossible, the nurse should be sensitive to the client’s timeorientation, as with follow-up appointments. When timingis essential, as with some medications, the nurse can explainthe importance of more precise timing.Environmental ControlEnvironmental control refers to a client’s ability to controlthe surroundings or direct factors in the environment(Giger & Davidhizar, 2007). People who believe they havecontrol of their health are more likely to seek care, tochange their behavior, and to follow treatment recommendations.Those who believe that illness is a result of natureor natural causes are less likely to seek traditional healthcare because they do not believe it can help them.Biologic VariationsBiologic variations exist among people from different culturalbackgrounds, and research is just beginning to helpus understand these variations. For example, we nowknow that differences related to ethnicity/cultural originscause variations in response to some psychotropic drugs(discussed earlier). Biologic variations based on physicalmakeup are said to arise from one’s race, whereas othercultural variations arise from ethnicity. For example, sicklecell anemia is found almost exclusively in African Americans,and Tay-Sachs disease is most prevalent in the Jewishcommunity.Socioeconomic Status and Social ClassSocioeconomic status refers to one’s income, education,and occupation. It strongly influences a person’s health,including whether or not the person has insurance andadequate access to health care or can afford prescribedtreatment. People who live in poverty are also at risk forthreats to health, such as inadequate housing, lead paint,gang-related violence, drug trafficking, or substandardschools.Social class has less influence in the United States,where barriers among the social classes are loose andmobility is common: people can gain access to betterschools, housing, health care, and lifestyle as they increasetheir income. In many other countries, however, socialclass is a powerful influence on social relationships andcan determine how people relate to one another, even in ahealth-care setting. For example, the caste system still

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 129exists in India, and people in the lowest caste may feelunworthy or undeserving of the same level of health care aspeople in higher castes. The nurse must determine whethersocial class is a factor in how clients relate to health-careproviders and the health-care system.Cultural Patterns and DifferencesKnowledge of expected cultural patterns provides a startingpoint for the nurse to begin to relate to people withethnic backgrounds different from his or her own (Andrews& Boyle, 2007). Being aware of the usual differences canhelp the nurse know what to ask or how to assess preferencesand health practices. Nevertheless, variations amongpeople from any culture are wide: Not everyone fits thegeneral pattern. Individual assessment of each person andfamily is necessary to provide culturally competent carethat meets the client’s needs. The following informationabout various ethnic groups should be a starting place forthe nurse in terms of learning about greetings, acceptablecommunication patterns and tone of voice, and beliefsregarding mental illness, healing, spirituality, and medicaltreatment.African AmericansSeveral terms are used to refer to African Americans, suchas Afro Americans, blacks, and persons of color. Therefore, itis best to ask what each client prefers.During illness, families are often a support system forthe sick person, although the client maintains his or herindependence, such as making his or her own health-caredecisions. Families often feel comfortable demonstratingpublic affection such as hugging and touching one another.Conversation among family and friends may be animatedand loud. Greeting a stranger usually includes a handshake,and direct eye contact indicates interest and respect.Silence may indicate a lack of trust of the caregiver or thesituation (Waters & Locks, 2005).The church is an important and valued support systemfor many African Americans, who may receive frequenthospital visits from ministers or congregation members.Prayer is an important part of healing. Some in the AfricanAmerican community may view the cause of mental illnessto be a spiritual imbalance or a punishment for sin. AfricanAmerican clients may use folk remedies in conjunctionwith Western medicine (Waters & Locks, 2005).American Indians or Native AmericansOlder adults usually prefer the term American Indian,whereas younger adults prefer Native American. ManyNative Americans refer to themselves by a tribal name,such as Winnebago or Navajo. A light-touch handshake isa respectful greeting with minimal direct eye contact.Communication is slow and may be punctuated by manylong pauses. It is important not to rush the speaker orinterrupt with questions. This culture is accustomed tocommunicating by telling stories, so communicating canbe a long, detailed process. Family members are reluctantto provide information about the client if he or she can doso, believing it violates the client’s privacy to talk abouthim or her. Orientation to time is flexible and does notcoincide with rigidly scheduled appointments.Mental illness is a culturally specific concept, andbeliefs about causation may include ghosts, breakingtaboos, or loss of harmony with the environment. Clientsare often quiet and stoic, making few, if any, requests.Experiences that involve seeing visions or hearing voicesmay have spiritual meaning; thus, these clients may notview such phenomena as illness. Native Americans withtraditional religious beliefs may be reluctant to discusstheir beliefs and practices with strangers. If the clientwears a medicine bag, the nurse should not remove it ifpossible. Others should not casually discuss or touch themedicine bag or other ritual healing objects. Other NativeAmericans belong to Christian denominations, but theymay incorporate healing practices or use a spiritual healeralong with Western medicine (Palacios, Butterfly, &Strickland, 2005).Arab AmericansThe preferred term of address may be by region, such asArab Americans or Middle Eastern Americans, or by countryof origin, such as Egyptian or Palestinian. Greetingsinclude a smile, direct eye contact, and a social commentabout family or the client. Using a loud voice indicates theimportance of the topic, as does repeating the message. Toappear respectful, those of Middle Eastern backgroundcommonly express agreement in front of a stranger, butit does not necessarily reflect their true feelings. Familiesmake collective decisions with the father, eldest son,uncle, or husband as the family spokesperson. Mostappointments viewed as official will be kept, althoughhuman concerns are more valued than is adhering to aschedule (Meleis, 2005).This culture believes mental illness results from suddenfears, attempts to manipulate family, wrath of God, orGod’s will, all of which focus on the individual. Loss ofcountry, family, or friends also may cause mental illness.Such clients may seek mental health care only as a lastresort after they have exhausted all family and communityresources. When sick, these clients expect family orhealth-care professionals to take care of them. The clientreserves his or her energy for healing and thus is likely topractice complete rest and abdication from all responsibilitiesduring illness. These clients view mental illnessmore negatively than physical illness and believe mentalillness to be something the person can control. Althoughearly immigrants were Christians, more recent immigrantsare Muslims. Prayer is very important to Muslims: strictMuslims pray five times a day, wash before every prayer,and pray in silence. Western medicine is the primarytreatment sought, but some may use home remedies and

130UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPamulets (charms or objects used for their protectivepowers).CambodiansThe preferred term for people from Cambodia is Khmer(pronounced Kuh-meer’) or Sino-Khmer (if Chinese Cambodian).Those who have assimilated into Western cultureuse a handshake for greeting, whereas others may slightlybow, bringing the palms together with the fingers pointedupward, and make no contact with the person they aregreeting. Many Asians speak softly, so it is important tolisten carefully rather than asking them to speak louder.Cambodian clients highly value politeness. Eye contact isacceptable, but women may lower their eyes to be polite.Silences are common and appropriate; nurses should avoidmeaningless chatter. These clients may consider it impoliteto disagree, so they say yes when not really agreeing orintending to comply. It is inappropriate to touch someone’shead without permission because some believe the soul isin the head. Cambodian clients usually include familymembers in making decisions. Orientation to time can beflexible (Kulig & Prak, 2005).Most Khmer emigrated to the United States after 1970and believe that mental illness is the result of the KhmerRouge war and associated brutalities. When ill, theyassume a passive role, expecting others to care for them.Many may use Western medicine and traditional healingpractices simultaneously. Buddhism is the primary religion,although some have converted to Christianity. Anaccha (holy person) may perform many elaborate ceremoniesin the person’s home but will not do so in the hospital.Healers may visit the client in the hospital but are unlikelyto disclose they are healers, much less what their practicesare. Some Khmer still have a naturalistic view of illnessand may be reluctant to have blood drawn, believing theywill lose body heat needed for harmony and balance (Kulig& Prak, 2005).ChineseThe Chinese are often shy in unfamiliar environments, sosocializing or friendly greetings are helpful. They mayavoid direct eye contact with authority figures to showrespect; keeping a respectful distance is recommended.Asking questions can be a sign of disrespect; silence is asign of respect. Chinese is an expressive language, soloudness is not necessarily a sign of agitation or anger.Traditional Chinese societies tend not to highly value timeurgency. Extended families are common, with the eldestmale member of the household making decisions andserving as the spokesperson for the family (Chin, 2005).Mental illness is thought to result from a lack of harmonyof emotions or from evil spirits. Health practicesmay vary according to how long immigrants have lived inthe United States. Immigrants from 40 to 60 years ago arestrong believers in Chinese folk medicine, whereas immigrantsfrom the last 20 years combine folk and Westernmedicine. First- and second-generation Chinese Americansare mostly oriented to Western medicine. Many Chineseuse herbalists and acupuncture, however, either before orin conjunction with Western medicine. Rarely, theseclients will seek a spiritual healer for psychiatric problemsto rid themselves of evil spirits. Many Chinese areBuddhists, but Catholic and Protestant religions are alsocommon.CubansCubans, or Cuban Americans if born in the United States,are typically outgoing and may speak loudly during normalconversation. Extended family is very important, and oftenmore than one generation resides in a household. Theseclients expect direct eye contact during conversation andmay view looking away as a lack of respect or honesty.Silence indicates awkwardness or uncertainty. Althoughorientation to social time may vary greatly, these clientsview appointments as business and are punctual (Varela,2005).Cuban clients view stress as a cause of both physicaland mental illness, and some believe mental illness ishereditary. Mental illness is a stigma for the family; thus,Cuban clients may hide or not publicly acknowledge suchproblems. The person in the sick role often is submissive,helpless, and dependent on others. Although Cuban clientsmay use herbal medicine to treat minor illness athome, they usually seek Western medicine for more seriousillness. Most Cubans are Catholic or belong to otherChristian denominations, so prayer and worship may bevery important.FilipinosSmiles rather than handshakes are a common form ofgreeting. Facial expressions are animated, and clients mayuse them rather than words to convey emotion. Filipinoclients consider direct eye contact impolite, so there islittle direct eye contact with authority figures such asnurses and physicians. Typically, Filipinos are soft spokenand avoid expressing disagreement (Rodriguez, de Guzman,& Cantos, 2005); however, their tone of voice may getlouder to emphasize what they are saying or as a sign ofanxiety or fear. They are likely to view medical appointmentsas business and thus be punctual.They believe the causes of mental illness to be both religiousand mystical. Filipinos are likely to view mental illnessas the result of a disruption of the harmonious functionof the whole person and the spiritual world. Thesecauses can include contact with a stronger life force,ghosts, or souls of the dead; disharmony among wind,vapors, diet, and shifted body organs; or physical andemotional strain, sexual frustration, and unrequited love.Most Filipinos are Catholic; when very ill, they may wantto see a priest and a physician. Prayer is important to theclient and family, and they often want to receive the religioussacraments while sick. Filipinos often seek both

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 131Western medical treatment and the help of healers toremove evil spirits. The ill client assumes a passive role,and the eldest male in the household makes decisions afterconferring with family members (Rodriguez, de Guzman,& Cantos, 2005).HaitiansHaiti has two official languages, French and Creole, and astrong oral culture that uses stories as educational tools. InHaiti, 80% of the people neither read nor write, but literacymay vary among Haitians in the United States. Videos,oral teaching, and demonstrations are effective ways tocommunicate information. Haitians are polite but shy,especially with authority figures, and may avoid direct eyecontact. Handshakes are the formal greeting of choice.Haitians may smile and nod as a sign of respect even whenthey do not understand what is being said. Tone of voiceand hand gestures may increase to emphasize what is beingsaid. There is little commitment to time or schedule inHaitian culture, but clients may be on time for medicalappointments if the provider emphasizes the need forpunctuality (Colin, 2005).Mental illness is not well accepted in Haitian culture.These clients usually believe mental illness to have supernaturalcauses. The sick person assumes a passive role,and family members provide care for the individual. Homeand folk remedies are often the first treatment used athome, and clients seek medical care when it is apparentthe person needs medical attention. Haitians are predominantlyCatholic and have a very strong belief in God’spower and ability to heal (Colin, 2005).Japanese AmericansJapanese Americans identify themselves by the generationin which they were born. Issei, the first generation ofJapanese Americans in the United States, have a strongsense of Japanese identity. Nisei, second-generationJapanese Americans born and educated in the UnitedStates, appear to be Westernized but have strong roots inJapanese culture. Sansei (third generation) and Yonsei(fourth generation) are assimilated into Western cultureand are less connected to Japanese culture.Greetings tend to be formal, such as a smile or smallbow for older generations and a handshake for youngergenerations. There is little touching, and eye contact isminimal, especially with authority figures. These clientscontrol facial expressions and avoid conflict or disagreement.Elders may nod frequently, but this does not necessarilyindicate understanding or agreement. Self-disclosureis unlikely unless trust has been established, and then onlyif the information is directly requested. Nurses shouldphrase questions to elicit more than just a yes or no answer.Promptness is important, so clients are often early forappointments (Shiba, Leong, & Oka, 2005).Mental illness brings shame and social stigma to thefamily, so clients are reluctant to seek help. Evil spirits arethought to cause loss of mental self-control as a punishmentfor bad behavior or failure to live a good life. Theseclients expect themselves and others to use will power toregain their lost self-control and often perceive those withmental illness as not trying hard enough. Western psychologicaltherapies based on self-disclosure, sharing feelings,and discussing one’s family experiences are very difficultfor many Japanese Americans. The nurse might incorrectlyview these clients as unwilling or uncooperative (Shiba,Leong, & Oka, 2005).Buddhism, Shinto, and Christianity are the most commonreligions among Japanese Americans, and religiouspractices vary with the religion. Prayer and offerings arecommon in Buddhist and Shinto religions and are usuallyperformed in conjunction with Western medicine.Mexican AmericansDiversity is wide among Mexican Americans in terms ofhealth practices and beliefs, depending on the client’seducation, socioeconomic status, generation, time spentin the United States, and affinity to traditional culture. Itis best for the nurse to ask the client how he or she wouldlike to be identified (e.g., Mexican American, Latino, orHispanic). Most Mexicans consider a handshake to be apolite greeting but do not appreciate other touch bystrangers, although touching and embracing warmly arecommon among family and friends. To convey respect,Mexican clients may avoid direct eye contact with authorityfigures. They usually prefer polite social interaction tohelp establish rapport before answering health-relatedquestions. Generally, one or two questions will produce awealth of information, so listening is important. Silence isoften a sign of disagreement, which these clients may usein place of words. Orientation to time is flexible; the clientmay be 15 or 20 minutes late for an appointment but willnot consider that as being late (Guarnero, 2005).There is no clear separation of mental and physical illness.Many Mexican Americans have a naturalistic or personalisticview of illness and believe disease is based onthe imbalance of the person and the environment, includingemotional, spiritual, social, and physical factors(Guarnero, 2005). Mexican Americans may seek medicalcare for severe symptoms while still using folk medicine todeal with spiritual or psychic influences. Between 80% and90% of Mexican Americans are Catholic and observe therites and sacraments of that religion.Puerto RicansPreferences for personal space vary among Puerto Ricans;so it is important to assess each individual. Typically,older and more traditional people prefer greater distanceand less direct eye contact, whereas younger people preferdirect eye contact and less distance with others.Puerto Ricans desire warm and smooth interpersonalrelationships and may express gratitude to health-careproviders with homemade traditional cooking; these

132UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPclients might interpret the refusal of such an offer as aninsult. There may be some difficulty being on time forappointments or limiting the length of an appointment( Juarbe, 2005).Physical illness is seen as hereditary, punishment for sin,or lack of attention to personal health. Mental illness isbelieved to be hereditary or a result of sufriamientos (suffering).Mental illness carries great stigma, and past or present historyof mental illness may not be acknowledged. Religious andspiritual practices are very important, and these clients mayuse spiritual healers or healing practices (Juarbe, 2005).RussiansA formal greeting or a handshake with direct eye contact isacceptable. These clients reserve touching or embracingand kissing on the cheeks for close friends and family.Tone of voice can be loud even in pleasant conversations.Most clients are on time or early for appointments (delPuerto & Sigal, 2005).Russians believe the cause of mental illness to be stressand moving into a new environment. Some Russian Christiansbelieve illness is God’s will or a test of faith. Sickpeople often put themselves on bed rest. Many Russiansdo not like to take any medications and will try home remediesfirst. Some older Russians believe that excessive druguse can be harmful and that many medicines can be moredamaging than natural remedies. Primary religious affiliationsare Eastern Orthodox, with a minority being Jewishor Protestant (del Puerto & Sigal, 2005).South AsiansSouth Asians living in the United States include peoplefrom India, Pakistan, Bangladesh, Sri Lanka, Nepal, Fiji,and East Africa. Preferred terms of identification may berelated to geography, such as South Asians, East Indians,Asian Indians, or Indo-Americans, or by religious affiliation,such as Sikhs, Hindus, or Muslims. Greetings areexpressed orally as well as in gestures. Hindus and Sikhspress their palms together while saying namaste (Hindus)or sasariyakal (Sikhs). Muslims take the palm of the righthand to their forehead and bow slightly while sayingAsSalamOAlaikuum. Shaking hands is common amongmen but not among women. Touching is not commonamong South Asians; rather, they express feelings througheyes and facial expressions. They may consider direct eyecontact, especially with elders, rude or disrespectful.Silence usually indicates acceptance, approval, or tolerance.Most South Asians have a soft tone of voice andconsider loudness to be disrespectful. Although not timeconscious about social activities, most South Asians arepunctual for scheduled appointments for health care (Lee,Lei, & Sue, 2001).South Asians believe mental illness to result from spellscast by an enemy or possession by evil spirits. Those whobelieve in Ayurvedic philosophy may believe a person issusceptible to mental problems related to physical imbalancesin the body. Sick people usually assume a passiverole and want to rest and be relieved of daily responsibilities.Hindus worship many gods and goddesses and believein a social caste system. Hindus believe that reciting charmsand performing rituals eliminate diseases, enemies, sins,and demons. Many believe that yoga eliminates certainmental illnesses. Muslims believe in one God and pray fivetimes daily after washing their hands. They believe thatreciting verses from the holy Koran eliminates diseasesand eases suffering. Sikhs also believe in one God and theequality of all people. Spiritual healing practices and prayerare common, but South Asians living in the United Statesreadily seek health care from Western physicians as well(Lee et al., 2001).VietnameseVietnamese greet with a smile and bow. A health-care providershould not shake a woman’s hand unless she offersher hand first. Touch in communication is more limitedamong older, more traditional people. Vietnamese mayconsider the head sacred and the feet profane, so the orderof touching is important. As a sign of respect, many ofthese clients avoid direct eye contact with those in authorityand with elders. Personal space is more distant than itis for European Americans. Typically, the Vietnamese aresoft spoken and consider raising the voice and pointing tobe disrespectful. They also may consider open expressionof emotions or conflict to be in bad taste. Punctuality forappointments is usual (Nowak, 2005).Vietnamese believe mental illness to be the result ofindividual disharmony or an ancestral spirit returning tohaunt the person because of past bad behavior. When sick,clients assume a passive role and expect to have everythingtheir way.The two primary religions are Catholicism and Buddhism.Catholics recite the rosary and say prayers and maywish to see a priest daily. Buddhists pray silently to themselves.Vietnamese people believe in both Western medicineand folk medicine. Some believe that traditional healerscan exorcise evil spirits. Other health practices includecoin rubbing, pinching the skin, acupuncture, and herbalmedicine (Nowak, 2005).Nurse’s Role in Working with Clientsof Various CulturesTo provide culturally competent care, the nurse mustfind out as much as possible about a client’s cultural values,beliefs, and health practices. Often, the client is thebest source for that information, so the nurse must askthe client what is important to him or her—for instance,“How would you like to be cared for?” or “What doyou expect (or want) me to do for you?” (Andrews &Boyle, 2007).

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 133SELF-AWARENESS ISSUESThe nurse must be aware of the factors thatinfluence a client’s response to illness, includingthe individual, interpersonal, and culturalfactors discussed earlier. Assessment of thesefactors can help guide the planning and implementationof nursing care. Biologic and hereditary factors cannot bechanged. Others, such as interpersonal factors, canbe changed but only with difficulty. For instance, helping aclient to develop a social support system requires more thansimply giving him or her a list of community contacts. Theclient needs to feel that these resources are valuable to himor her; must perceive them as helpful, responsive, and supportive;and must be willing to use them.Nurses with limited experience in working with variousethnic groups may feel anxious when encounteringsomeone from a different cultural background and worryabout saying “the wrong thing” or doing something offensiveor disrespectful to the client or family. Nurses mayhave stereotypical concepts about some ethnic groups andbe unaware of them until they encounter a client from thatgroup. It is a constant challenge to remain aware of one’sfeelings and to handle them effectively.Cultural awarenessAt the initial meeting, the nurse may rely on what he orshe knows about a client’s particular cultural group such aspreferences for greeting, eye contact, and physical distance.Based on the client’s behavior, the nurse can alter thatapproach as needed. For example, if a client from a culturethat does not usually shake hands offers the nurse his or herhand, the nurse should return the handshake. Variationamong members of the same cultural group is wide, and thenurse must remain alert for these individual differences.A client’s health practices and religious beliefs are otherimportant areas to assess. The nurse can ask, “Do you followany dietary preferences or restrictions?” and “Howcan I assist you in practicing your religious or spiritualbeliefs?” The nurse also can gain an understanding of theclient’s health and illness beliefs by asking, “How do youthink this health problem came about?” and “What kindsof remedies have you tried at home?”An open and objective approach to the client is essential.Clients will be more likely to share personal and culturalinformation if the nurse is genuinely interested inknowing and does not appear skeptical or judgmental.The nurse should ask these same questions even to clientsfrom his or her own cultural background. Again, peoplein a cultural group vary widely, so the nurse should notassume that he or she knows what a client believes orpractices just because the nurse shares the same culture.Points to Consider When Workingwith Individual Responses to Illness• Approach the client with a genuine caring attitude.• Ask the client at the beginning of the interview how heor she prefers to be addressed and ways the nurse canpromote spiritual, religious, and health practices.• Recognize any negative feelings or stereotypes and discussthem with a colleague to dispel myths andmisconceptions.• Remember that a wide variety of factors influence theclient’s complex response to illness.Critical Thinking Questions1. What is the cultural and ethnic background of yourfamily? How does that influence your beliefs aboutmental illness?2. How would you describe yourself in terms of the individualcharacteristics that affect one’s response toillness, such as growth and development, biologicfactors, self-efficacy, hardiness, resilience and resourcefulness,and spirituality?3. What experiences do you have with people whoseculture is different than yours? Do you react or behavedifferently with clients whose culture is differentthan yours?

134UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPINTERNET RESOURCESRESOURCE• Culture Med (Extensive bibliography of transculturalnursing articles)• National MultiCultural Institute• Cultural diversity in nursing• Report of the Surgeon General: Overview of Diversityand Mental Health ServicesINTERNET ADDRESShttps://culturedmed.sunyit.edu/index.php/bibliographiesby-cultural-aspect/transcultural-nursinghttp://www.nmci.orghttp://www.culturediversity.orghttp://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec8.htmlKEY POINTS• Each client is unique with different biologic,psychological, and social factors thatinfluence his or her response to illness.• Individual factors that influence a client’sresponse to illness include age, growth, and development;biologic and genetic factors; hardiness, resilience,and resourcefulness; and self-efficacy and spirituality.• Biologic makeup includes the person’s heredity andphysical health.• Younger clients may have difficulty expressing theirthoughts and feelings, so they often have poorer outcomeswhen experiencing stress or illness at an early age.• People who have difficulty negotiating the tasks of psychosocialdevelopment have less effective skills to copewith illness.• There are cultural/ethnic differences in how people respondto certain psychotropic drugs; these differencescan affect dosage and side effects. Nurses must be awareof these cultural differences when treating clients. Clientsfrom non-Western countries generally require lowerdoses of psychotropic drugs to produce desired effects.• Self-efficacy is a belief that a person’s abilities and effortscan influence the events in her or his life. A person’ssense of self-efficacy is an important factor in copingwith stress and illness.• Hardiness is a person’s ability to resist illness whenunder stress.• Resilience is a person’s ability to respond in a healthymanner to stressful circumstances or risky situations.• Resourcefulness is demonstrated in one’s ability to managedaily activities and is a personal characteristic acquiredthrough interactions with others.• Spirituality involves the inner core of a person’s beingand his or her beliefs about the meaning of life andthe purpose for living. It may include belief in God or ahigher power, the practice of religion, cultural beliefsand practices, and a relationship with the environment.• Interpersonal factors that influence the client’s response toillness include a sense of belonging, or personal involvementin a system or an environment, and social networks, whichprovide social support or emotional sustenance.• The increasing social and cultural diversity in the UnitedStates and Canada makes it essential for nurses to beknowledgeable about the health and cultural practicesof various ethnic or racial groups. To provide competentnursing care, nurses must be sensitive to and knowledgeableabout factors that influence the care of clients,including issues related to culture, race, gender, sexualorientation, and social and economic situations.• Culture has the most influence on a person’s health beliefsand behaviors.• A model for assessing clients from various ethnic backgroundsincludes six cultural phenomena: communicationtechniques and style, physical distance and space,social organization, time orientation, environmental control,and biologic variations.• Socioeconomic status has a strong influence on a person’shealth. It may determine whether or not the personhas insurance, adequate access to health care, or theability to afford prescribed treatment.• Knowledge of various cultural patterns and differenceshelps the nurse begin to relate to persons of differentethnic backgrounds.• Nurses who are unsure of a person’s social or culturalpreferences need to ask the client directly during theinitial encounter about preferred terms of address andways the nurse can help support the client’s spiritual,religious, or health practices.REFERENCESAndrews, M. M., & Boyle, J. S. (2007). Transcultural concepts in nursingcare (5th ed.). Philadelphia: Lippincott Williams & Wilkins.Anthony, K. H. (2008). Helping partnerships that facilitate recovery fromsevere mental illness. Journal of Psychosocial Nursing and MentalHealth Services, 46(7), 24–28, 29–33.Black, K., & Lobo, M. (2008). A conceptual review of family resiliencefactors. Journal of Family Nursing, 14(1), 33–55.Buchanan, B. W., & Carpenter, W. T. (2005). Concept of schizophrenia.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 1329–1345). Philadelphia: LippincottWilliams & Wilkins.

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS 135Carless, D., & Douglas, K. (2008). Social support for and through exerciseand sport in a sample of men with serious mental illness. Issuesin Mental Health Nursing, 29(11), 1179–1199.Chang, H. J., Zauszniewski, J. A., Heinzer, M. M., Musil, C. M., & Tsai,W. C. (2007). Adaptive functioning and depressive symptoms inschool-aged children. Journal of Advanced Nursing, 60(5), 502–512.Chanokruthai, C., Williams, R. A., & Hagerty, B. M. (2005). The role ofsense of belonging and social support on stress and depression inindividuals with depression. Archives of Psychiatric Nursing, 19(1),18–29.Chaudry, H. R. (2008). Psychiatric care in Asia: Spirituality and religiousconnotations. International Review of Psychiatry, 20(5), 477–483.Chin, P. (2005). Chinese. In J. G. Lipson & S. L. Dibble (Eds.), Cultureand clinical care (pp. 98–108). San Francisco: UCSF Nursing Press.Colin, J. M. (2005). Haitians. In J. G. Lipson & S. L. Dibble (Eds.), Cultureand clinical care (pp. 221–235). San Francisco: UCSF Nursing Press.Cutler, C. G. (2005). Self-efficacy and social adjustment of patients withmood disorder. Journal of the American Psychiatric Nurses Association,11(5), 283–289.del Puerto, L. E., & Sigal, E. (2005) Russians and others from the formerSoviet Union. In J. G. Lipson & S. L. Dibble (Eds.), Culture andclinical care (pp. 415–430). San Francisco: UCSF Nursing Press.Edward, K., & Warelow, P. (2005). Resilience: When coping is emotionallyintelligent. Journal of the American Psychiatric Nurses Association,11(2), 101–102.Giger, J. N., & Davidhizar, R. E. (2007). Transcultural nursing: Assessmentand intervention (5th ed.). St. Louis: Mosby.Granerud, A., & Severinsson, E. (2006). The struggle for social integrationin the community: The experiences of people with mental health problems.Journal of Psychiatric and Mental Health Nursing, 13(3), 288–293.Greeff, A. P., Vansteenween, A., & Mieke, I. (2006). Resiliency in familieswith a member with a psychological disorder. American Journal ofFamily Therapy, 34(4), 285–300.Guarnero, P. A. (2005). Mexicans. In J. G. Lipson & S. L. Dibble (Eds.),Culture and clinical care (pp. 330–342). San Francisco: UCSF NursingPress.Huguelet, P., Mohr, S., Borras, L., Gillieron, C., & Brandt, P. (2006).Spirituality and religious practices among outpatients with schizophreniaand their clinicians. Psychiatric Services, 57(3), 366–372.Juarbe, T. C. (2005). Puerto Ricans. In J. G. Lipson & S. L. Dibble (Eds.),Culture and clinical care (pp. 389–404). San Francisco: UCSF NursingPress.Keyes, C. L. (2007). Promoting and protecting mental health as flourishing:A complementary strategy for improving national mental health.The American Psychologist, 62(2), 95–108.Kobasa, S. C. (1979). Stressful life events, personality, and health: Aninquiry into hardiness. Journal of Personality and Social Psychology,37(1), 1–11.Kulig, J. C., & Prak, S. (2005). Cambodians (Khmer). In J. G. Lipson &S. L. Dibble (Eds.), Culture and clinical care (pp. 73–84). SanFrancisco: UCSF Nursing Press.Lee, J., Lei, A., & Sue, S. (2001). The current state of mental healthresearch on Asian Americans. Journal of Human Behavior in the SocialEnvironment, 3(3/4), 159–178.Maddi, S. R. (2005). On hardiness and other pathways to resilience.American Psychologist, 60(3), 261–262.Meleis, A. I. (2005). Arabs. In J. G. Lipson & S. L. Dibble (Eds.),Culture and clinical care (pp. 42–57). San Francisco: UCSF NursingPress.Morgan, A. J., & Jorm, A. F. (2008). Self-help interventions for depressivedisorders and depressive symptoms: A systematic review, Annalsof General Psychiatry, 7, 13.Nowak, T. T. (2005) Vietnamese. In J. G. Lipson & S. L. Dibble (Eds.),Culture and clinical care (pp. 446–460). San Francisco: UCSF NursingPress.Palacios, J., Butterfly, R., & Strickland, C. J. (2005). American Indians/Alaskan Natives. In J. G. Lipson & S. L. Dibble (Eds.), Culture andclinical care (pp. 27–41). San Francisco: UCSF Nursing Press.Purnell, L. D., & Paulanka, B. J. (Eds.). (2008). Transcultural healthcare:A culturally competent approach (3rd ed.). Philadelphia: F. A. Davis.Reid, J., Lloyd, C., & de Groot, L. (2005). The psychoeducationneeds of parents who have an adult son of daughter with a mentalillness. Australian e-Journal for the Advancement of Mental Health,4(2), 1–13.Rodriguez, D. M., de Guzman, C. P., & Cantos, A. (2005). Filipinos.In J. G. Lipson & S. L. Dibble (Eds.), Culture and clinical care(pp. 177–191). San Francisco: UCSF Nursing Press.Shiba, G., Leong, Y. M., & Oka, R. (2005). Japanese. In J. G. Lipson &S. L. Dibble (Eds.), Culture and clinical care (pp. 304–316). SanFrancisco: UCSF Nursing Press.Vanderhorst, R. K., & McLaren, S. (2005). Social relationships as predictorsof depression and suicidal ideation in older adults. Aging andMental Health, 9(6), 517–525.Varela, L. (2005). Cubans. In J. G. Lipson & S. L. Dibble (Eds.), Cultureand clinical care (pp. 122–131). San Francisco: UCSF Nursing Press.Waters, C. M., & Locks, S. (2005). African Americans. In J. G. Lipson &S. L. Dibble (Eds.), Culture and clinical care (pp. 14–26). SanFrancisco: UCSF Nursing Press.ADDITIONAL READINGSBirks, M. J., Chapman, Y., & Francis, K. (2007). Breaching the wall:Interviewing people from other cultures. Journal of TransculturalNursing, 18(2), 150–156.Ida, D. J. (2007). Cultural competency and recovery within diversepopulations. Psychiatric Rehabilitation Journal, 31(1), 49–53.Lloyd, R. (2007). Modeling community-based, self-help mental healthrehabilitation reform. Australasian Psychiatry: Bulleting of RoyalAustralian and New Zealand College of Psychiatrists, 15(Suppl. 1),S99–S103.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following is important for nurses to rememberwhen administering psychotropic drugs tononwhites?a. Lower doses may be used to produce desiredeffects.b. Fewer side effects occur with nonwhite clients.c. Response to the drug is similar to that in whites.d. No generalization can be made.2. Which of the following states the naturalistic view ofwhat causes illness?a. Illness is a natural part of life and thereforeunavoidable.b. Illness is caused by cold, heat, wind, and dampness.c. Only natural agents are effective in treating illness.d. Outside agents, such as evil spirits, upset the body’snatural balance.3. Which of the following is most influential in determininghealth beliefs and practices?a. Cultural factorsb. Individual factorsc. Interpersonal factorsd. All the above are equally influential.4. Which of the following assessments indicates positivegrowth and development for a 30-year-old adult?a. Is dissatisfied with body imageb. Enjoys social activities with three or four close friendsc. Frequently changes jobs to “find the right one”d. Plans to move from parental home in near future5. Which of the following statements would cause concernfor achievement of developmental tasks of a 55-year old woman?a. “I feel like I’m taking care of my parents now.”b. “I really enjoy just sitting around visiting withfriends.”c. “My children need me now just as much as whenthey were small.”d. “When I retire, I want a smaller house to take care of.”6. Which of the following client statements would indicateself-efficacy?a. “I like to get several opinions before deciding acourse of action.”b. “I know if I can learn to relax, I will feel better.”c. “I’m never sure if I’m making the right decision.”d. “No matter how hard I try to relax, something alwayscomes up.”MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. A handshake is considered an acceptable greeting foranyone in which of the following cultures?a. Filipinob. Haitianc. Mexican Americand. Native Americane. South Asianf. White European American2. Direct eye contact may be considered disrespectful inwhich of the following cultures?a. African Americanb. Arab Americansc. Chinesed. Russiane. South Asianf. Vietnamese136

CHAPTER 7 • CLIENT’S RESPONSE TO ILLNESS137SHORT-ANSWER QUESTIONS1. Briefly explain culturally competent nursing care.2. What is the result of achieving or failing to achieve a psychosocial developmental task,according to Erik Erikson?

8AssessmentLearning ObjectivesAfter reading this chapter, you should be able to1. Identify the categories used to assess the client’s mental health status.Key Terms• abstract thinking• affect• automatisms• blunted affect• broad affect• circumstantial thinking• concrete thinking• delusion• duty to warn• flat affect• flight of ideas• hallucinations• ideas of reference• inappropriate affect• insight• judgment• labile• loose associations• mood• neologisms• psychomotor retardation• restricted affect2. Formulate questions to obtain information in each category.3. Describe the client’s functioning in terms of self-concept, roles, andrelationships.4. Recognize key physiologic functions that frequently are impaired in peoplewith mental disorders.5. Obtain and organize psychosocial assessment data to use as a basis forplanning nursing care.6. Examine one’s own feelings and any discomfort discussing suicide, homicide,or self-harm behaviors with a client.• self-concept• tangential thinking• thought blocking• thought broadcasting• thought content• thought insertion• thought process• thought withdrawal• waxy flexibility• word salad138Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!

CHAPTER 8 • ASSESSMENT 139Client’s Health StatusThe client’s health status also can affect the psychosocialassessment. If the client is anxious, tired, or in pain, thenurse may have difficulty eliciting the client’s full participationin the assessment. The information that the nurseobtains may reflect the client’s pain or anxiety rather thanan accurate assessment of the client’s situation. The nurseneeds to recognize these situations and deal with thembefore continuing the full assessment. The client may needto rest, receive medications to alleviate pain, or be calmedbefore the assessment can continue.Client’s Previous Experiences/Misconceptions About Health CareBuilding a picture of your client through psychosocialassessmentThe client’s perception of his or her circumstances canelicit emotions that interfere with obtaining an accuratepsychosocial assessment. If the client is reluctant to seektreatment or has had previous unsatisfactory experienceswith the health-care system, he or she may have difficultyanswering questions directly. The client may minimize ormaximize symptoms or problems or may refuse to provideinformation in some areas. The nurse must address the client’sfeelings and perceptions to establish a trusting workingrelationship before proceeding with the assessment.ASSESSMENT IS THE FIRST STEP of the nursing process and involvesthe collection, organization, and analysis of informationabout the client’s health. In psychiatric–mentalhealth nursing, this process is often referred to as apsychosocial assessment, which includes a mental statusexamination. The purpose of the psychosocial assessmentis to construct a picture of the client’s current emotionalstate, mental capacity, and behavioral function. Thisassessment serves as the basis for developing a plan of careto meet the client’s needs. The assessment is also a clinicalbaseline used to evaluate the effectiveness of treatmentand interventions or a measure of the client’s progress(American Nurses Association, 2007).FACTORS INFLUENCING ASSESSMENTClient Participation/FeedbackA thorough and complete psychosocial assessment requiresactive client participation. If the client is unable or unwillingto participate, some areas of the assessment will be incompleteor vague. For example, the client who is extremelydepressed may not have the energy to answer questions orcomplete the assessment. Clients exhibiting psychoticthought processes or impaired cognition may have an insufficientattention span or may be unable to comprehend thequestions being asked. The nurse may need to have severalcontacts with such clients to complete the assessment orgather further information as the client’s condition permits.Client’s Ability to UnderstandThe nurse also must determine the client’s ability to hear,read, and understand the language being used in theassessment. If the client’s primary language differs fromthat of the nurse, the client may misunderstand or misinterpretwhat the nurse is asking, which results in inaccurateinformation. A client with impaired hearing also mayfail to understand what the nurse is asking. It is importantthat the information in the assessment reflects theclient’s health status; it should not be a result of poorcommunication.Nurse’s Attitude and ApproachThe nurse’s attitude and approach can influence the psychosocialassessment. If the client perceives the nurse’squestions to be short and curt or feels rushed or pressuredto complete the assessment, he or she may provide onlysuperficial information or omit discussing problems insome areas altogether. The client also may refrain fromproviding sensitive information if he or she perceives thenurse as nonaccepting, defensive, or judgmental. Forexample, a client may be reluctant to relate instances ofchild abuse or domestic violence if the nurse seems uncomfortableor nonaccepting. The nurse must be aware of hisor her own feelings and responses and approach the assessmentmatter-of-factly.

140UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPHOW TO CONDUCT THE INTERVIEWEnvironmentThe nurse should conduct the psychosocial assessment inan environment that is comfortable, private, and safe forboth the client and the nurse. An environment that is fairlyquiet with few distractions allows the client to give his orher full attention to the interview. Conducting the interviewin a place such as a conference room ensures the clientthat no one will overhear what is being discussed. Thenurse should not choose an isolated location for the interview,however, particularly if the client is unknown to thenurse or has a history of any threatening behavior. Thenurse must ensure the safety of self and client even if thatmeans another person is present during the assessment.Input From Family and FriendsIf family members, friends, or caregivers have accompaniedthe client, the nurse should obtain their perceptionsof the client’s behavior and emotional state. How this isaccomplished depends on the situation. Sometimes theclient does not give permission for the nurse to conductseparate interviews with family members. The nurseshould then be aware that friends or family may not feelcomfortable talking about the client in his or her presenceand may provide limited information. Or the client maynot feel comfortable participating in the assessment withoutfamily or friends. This, too, may limit the amount ortype of information the nurse obtains. It is desirable toconduct at least part of the assessment without others,especially in cases of suspected abuse or intimidation. Thenurse should make every effort to assess the client in privacyin cases of suspected abuse.How to Phrase QuestionsThe nurse may use open-ended questions to start theassessment (see Chapter 6). Doing so allows the client tobegin as he or she feels comfortable and also gives the nursean idea about the client’s perception of his or her situation.Examples of open-ended questions are as follows:• What brings you here today?• Tell me what has been happening to you.• How can we help you?If the client cannot organize his or her thoughts, or hasdifficulty answering open-ended questions, the nurse mayneed to use more direct questions to obtain information.Questions need to be clear, simple, and focused on onespecific behavior or symptom; they should not cause theclient to remember several things at once. Questionsregarding several different behaviors or symptoms—“Howare your eating and sleeping habits and have you beentaking any over-the-counter medications that affect youreating and sleeping?”—can be confusing to the client.The following are examples of focused or closed-endedquestions:• How many hours did you sleep last night?• Have you been thinking about suicide?• How much alcohol have you been drinking?• How well have you been sleeping?• How many meals a day do you eat?• What over-the-counter medications are you taking?The nurse should use a nonjudgmental tone and language,particularly when asking about sensitive informationsuch as drug or alcohol use, sexual behavior, abuse orviolence, and childrearing practices. Using nonjudgmentallanguage and a matter-of-fact tone avoids giving the clientverbal cues to become defensive or to not tell the truth.For example, when asking a client about his or her parentingrole, the nurse should ask, “What types of disciplinedo you use?” rather than, “How often do you physicallypunish your child?” The first question is more likely toelicit honest and accurate information; the second questiongives the impression that physical discipline is wrong,and it may cause the client to respond dishonestly.CONTENT OF THE ASSESSMENTThe information gathered in a psychosocial assessmentcan be organized in many different ways. Most assessmenttools or conceptual frameworks contain similar categorieswith some variety in arrangement or order. The nurseshould use some kind of organizing framework so that heor she can assess the client in a thorough and systematicway that lends itself to analysis and serves as a basis for theclient’s care. The framework for psychosocial assessmentdiscussed here and used throughout this textbook containsthe following components:• History• General appearance and motor behavior• Mood and affect• Thought process and content• Sensorium and intellectual processes• Judgment and insight• Self-concept• Roles and relationships• Physiologic and self-care concernsBox 8.1 lists the factors the nurse should include ineach of these areas of the psychosocial assessment.HistoryBackground assessments include the client’s history, ageand developmental stage, cultural and spiritual beliefs,and beliefs about health and illness. The history of the client,as well as his or her family, may provide some insightinto the client’s current situation. For example, has the clientexperienced similar difficulties in the past? Has the

CHAPTER 8 • ASSESSMENT 141Box 8.1 PSYCHOSOCIAL ASSESSMENT COMPONENTSHistoryAgeDevelopmental stageCultural considerationsSpiritual beliefsPrevious historyGeneral assessment and motor behaviorHygiene and groomingAppropriate dressPostureEye contactUnusual movements or mannerismsSpeechMood and affectExpressed emotionsFacial expressionsThought process and contentContent (what client is thinking)Process (how client is thinking)Clarity of ideasSelf-harm or suicide urgesSensorium and intellectual processesOrientationConfusionMemoryAbnormal sensory experiences or misperceptionsConcentrationAbstract thinking abilitiesJudgment and insightJudgment (interpretation of environment)Decision-making abilityInsight (understanding one’s own part in currentsituation)Self-conceptPersonal view of selfDescription of physical selfPersonal qualities or attributesRoles and relationshipsCurrent rolesSatisfaction with rolesSuccess at rolesSignificant relationshipsSupport systemsPhysiologic and self-care considerationsEating habitsSleep patternsHealth problemsCompliance with prescribed medicationsAbility to perform activities of daily livingclient been admitted to the hospital, and if so, what wasthat experience like? A family history that is positive foralcoholism, bipolar disorder, or suicide is significantbecause it increases the client’s risk for these problems.The client’s chronological age and developmental stageare important factors in the psychosocial assessment. Thenurse evaluates the client’s age and developmental level forcongruence with expected norms. For example, a clientmay be struggling with personal identity and attemptingto achieve independence from his or her parents. If the clientis 17 years old, these struggles are normal and anticipatedbecause these are two of the primary developmentaltasks for the adolescent. If the client is 35 years old andstill struggling with these issues of self-identity and independence,the nurse will need to explore the situation. Theclient’s age and developmental level also may be incongruentwith expected norms if the client has a developmentaldelay or mental retardation.The nurse must be sensitive to the client’s cultural andspiritual beliefs to avoid making inaccurate assumptionsabout his or her psychosocial functioning (Schultz &Videbeck, 2009). Many cultures have beliefs and valuesabout a person’s role in society or acceptable social orpersonal behavior that may differ from those of the nurse.Western cultures generally expect that as a person reachesadulthood, he or she becomes financially independent,leaves home, and makes his or her own life decisions. Incontrast, in some Eastern cultures, three generations maylive in one household, and elders of the family make majorlife decisions for all. Another example is the assessment ofeye contact. Western cultures consider good eye contact tobe a positive characteristic indicating self-esteem and payingattention. People from other cultures, such as Japan,consider such eye contact to be a sign of disrespect.The nurse must not stereotype clients. Just because aperson’s physical characteristics are consistent with a particularrace, he or she may not have the attitudes, beliefs,and behaviors traditionally attributed to that group. Forexample, many people of Asian ancestry have beliefs andvalues that are more consistent with Western beliefs andvalues than with those typically associated with Asiancountries. To avoid making inaccurate assumptions, thenurse must ask clients about the beliefs or health practicesthat are important to them or how they view themselves inthe context of society or relationships (see the section‘Cultural Patterns and Differences’ in Chapter 7).

142UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPThe nurse also must consider the client’s beliefs abouthealth and illness when assessing the client’s psychosocialfunctioning. Some people view emotional or mental problemsas family concerns to be handled only among familymembers. They may view seeking outside or professionalhelp as a sign of individual weakness. Others may believethat their problems can be solved only with the right medication,and they will not accept other forms of therapy.Another common problem is the misconception that oneshould take medication only when feeling sick. Many mentaldisorders, like some medical conditions, may requireclients to take medications on a long-term basis, perhapseven for a lifetime. Just like people with diabetes must takeinsulin and people with hypertension need antihypertensivemedications, people with recurrent depression mayneed to take antidepressants on a long-term basis.General Appearance and Motor BehaviorThe nurse assesses the client’s overall appearance, includingdress, hygiene, and grooming. Is the client appropriatelydressed for his or her age and the weather? Is the clientunkempt or disheveled? Does the client appear to be his orher stated age? The nurse also observes the client’s posture,eye contact, facial expression, and any unusual tics or tremors.He or she documents observations and examples ofbehaviors to avoid personal judgment or misinterpretation.Specific terms used in making assessments of generalappearance and motor behavior include the following:• Automatisms: repeated purposeless behaviors often indicativeof anxiety, such as drumming fingers, twistinglocks of hair, or tapping the foot• Psychomotor retardation: overall slowed movements• Waxy flexibility: maintenance of posture or positionover time even when it is awkward or uncomfortableThe nurse assesses the client’s speech for quantity, quality,and any abnormalities. Does the client talk nonstop?Does the client perseverate (seem to be stuck on one topicand unable to move to another idea)? Are responses a minimal“yes” or “no” without elaboration? Is the content ofthe client’s speech relevant to the question being asked? Isthe rate of speech fast or slow? Is the tone audible or loud?Does the client speak in a rhyming manner? Does the clientuse neologisms (invented words that have meaningonly for the client)? The nurse notes any speech difficultiessuch as stuttering or lisping.Mood and AffectMood refers to the client’s pervasive and enduring emotionalstate. Affect is the outward expression of the client’semotional state. The client may make statements aboutfeelings, such as “I’m depressed” or “I’m elated,” or thenurse may infer the client’s mood from data such as posture,gestures, tone of voice, and facial expression. Thenurse also assesses for consistency among the client’smood, affect, and situation. For instance, the client mayhave an angry facial expression but deny feeling angry orupset in any way. Or the client may be talking about therecent loss of a family member while laughing and smiling.The nurse must note such inconsistencies.Common terms used in assessing affect include thefollowing:• Blunted affect: showing little or a slow-to-respond facialexpression• Broad affect: displaying a full range of emotionalexpressions• Flat affect: showing no facial expression• Inappropriate affect: displaying a facial expression thatis incongruent with mood or situation; often silly orgiddy regardless of circumstances• Restricted affect: displaying one type of expression,usually serious or somber.The client’s mood may be described as happy, sad,depressed, euphoric, anxious, or angry. When the clientexhibits unpredictable and rapid mood swings fromdepressed and crying to euphoria with no apparent stimuli,the mood is called labile (rapidly changing).The nurse may find it helpful to ask the client to estimatethe intensity of his or her mood. The nurse can do soby asking the client to rate his or her mood on a scale of 1to 10. For example, if the client reports being depressed,the nurse might ask, “On a scale of 1 to 10, with 1 beingleast depressed and 10 being most depressed, where wouldyou place yourself right now?”Thought Process and ContentThought process refers to how the client thinks. The nursecan infer a client’s thought process from speech and speechpatterns. Thought content is what the client actually says.The nurse assesses whether or not the client’s verbalizationsmake sense; that is, if ideas are related and flow logicallyfrom one to the next. The nurse also must determinewhether the client seems preoccupied, as if talking or payingattention to someone or something else. When the nurseencounters clients with marked difficulties in thought processand content, he or she may find it helpful to ask focusedquestions requiring short answers. Common terms relatedto the assessment of thought process and content includethe following (American Psychiatric Association, 2000):• Circumstantial thinking: a client eventually answers aquestion but only after giving excessive unnecessarydetail• Delusion: a fixed false belief not based in reality• Flight of ideas: excessive amount and rate of speechcomposed of fragmented or unrelated ideas• Ideas of reference: client’s inaccurate interpretationthat general events are personally directed to him or

CHAPTER 8 • ASSESSMENT 143her, such as hearing a speech on the news and believingthe message had personal meaning• Loose associations: disorganized thinking that jumpsfrom one idea to another with little or no evident relationbetween the thoughts• Tangential thinking: wandering off the topic and neverproviding the information requested• Thought blocking: stopping abruptly in the middle of asentence or train of thought; sometimes unable to continuethe idea• Thought broadcasting: a delusional belief that otherscan hear or know what the client is thinking• Thought insertion: a delusional belief that others areputting ideas or thoughts into the client’s head—that is,the ideas are not those of the client• Thought withdrawal: a delusional belief that others aretaking the client’s thoughts away and the client is powerlessto stop it• Word salad: flow of unconnected words that convey nomeaning to the listener.ASSESSMENT OF SUICIDE OR HARMTOWARD OTHERSThe nurse must determine whether the depressed or hopelessclient has suicidal ideation or a lethal plan. The nursedoes so by asking the client directly, “Do you have thoughtsof suicide?” or “What thoughts of suicide have you had?”Box 8.2 lists assessment questions the nurse should askany client who has suicidal ideas.Likewise, if the client is angry, hostile, or making threateningremarks about a family member, spouse, or anyoneelse, the nurse must ask if the client has thoughts or plansabout hurting that person. The nurse does so by questioningthe client directly:• What thoughts have you had about hurting (person’sname)?• What is your plan?• What do you want to do to (person’s name)?Box 8.2SUICIDE ASSESSMENTQUESTIONSIdeation: “Are you thinking about killing yourself?”Plan: “Do you have a plan to kill yourself?”Method: “How do you plan to kill yourself?”Access: “How would you carry out this plan? Do youhave access to the means to carry out the plan?”Where: “Where would you kill yourself?”When: “When do you plan to kill yourself?”Timing: “What day or time of day do you plan to killyourself?”When a client makes specific threats or has a plan toharm another person, health-care providers are legallyobligated to warn the person who is the target of the threatsor plan. The legal term for this is duty to warn. This is onesituation in which the nurse must breach the client’s confidentialityto protect the threatened person.Sensorium and Intellectual ProcessesOrientationOrientation refers to the client’s recognition of person, place,and time—that is, knowing who and where he or she is andthe correct day, date, and year. This is often documented as“oriented 3.” Occasionally, a fourth sphere, situation, isadded (whether or not the client accurately perceives his orher current circumstances). Absence of correct informationabout person, place, and time is referred to as disorientation,or “oriented 1” (person only) or “oriented 2”(person and place). The order of person, place, and time issignificant. When a person is disoriented, he or she firstloses track of time, then place, and finally person. Orientationreturns in the reverse order: first, the person knowswho he or she is, then realizes place, and finally time.Disorientation is not synonymous with confusion. Aconfused person cannot make sense of his or her surroundingsor figure things out even though he or she maybe fully oriented.MemoryThe nurse directly assesses memory, both recent andremote, by asking questions with verifiable answers. Forexample, if the nurse asks, “Do you have any memoryproblems?” the client may inaccurately respond “no,”and the nurse cannot verify that. Similarly, if the nurseasks, “What did you do yesterday?” the nurse may beunable to verify the accuracy of the client’s responses.Hence, questions to assess memory generally include thefollowing:• What is the name of the current president?• Who was the president before that?• In what county do you live?• What is the capital of this state?• What is your social security number?Ability to ConcentrateThe nurse assesses the client’s ability to concentrate byasking the client to perform certain tasks:• Spell the word world backward.• Begin with the number 100, subtract 7, subtract 7 again,and so on. This is called “serial sevens.”• Repeat the days of the week backward.• Perform a three-part task, such as “Take a piece ofpaper in your right hand, fold it in half, and put it onthe floor.” (The nurse should give the instructions atone time.)

144UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPAbstract Thinking and Intellectual AbilitiesWhen assessing intellectual functioning, the nurse mustconsider the client’s level of formal education. Lack of formaleducation could hinder performance in many tasks inthis section of the assessment.The nurse assesses the client’s ability to use abstract thinking,which is to make associations or interpretations about asituation or comment. The nurse usually can do so by askingthe client to interpret a common proverb such as “a stitch intime saves nine.” If the client can explain the proverb correctly,his or her abstract thinking abilities are intact. If theclient provides a literal explanation of the proverb and cannotinterpret its meaning, abstract thinking abilities are lacking.When the client continually gives literal translations,this is evidence of concrete thinking. For instance,• Proverb: A stitch in time saves nine.Abstract meaning: If you take the time to fix somethingnow, you’ll avoid bigger problems in the future.Literal translation: Don’t forget to sew up holes inyour clothes (concrete thinking).• Proverb: People who live in glass houses shouldn’t throwstones.Abstract meaning: Don’t criticize others for thingsyou also may be guilty of doing.Literal translation: If you throw a stone at a glasshouse, the glass will break (concrete thinking).The nurse also may assess the client’s intellectual functioningby asking him or her to identify the similaritiesbetween pairs of objects, for example, “What is similarabout an apple and an orange?” or “What do the newspaperand the television have in common?”activity also may indicate poor judgment. The nurse alsomay assess a client’s judgment by asking the client hypotheticalquestions, such as “If you found a stampedaddressed envelope on the ground, what would you do?”Insight is the ability to understand the true nature ofone’s situation and accept some personal responsibilityfor that situation. The nurse frequently can infer insightfrom the client’s ability to describe realistically thestrengths and weaknesses of his or her behavior. Anexample of poor insight would be a client who places allblame on others for his own behavior, saying, “It’s mywife’s fault that I drink and get into fights, because shenags me all the time.” This client is not accepting responsibilityfor his drinking and fighting. Another example ofpoor insight would be the client who expects all problemsto be solved with little or no personal effort: “The problemis my medication. As soon as the doctor gets the medicationright, I’ll be just fine.”Self-ConceptSelf-concept is the way one views oneself in terms of personalworth and dignity. To assess a client’s self-concept,the nurse can ask the client to describe himself or herselfand what characteristics he or she likes and what he or shewould change. The client’s description of self in terms ofphysical characteristics gives the nurse information aboutthe client’s body image, which is also part of self-concept.Sensory-Perceptual AlterationsSome clients experience hallucinations (false sensoryperceptions or perceptual experiences that do not reallyexist). Hallucinations can involve the five senses andbodily sensations. Auditory hallucinations (hearingvoices) are the most common; visual hallucinations (seeingthings that don’t really exist) are the second mostcommon. Initially, clients perceive hallucinations as realexperiences, but later in the illness, they may recognizethem as hallucinations.Judgment and InsightJudgment refers to the ability to interpret one’s environmentand situation correctly and to adapt one’s behaviorand decisions accordingly. Problems with judgment may beevidenced as the client describes recent behavior and activitiesthat reflect a lack of reasonable care for self or others.For example, the client may spend large sums of money onfrivolous items when he or she cannot afford basic necessitiessuch as food or clothing. Risky behaviors such as pickingup strangers in bars or engaging in unprotected sexualSelf-concept

CHAPTER 8 • ASSESSMENT 145Also included in an assessment of self-concept are theemotions that the client frequently experiences, such assadness or anger, and whether or not the client is comfortablewith those emotions. The nurse also must assess theclient’s coping strategies. He or she can do so by asking,“What do you do when you have a problem? How do yousolve it? What usually works to deal with anger ordisappointment?”Roles and RelationshipsPeople function in their community through various rolessuch as mother, wife, son, daughter, teacher, secretary, orvolunteer. The nurse assesses the roles the client occupies,client satisfaction with those roles, and whether the clientbelieves he or she is fulfilling the roles adequately. Thenumber and type of roles may vary, but they usually includefamily, occupation, and hobbies or activities. Family rolesinclude son or daughter, sibling, parent, child, and spouseor partner. Occupation roles can be related to a career orschool or both. The ability to fulfill a role or the lack of adesired role is often central to the client’s psychosocialfunctioning. Changes in roles also may be part of the client’sdifficulty.Relationships with other people are important to one’ssocial and emotional health. Relationships vary in terms ofsignificance, level of intimacy or closeness, and intensity.The inability to sustain satisfying relationships can resultfrom mental health problems or can contribute to theworsening of some problems. The nurse must assess therelationships in the client’s life, the client’s satisfactionwith those relationships, or any loss of relationships. Commonquestions include the following:• Do you feel close to your family?• Do you have or want a relationship with a significantother?• Are your relationships meeting your needs for companionshipor intimacy?• Can you meet your sexual needs satisfactorily?• Have you been involved in any abusive relationships?If the client’s family relationships seem to be a significantsource of stress or if the client is closely involvedwith his or her family, a more in-depth assessment of thisarea may be useful. Box 8.3 is the McMaster FamilyAssessment Device, an example of such an in-depth familyassessment.Physiologic and Self-Care ConsiderationsWhen doing a psychosocial assessment, the nurse mustinclude physiologic functioning. Although a full physicalhealth assessment may not be indicated, emotional problemsoften affect some areas of physiologic function.Emotional problems can greatly affect eating and sleepingpatterns: Under stress, people may eat excessively or not atall and may sleep up to 20 hours a day or may be unable tosleep more than 2 or 3 hours a night. Clients with bipolardisorder may not eat or sleep for days. Clients with majordepression may not be able to get out of bed. Therefore, thenurse must assess the client’s usual patterns of eating andsleeping and then determine how those patterns havechanged.The nurse also asks the client if he or she has any majoror chronic health problems and if he or she takes prescribedmedications as ordered and follows dietary recommendations.The nurse also explores the client’s use ofalcohol and over-the-counter or illicit drugs. Such questionsrequire nonjudgmental phrasing; the nurse mustreassure the client that truthful information is crucial indetermining the client’s plan of care.Noncompliance with prescribed medications is animportant area. If the client has stopped taking medicationor is taking medication other than as prescribed, the nursemust help the client feel comfortable enough to reveal thisinformation. The nurse also explores the barriers to compliance.Is the client choosing noncompliance because ofundesirable side effects? Has the medication failed to producethe desired results? Does the client have difficultyobtaining the medication? Is the medication too expensivefor the client?DATA ANALYSISAfter completing the psychosocial assessment, the nurseanalyzes all the data that he or she has collected. Dataanalysis involves thinking about the overall assessmentrather than focusing on isolated bits of information. Thenurse looks for patterns or themes in the data that lead toconclusions about the client’s strengths and needs and to aparticular nursing diagnosis. No one statement or behavioris adequate to reach such a conclusion. The nurse alsomust consider the congruence of all information providedby the client, family, or caregivers, as well as his or her ownobservations. It is not uncommon for the client’s perceptionof his or her behavior and situation to differ from thatof others. Assessments in a variety of areas are necessaryto support nursing diagnoses such as Chronic Low Self-Esteem or Ineffective Coping.Traditionally, data analysis leads to the formulation ofnursing diagnoses as a basis for the client’s plan of care.Nursing diagnoses have been an integral part of the nursingprocess for many years. With the sweeping changesoccurring in health care, however, the nurse also mustarticulate the client’s needs in ways that are clear to healthteam members in other disciplines as well as to familiesand caregivers. For example, a multidisciplinary treatmentplan or critical pathway may be the vehicle for planningcare in some agencies. A plan of care that is useful to theclient’s family for home care may be necessary. The nursemust describe and document goals and interventions that

146UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPBox 8.3 McMASTER FAMILY ASSESSMENT DEVICEInstructions: Following are a number of statements about families. Please read each statement carefully, and decide howwell it describes your own family. You should answer according to how you see your family. For each statement, there arefour possible responses:Strongly agree (SA)Agree (A)Disagree (D)Strongly disagree (SD)Check SA if you believe the statement describes your family very accurately.Check A if you believe the statement describes your family for the most part.Check D if you believe the statement does not describe your family for the most part.Check SD if you believe the statement does not describe your family at all.Try not to spend too much time thinking about each statement, but respond as quickly and honestly as you can. If you havetrouble with one, answer with your first reaction. Please be sure to answer every statement, and mark all your answers in thespace provided next to each statement.STATEMENTS SA A D SD1. Planning family activities is difficult because we misunderstand each other. _____ _____ _____ _____2. We resolve most everyday problems around the house. _____ _____ _____ _____3. When someone is upset, the others know why. _____ _____ _____ _____4. When you ask someone to do something, you have to check that they did it. _____ _____ _____ _____5. If someone is in trouble, the others become too involved. _____ _____ _____ _____6. In times of crisis we can turn to each other for support. _____ _____ _____ _____7. We don’t know what to do when an emergency comes up. _____ _____ _____ _____8. We sometimes run out of things that we need. _____ _____ _____ _____9. We are reluctant to show our affection to each other. _____ _____ _____ _____10. We make sure members meet their family responsibilities. _____ _____ _____ _____11. We cannot talk to each other about the sadness we feel. _____ _____ _____ _____12. We usually act on our decisions regarding problems. _____ _____ _____ _____13. You only get the interest of others when something is important to them. _____ _____ _____ _____14. You can’t tell how a person is feeling from what they are saying. _____ _____ _____ _____15. Family tasks don’t get spread around enough. _____ _____ _____ _____16. Individuals are accepted for what they are. _____ _____ _____ _____17. You can easily get away with breaking the rules. _____ _____ _____ _____18. People come right out and say things instead of hinting at them. _____ _____ _____ _____19. Some of us just don’t respond emotionally. _____ _____ _____ _____20. We know what to do in an emergency. _____ _____ _____ _____21. We avoid discussing our fears and concerns. _____ _____ _____ _____22. It is difficult to talk to each other about tender feelings. _____ _____ _____ _____23. We have trouble meeting our bills. _____ _____ _____ _____24. After our family tries to solve a problem, we usually discuss whether_____ _____ _____ _____it worked or not.25. We are too self-centered. _____ _____ _____ _____26. We can express our feelings to each other. _____ _____ _____ _____27. We have no clear expectations about toilet habits. _____ _____ _____ _____28. We do not show our love for each other. _____ _____ _____ _____29. We talk to people directly rather than through go-betweens. _____ _____ _____ _____30. Each of us has particular duties and responsibilities. _____ _____ _____ _____31. There are lots of bad feelings in the family. _____ _____ _____ _____

CHAPTER 8 • ASSESSMENT 147Box 8.3 McMASTER FAMILY ASSESSMENT DEVICE ContinuedSTATEMENTS SA A D SD32. We have rules about hitting people. _____ _____ _____ _____33. We get involved with each other only when something interests us. _____ _____ _____ _____34. There’s little time to explore personal interests. _____ _____ _____ _____35. We often don’t say what we mean. _____ _____ _____ _____36. We feel accepted for what we are. _____ _____ _____ _____37. We show interest in each other when we can get something out of it personally. _____ _____ _____ _____38. We resolve most emotional upsets that come up. _____ _____ _____ _____39. Tenderness takes second place to other things in our family. _____ _____ _____ _____40. We discuss who is to do household jobs. _____ _____ _____ _____41. Making decisions is a problem for our family. _____ _____ _____ _____42. Our family shows interest in each other only when they can get_____ _____ _____ _____something out of it.43. We are frank with each other. _____ _____ _____ _____44. We don’t hold to any rules or standards. _____ _____ _____ _____45. If people are asked to do something, they need reminding. _____ _____ _____ _____46. We are able to make decisions about how to solve problems. _____ _____ _____ _____47. If the rules are broken, we don’t know what to expect. _____ _____ _____ _____48. Anything goes in our family. _____ _____ _____ _____49. We express tenderness. _____ _____ _____ _____50. We control problems involving feelings. _____ _____ _____ _____51. We don’t get along well together. _____ _____ _____ _____52. We don’t talk to each other when we are angry. _____ _____ _____ _____53. We are generally dissatisfied with the family duties assigned to us. _____ _____ _____ _____54. Even though we mean well, we intrude too much into each other’s lives. _____ _____ _____ _____55. There are rules about dangerous situations. _____ _____ _____ _____56. We confide in each other. _____ _____ _____ _____57. We cry openly. _____ _____ _____ _____58. We don’t have reasonable transport. _____ _____ _____ _____59. When we don’t like what someone has done, we tell them. _____ _____ _____ _____60. We try to think of different ways to solve problems. _____ _____ _____ _____Source: Schutle, N. S., & Malouff, J. M. (1995). Sourcebook of adult assessment strategies. New York: Plenum Press,Brown University/Butler Hospital Family Research Program, © 1982.many others, not just professional nurses, can understand.The descriptions must contain no jargon or terms that areunclear to the client, family, or other providers of care.Psychological TestsPsychological tests are another source of data for the nurseto use in planning care for the client. Two basic types oftests are intelligence tests and personality tests. Intelligencetests are designed to evaluate the client’s cognitive abilitiesand intellectual functioning. Personality tests reflect theclient’s personality in areas such as self-concept, impulsecontrol, reality testing, and major defenses (Adams &Culbertson, 2005). Personality tests may be objective(constructed of true-and-false or multiple-choice questions).Table 8.1 describes selected objective personalitytests. The nurse compares the client’s answers with standardanswers or criteria and obtains a score or scores.Other personality tests, called projective tests, areunstructured and are usually conducted by the interviewmethod. The stimuli for these tests, such as pictures orRorschach’s inkblots, are standard, but clients may respondwith answers that are very different. The evaluator analyzesthe client’s responses and gives a narrative result of

148UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPTable 8.1OB JECTIVE MEASURESOF PERSONALITYTable 8.2PROJECTIVE MEASURESOF PERSONALITYTestDescriptionTestDescriptionMinnesota MultiphasicPersonalityInventory (MMPI)MMPI-2Milton Clinical MultiaxialInventory(MCMI) andMCMI-II (revisedversion)Psychological ScreeningInventory (PSI)Beck DepressionInventory (BDI)Tennessee Self-Concept Scale(TSCS)the testing. Table 8.2 lists commonly used projectivepersonality tests.Both intelligence tests and personality tests are frequentlycriticized as being culturally biased. It is importantto consider the client’s culture and environment whenevaluating the importance of scores or projections fromany of these tests; they can provide useful informationabout the client in some circumstances but may not besuitable for all clients.Psychiatric Diagnoses566 multiple-choice items;provides scores on 10 clinicalscales such as hypochondriasis,depression, hysteria, andparanoia; four special scalessuch as anxiety and alcoholism;three validity scalesto evaluate the truth andaccuracy of responsesRevised version of MMPI with567 multiple-choice items;provides scores on sameareas as MMPI175 true–false items; providesscores on various personalitytraits and personalitydisorders103 true–false items; used toscreen for the need for psychologicalhelp21 items rated on scale of 0–3to indicate level ofdepression100 true–false items; providesinformation on 14 scalesrelated to self-conceptSource: Adams, R. L., & Culbertson, J. L. (2005). Personality assessment: Adultsand children. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 874–895). Philadelphia: Lippincott Williams & Wilkins.Medical diagnoses of psychiatric illness are found in theDiagnostic and Statistical Manual of Mental Disorders, 4thedition, Text Revision (DSM-IV-TR). This taxonomy is universallyused by psychiatrists and by some therapists inthe diagnosis of psychiatric illnesses. The DSM-IV-TR classifiesmental disorders into categories. It describes eachdisorder and provides diagnostic criteria to distinguishRorschach testThematic ApperceptionTest (TAT)Sentence completiontestone from another. Although the DSM-IV-TR is not a substitutefor a thorough psychosocial nursing assessment, thedescriptions of disorders and related behaviors can be avaluable resource for the nurse to use as a guide. The DSM-IV-TR uses a multiaxial system to provide the format for acomplete psychiatric diagnosis:• Axis I: clinical disorders, other conditions that may be afocus of clinical attention• Axis II: personality disorders, mental retardation• Axis III: general medical conditions• Axis IV: psychosocial and environmental problems• Axis V: global assessment of functioning (GAF).The psychosocial and environmental problems categorizedon axis IV include educational, occupational, housing, financial,and legal problems as well as difficulties with the socialenvironment, relationships, and access to health care.The GAF is used to make a judgment about the client’soverall level of functioning (Box 8.4). The GAF score givento the client may describe his or her current level of functioningas well as the highest level of functioning in thepast year or 6 months. This information is useful in settingappropriate goals for the client’s care.Mental Status Exam10 stimulus cards of inkblots;client describes perceptionsof inkblots; narrative interpretationdiscusses areas such ascoping styles, interpersonalattitudes, characteristics ofideation20 stimulus cards with pictures;client tells a story about thepicture; narrative interpretationdiscusses themes about moodstate, conflict, quality of interpersonalrelationshipsClient completes a sentence frombeginnings such as “I oftenwish,” “Most people,” and“When I was young.”Source: Adams, R. L., & Culbertson, J. L. (2005). Personality assessment: Adultsand children. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 874–895). Philadelphia: Lippincott Williams &Wilkins.Often, psychiatrists, therapists, or other clinicians performa cursory abbreviated exam that focuses on the client’s

CHAPTER 8 • ASSESSMENT 149Box 8.4 GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALEConsider psychological, social, and occupational functioning on a hypothetical continuum of mental health to illness. Do notinclude impairment in functioning due to physical (or environmental) limitations. (Note: Use intermediate codes when appropriate,e.g., 45, 68, 72.)CODE1009190818071706160515041403130212011101Superior functioning in a wide range of activities; life’s problems never seem to get out of hand; is sought outby others because of his or her many positive qualities. No symptoms.Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested andinvolved in a wide range of activities, socially effective, and generally satisfied with life; no more than everydayproblems or concerns (e.g., an occasional argument with family members).If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficultyconcentrating after family argument); no more than slight impairment in social, occupational, or school functioning(e.g., temporarily falling behind in schoolwork).Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, orschool functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well;has some meaningful interpersonal relationships.Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficultyin social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers).Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairmentin social, occupational, or school functioning (e.g., no friends, unable to keep a job).Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) ormajor impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g.,depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children,is defiant at home, and is failing at school).Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication orjudgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to functionin almost all areas (e.g., stays in bed all day; no job, home, or friends).Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequently violent,manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or grossimpairment in communication (e.g., largely incoherent or mute).Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintainminimal personal hygiene or serious suicidal act with clear expectation of death.0 Inadequate information.The rating of overall psychological functioning on a scale of 0–100 was operationalized by Luborsky in the Health-Sickness Rating Scale (Luborsky, L. (1962).Clinicians’ judgments of mental health. Archives of General Psychiatry, 7, 407–417). Spitzer and colleagues developed a revision of the Health-Sickness RatingScale called the Global Assessment Scale (GAS) (Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The global assessment scale: A procedure for measuringoverall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766–771). A modified version of the GAS was included in DSM-III-R as theGlobal Assessment of Functioning (GAF) Scale.

150UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPcognitive abilities. These exams usually include items suchas orientation to person, time, place, date, season, and dayof the week; ability to interpret proverbs; ability to performmath calculations; memorization and short-termrecall; naming common objects in the environment; abilityto follow multistep commands; and ability to write or copya simple drawing. The fewer tasks the client completesaccurately, the greater the cognitive deficit. Because thisexam assesses cognitive ability, it is often used to screenfor dementia. However, cognition may also be impaired(usually temporarily) when clients are depressed orpsychotic.SELF-AWARENESS ISSUESSelf-awareness is crucial when a nurse is tryingto obtain accurate and complete informationfrom the client during the assessmentprocess. The nurse must be aware of any feelings,biases, and values that could interfere with the psychosocialassessment of a client with different beliefs, values,and behaviors. The nurse cannot let personal feelingsand beliefs influence the client’s treatment. Self-awarenessdoes not mean the nurse’s beliefs are wrong or mustchange, but it does help the nurse to be open and acceptingof others’ beliefs and behaviors even when the nursedoes not agree with them.Two areas that may be uncomfortable or difficult for thenurse to assess are sexuality and self-harm behaviors. Thebeginning nurse may feel uncomfortable, as if prying intopersonal matters, when asking questions about a client’sintimate relationships and behavior and any self-harmbehaviors or thoughts of suicide. Asking such questions,however, is essential to obtaining a thorough and completeassessment. The nurse needs to remember that it may beuncomfortable for the client to discuss these topics as well.The nurse may hold beliefs that differ from the client’s,but he or she must not make judgments about the client’spractices. For example, the nurse may believe abortion is asin, but the client might have had several elective abortions.Or the nurse may believe that adultery is wrong, but,during the course of an assessment, he or she may discoverthat a client has had several extramarital affairs.Being able to listen to the client without judgment andto support the discussion of personal topics takes practiceand usually gets easier with experience. Talking to moreexperienced colleagues about such discomfort and methodsto alleviate it often helps. It may also help for the nurseto preface uncomfortable questions by saying to the client,“I need to ask you some personal questions. Remember,this is information that will help the staff provide bettercare for you.”The nurse must assess the client for suicidal thoughts.Some beginning nurses feel uncomfortable discussing suicideor believe that asking about suicide might suggest itto a client who had not previously thought about it. This isnot the case. It has been shown that the safest way to assessa client with suspected mental disorders is to ask him orher clearly and directly about suicidal ideas. It is the nurse’sprofessional responsibility to keep the client’s safety needsfirst and foremost, and this includes overcoming any personaldiscomfort in talking about suicide (Schultz &Videbeck, 2009).Points to Consider When Doinga Psychosocial Assessment• The nurse is trying to gain all the information needed tohelp the client. Judgments are not part of the assessmentprocess.• Being open, clear, and direct when asking about personalor uncomfortable topics helps to alleviate the client’sanxiety or hesitancy about discussing the topic.• Examining one’s own beliefs and gaining self-awarenessis a growth-producing experience for the nurse.• If the nurse’s beliefs differ strongly from those of the client,the nurse should express his or her feelings to colleaguesor discuss the differences with them. The nursemust not allow personal beliefs to interfere with thenurse–client relationship and the assessment process.Critical Thinking Questions1. The nurse is preparing to do a psychosocial assessmentfor a client who is seeking help because she hasbeen physically abusive to her children. What feelingsmight the nurse experience? How does thenurse view this client?2. During the assessment, the client reports having threegrown children. She has frequent contact with one ofthem, but no contact with the other two. What willthe nurse ask about these relationships? What if theclient is reluctant to discuss these relationships? Isthis information essential for the assessment?3. The nurse is assessing a client who is illiterate. Howwill the nurse assess the intellectual functioning ofthis client? What other areas of a psychosocial assessmentmight be impaired by the client’s inabilityto read or write?KEY POINTS• The purpose of the psychosocial assessmentis to construct a picture of the client’s currentemotional state, mental capacity, andbehavioral function. This baseline clinicalpicture serves as the basis for developing a plan of care tomeet the client’s needs.

CHAPTER 8 • ASSESSMENT 151• The components of a thorough psychosocial assessmentinclude the client’s history, general appearance andmotor behavior, mood and affect, thought process andcontent, sensorium and intellectual process, judgmentand insight, self-concept, roles and relationships, andphysiologic and self-care considerations.• Several important factors in the client can influence thepsychosocial assessment: ability to participate and givefeedback, physical health status, emotional well-beingand perception of the situation, and ability tocommunicate.• The nurse’s attitude and approach can greatly influencethe psychosocial assessment. The nurse must conductthe assessment professionally, nonjudgmentally, andmatter-of-factly while not allowing personal feelings toinfluence the interview.• To avoid making inaccurate assumptions about the client’spsychosocial functioning, the nurse must be sensitiveto the client’s cultural and spiritual beliefs. Manycultures have values and beliefs about a person’s role insociety or acceptable social or personal behavior thatmay differ from the beliefs and values of the nurse.• Accurate analysis of assessment data involves consideringthe entire assessment and identifying patterns ofbehavior as well as congruence among components andsources of information.• Self-awareness on the nurse’s part is crucial to obtainan accurate, objective, and thorough psychosocialassessment.• Areas that are often difficult for nurses to assess includesexuality and self-harm behaviors and suicidality.Discussion with colleagues and experience with clientscan help the nurse to deal with uncomfortable feelings.• The client’s safety is a priority; therefore, asking clientsclearly and directly about suicidal ideation is essential.ReferencesAdams, R. L., & Culbertson, J. L. (2005). Personality assessment: Adultsand children. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensivetextbook of psychiatry (Vol. 1, 8th ed., pp. 874–895). Philadelphia:Lippincott Williams & Wilkins.American Nurses Association. (2007). Psychiatric–mental health nursing:Scope and standards of practice. Washington, DC: American NursesPublishing.American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans. Philadelphia: Lippincott, Williams & Wilkins(8th ed.).

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following is an example of an open-endedquestion?a. Who is the current president of the United States?b. What concerns you most about your health?c. What is your address?d. Have you lost any weight recently?2. Which of the following is an example of a closed-endedquestion?a. How have you been feeling lately?b. How is your relationship with your wife?c. Have you had any health problems recently?d. Where are you employed?3. Assessment data about the client’s speech patterns arecategorized in which of the following areas?a. Historyb. General appearance and motor behaviorc. Sensorium and intellectual processesd. Self-concept4. When the nurse is assessing whether or not the client’sideas are logical and make sense, the nurse is examiningwhich of the following?a. Thought contentb. Thought processc. Memoryd. Sensorium5. The client’s belief that a news broadcast has specialmeaning for him or her is an example ofa. Abstract thinkingb. Flight of ideasc. Ideas of referenced. Thought broadcasting6. The client who believes everyone is out to get him orher is experiencing a(n)a. Delusionb. Hallucinationc. Idea of referenced. Loose association7. To assess the client’s ability to concentrate, the nursewould instruct the client to do which of the following?a. Explain what “a rolling stone gathers no moss”means.b. Name the last three presidents.c. Repeat the days of the week backward.d. Tell what a typical day is like.MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Assessment of sensorium and intellectual processesincludes which of the following?a. Concentrationb. Emotional feelingsc. Memoryd. Judgmente. Orientationf. Thought process2. Assessment of suicidal risk includes which of thefollowing?a. Intent to dieb. Judgmentc. Insightd. Methode. Planf. Reason152

CHAPTER 8 • ASSESSMENT153SHORT-ANSWER QUESTIONSIdentify a question that the nurse might ask to assess each of the following.1. Abstract thinking ability2. Insight3. Self-concept4. Judgment5. Mood6. Orientation

154 UNIT 2 • BUILDING THE NURSE–CLIENT RELATIONSHIPCLINICAL EXAMPLEThe nurse at a mental health clinic is meeting a new client for the first time and plans to doa psychosocial assessment. When the client arrives, the nurse finds a young woman wholooks somewhat apprehensive and is crying and twisting facial tissues in her hands. Theclient can tell the nurse her name and age but begins crying before she can provide anyother information. The nurse knows it is essential to obtain information from this youngwoman, but it is clear she will have trouble answering all interview questions at this time.1. How should the nurse approach the crying client? What should the nurse say and do?2. Identify five questions that the nurse would choose to ask this client initially. Give arationale for the chosen questions.3. What, if any, assumptions might the nurse make about this client and her situation?4. If the client decided to leave the clinic before the assessment formally began, what wouldthe nurse need to do?

CURRENT SOCIALAND EMOTIONALCONCERNSUnit 3Chapter 9 Legal and Ethical IssuesChapter 10 Anger, Hostility, and AggressionChapter 11 Abuse and ViolenceChapter 12 Grief and Loss

9Legal and EthicalIssuesLearning ObjectivesAfter reading this chapter, you should be able to1. Describe the rights of the client in a psychiatric setting.Key Terms• assault• autonomy• battery• beneficence• breach of duty• causation• deontology• duty• duty to warn• ethical dilemma• ethics• false imprisonment• fidelity• injury or damage• justice• least restrictive environment• malpractice• mandatory outpatient treatment• negligence• nonmaleficence• restraint• seclusion• standards of care• tort• utilitarianism• veracity1562. Discuss the legal and ethical issues related to seclusion and restraint.3. Describe the components of malpractice.4. Identify pertinent ethical issues in the practice of psychiatric nursing.5. Discuss the meaning of standard of care.6. Describe the most common types of torts in the mental health setting.HISTORICALLY, CLIENTS WITH MENTAL illness had few rights and were subjectedto institutionalization, warehousing, and inhumane treatment (see Chapter1). In the 1970s, recognition of patient’s rights and changes in lawsgoverning commitment improved the rights of clients. This chapterdiscusses the legal considerations related to mental health treatment andethical issues that commonly arise in mental health settings.LEGAL CONSIDERATIONSRights of Clients and Related IssuesClients receiving mental health care retain all civil rights afforded to allpeople except the right to leave the hospital in the case of involuntarycommitment (discussed later). They have the right to refuse treatment, tosend and to receive sealed mail, and to have or refuse visitors. Any restrictions(e.g., mail, visitors, and clothing) must be made for a verifiable, documentedreason. These decisions can be made by a court or a designateddecision-making person or persons, for example, primary nurse or treatmentteam, depending on local laws or regulations. Examples include thefollowing:• A suicidal client may not be permitted to keep a belt, shoelaces, or scissorsbecause he or she may use these items for self-harm.• A client who becomes aggressive after having a particular visitor mayhave that person restricted from visiting for a period of time.Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 9 • LEGAL AND ETHICAL ISSUES 157Box 9.1HIGHLIGHTS OF PATIENT’SBILL OF RIGHTS• To be informed about benefits, qualifications of allproviders, available treatment options, and appealsand grievance procedures• Confidentiality• Choice of providers• Treatment determined by professionals, not third-partypayers• Parity• Nondiscrimination• All benefits within scope of benefit plan• Treatment that affords greatest protection andbenefit• Fair and valid treatment review processes• Treating professionals and payers held accountablefor any injury caused by gross incompetence, negligence,or clinically unjustified decisions.represent a danger to themselves or others when under theinfluence.Release from the HospitalClients admitted to the hospital voluntarily have the rightto leave, provided they do not represent a danger to themselvesor others. They can sign a written request for dischargeand can be released from the hospital againstmedical advice. If a voluntary client who is dangerous tohimself or herself or to others signs a request for discharge,the psychiatrist may file for a civil commitment todetain the client against his or her will until a hearing cantake place to decide the matter.While in the hospital, the committed client may takemedications and improve fairly rapidly, making him or hereligible for discharge when he or she no longer represents adanger. Some clients stop taking their medications afterdischarge and once again become threatening, aggressive,or dangerous. Mental health clinicians increasingly havebeen held legally liable for the criminal actions of suchclients; this situation contributes to the debate aboutextended civil commitment for dangerous clients.• A client making threatening phone calls to others outsidethe hospital may be permitted only supervisedphone calls until his or her condition improves.The American Psychiatric Association (APA) developedPrinciples for the Provision of Mental Health and SubstanceAbuse Treatment Services. This mental healthpatient’s bill of rights is summarized in Box 9.1. The entiredocument can be accessed at http://www.apa.org/topics/rights/.Involuntary HospitalizationMost clients are admitted to inpatient settings on a voluntarybasis, which means they are willing to seek treatmentand agree to be hospitalized. Some clients, however, do notwish to be hospitalized and treated. Health-care professionalsrespect these wishes unless clients are a danger to themselvesor others (i.e., they are threatening or have attemptedsuicide or represent a danger to others). Clients hospitalizedagainst their will under these conditions are committedto a facility for psychiatric care until they no longer pose adanger to themselves or to anyone else. Each state has lawsthat govern the civil commitment process, but such laws aresimilar across all 50 states. Civil commitment or involuntaryhospitalization curtails the client’s right to freedom (theability to leave the hospital when he or she wishes). Allother client rights, however, remain intact.A person can be detained in a psychiatric facility for 48to 72 hours on an emergency basis until a hearing can beconducted to determine whether or not he or she shouldbe committed to a facility for treatment for a specifiedperiod. Many states have similar laws governing the commitmentof clients with substance abuse problems whoVoluntary clients may sign a written request for dischargeagainst medical advice

158UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSMandatory Outpatient TreatmentLegally mandatory outpatient treatment (MOT) is therequirement that clients continue to participate in treatmenton an involuntary basis after their release from thehospital into the community. This may involve taking prescribedmedication, keeping appointments with healthcareproviders for follow-up, and attending specifictreatment programs or groups (Cullen-Drill & Schilling,2008). In the United States, all but eight states have lawsfor some type of MOT. A complete list can be obtained onthe website for the Treatment Advocacy Center (2009).Benefits of MOT include shorter inpatient hospital stays,although these individuals may be hospitalized more frequently(Segal & Burgess, 2006a); reduced mortality riskfor clients considered dangerous to self or others (Segal &Burgess, 2006b); and protection of clients from criminalvictimization by others.MOT is sometimes also called conditional release oroutpatient commitment. Court-ordered outpatient treatmentis most common among persons with severe andpersistent metal illness who have had frequent and multiplecontacts with mental health, social welfare, and criminaljustice agencies (Swartz, Swanson, Kim, & Petrila,2006). This supports the notion that clients are given severalopportunities to voluntarily comply with outpatienttreatment recommendations and that court-ordered treatmentis considered when those attempts have been repeatedlyunsuccessful. The court’s concern is that clients withpsychiatric disorders have civil rights and should not beunreasonably required to participate in any activitiesagainst their will. Another concern is that once courtorderedtreatment was permitted, it would be used withever-increasing numbers of people. However, such anincrease has not occurred (Geller, Fisher, Grudzinskas,Clayfield, & Lawlor, 2006). Communities counter thatthey deserve protection against dangerous people withhistories of not taking their medications and who maybecome threats.ConservatorshipThe appointment of a conservator or legal guardian is aseparate process from civil commitment. People who aregravely disabled; are found to be incompetent; cannot providefood, clothing, and shelter for themselves even whenresources exist; and cannot act in their own best interestsmay require appointment of a conservator. In these cases,the court appoints a person to act as a legal guardian whoassumes many responsibilities for the person, such as givinginformed consent, writing checks, and entering contracts.The client with a guardian loses the right to enterinto legal contracts or agreements that require a signature(e.g., marriage or mortgage). This affects many daily activitiesthat are usually taken for granted. Because conservatorsor guardians speak for clients, the nurse must obtain consentor permission from the conservator. Some states distinguishbetween conservator of the person (synonymouswith legal guardian) and conservator of financial affairsonly––also known as power of attorney for financialmatters.Least Restrictive EnvironmentClients have the right to treatment in the least restrictiveenvironment appropriate to meet their needs. This conceptwas central to the deinstitutionalization movementdiscussed in Chapters 1 and 4. It means that a client doesnot have to be hospitalized if he or she can be treated in anoutpatient setting or in a group home. It also means thatthe client must be free of restraint or seclusion unless it isnecessary.Restraint is the direct application of physical force to aperson, without his or her permission, to restrict his or herfreedom of movement. The physical force may be humanor mechanical or both. Human restraint occurs when staffmembers physically control the client and move him orher to a seclusion room. Mechanical restraints are devices,usually ankle and wrist restraints, fastened to the bedframe to curtail the client’s physical aggression, such ashitting, kicking, and hair pulling.Seclusion is the involuntary confinement of a person ina specially constructed, locked room equipped with a securitywindow or camera for direct visual monitoring. Forsafety, the room often has a bed bolted to the floor and amattress. Any sharp or potentially dangerous objects, suchSeclusion

CHAPTER 9 • LEGAL AND ETHICAL ISSUES 159CLINICAL VIGNETTE: SECLUSIONThe goal of seclusion is to give the client the opportunity toregain self-control, both emotionally and physically. Most clientswho have been secluded, however, have very differentfeelings and thoughts about seclusion. Clients report feelingangry, agitated, bored, frustrated, helpless, and afraid whilein seclusion. They perceive seclusion as a punishment and receivethe message that they were “bad.” Many clients are notclear about the reasons for seclusion or the criteria for exitingseclusion, and they believe that seclusion lasted too long. Ingeneral, clients think that other interventions such as interactionwith staff, a place to calm down or scream when needed,or the presence of a family member could reduce or eliminatethe need for seclusion. Clients who had not been secludeddescribe the seclusion of others in more positive terms, suchas helpful, caring, fair, and good. However, these clients alsoexpress the wish that “that never happens to me.”as pens, glasses, belts, and matches, are removed from theclient as a safety precaution. Seclusion decreases stimulation,protects others from the client, prevents propertydestruction, and provides privacy for the client. The goal isto give the client the opportunity to regain physical andemotional self-control.Short-term use of restraint or seclusion is permittedonly when the client is imminently aggressive and dangerousto himself or herself or to others, and all other meansof calming the client have been unsuccessful (see Chapter10). For adult clients, use of restraint and seclusionrequires a face-to-face evaluation by a licensed independentpractitioner within 1 hour of restraint or seclusionand every 8 hours thereafter, a physician’s order every4 hours, documented assessment by the nurse every 1 to2 hours, and close supervision of the client. For children,the physician’s order must be renewed every 2 hours, witha face-to-face evaluation every 4 hours. The nurse assessesthe client for any injury and provides treatment as needed.Staff must monitor a client in restraints continuously on a1:1 basis for the duration of the restraint period. A clientin seclusion is monitored 1:1 for the first hour and thenmay be monitored by audio and video equipment. Thenurse monitors and documents the client’s skin condition,blood circulation in hands and feet (for the client inrestraints), emotional well-being, and readiness to discontinueseclusion or restraint. He or she observes the clientclosely for side effects of medications, which may be givenin large doses in emergencies. The nurse or designatedcare provider also implements and documents offers offood, fluids, and opportunities to use the bathroom perfacility policies and procedures (Joint Commission onAccreditation of Healthcare Organizations, 2008).As soon as possible, staff members must inform the clientof the behavioral criteria that will be used to determinewhether to decrease or to end the use of restraint or seclusion.Criteria may include the client’s ability to verbalizefeelings and concerns rationally, to make no verbal threats,to have decreased muscle tension, and to demonstrate selfcontrol.If a client remains in restraints for 1 to 2 hours, twostaff members can free one limb at a time for movement andexercise. Frequent contact by the nurse promotes ongoingassessment of the client’s well-being and self-control. It alsoprovides an opportunity for the nurse to reassure the clientthat restraint is a restorative, not a punitive, procedure. Followingrelease from seclusion or restraint, a debriefing sessionis required within 24 hours.The nurse also should offer support to the client’s family,who may be angry or embarrassed when the client isrestrained or secluded. A careful and thorough explanationabout the client’s behavior and subsequent use ofrestraint or seclusion is important. If the client is an adult,however, such discussion requires a signed release of information.In the case of minor children, signed consent isnot required to inform parents or guardians about the useof restraint or seclusion. Providing the family with informationmay help prevent legal or ethical difficulties. It alsokeeps the family involved in the client’s treatment.ConfidentialityThe protection and privacy of personal health informationis regulated by the federal government through the HealthInsurance Portability and Accountability Act (HIPAA) of1996. The law guarantees the privacy and protection ofhealth information and outlines penalties for violations.Mandatory compliance with the Final HIPAA PrivacyRule took effect on April 14, 2003, for all health-care providers,including individuals and organizations that provideor pay for care. Both civil (fines) and criminal (prisonsentences) penalties exist for violation of patient privacy.Protected health information is any individually identifiablehealth information in oral, written, or electronic form.Mental health and substance abuse records have additionalspecial protection under the privacy rules.Some believe that these strict confidentiality policies maypose a barrier to collaboration among providers and families(Chen, 2008). In community mental health settings,compliance with the privacy rule has decreased communicationand collaboration among providers and communicationwith family caregivers, which may have a negativeimpact on patient care as well as the rights of families (Gray,Robinson, Seddon, & Roberts, 2008). Education programs for

160UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSBox 9.2TARASOFF VS. REGENTSOF THE UNIVERSITY OFCALIFORNIA (1976)In 1969, a graduate student at the University of California,Prosenjit Poddar, dated a young woman named TatianaTarasoff for a short time. After the brief relationship ended,Poddar sought counseling with a psychologist at theuniversity. He confided to the therapist that he intended tokill his former girlfriend when she returned from Brazil atthe end of the summer. The psychologist contacted theuniversity campus police, who detained and questionedPoddar. He was released because he appeared rational,promised to stay away from Tarasoff, and claimed hewould not harm her. Two months later, shortly after herreturn from Brazil, Tatiana Tarasoff was murdered byPoddar on October 27, 1969. Her parents sued the Universityof California, claiming that the therapist had a duty towarn their daughter of Poddar’s threats. The CaliforniaSupreme Court concluded that the protective privilegeends where the public peril begins.clients and families about the privacy regulation as well asestablishment of open lines of communication betweenclients and families before a crisis occurs may help decreasethese difficulties.Duty to Warn Third PartiesOne exception to the client’s right to confidentiality is the dutyto warn, based on the California Supreme Court decision inTarasoff vs. Regents of the University of California (Box 9.2). Asa result of this decision, mental health clinicians have a dutyto warn identifiable third parties of threats made by clients,even if these threats were discussed during therapy sessionsotherwise protected by privilege. Based on the Tarasoff decision,many states have enacted laws regarding warning a thirdparty of threats or danger. The clinician must base his or herdecision to warn others on the following:• Is the client dangerous to others?• Is the danger the result of serious mental illness?• Is the danger serious?• Are the means to carry out the threat available?• Is the danger targeted at identifiable victims?• Is the victim accessible?For example, if a man were admitted to a psychiatricfacility stating he was going to kill his wife, the duty towarn his wife is clear. If, however, a client with paranoiawere admitted saying, “I’m going to get them before theyget me,” but providing no other information, there is nospecific third party to warn. Decisions about the duty towarn third parties usually are made by psychiatrists or byqualified mental health therapists in outpatient settings.Insanity DefenseOne legal issue that sparks controversy is the insanitydefense, with insanity having a legal meaning but nomedical definition. The argument that a person accusedof a crime is not guilty because that person cannot controlhis or her actions or cannot understand the wrongfulnessof the act is known as the M’Naghten Rule. Whenthe person meets the criteria, he or she may be foundguilty by reason of insanity. The public perception of theinsanity defense is that it is used in 33% to 45% of majorcriminal cases and that it is usually successful; that is, theperson accused of the crime “gets off” and is free immediately(Melton, Petrila, Poythree, & Slobogin, 2007). Inactuality, this defense is used in only 0.9% (9 in 1,000) ofall criminal cases and is successful in less than 20% ofthose cases.Four states—Idaho, Kansas, Montana, and Utah—haveabolished the insanity defense. Thirteen states, includingIdaho, Kansas, Montana and Utah, have a law allowing averdict of guilty but insane. Ideally, this means that theperson is held responsible for the criminal behavior butcan receive treatment for mental illness. Critics of this verdict,including the APA, argue that people do not alwaysreceive needed psychiatric treatment and that this verdictabsolves the legal system of its responsibility.Nursing LiabilityNurses are responsible for providing safe, competent, legal,and ethical care to clients and families. Professional guidelinessuch as the American Nurses Association’s (ANA’s)Code of Ethics for Nurses with Interpretive Statements (2001)and the ANA’s Psychiatric–Mental Health Nursing: Scope andStandards of Practice (2007) outline the nurse’s responsibilitiesand provide guidance (see Chapter 1). Nurses areexpected to meet standards of care, meaning the care theyprovide to clients meets set expectations and is what anynurse in a similar situation would do. Standards of care aredeveloped from professional standards (cited earlier in thisparagraph), state nurse practice acts, federal agency regulations,agency policies and procedures, job descriptions,and civil and criminal laws.TortsA tort is a wrongful act that results in injury, loss, or damage.Torts may be either unintentional or intentional.Unintentional Torts: Negligence and Malpractice. Negligenceis an unintentional tort that involves causing harm byfailing to do what a reasonable and prudent person woulddo in similar circumstances. Malpractice is a type of negligencethat refers specifically to professionals such asnurses and physicians (Springhouse, 2004). Clients orfamilies can file malpractice lawsuits in any case of injury,loss, or death. For a malpractice suit to be successful,that is, for the nurse, physician, or hospital or agency to be

CHAPTER 9 • LEGAL AND ETHICAL ISSUES 161liable, the client or family needs to prove the following fourelements:1. Duty: A legally recognized relationship (i.e., physicianto client, nurse to client) existed. The nurse had a dutyto the client, meaning that the nurse was acting in thecapacity of a nurse.2. Breach of duty: The nurse (or physician) failed toconform to standards of care, thereby breaching orfailing the existing duty. The nurse did not act as a reasonable,prudent nurse would have acted in similarcircumstances.3. Injury or damage: The client suffered some type of loss,damage, or injury.4. Causation: The breach of duty was the direct cause ofthe loss, damage, or injury. In other words, the loss,damage, or injury would not have occurred if the nursehad acted in a reasonable, prudent manner.Not all injury or harm to a client can be prevented, nor doall client injuries result from malpractice. The issues arewhether or not the client’s actions were predictable or foreseeable(and, therefore, preventable) and whether or notthe nurse carried out appropriate assessment, interventions,and evaluation that met the standards of care. In themental health setting, lawsuits most often are related tosuicide and suicide attempts. Other areas of concerninclude clients harming others (staff, family, or other clients),sexual assault, and medication errors.Intentional Torts. Psychiatric nurses also may be liablefor intentional torts or voluntary acts that result in harm tothe client. Examples include assault, battery, and falseimprisonment.Assault involves any action that causes a person to fearbeing touched in a way that is offensive, insulting, orphysically injurious without consent or authority. Examplesinclude making threats to restrain the client to givehim or her an injection for failure to cooperate. Batteryinvolves harmful or unwarranted contact with a client;actual harm or injury may or may not have occurred.Examples include touching a client without consent orunnecessarily restraining a client. False imprisonment isdefined as the unjustifiable detention of a client such asthe inappropriate use of restraint or seclusion.Proving liability for an intentional tort involves threeelements (Springhouse, 2004):1. The act was willful and voluntary on the part of thedefendant (nurse).2. The nurse intended to bring about consequences orinjury to the person (client).3. The act was a substantial factor in causing injury orconsequences.Prevention of LiabilityNurses can minimize the risk for lawsuits through safe,competent nursing care and descriptive, accurateBox 9.3 STEPS TO AVOID LIABILITYPractice within the scope of state laws and nursepractice act.Collaborate with colleagues to determine the bestcourse of action.Use established practice standards to guide decisionsand actions.Always put the client’s rights and welfare first.Develop effective interpersonal relationships with clientsand families.Accurately and thoroughly document all assessmentdata, treatments, interventions, and evaluations ofthe client’s response to care.documentation. Box 9.3 highlights ways to minimize therisk for liability.ETHICAL ISSUESEthics is a branch of philosophy that deals with values ofhuman conduct related to the rightness or wrongness ofactions and to the goodness and badness of the motivesand ends of such actions (King, 1984). Ethical theories aresets of principles used to decide what is morally right orwrong.Utilitarianism is a theory that bases decisions on“the greatest good for the greatest number.” Decisionsbased on utilitarianism consider which action wouldproduce the greatest benefit for the most people. Deontologyis a theory that says decisions should be basedon whether or not an action is morally right with noregard for the result or consequences. Principles usedas guides for decision-making in deontology includeautonomy, beneficence, nonmaleficence, justice, veracity,and fidelity.Autonomy refers to the person’s right to self-determinationand independence. Beneficence refers to one’s duty to benefitor to promote good for others. Nonmaleficence is therequirement to do no harm to others either intentionallyor unintentionally. Justice refers to fairness; that is, treatingall people fairly and equally without regard for socialor economic status, race, sex, marital status, religion, ethnicity,or cultural beliefs. Veracity is the duty to be honestor truthful. Fidelity refers to the obligation to honor commitmentsand contracts.All these principles have meaning in health care. Thenurse respects the client’s autonomy through patient’s rights,informed consent, and encouraging the client to makechoices about his or her health care. The nurse has a duty totake actions that promote the client’s health (beneficence)

162UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSand that do not harm the client (nonmaleficence). The nursemust treat all clients fairly (justice), be truthful and honest(veracity), and honor all duties and commitments to clientsand families (fidelity).Ethical Dilemmas in Mental HealthAn ethical dilemma is a situation in which ethical principlesconflict or when there is no one clear course of action in agiven situation. For example, the client who refuses medicationor treatment is allowed to do so based on the principleof autonomy. If the client presents an imminent threat ofdanger to self or others, however, the principle of nonmaleficence(do no harm) is at risk. To protect the client or othersfrom harm, the client may be involuntarily committed to ahospital, even though some may argue that this action violateshis or her right to autonomy. In this example, the utilitariantheory of doing the greatest good for the greatest number(involuntary commitment) overrides the individualclient’s autonomy (right to refuse treatment). Ethical dilemmasare often complicated and charged with emotion, makingit difficult to arrive at fair or “right” decisions.Many dilemmas in mental health involve the client’sright to self-determination and independence (autonomy)and concern for the “public good” (utilitarianism). Examplesinclude the following:• Once a client is stabilized on psychotropic medication,should the client be forced to remain on medicationthrough the use of enforced depot injections or throughoutpatient commitment?• Are psychotic clients necessarily incompetent, or dothey still have the right to refuse hospitalization andmedication?• Can consumers of mental health care truly be empoweredif health-care professionals “step in” to makedecisions for them “for their own good”?• Should physicians break confidentiality to report clientswho drive cars at high speeds and recklessly?• Should a client who is loud and intrusive to otherclients on a hospital unit be secluded from the others?• A health-care worker has an established relationshipwith a person who later becomes a client in the agencywhere the health-care worker practices. Can the healthcareworker continue the relationship with the personwho is now a client?• To protect the public, can clients with a history of violencetoward others be detained after their symptomsare stable?• When a therapeutic relationship has ended, can ahealth-care professional ever have a social or intimaterelationship with someone he or she met as a client?• Is it possible to maintain strict professional boundaries(i.e., no previous, current, or future personal relationshipswith clients) in small communities and ruralareas where all people in the community know oneanother?The nurse will confront some of these dilemmas directly,and he or she will have to make decisions about a courseof action. For example, the nurse may observe behaviorbetween another health-care worker and a client thatBox 9.4 AMERICAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSES1. The nurse, in all professional relationships, practices withcompassion and respect for the inherent dignity, worth,and uniqueness of every individual, unrestricted by considerationsof social or economic status, personal attributes,or the nature of health problems.2. The nurse’s primary commitment is to the patient, whetheran individual, a family, a group, or a community.3. The nurse promotes, advocates for, and strives to protectthe health, safety, and rights of the patient.4. The nurse is responsible and accountable for individualnursing practice and determines the appropriate delegationof tasks consistent with the nurse’s obligation toprovide optimum patient care.5. The nurse owes the same duties to self as to others, includingthe responsibility to preserve integrity and safety,to maintain competence, and to continue personal andprofessional growth.6. The nurse participates in establishing, maintaining, andimproving health-care environments and conditions ofemployment conducive to the provision of quality healthcare and consistent with the values of the professionthrough individual and collective action.7. The nurse participates in the advancement of the professionthrough contributions to practice, education, administration,and knowledge development.8. The nurse collaborates with other health professionalsand the public in promoting community, national, andinternational efforts to meet health needs.9. The profession of nursing, as represented by associationsand their members, is responsible for articulating nursingvalues, for maintaining the integrity of the professionand its practice, and for shaping social policy.American Nurses Association. (2001). Code of ethics for nurses. Washington, DC: American Nurses Publishing.

CHAPTER 9 • LEGAL AND ETHICAL ISSUES 163seems flirtatious or inappropriate. Another dilemma mightrepresent the policies or common practice of the agencywhere the nurse is employed; the nurse may have to decidewhether he or she can support those practices or seek aposition elsewhere. An example would be an agency thattakes clients with a history of medication noncomplianceonly if they are scheduled for depot injections or remainon an outpatient commitment status. Yet other dilemmasare in the larger social arena; the nurse’s decision is whetherto support current practice or to advocate for change onbehalf of clients, such as laws permitting people to bedetained after treatment is completed when there is apotential of future risk for violence.Ethical Decision-MakingThe ANA published a Code of Ethics for Nurses (2001) toguide choices about ethical actions (Box 9.4). Models forethical decision-making include gathering information,clarifying values, identifying options, identifying legalconsiderations and practical restraints, building consensusfor the decision reached, and reviewing and analyzingthe decision to determine what was learned (Abma &Widdershoven, 2006).SELF-AWARENESS ISSUESAll nurses have beliefs about what is right orwrong and good or bad. That is, they have valuesjust like all other people. Being a memberof the nursing profession, however, presumes aduty to clients and families under the nurse’s care: a duty toprotect rights, to be an advocate, and to act in the clients’best interests even if that duty is in conflict with the nurse’spersonal values and beliefs. The nurse is obligated to engagein self-awareness by identifying clearly and examining hisor her own values and beliefs so they do not become confusedwith or overshadow a client’s. For example, if a clientis grieving over her decision to have an abortion, the nursemust be able to provide support to her even though thenurse may be opposed to abortion. If the nurse cannot dothat, then he or she should talk to colleagues to find someonewho can meet that client’s needs.Points to Consider When ConfrontingEthical Dilemmas• Talk to colleagues or seek professional supervision.Usually, the nurse does not need to resolve an ethicaldilemma alone.• Spend time thinking about ethical issues and determinewhat your values and beliefs are regarding situationsbefore they occur.• Be willing to discuss ethical concerns with colleaguesor managers. Being silent is condoning the behavior.Critical Thinking Questions1. Some clients with psychiatric disorders makeheadlines when they commit crimes against othersthat involve serious injury or death. With treatmentand medication, these clients are rational and representno threat to others, but they have a history of stoppingtheir medications when released from treatmentfacilities. Where and how should these clients betreated? What measures can protect their individualrights as well as the public right to safety?2. Some critics of deinstitutionalization argue thattaking people who are severely and persistentlymentally ill out of institutions and closing some orall those institutions have worsened the mentalhealth crisis. These closings have made it difficultfor this minority of mentally ill clients to receivenecessary inpatient treatment. Opponents counterthat institutions are harmful because they segregatethe mentally ill from the community, limit autonomy,and contribute to the loss of social skills. With whichviewpoint do you agree? Why?KEY POINTS• Clients can be involuntarily hospitalized ifthey present an imminent danger of harmto themselves or others.• Patients’ rights include the right to receiveand refuse treatment, to be involved in theplan of care, to be treated in the least restrictive environment,to refuse to participate in research, and to haveunrestricted visitors, mail, and phone calls.• The use of seclusion (confinement in a locked room)and restraint (direct application of physical force) fallsunder the domain of the patient’s right to the leastrestrictive environment. Short-term use is permittedonly if the client is imminently aggressive and dangerousto himself or herself or to others.• Mental health clinicians have a legal obligation to breachclient confidentiality to warn a third party of directthreats made by the client.• Nurses have the responsibility to provide safe, competent,legal, and ethical care as outlined in nurse practice acts,the Scope and Standards of Psychiatric–Mental HealthNursing Practice, and the Code of Ethics for Nurses.• A tort is a wrongful act that results in injury, loss, ordamage. Negligence is an unintentional tort causingharm through failure to act.• Malpractice is negligence by health professionals in casesin which they have a duty to the client that is breached,thereby causing injury or damage to the client.• Intentional torts include assault, battery, and falseimprisonment.

164UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSINTERNET RESOURCESRESOURCES• American Academy of Psychiatry and the Law• ADA (Americans With Disabilities Act) InformationCenter• Institute of Law, Psychiatry, and Public Policy• Mental Health Matters: Information and Resources• Mental Health Patient’s Bill of Rights• State Mental Health Laws• Chart of State Insanity Defense LawsINTERNET ADDRESShttp://www.aapl.orghttp://www.eeoc.gov/types/ada.htmlhttp://www.ilppp.virginia.eduhttp://www.mental-health-matters.comhttp://www.apa.org/topics/rights/http://www.megalaw.com/top/mentalhealth.phphttp://www.pbs.org/wgbh/pages/frontline/shows/crime/trial/states.html• Ethical theories are sets of principles used to decidewhat is morally right or wrong, such as utilitarianism(the greatest good for the greatest number) and deontology(using principles such as autonomy, beneficence,nonmaleficence, justice, veracity, and fidelity), to makeethical decisions.• Ethical dilemmas are situations that arise when principlesconflict or when there is no single clear course ofaction in a given situation.• Many ethical dilemmas in mental health involve a conflictbetween the client’s autonomy and concerns for thepublic good (utilitarianism).REFERENCESAbma, T. A., & Widdershoven, G. A. (2006). Moral deliberation inpsychiatric nursing practice. Nursing Ethics, 13(5), 546–557.American Nurses Association. (2007). Psychiatric–mental health nursing:Scope and standards of practice. Washington, DC: American NursesPublishing, American Nurses Foundation/American NursesAssociation.American Nurses Association. (2001). Code of ethics for nurses with interpretivestatements. Washington, DC: American Nurses Publishing.Chen, F. P. (2008). A fine line to walk: Case managers’ perspectives onsharing information with families. Qualitative Health Research,18(11), 1556–1565.Cullen-Drill, M., & Schilling, K. (2008). The case for mandatory outpatienttreatment. Journal of Psychosocial and Mental Health Nursing,46(2), 33–41.Geller, J. L., Fisher, W. H., Grudzinskas, A. J. Jr., Clayfield, J. C., &Lawlor, T. (2006). Involuntary outpatient treatment as “deinstitutionalizedcoercion”: The net-widening concerns. InternationalJournal of Law and Psychiatry, 29(6), 551–562.Gray, B., Robinson, C., Seddon, D., & Roberts, A. (2008). “Confidentialitysmokescreens” and carers for people with mental health problems:The perspective of professionals. Health and Social Care in theCommunity, 16(4), 378–387.Joint Commission on Accreditation of Healthcare Organizations. (2008).Restraint and seclusion standards for behavioral health. Oakbrook, IL:Author.King, E. C. (1984). Affective education in nursing: A guide to teaching andassessment. Rockville, MD: Aspen Systems.Melton, G., Petrila, J., Poythree, N, & Slobogin, C. (2007). Psychologicalevaluations for the courts: A handbook for mental health professionalsand lawyers (3rd ed.). New York: Guilford Press.Segal, S. P., & Burgess, P. M. (2006a). Conditional release: A less restrictivealternative to hospitalization? Psychiatric Services, 57(11),1600–1606.Segal, S. P., & Burgess, P. M. (2006b). Effect of conditional release fromhospitalization on mortality risk. Psychiatric Services, 57(11),1607–1613.Springhouse. (2004). Nurses’ legal handbook (5th ed.). Philadelphia:Lippincott Williams & Wilkins.Swartz, M. S., Swanson, J. W., Kim, M., & Petrila, J. (2006). Use of outpatientcommitment or related civil court treatment orders in 5 U.S.communities. Psychiatric Services, 57(3), 343–349.Treatment Advocacy Center. (2009). Standards for assisted treatment:State-by-state summary. Retrieved January 4, 2009, from http://www.psychlaws.org/LegalResources/statechart.htm.ADDITIONAL READINGSAppelbaum, P. S. (2005). Assessing Kendra’s law: Five years of outpatientcommitment in New York. Psychiatric Services, 56(7), 791–792.Appelbaum, P. S. (2006). Insanity, guilty minds, and psychiatrictestimony. Psychiatric Services, 57(10), 1370–1372.Campbell, R. J., Yonge, O., & Austin, W. (2005). Intimacy boundariesbetween mental health nurses and psychiatric patients. Journal ofPsychosocial Nursing, 43(5), 32–39.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The client who is involuntarily committed to an inpatientpsychiatric unit loses which of the followingrights?a. Right to freedomb. Right to refuse treatmentc. Right to sign legal documentsd. The client loses no rights.2. A client has a prescription for Haloperidol, 5 mg orallytwo times a day, as ordered by the physician. The clientis suspicious and refuses to take the medication. Thenurse says, “If you don’t take this pill, I’ll get an orderto give you an injection.” The nurse’s statement is anexample ofa. Assaultb. Batteryc. Malpracticed. Unintentional tort3. A hospitalized client is delusional, yelling, “The worldis coming to an end. We must all run to safety!” Whenother clients complain that this client is loud andannoying, the nurse decides to put the client in seclusion.The client has made no threatening gesturesor statements to anyone. The nurse’s action is anexample ofa. Assaultb. False imprisonmentc. Malpracticed. Negligence4. Which of the following would indicate a duty to warn athird party?a. A client with delusions states, “I’m going to get thembefore they get me.”b. A hostile client says, “I hate all police.”c. A client says he plans to blow up the federalgovernment.d. A client states, “If I can’t have my girlfriend back,then no one can have her.”5. The nurse gives the client quetiapine (Seroquel) inerror when olanzapine (Zyprexa) was ordered. The clienthas no ill effects from the quetiapine. In addition tomaking a medication error, the nurse has committedwhich of the following?a. Malpracticeb. Negligencec. Tort (unintentional)d. None of the aboveMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Which of the following elements are essential in a clinician’sduty to warn?a. Client makes threatening statementsb. History of violencec. Potential victim(s) are identifiabled. Potential victim is easy to locatee. Threat is not a delusionf. Threat of harm is serious2. Which of the following elements are necessary to proveliability in a malpractice lawsuit?a. Client is injuredb. Failure to conform to standards of carec. Injury caused by breach of dutyd. Injuries must be visible and verifiede. Nurse intended to cause harmf. Recognized relationship between client and nurse165

10Anger, Hostility,and AggressionLearning ObjectivesAfter reading this chapter, you should be able to:1. Discuss anger, hostility, and aggression.Key Terms• acting out• anger• catharsis• crisis phase• escalation phase• hostility• impulse control• physical aggression• postcrisis phase• recovery phase• triggering phase2. Describe psychiatric disorders that may be associated with an increased riskfor hostility and physical aggression in clients.3. Describe the signs, symptoms, and behaviors associated with the fivephases of aggression.4. Discuss appropriate nursing interventions for the client during the fivephases of aggression.5. Describe important issues for nurses to be aware of when working withangry, hostile, or aggressive clients.ANGER, A NORMAL HUMAN EMOTION, is a strong, uncomfortable, emotionalresponse to a real or perceived provocation. Anger results when a person isfrustrated, hurt, or afraid. Handled appropriately and expressed assertively,anger can be a positive force that helps a person to resolve conflicts, solveproblems, and make decisions. Anger energizes the body physically for selfdefense,when needed, by activating the “fight-or-flight” response mechanismsof the sympathetic nervous system. When expressed inappropriatelyor suppressed, however, anger can cause physical or emotional problems orinterfere with relationships (Koh, Kim, Kim, Park, & Han, 2008).Hostility, also called verbal aggression, is an emotion expressed throughverbal abuse, lack of cooperation, violation of rules or norms, or threateningbehavior (Schultz & Videbeck, 2009). A person may express hostilitywhen he or she feels threatened or powerless. Hostile behavior is intendedto intimidate or cause emotional harm to another, and it can lead to physicalaggression. Physical aggression is behavior in which a person attacksor injures another person or that involves destruction of property. Bothverbal and physical aggression are meant to harm or punish another personor to force someone into compliance. Some clients with psychiatricdisorders display hostile or physically aggressive behavior that representsa challenge to nurses and other staff members.166Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 167HostilityViolence and abuse are discussed in Chapter 11, andself-directed aggression such as suicidal behavior is presentedin Chapter 15. The focus of this chapter is thenurse’s role in recognizing and managing hostile andaggressive behavior that clients direct toward others withinpsychiatric settings.ONSET AND CLINICAL COURSEAngerAlthough anger is normal, it often is perceived as a negativefeeling. Many people are not comfortable expressinganger directly. Nevertheless, anger can be a normal andhealthy reaction when situations or circumstances areunfair or unjust, personal rights are not respected, or realisticexpectations are not met. If the person can express hisor her anger assertively, problem-solving or conflict resolutionis possible.Anger becomes negative when the person denies it,suppresses it, or expresses it inappropriately. A person maydeny or suppress (i.e., hold in) angry feelings if he or sheis uncomfortable expressing anger. Possible consequencesare physical problems such as migraine headaches, ulcers,or coronary artery disease and emotional problems such asdepression and low self-esteem.Anger that is expressed inappropriately can lead to hostilityand aggression. The nurse can help clients expressanger appropriately by serving as a model and by roleplayingassertive communication techniques. Assertivecommunication uses “I” statements that express feelingsand are specific to the situation, for example, “I feel angrywhen you interrupt me,” or “I am angry that you changedthe work schedule without talking to me.” Statementssuch as these allow appropriate expression of anger andcan lead to productive problem-solving discussions andreduced anger.Some people try to express their angry feelings byengaging in aggressive but safe activities such as hitting apunching bag or yelling. Such activities, called catharsis,are supposed to provide a release for anger. However,catharsis can increase rather than alleviate angry feelings.Therefore, cathartic activities may be contraindicated forangry clients. Activities that are not aggressive, such aswalking or talking with another person, are more likely tobe effective in decreasing anger (Jacob & Pelham, 2005).Shapiro (2005) reported that high hostility is associatedwith increased risk for coronary artery disease and hypertension.Hostility can lead to angry outbursts that are noteffective for anger expression. Effective methods of angerexpression, such as using assertive communication, toexpress anger should replace angry aggressive outbursts oftemper such as yelling or throwing things. Controllingone’s temper or managing anger effectively should not beconfused with suppressing angry feelings, which can leadto the problems described earlier.Anger suppression is especially common in women, whohave been socialized to maintain and enhance relationshipswith others and to avoid the expression of so-called negativeor unfeminine emotions such as anger. Women’s angeroften results when people deny them power or resources,treat them unjustly, or behave irresponsibly toward them.School-age girls report experiences of disrespect, dismissal,and denial of the right to express anger (van-Daalen-Smith,2008). The offenders are not strangers, but are usually theirclosest intimates. Manifestations of anger suppressionthrough somatic complaints and psychological problemsare more common among women than men. Women mustrecognize that anger awareness and expression are necessaryfor their growth and development.Hostility and AggressionHostile and aggressive behavior can be sudden and unexpected.Often, however, stages or phases can be identifiedin aggressive incidents: a triggering phase (incident orsituation that initiates an aggressive response), an escalationphase, a crisis phase, a recovery phase, and a postcrisisphase. These phases and their signs, symptoms, andbehaviors are discussed later in the chapter.As a client’s behavior escalates toward the crisis phase,he or she loses the ability to perceive events accurately,

168UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSAssertive communicationsolve problems, express feelings appropriately, or controlhis or her behavior; behavior escalation may lead to physicalaggression. Therefore, interventions during the triggeringand escalation phases are key to preventing physicallyaggressive behavior (discussion to follow).RELATED DISORDERSThe media gives a great deal of attention to people withmental illness who commit aggressive acts. This gives thegeneral public the mistaken idea that most people withmental illness are aggressive and should be feared. In reality,clients with psychiatric disorders are much more likelyto hurt themselves than other people.Although most clients with psychiatric disorders are notaggressive, clients with a variety of psychiatric diagnosescan exhibit angry, hostile, and aggressive behavior. Clientswith paranoid delusions may believe others are out to getthem; believing they are protecting themselves, they retaliatewith hostility or aggression. Some clients have auditoryhallucinations that command them to hurt others. Aggressivebehavior also is seen in clients with dementia, delirium,head injuries, intoxication with alcohol or otherdrugs, and antisocial and borderline personality disorders.Violent patients tend to be more symptomatic, have poorerfunctioning, and a marked lack of insight compared withnonviolent patients (Dolan & Davies, 2006).Some clients with depression have anger attacks. Thesesudden intense spells of anger typically occur in situationsin which the depressed person feels emotionally trapped.Anger attacks involve verbal expressions of anger or ragebut no physical aggression. Clients describe these angerattacks as uncharacteristic behavior that is inappropriatefor the situation and followed by remorse. The angerattacks seen in some depressed clients may be related toirritable mood, overreaction to minor annoyances, anddecreased coping abilities (Akiskal, 2005).Intermittent explosive disorder is a rare psychiatricdiagnosis characterized by discrete episodes of aggressiveimpulses that result in serious assaults or destruction ofproperty. The aggressive behavior the person displays isgrossly disproportionate to any provocation or precipitatingfactor. This diagnosis is made only if the client hasno other comorbid psychiatric disorders, as previouslydiscussed. The person describes a period of tension orarousal that the aggressive outburst seems to relieve.Afterward, however, the person is remorseful and embarrassed,and there are no signs of aggressiveness betweenepisodes (Greenberg, 2005). Intermittent explosive disorderdevelops between late adolescence and the thirddecade of life (American Psychiatric Association, 2000).Clients with intermittent explosive disorder typically arelarge men with dependent personality features whorespond to feelings of uselessness or ineffectiveness withviolent outbursts.Acting out is an immature defense mechanism by whichthe person deals with emotional conflicts or stressorsthrough actions rather than through reflection or feelings.The person engages in acting-out behavior, such as verbalor physical aggression, to feel temporarily less helpless orpowerless. Children and adolescents often “act out” whenthey cannot handle intense feelings or deal with emotionalconflict verbally. To understand acting-out behaviors, it isimportant to consider the situation and the person’s abilityto deal with feelings and emotions.ETIOLOGYNeurobiologic TheoriesResearchers have examined the role of neurotransmittersin aggression in animals and humans, but they have beenunable to identify a single cause. Findings reveal that serotoninplays a major inhibitory role in aggressive behavior;therefore, low serotonin levels may lead to increasedaggressive behavior. This finding may be related to theanger attacks seen in some clients with depression. Inaddition, increased activity of dopamine and norepinephrinein the brain is associated with increased impulsivelyviolent behavior. Further, structural damage to the limbicsystem and the frontal and temporal lobes of the brain mayalter the person’s ability to modulate aggression; this canlead to aggressive behavior (Siever, 2008).

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 169Psychosocial TheoriesInfants and toddlers express themselves loudly andintensely, which is normal for these stages of growth anddevelopment. Temper tantrums are a common responsefrom toddlers whose wishes are not granted. As a childmatures, he or she is expected to develop impulse control(the ability to delay gratification) and socially appropriatebehavior. Positive relationships with parents, teachers, andpeers; success in school; and the ability to be responsiblefor oneself foster development of these qualities. Childrenin dysfunctional families with poor parenting, childrenwho receive inconsistent responses to their behavior, andchildren whose families are of lower socioeconomic statusare at increased risk for failing to develop socially appropriatebehavior. This lack of development can result in aperson who is impulsive, easily frustrated, and prone toaggressive behavior.Leary, Twenge, and Quinlivan (2006) found a relationshipbetween interpersonal rejection and aggression. Rejectioncan lead to anger and aggression when that rejectioncauses the individual emotional pain or frustration, or is athreat to self-esteem. Aggressive behavior was often seen asa means of re-establishing control, improving mood,or achieving retribution.CULTURAL CONSIDERATIONSWhat a culture considers acceptable strongly influencesthe expression of anger. The nurse must be aware of culturalnorms to provide culturally competent care. In theUnited States, women traditionally were not permitted toexpress anger openly and directly because doing so wouldnot be “feminine” and would challenge male authority.That cultural norm has changed slowly during the past25 years. Some cultures, such as Asian and Native American,see expressing anger as rude or disrespectful and avoid itat all costs. In these cultures, trying to help a clientexpress anger verbally to an authority figure would beunacceptable.Ethnic or minority status can play a role in the diagnosisand treatment of psychiatric illness. Patients with darkskin, regardless of race, are sometimes perceived as moredangerous than light-skinned patients, and therefore morelikely to experience compulsory hospitalizations, increaseduse of restraints, higher doses of medication, and so forth.One study found that Caucasian children and adolescentswere more often diagnosed with depression or substanceabuse disorders, while African-American and Hispanic/Latino patients received psychotic or behavioral disorderdiagnoses (Muroff, Edelsohm, Joe, & Ford, 2008). TheEuropean Board of Medical Specialists recognizes culturalawareness issues as a core component of psychiatry training,but few medical schools provide training in culturalissues (Qureshi, Collazos, Ramos, & Casas, 2008). Theseauthors propose that education to develop culturalcompetence is needed to provide quality care to immigrantsand minority group patients.Hwa-Byung or hwabyeong is a culture-bound syndromethat literally translates as anger syndrome or fire illness,attributed to the suppression of anger (Choi & Lee, 2007).It is seen in Korea, predominately in women, and is characterizedby sighing, abdominal pain, insomnia, irritability,anxiety, and depression. Western psychiatrists wouldbe likely to diagnose it as depression or somatizationdisorder.Two culture-bound syndromes involve aggressive behavior.Bouffée delirante, a condition observed in West Africaand Haiti, is characterized by a sudden outburst of agitatedand aggressive behavior, marked confusion, and psychomotorexcitement. These episodes may include visual andauditory hallucinations and paranoid ideation that resemblebrief psychotic episodes. Amok is a dissociative episodecharacterized by a period of brooding followed by an outburstof violent, aggressive, or homicidal behavior directedat other people and objects. This behavior is precipitated bya perceived slight or insult and is seen only in men. Originallyreported from Malaysia, similar behavior patterns areseen in Laos, the Philippines, Papua New Guinea, Polynesia(cafard), Puerto Rico (mal de pelea), and among the Navajo(iich’aa) (Moitabai, 2005).TREATMENTThe treatment of aggressive clients often focuses on treatingthe underlying or comorbid psychiatric diagnosis suchas schizophrenia or bipolar disorder. Successful treatmentof comorbid disorders results in successful treatment ofaggressive behavior. Lithium has been effective in treatingaggressive clients with bipolar disorder, conduct disorders(in children), and mental retardation. Carbamazepine(Tegretol) and valproate (Depakote) are used to treataggression associated with dementia, psychosis, and personalitydisorders. Atypical antipsychotic agents such asclozapine (Clozaril), risperidone (Risperdal), and olanzapine(Zyprexa) have been effective in treating aggressiveclients with dementia, brain injury, mental retardation,and personality disorders. Benzodiazepines can reduceirritability and agitation in older adults with dementia, butthey can result in the loss of social inhibition for otheraggressive clients, thereby increasing rather than reducingtheir aggression.Haloperidol (Haldol) and lorazepam (Ativan) are commonlyused in combination to decrease agitation or aggressionand psychotic symptoms. Patients who are agitatedand aggressive but not psychotic benefit most from lorazepamwhich can be given in 2-mg doses, every 45 to60 minutes (Garlow, Purselle, & D’Orio, 2006). Goedhardand associates (2006) found that atypical antipsychoticswere more effective than conventional antipsychotics foraggressive, psychotic clients. Use of antipsychotic medicationsrequires careful assessment for the development of

170UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSextrapyramidal side effects, which can be quickly treatedwith benztropine (Cogentin). Chapter 2 provides a fulldiscussion of these medications and their side effects.Although not a treatment per se, the short-term use ofseclusion or restraint may be required during the crisisphase of the aggression cycle to protect the client and othersfrom injury. Many legal and ethical safeguards governthe use of seclusion and restraint (see Chapter 9).APPLYING THE NURSING PROCESSAssessment and effective intervention with angry or hostileclients can often prevent aggressive episodes (see theaccompanying nursing care plan in this chapter). Earlyassessment, judicious use of medications, and verbal interactionwith an angry client can often prevent anger fromescalating into physical aggression.Nursing Care Plan | Aggressive BehaviorNursing DiagnosisRisk for Other-Directed Violence: At risk for behaviors in which an individual demonstratesthat he/she can be physically, emotionally, and/or sexually harmful to others.RISK FACTORS• Actual or potential physical acting out of violence• Destruction of property• Homicidal or suicidal ideation• Physical danger to self or others• History of assaultive behavior or arrests• Neurologic illness• Disordered thoughts• Agitation or restlessness• Lack of impulse control• Delusions, hallucinations, or other psychoticsymptoms• Personality disorder or other psychiatric symptoms• Manic behavior• Conduct disorder• Posttraumatic stress disorder• Substance useEXPECTED OUTCOMESImmediateThe client will• Refrain from harming others or destroying property• Be free of self-inflicted harm• Demonstrate decreased acting-out behavior• Experience decreased restlessness or agitation• Experience decreased fear, anxiety, or hostilityStabilizationThe client will• Demonstrate the ability to exercise internal controlover his or her behavior• Be free of psychotic behavior• Identify ways to deal with tension and aggressivefeelings in a nondestructive manner• Express feelings of anxiety, fear, anger, or hostilityverbally or in a nondestructive manner; e.g., talk withstaff about these feelings at least once per day by aspecified date• Verbalize an understanding of aggressive behavior,associated disorder(s), and medications, if anyCommunityThe client will• Participate in therapy for underlying or associatedpsychiatric problems• Demonstrate internal control of behavior whenconfronted with stressIMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Build a trust relationship with this client as soon aspossible, ideally well in advance of aggressive episodes.RationaleFamiliarity with and trust in the staff members candecrease the client’s fears and facilitate communication.(continued)

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 171Nursing Care Plan | Aggressive Behavior, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Be aware of factors that increase the likelihood ofviolent behavior or agitation. Use verbal communicationor PRN medication to intervene before theclient’s behavior reaches a destructive point andphysical restraint becomes necessary.If the client tells you (verbally or nonverbally) thathe or she feels hostile or destructive, try to help theclient express these feelings in nondestructive ways(e.g., use communication techniques or take theclient to the gym for physical exercise).Be aware of PRN medication and procedures forobtaining seclusion or restraint orders.*Develop and practice consistent techniques ofrestraint as part of nursing orientation and continuingeducation.*Develop instructions in safe techniques for carryingclients.Be familiar with restraint, seclusion, and staff assistanceprocedures and legal requirements.Always maintain control of yourself and the situation;remain calm. If you do not feel competent in dealingwith a situation, obtain assistance as soon as possible.Calmly and respectfully assure the client that you(the staff) will provide control if he or she cannotcontrol himself or herself, but do not threaten theclient.*Notify the charge nurse and supervisor as soon aspossible in a (potentially) aggressive situation; tellthem your assessment of the situation and the needfor help, the client’s name, care plan, and ordersfor medication, seclusion, or restraint.*Follow the hospital staff assistance plan (e.g., useintercom system to page “Code _____,” area); then,if possible, have one staff member meet the additionalstaff at the unit door to give them the client’sname, situation, goal, plan, and so forth.RationaleA period of building tension often precedes acting out;however, a client who is intoxicated or psychotic maybecome violent without warning. Signs of increasingagitation include increased restlessness, motoractivity (e.g., pacing), voice volume, verbal cues (I’mafraid of losing control.), threats, decreased frustrationtolerance, and frowning or clenching fists.The client can try out new behaviors with you in anonthreatening environment and learn nondestructiveways to express feelings rather than acting out.In an aggressive situation you will need to make decisionsand act quickly. If the client is severely agitated,medication may be necessary to decrease the agitation.Consistent techniques let each staff person know whatis expected and will increase safety and effectiveness.Consistent techniques increase safety and effectiveness.You must be prepared to act and direct other staff inthe safe management of the client. You are legallyaccountable for your decisions and actions.Your behavior provides a role model for the client andcommunicates that you can and will provide control.The client may fear loss of control and may be afraidof what he or she may do if he or she begins toexpress anger. Showing that you are in controlwithout competing with the client can reassure theclient without lowering his or her self-esteem.You may need assistance from staff members who areunfamiliar with this client. They will be able to helpmore effectively and safely if they are aware of thisinformation.The need for help may be immediate in an emergencysituation. Any information that can be given toarriving staff will be helpful in ensuring safety andeffectiveness in dealing with this client.IF THE CLIENT HAS A WEAPONIf you are not properly trained or skilled in dealingsafely with a client who has a weapon, do not attemptto remove the weapon. Keep something (like a pillow,mattress, or a blanket wrapped around your arm)between you and the weapon.Avoiding personal injury, summoning help, leavingthe area, or protecting other clients may be the onlythings you can realistically do. You may risk furtherdanger by attempting to remove a weapon or subduean armed client.(continued)

172UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSIF THE CLIENT HAS A WEAPONNursing Care Plan | Aggressive Behavior, cont.If it is necessary to remove the weapon, try to kick it outof the client’s hand. (Never reach for a knife or otherweapon with your hand.)Distract the client momentarily to remove the weapon(throw water in the client’s face, or yell suddenly).*You may need to summon outside assistance (especiallyif the client has a gun). When this is done,total responsibility is delegated to the outsideauthorities.Remain aware of the client’s body space or territory;do not trap the client.Allow the client freedom to move around (within safelimits) unless you are trying to restrain him or her.Decrease stimulation by turning television off or loweringthe volume, lowering the lights, asking othersto leave the area (or you can go with the client toanother room).Talk with the client in a low, calm voice. Call the clientby name, tell the client your name, where youare, and so forth.Tell the client what you are going to do and what youare doing. Use simple, clear, direct speech; repeat ifnecessary. Do not threaten the client, but state limitsand expectations.Do not use physical restraints or techniques withoutsufficient reason.*When a decision has been made to subdue orrestrain the client, act quickly and cooperativelywith other staff members. Tell the client in amatter-of-fact manner that he or she will berestrained, subdued, or secluded; allow no bargainingafter the decision has been made. Reassurethe client that he or she will not be hurt and thatrestraint or seclusion is to ensure safety.*While subduing or restraining the client, talk withother staff members to ensure coordination ofeffort (e.g., do not attempt to carry the client untilyou are sure that everyone is ready).Do not strike the client.Do not help to restrain or subdue the client if you areangry (if enough other staff members are present).Do not restrain or subdue the client as a punishment.Do not recruit or allow other clients to help inrestraining or subduing a client.Reaching for a weapon increases your physicalvulnerability.Distracting the client’s attention may give you an opportunityto remove the weapon or subdue the client.Exceeding your abilities may place you in grave danger.It is not necessary to try to deal with a situationbeyond your control or to assume personal risk.Potentially violent people have a body space zone upto four times larger than that of other people. Thatis, you need to stay farther away from them forthem to not feel trapped or threatened.Interfering with the client’s mobility without theintent of restraint may increase the client’s frustration,fears, or perception of threat.If the client is feeling threatened, he or she can perceiveany stimulus as a threat. The client is unableto deal with excess stimuli when agitated.Using a low voice may help prevent increasing agitation.The client may be disoriented or unaware ofwhat is happening.The client’s ability to understand the situation and toprocess information is impaired. Clear limits let theclient know what is expected of him or her.The client has a right to the fewest restrictions possiblewithin the limits of safety and prevention ofdestructive behavior.Firm limits must be set and maintained. Bargaininginterjects doubt and will undermine the limit.Direct verbal communication will promote cooperationand safety.Physical safety of the client is a priority.Staff members must maintain self-control at all timesand act in the client’s best interest. There is no justificationfor being punitive to a client.Physical safety of all clients is a priority. Other clientsare not responsible for controlling the behavior of aclient and should not assume a staff role.(continued)

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 173IF THE CLIENT HAS A WEAPONNursing Care Plan | Aggressive Behavior, cont.If possible, do not allow other clients to watch staffsubduing the client. Take them to a different area,and involve them in activities or discussion.Obtain additional staff assistance when needed. Havesomeone clear furniture and so forth from the areathrough which you will be carrying the client.When placing the client in restraints or seclusion,tell the client what you are doing and why (e.g., toregain control or protect the client from injuringhimself, herself, or others). Use simple, conciselanguage in a nonjudgmental, matter-of-fact manner.See Nursing Diagnosis: Risk for Injury.Tell the client where he or she is, that he or she willbe safe, and that staff members will check on himor her. Tell the client how to summon the staff.Reorient the client or remind him or her of the reasonfor restraint as necessary.Reassess the client’s need for continued seclusion orrestraint and release the client or decrease restraintas soon as it is safe and therapeutic. Base your decisionson the client’s, not the staff’s, needs.Remain aware of the client’s feelings (including fear),dignity, and rights.Carefully observe the client and promptly completedocumentation in keeping with hospital policy.Bear in mind possible legal implications.Administer medications safely; take care to prepare correctdosage, identify correct sites for administration,withdraw plunger to aspirate for blood, and so forth.Take care to avoid needlestick injury and other injuriesthat may involve exposure to the client’s bloodor body fluids.Monitor the client for effects of medications, andintervene as appropriate.Talk with other clients after the situation is resolved;allow them to express feelings about the situation.Other clients may be frightened, agitated, or endangeredby client with aggressive behavior. They needsafety and reassurance at this time.Transporting a client who is agitated can be dangerousif attempted without sufficient help and sufficientspace.The client’s ability to understand what is happeningto him or her may be impaired.Being placed in seclusion or restraints can be terrifyingto a client. Your assurances may help alleviatethe client’s fears.The client has a right to the least restrictions possiblewithin the limits of safety and prevention ofdestructive behavior.The client is a worthwhile person regardless of his orher unacceptable behavior.Accurate, complete documentation is essential, asrestraint, seclusion, assault, and so forth are situationsthat may result in legal action.When you are in a stressful situation and under pressureto move quickly, the possibility of errors in dosage oradministration of medication is increased.Hepatitis C, HIV, and other diseases are transmittedby exposure to blood or body fluids.Psychoactive drugs can have adverse effects, such asallergic reactions, hypotension, and pseudoparkinsoniansymptoms.Other clients have needs; be careful not to give attentiononly to the client who is acting out.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.).Philadelphia: Lippincott Williams & Wilkins.AssessmentThe nurse should be aware of factors that influence aggressionin the psychiatric environment, or unit milieu. Aggressivebehavior is less common on psychiatric units withstrong psychiatric leadership, clear staff roles, and plannedand adequate events such as staff–client interaction, groupinteraction, and activities. Conversely, when predictabilityof meetings or groups and staff–client interactionsare lacking, clients often feel frustrated and bored, andaggression was more common and intense. A lack of psychologicalspace—having no privacy, being unable to getsufficient rest—may be more important in triggeringaggression than a lack of physical space.In addition to assessing the unit milieu, the nurse needsto assess individual clients carefully. A history of violent oraggressive behavior is one of the best predictors of futureaggression. Determining how the client with a history of

174UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSaggression handles anger and what the client believes ishelpful is important in assisting him or her to control ornonaggressively manage angry feelings. Clients who areangry and frustrated and believe that no one is listening tothem are more prone to behave in a hostile or aggressivemanner. In addition to a past history of violence, a historyof being personally victimized and one of substance abuseincrease a client’s likelihood of aggressive behavior. Individualcues can help the nurse recognize when aggressivebehavior is imminent (Pryor, 2005). These cues includewhat the client is saying; changes in the client’s voice—volume, pitch, speed; changes in the client’s facial expression;and changes in the client’s behavior.The nurse should assess the client’s behavior to determinewhich phase of the aggression cycle he or she is in sothat appropriate interventions can be implemented. Thefive phases of aggression and their signs, symptoms, andbehaviors are presented in Table 10.1. Assessment of clientsmust take place at a safe distance. The nurse canapproach the client while maintaining an adequate distanceso that the client does not feel trapped or threatened. Toensure staff safety and exhibit teamwork, it may be prudentfor two staff members to approach the client.Data AnalysisNursing diagnoses commonly used when working withaggressive clients include the following:• Risk for Other-Directed Violence• Ineffective CopingIf the client is intoxicated, depressed, or psychotic, additionalnursing diagnoses may be indicated.Outcome IdentificationExpected outcomes for aggressive clients may include thefollowing:1. The client will not harm or threaten others.2. The client will refrain from behaviors that are intimidatingor frightening to others.3. The client will describe his or her feelings and concernswithout aggression.4. The client will comply with treatment.InterventionHostility or verbally aggressive behavior can be intimidatingor frightening even for experienced nurses. Clientsexhibiting these behaviors are also threatening to other clients,staff, and visitors. In social settings, the most frequentresponse to hostile people is to get as far away from them aspossible. In the psychiatric setting, however, engaging thehostile person in dialogue is most effective to prevent thebehavior from escalating to physical aggression.Interventions are most effective and least restrictive whenimplemented early in the cycle of aggression. This sectionpresents interventions for the management of the milieu(which benefit all clients regardless of setting) and specificinterventions for each phase of the aggression cycle.Managing the EnvironmentIt is important to consider the environment for all clientswhen trying to reduce or eliminate aggressive behavior.Group and planned activities such as playing card games,watching and discussing movies, or participating in informalTable 10.1FIVE-PHASE AGGRESSION CYCLEPhase Definition Signs, Symptoms, and BehaviorsTriggering An event or circumstances in the environmentinitiates the client’s response, which is oftenanger or hostility.Restlessness, anxiety, irritability, pacing, muscletension, rapid breathing, perspiration, loud voice,angerEscalation Client’s responses represent escalating behaviorsthat indicate movement toward a loss ofcontrol.Pale or flushed face, yelling, swearing, agitated,threatening, demanding, clenched fists, threateninggestures, hostility, loss of ability to solve theproblem or think clearlyCrisisDuring a period of emotional and physical crisis,the client loses control.Loss of emotional and physical control, throwingobjects, kicking, hitting, spitting, biting, scratching,shrieking, screaming, inability to communicateclearlyRecovery Client regains physical and emotional control. Lowering of voice; decreased muscle tension; clearer,PostcrisisClient attempts reconciliation with others andreturns to the level of functioning before theaggressive incident and its antecedents.more rational communication; physical relaxationRemorse; apologies; crying; quiet, withdrawnbehaviorAdapted from Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). Psychiatric nursing (5th ed.). St. Louis: Mosby, Inc.

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 175CLINICAL VIGNETTE: ESCALATION PHASEJohn, 35 years of age, was admitted to the hospital forschizophrenia. John has a history of aggressive behavior,usually precipitated by voices telling him that he will beharmed by staff and must kill them to protect himself. Johnhad not been taking his prescribed medication for 2 weeksbefore hospitalization. The nurse observes John pacing inthe hall, muttering to himself, and avoiding close contactwith anyone else.Suddenly, John begins to yell, “I can’t take it. I can’t stayhere!” His fists are clenched, and he is very agitated. Thenurse approaches John, remaining 6 feet away from him,and says, “John, tell me what is happening.” John runs tothe end of the hall and will not talk to the nurse. The nurseasks John to take a PRN medication and go to his room. Herefuses both. As he begins to pick up objects from a nearbytable, the nurse summons other staff to assist.discussions give clients the opportunity to talk about eventsor issues when they are calm. Activities also engage clients inthe therapeutic process and minimize boredom. Schedulingone-to-one interactions with clients indicates the nurse’sgenuine interest in the client and a willingness to listen tothe client’s concerns, thoughts, and feelings. Knowing whatto expect enhances the client’s feelings of security.If clients have a conflict or dispute with one another,the nurse can offer the opportunity for problem-solving orconflict resolution. Expressing angry feelings appropriately,using assertive communication statements, andnegotiating a solution are important skills clients can practice.These skills will be useful for the client when he orshe returns to the community.If a client is psychotic, hyperactive, or intoxicated, thenurse must consider the safety and security of other clients,who may need protection from the intrusive or threateningdemeanor of that client. Talking with other clients abouttheir feelings is helpful, and close supervision of the clientwho is potentially aggressive is essential.Managing Aggressive BehaviorIn the triggering phase, the nurse should approach the clientin a nonthreatening, calm manner in order to de-escalate theclient’s emotion and behavior. Conveying empathy for theclient’s anger or frustration is important. The nurse canencourage the client to express his or her angry feelings verbally,suggesting that the client is still in control and canmaintain that control. Use of clear, simple, short statementsis helpful. The nurse should allow the client time to expresshimself or herself. The nurse can suggest that the client go toa quiet area or may get assistance to move other clients todecrease stimulation. Medications (PRN, or as needed)should be offered, if ordered. As the client’s anger subsides,the nurse can help the client to use relaxation techniquesand look at ways to solve any problem or conflict that mayexist (Marder, 2006). Physical activity, such as walking, alsomay help the client relax and become calmer.If these techniques are unsuccessful and the client progressesto the escalation phase (period when client buildstoward loss of control), the nurse must take control of thesituation. The nurse should provide directions to the clientin a calm, firm voice. The client should be directed to take atime-out for cooling off in a quiet area or his or her room.The nurse should tell the client that aggressive behavior isnot acceptable and that the nurse is there to help the clientregain control. If the client refused medications during thetriggering phase, the nurse should offer them again.If the client’s behavior continues to escalate and he or sheis unwilling to accept direction to a quiet area, the nurseshould obtain assistance from other staff members. Initially,four to six staff members should remain ready within sightof the client but not as close as the primary nurse talkingwith the client. This technique, sometimes called a “show offorce,” indicates to the client that the staff will control thesituation if the client cannot do so. Sometimes the presenceof additional staff convinces the client to accept medicationand take the time-out necessary to regain control.When the client becomes physically aggressive (crisisphase), the staff must take charge of the situation for thesafety of the client, staff, and other clients. Psychiatricfacilities offer training and practice in safe techniques formanaging behavioral emergencies, and only staff withsuch training should participate in the restraint of a physicallyaggressive client. The nurse’s decision to use seclusionor restraint should be based on the facility’s protocolsand standards for restraint and seclusion. The nurse shouldobtain a physician’s order as soon as possible after decidingto use restraint or seclusion.Four to six trained staff members are needed to restrainan aggressive client safely. Children, adolescents, and femaleclients can be just as aggressive as adult male clients. Theclient is informed that his or her behavior is out of controland that the staff is taking control to provide safety and preventinjury. Four staff members each take a limb, one staffmember protects the client’s head, and one staff memberhelps control the client’s torso, if needed. The client is transportedby gurney or carried to a seclusion room, andrestraints are applied to each limb and fastened to the bedframe. If PRN medication has not been taken earlier,the nurse may obtain an order for intramuscular (IM)me dication in this type of emergency situation. As noted

176UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSpreviously, the nurse performs close assessment of the clientin seclusion or restraint and documents the actions.As the client regains control (recovery phase), he orshe is encouraged to talk about the situation or triggersthat led to the aggressive behavior. The nurse should helpthe client relax, perhaps sleep, and return to a calmer state.It is important to help the client explore alternatives toaggressive behavior by asking what the client or staff cando next time to avoid an aggressive episode. The nursealso should assess staff members for any injuries and completethe required documentation such as incident reportsand flow sheets. The staff usually has a debriefing sessionto discuss the aggressive episode, how it was handled,what worked well or needed improvement, and how thesituation could have been defused more effectively. It alsois important to encourage other clients to talk about theirfeelings regarding the incident. However, the aggressiveclient should not be discussed in detail with other clients.In the postcrisis phase, the client is removed from restraintor seclusion as soon as he or she meets the behavioral criteria.The nurse should not lecture or chastise the client for theaggressive behavior but should discuss the behavior in acalm, rational manner. The client can be given feedback forregaining control, with the expectation that he or she will beable to handle feelings or events in a nonaggressive mannerin the future. The client should be reintegrated into the milieuand its activities as soon as he or she can participate.EvaluationCare is most effective when the client’s anger can be defusedin an earlier stage, but restraint or seclusion is sometimesnecessary to handle physically aggressive behavior. Thegoal is to teach angry, hostile, and potentially aggressiveclients to express their feelings verbally and safely withoutthreats or harm to others or destruction of property.WORKPLACE HOSTILTIYIn July 2008, the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) issued a sentinel eventalert concerning “intimidating and disruptive behaviors”that undermine a culture of safety and lead to errors,decreased patient satisfactions, preventable adverse outcomes,increased healthcare costs, and loss of qualified personnel(JCAHO, 2008). These undesirable behaviorsinclude overt actions such as verbal outbursts and physicalthreats, as well as passive activities like refusing to performassigned tasks or an uncooperative attitude. Disruptive andintimidating behaviors are often demonstrated by healthcareproviders in power positions and can manifest as:reluctance or refusal to answer questions, return phonecalls or answer pages; condescending or intimidating languageor voice tone/volume; and impatience.This problem prompted JCAHO to include new standardson leadership effective January 2009. Any accreditedhealthcare organization must have a code of conduct thatdefines acceptable and disruptive and inappropriate behaviors.Additionally, leaders in these organizations must createand implement a process for managing disruptive and inappropriatebehaviors (JCAHO, 2008). Several action steps havebeen suggested to accomplish this new standard of behavior.COMMUNITY-BASED CAREFor many clients with aggressive behavior, effective managementof the comorbid psychiatric disorder is the key tocontrolling aggression. Regular follow-up appointments,compliance with prescribed medication, and participationin community support programs help the client to achievestability. Anger management groups are available to helpclients express their feelings and to learn problem-solvingand conflict-resolution techniques.Studies of client assaults on staff in the communitybecome increasingly important as more clients experiencerapid discharge from inpatient or acute care settings.Assaults by clients in the community were caused partly bystressful living situations, increased access to alcohol anddrugs, availability of lethal weapons, and noncompliancewith medications. Episodes of assault were often precipitatedby denial of services, acute psychosis, and excessivestimulation (Flannery, Laudani, Levitre, & Walker, 2006).Flannery, Juliano, Cronin, and Walker (2006) studiedassaults by clients in community residences, includingphysical or sexual assaults, nonverbal intimidation, andverbal threats. Clients who were assaultive were most likelyto be older male clients with schizophrenia and youngerclients with personality disorders. These authors describedthe assaulted staff action program (ASAP) established inMassachusetts to help staff victims cope with the psychologicalsequelae of assaults by clients in community-basedresidential programs. In addition, ASAP works with staff todetermine better methods of handling situations withaggressive clients and ways to improve safety in communitysettings. It is their belief that similar programs wouldbe beneficial to staff in residential settings in other states.SELF-AWARENESS ISSUESThe nurse must be aware of how he or she dealswith anger before helping clients do so. Thenurse who is afraid of angry feelings may avoida client’s anger, which allows the client’s behaviorto escalate. If the nurse’s response is angry, the situationcan escalate into a power struggle, and the nurse loses theopportunity to “talk down” the client’s anger.It is important to practice and gain experience in usingtechniques for restraint and seclusion before attemptingthem with clients in crisis. There is a risk for staff injurywhenever a client is aggressive. Ongoing education andpractice of safe techniques are essential to minimize oravoid injury to both staff and clients. The nurse must be

CHAPTER 10 • ANGER, HOSTILITY, AND AGGRESSION 177INTERNET RESOURCESAnger management http://www.apa.org/topics/controlanger.htmlIntermittent explosive disorder http://www.mayoclinic.com/health/intermittent-explosive-disorder/DS00730Workplace hostility in healthcare http://www.nursezone.com/Nursing-News-Events/more-news.aspx?ID=18428calm, nonjudgmental, and nonpunitive when using techniquesto control a client’s aggressive behavior. Inexperiencednurses can learn from watching experienced nursesdeal with clients who are hostile or aggressive.When verbal techniques fail to defuse a client’s anger andthe client becomes aggressive, the nurse may feel frustratedor angry, as if he or she failed. The client’s aggressive behavior,however, does not necessarily reflect the nurse’s skills andabilities. Some clients have a limited capacity to control theiraggressive behaviors, and the nurse can help them to learnalternative ways to handle angry or aggressive impulses.Points to Consider When Workingwith Clients Who Are Angry, Hostile,or Aggressive• Identify how you handle angry feelings; assess your useof assertive communication and conflict resolution. Increasingyour skills in dealing with your angry feelingswill help you to work more effectively with clients.• Discuss situations or the care of potentially aggressiveclients with experienced nurses.• Do not take the client’s anger or aggressive behavior personallyor as a measure of your effectiveness as a nurse.KEY POINTS• Anger, expressed appropriately, can be apositive force that helps the person solveproblems and make decisions.• Hostility, also called verbal aggression, isbehavior meant to intimidate or cause emotional harmto another and can lead to physical aggression.• Physical aggression is behavior meant to harm, punish,or force into compliance another person.• Most clients with psychiatric disorders are not aggressive.Clients with schizophrenia, bipolar disorder, dementia,head injury, antisocial or borderline personality disorders,or conduct disorder, and those intoxicated with alcoholor other drugs, may be aggressive. Rarely, clientsmay be diagnosed with intermittent explosive disorder.• Treatment of aggressive clients often involves treatingthe comorbid psychiatric disorder with mood stabilizersor antipsychotic medications.Critical Thinking Questions1. Many community-based residential programs willnot admit a client with a recent history of aggression.Is this fair to the client? What factors should influencesuch decisions?2. If an aggressive client injures another client or a staffperson, should criminal charges be filed against theclient? Why or why not?• Assessment and effective intervention with angry orhostile clients can often prevent aggressive episodes.• Aggressive behavior is less common and less intense onunits with strong psychiatric leadership, clear staff roles,and planned and adequate events such as staff–clientinteraction, group interaction, and activities.• The nurse must be familiar with the signs, symptoms,and behaviors associated with the triggering, escalation,crisis, recovery, and postcrisis phases of the aggressioncycle.• In the triggering phase, nursing interventions includespeaking calmly and nonthreateningly, conveying empathy,listening, offering PRN medication, and suggestingretreat to a quiet area.• In the escalation phase, interventions include using adirective approach, taking control of the situation, usinga calm, firm voice for giving directions, directing theclient to take a time-out in a quiet place, offering PRNmedication, and making a “show of force.”• In the crisis phase, experienced, trained staff can use thetechniques of seclusion or restraint to deal quickly withthe client’s aggression.• During the recovery phase, interventions include helpingclients to relax, assisting them to regain self-control,and discussing the aggressive event rationally.• In the postcrisis phase, the client is reintegrated into themilieu.• Important self-awareness issues include examining howone handles angry feelings and deals with one’s own reactionsto angry clients.

178UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSREFERENCESAkiskal, H. S. (2005). Mood disorders: Historical introduction and conceptualoverview. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensivetextbook of psychiatry (Vol. 1, 8th ed., pp. 1559–1575). Philadelphia:Lippincott Williams & Wilkins.American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Choi, Y. J., & Lee, K. J. (2007). Evidence-based nursing: Effects of a structurednursing program for the health promotion of Korean womenwith Hwa-Byung. Archives of Psychiatric Nursing, 21(1), 12–16.Dolan, M., & Davies, G. (2006). Psychopathy and institutional outcomein patients with schizophrenia in forensic settings in the UK.Schizophrenia Research, 81(2–3), 277–281.Flannery, R. J., Jr., Juliano, J., Cronin, S., & Walker, A. P. (2006).Characteristics of assaultive patients: Fifteen-year analysis of theAssaulted Staff Action Program (ASAP). Psychiatric Quarterly, 77(3),239–249.Flannery, R. J., Jr., Laudani, L., Levitre, V., & Walker, A. P. (2006).Precipitants of psychiatric patient assaults on staff: Three-yearempirical inquiry of the Assaulted Staff Action Program (ASAP).International Journal of Emergency Mental Health, 8(1), 15–22.Garlow, S. J., Purselle, D., & D’Orio, B. (2006). Psychiatric emergencies.In A. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials of clinicalpsychopharmacology (2nd ed., pp. 707–724). Washington, DC:American Psychiatric Publishing.Goedhard, L. E., Stolker, J. J., Heerdink, E. R., et al. (2006).Pharmacotherapy for the treatment of aggressive behavior in generaladult psychiatry: A systematic review. Journal of Clinical Psychiatry,67(7), 1013–1024.Greenberg, H. A. (2005). Impulse-control disorders not elsewhere specified.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 2035–2054). Philadelphia: LippincottWilliams & Wilkins.Jacob, R. G., & Pelham, W. E. (2005). Behavior therapy. In B. J. Sadock& V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 2,8th ed., pp. 2498–2548). Philadelphia: Lippincott Williams &Wilkins.JCAHO. (2008). Sentinel event alert: Behaviors that undermine a cultureof safety. Retrieved January 5, 2008: http://www.jointcomission.org.Koh, K. B., Kim, D. K., Kim, S. Y., Park, J. K., & Han, M. (2008). Therelation between anger management style, mood and somatic symptomsin anxiety disorders and somatoform disorders. PsychiatryResearch, 160(3), 372–279.Leary, M. R., Twenge, J. M., & Quinlivan, E. (2006). Interpersonal rejectionas a determinant of anger and aggression. Personality and SocialPsychology Review, 10(2), 1111–1132.Marder, S. R. (2006). A review of agitation in mental illness: Treatmentguidelines and current therapies. Journal of Clinical Psychiatry,67(Suppl. 10), 13–21.Moitabai, R. (2005). Culture-bound syndromes with psychotic features.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 1538–1542). Philadelphia: LippincottWilliams & Wilkins.Muroff, J., Edelsohm, G. A., Joe, S., & Ford, B. C. (2008). The role ofrace in diagnostic disposition decision making in a pediatric psychiatricemergency service. General Hospital Psychiatry, 30(3),269–276.Pryor, J. (2005). What cues do nurses use to predict aggression in peoplewith acquired brain injury? Journal of Neuroscience Nursing, 37(2),117–121.Qureshi, A., Collazos, F., Ramos, M., & Casas, M. (2008). Cultural competencetraining in psychiatry. European Psychiatry, 23(Suppl. 1),49–58.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Shapiro, P. A. (2005). Cardiovascular disorders. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 2, 8th ed.,pp. 2136–2148). Philadelphia: Lippincott Williams & Wilkins.Siever, L. J. (2008). Neurobiology of aggression and violence. AmericanJournal of Psychiatry, 165(4), 429–442.van-Daalen-Smith, C. (2008). Living as a chameleon: Girls, anger, andmental health. Journal of School Nursing, 24(3), 116–123.ADDITIONAL READINGSBjorkdahl, A., Heilig, M., Palmstierna, T., & Hansebo, G. (2007).Changes in the occurrences of coercive interventions and staff injurieson a psychiatric intensive care unit. Archives of PsychiatricNursing, 21(5), 270–277.Brescoli, V. L., & Uhlmann, E. L. (2008). Can an angry woman getahead? Status conferral, gender, and expression of emotion in theworkplace. Psychological Science, 19(3), 268–275.Needham, I., Abderhalden, C., Halfens, R. J., et al. (2005) Non-somaticeffects of patient aggression on nurses: A systematic review. Journalof Advanced Nursing, 49(3), 283–296.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following is an example of assertivecommunication?a. “I wish you would stop making me angry.”b. “I feel angry when you walk away when I’m talking.”c. “You never listen to me when I’m talking.”d. “You make me angry when you interrupt me.”2. Which of the following statements about anger is true?a. Expressing anger openly and directly usually leadsto arguments.b. Anger results from being frustrated, hurt, or afraid.c. Suppressing anger is a sign of maturity.d. Angry feelings are a negative response to a situation.3. Which of the following types of drugs requires cautioususe with potentially aggressive clients?a. Antipsychotic medicationsb. Benzodiazepinesc. Mood stabilizersd. Lithium4. A client is pacing in the hallway with clenched fists anda flushed face. He is yelling and swearing. Which phaseof the aggression cycle is he in?a. Angerb. Triggeringc. Escalationd. Crisis5. The nurse observes a client muttering to himself andpounding his fist in his other hand while pacing in thehallway. Which of the following principles should guidethe nurse’s action?a. Only one nurse should approach an upset client toavoid threatening the client.b. Clients who can verbalize angry feelings are less likelyto become physically aggressive.c. Talking to a client with delusions is not helpful,because the client has no ability to reason.d. Verbally aggressive clients often calm down on theirown if staff members don’t bother them.MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Behaviors observed during the recovery phase of theaggression cycle.a. Angry feelingsb. Anxietyc. Client apologizes to staffd. Decreased muscle tensione. Lowered voice volumef. Rational communication2. Statements that are examples of unacceptable behaviorsunder the new JCAHO standards for a culture of safety.a. “According to your performance evaluation, youmust decrease your absenteeism.”b. “Don’t page me again, I’m very busy.”c. “If you tell my supervisor, you’ll never hear the endof it.”d. “I don’t deserve to be yelled at.”e. “I haven’t seen such stupid behavior since gradeschool.”f. “I request a different assignment today.”179

11Abuse and ViolenceLearning ObjectivesAfter reading this chapter, you should be able to:Key Terms• abuse• acute stress disorder• child abuse• cycle of violence• date rape (acquaintance rape)• dissociation• dissociative disorders• elder abuse• family violence• grounding techniques• intergenerational transmissionprocess• intimate partner violence• neglect• physical abuse• posttraumatic stress disorder• psychological abuse (emotionalabuse)• rape• repressed memories• restraining order• sexual abuse• sodomy• stalking• survivor1801. Discuss the characteristics, risk factors, and family dynamics of abusive andviolent behavior.2. Examine the incidences of and trends in domestic violence, child and elderabuse, and rape.3. Describe responses to abuse, specifically posttraumatic stress disorder anddissociative identity disorder.4. Apply the nursing process to the care of clients who have survived abuseand violence.5. Provide education to clients, families, and communities to promote preventionand early intervention of abuse and violence.6. Evaluate your own experiences, feelings, attitudes, and beliefs about abusiveand violent behavior.VIOLENT BEHAVIOR HAS BEEN identified as a national health concern and apriority for intervention in the United States, where occurrences exceed2 million per year. The most alarming statistics relate to violence in thehome and abuse, or the wrongful use and maltreatment of another person.Statistics show that most abuse is perpetrated by someone the victimknows. Victims of abuse are found across the life span, and they can bespouses or partners, children, or elderly parents.This chapter discusses domestic abuse (intimate partner abuse, childabuse/neglect, and elder abuse) and rape. Because many survivors of abusesuffer long-term emotional trauma, the chapter also discusses disordersassociated with abuse and violence: posttraumatic stress disorder (PTSD)and dissociative disorders. Other long-term problems associated withabuse and trauma include substance abuse (see Chapter 17) and depression(see Chapter 15).Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!

CHAPTER 11 • ABUSE AND VIOLENCE 181CLINICAL PICTURE OF ABUSE ANDVIOLENCEVictims of abuse or violence certainly can have physicalinjuries needing medical attention, but they also experiencepsychological injuries with a broad range of responses.Some clients are agitated and visibly upset; others arewithdrawn and aloof, appearing numb or oblivious to theirsurroundings. Often, domestic violence remains undisclosedfor months or even years because victims fear theirabusers. Victims frequently suppress their anger andresentment and do not tell anyone. This is particularlytrue in cases of childhood sexual abuse.Survivors of abuse often suffer in silence and continueto feel guilt and shame. Children particularly cometo believe that somehow they are at fault and did somethingto deserve or provoke the abuse. They are morelikely to miss school, are less likely to attend college,and continue to have problems through adolescence intoadulthood. As adults, they usually feel guilt or shame fornot trying to stop the abuse. Survivors feel degraded,humiliated, and dehumanized. Their self-esteem isextremely low, and they view themselves as unlovable.They believe they are unacceptable to others, contaminated,or ruined. Depression, suicidal behavior, andmarital and sexual difficulties are common (Child WelfareInformation Gateway, 2008).Victims and survivors of abuse may have problemsrelating to others. They find trusting others, especiallyauthority figures, to be difficult. In relationships, theiremotional reactions are likely to be erratic, intense, andperceived as unpredictable. Intimate relationships maytrigger extreme emotional responses such as panic, anxiety,fear, and terror. Even when survivors of abuse desirecloseness with another person, they may perceive actualcloseness as intrusive and threatening.Nurses should be particularly sensitive to the abusedclient’s need to feel safe, secure, and in control of his orher body. They should take care to maintain the client’spersonal space, assess the client’s anxiety level, and askpermission before touching him or her for any reason.Because the nurse may not always be aware of a history ofabuse when initially working with a client, he or sheshould apply these cautions to all clients in the mentalhealth setting.CHARACTERISTICS OF VIOLENTFAMILIESFamily violence encompasses spouse battering; neglectand physical, emotional, or sexual abuse of children; elderabuse; and marital rape. In many cases, family memberstolerate abusive and violent behavior from relatives theywould never accept from strangers. In violent families, thehome, which is normally a safe haven of love and protection,may be the most dangerous place for victims.Family violenceResearch studies have identified some common characteristicsof violent families regardless of the type of abusethat exists. They are discussed next and in Box 11.1.Social IsolationOne characteristic of violent families is social isolation.Members of these families keep to themselves and usuallydo not invite others into the home or tell them what ishappening. Often, abusers threaten victims with evengreater harm if they reveal the secret. They may tell childrenthat a parent, sibling, or pet will die if anyone outsidethe family learns of the abuse. So children keep the secretout of fear, which prevents others from “interfering withprivate family business.”Abuse of Power and ControlThe abusive family member almost always holds a positionof power and control over the victim (child, spouse,or elderly parent). The abuser exerts not only physicalBox 11.1CHARACTERISTICS OFVIOLENT FAMILIESSocial isolationAbuse of power and controlAlcohol and other drug abuseIntergenerational transmission process

182UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSpower but also economic and social control. He or she isoften the only family member who makes decisions,spends money, or spends time outside the home withother people. The abuser belittles and blames the victim,often by using threats and emotional manipulation. If theabuser perceives any indication, real or imagined, of victimindependence or disobedience, violence usually escalates.Twenty-two percent of nonfatal violence againstwomen is perpetrated by an intimate partner, comparedwith only 3% of men injured by an intimate partner. Intimatepartners are responsible for one third of femalehomicides, whereas only 3% of male homicides are committedby a female intimate partner (Bureau of JusticeStatistics, 2007).Alcohol and Other Drug AbuseSubstance abuse, especially alcoholism, has been associatedwith family violence. This finding does not implya cause-and-effect relationship. Alcohol does not causethe person to be abusive; rather, an abusive person alsois likely to use alcohol or other drugs. Two thirds ofvictims of intimate violence report that alcohol wasinvolved in the violent incident. Women whose partnersabused alcohol were 3.6 times more likely thanother women to be assaulted by their partners (MarinInstitute, 2008). Although alcohol may not cause theabuse, many researchers believe that alcohol maydiminish inhibitions and make violent behavior moreintense or frequent.Alcohol is also cited as a factor in acquaintance rape ordate rape. According to the Marin Institute (2008), 40% ofconvicted rape and sexual assault offenders reported drinkingalcohol at the time of their crime. In addition, use ofthe illegal drug flunitrazepam (Rohypnol) to subduepotential victims of date rape is on the rise in the UnitedStates (van der Kolk, 2005).Intergenerational Transmission ProcessThe intergenerational transmission process shows thatpatterns of violence are perpetuated from one generationto the next through role modeling and social learning (vander Kolk, 2005). Intergenerational transmission suggeststhat family violence is a learned pattern of behavior. Forexample, children who witness violence between theirparents learn that violence is a way to resolve conflict andis an integral part of a close relationship. Statistics showthat one third of abusive men are likely to have come fromviolent homes where they witnessed wife-beating or wereabused themselves. Women who grew up in violent homesare 50% more likely to expect or accept violence in theirown relationships. Not all persons exposed to family violence,however, become abusive or violent as adults.Therefore, this single factor does not explain the perpetuationof violent behavior.CULTURAL CONSIDERATIONSAlthough domestic violence affects families of all ethnicities,races, ages, national origins, sexual orientations, religions,and socioeconomic backgrounds, a specific population isparticularly at risk: immigrant women. Battered immigrantwomen face legal, social, and economic problems differentfrom U.S. citizens who are battered and from people of othercultural, racial, and ethnic origins who are not battered:• The battered woman may come from a culture that acceptsdomestic violence.• She may believe she has less access to legal and socialservices than do U.S. citizens.• If she is not a citizen, she may be forced to leave theUnited States if she seeks legal sanctions against herhusband or attempts to leave him.• She is isolated by cultural dynamics that do not permit herto leave her husband; economically, she may be unable togather the resources to leave, work, or go to school.• Language barriers may interfere with her ability to call911, learn about her rights or legal options, and obtainshelter, financial assistance, or food.It may be necessary for the nurse to obtain the assistanceof an interpreter whom the woman trusts, makereferrals to legal services, and assist the woman to contactthe Department of Immigration to deal with these additionalconcerns.INTIMATE PARTNER VIOLENCEIntimate partner violence is the mistreatment or misuse ofone person by another in the context of an emotionally intimaterelationship. The relationship may be spousal, betweenpartners, boyfriend, girlfriend, or an estranged relationship.The abuse can be emotional or psychological, physical, sexual,or a combination (which is common). Psychologicalabuse (emotional abuse) includes name-calling, belittling,screaming, yelling, destroying property, and making threatsas well as subtler forms, such as refusing to speak to orignoring the victim. Physical abuse ranges from shovingand pushing to severe battering and choking and mayinvolve broken limbs and ribs, internal bleeding, brain damage,and even homicide. Sexual abuse includes assaults duringsexual relations such as biting nipples, pulling hair,slapping and hitting, and rape (discussed later).From 90% to 95% of domestic violence victims arewomen, and one in three women in the United States is estimatedto have been beaten by a spouse at least once. Eachyear, as many as 5.3 million women in the United Statesexperience a serious assault by a partner. Eight percent ofU.S. homicides involve one spouse killing another, and 3 ofevery 10 female homicide victims are murdered by theirspouse, ex-spouse, boyfriend, or ex-boyfriend. Of all intimatepartner homicides, 25% are male and 75% are female(Centers for Disease Control and Prevention [CDC], 2008).

CHAPTER 11 • ABUSE AND VIOLENCE 183CLINICAL VIGNETTE: INTIMATE PARTNER VIOLENCEDarlene sat in the bathroom trying to regain her balance andholding a cold washcloth to her face. She looked in the mirrorand saw a large, red, swollen area around her eye and cheekwhere her husband, Frank, had hit her. They had been marriedfor only 6 months, and this was the second time that he hadgotten angry and struck her in the face before storming out ofthe house. Last time, he was so sorry the day after it happenedthat he brought her flowers and took her out to dinner to apologize.He said he loved her more than ever and felt terribleabout what had happened. He said it was because he had hadan argument with his boss over getting a raise and went outdrinking after work before coming home. He had promisednot to go out drink anymore and that it would never happenagain. For several weeks after he quit drinking, he was wonderful,and it felt like it was before they got married. She rememberedthinking that she must try harder to keep himhappy because she knew he really did love her.But during the past 2 weeks, he had been increasinglysilent and sullen, complaining about everything. He didn’tlike the dinners she cooked and said he wanted to go out toeat even though money was tight and their credit cardswere loaded with charges they couldn’t pay off. He begandrinking again. After a few hours of drinking tonight, heyelled at her and said she was the cause of all his moneyproblems. She tried to reason with him, but he hit her, andthis time he knocked her to the floor and her head hit thetable. She was really frightened now, but what should shedo? She couldn’t move out; she had no money of her ownand her job just didn’t pay enough to support her. Shouldshe go to her parents? She couldn’t tell them about whathappened because they never wanted her to marry Frank inthe first place. They would probably say, “We told you soand you didn’t listen. Now you married him and you’ll haveto deal with his problems.” She was too embarrassed to tellher friends, most of whom were “their” friends and hadnever seen this violent side of Frank. They probably wouldn’tbelieve her. What should she do? Her face and head werereally beginning to hurt now. “I’ll talk to him tomorrowwhen he is sober and tell him he must get some help for thedrinking problem. When he’s sober, he is reasonable andhe’ll see that this drinking is causing a big problem for ourmarriage,” she thought.An estimated 324,000 women experience violencewhile pregnant. Battering during pregnancy leads toadverse outcomes, such as miscarriage and stillbirth, aswell as to further physical and psychological problems forthe woman. The increase in violence often results from thepartner’s jealousy, possessiveness, insecurity, and lessenedphysical and emotional availability of the pregnant woman(Bacchus, Mezey, & Bewley, 2006).Domestic violence occurs in same-sex relationshipswith the same statistical frequency as in heterosexual relationshipsand affects 50,000 lesbian women and 500,000gay men each year. Although same-sex battering mirrorsheterosexual battering in prevalence, its victims receivefewer protections. Seven states define domestic violence ina way that excludes same-sex victims. Twenty-one otherstates have sodomy laws that designate sodomy (analintercourse) as a crime; thus, same-sex victims must firstconfess to the crime of sodomy to prove a domestic relationshipbetween partners. The same-sex batterer has anadditional weapon to use against the victim: the threat ofrevealing the partner’s homosexuality to friends, family,employers, or the community.Clinical PictureBecause abuse often is perpetrated by a husband against awife, that example is used in this section. These samepatterns are consistent, however, between partners whoare not married, between same-sex partners, and withwives who abuse their husbands.An abusive husband often believes his wife belongs tohim (like property) and becomes increasingly violent andabusive if she shows any sign of independence, such as gettinga job or threatening to leave. Typically, the abuser hasstrong feelings of inadequacy and low self-esteem as well aspoor problem-solving and social skills. He is emotionallyimmature, needy, irrationally jealous, and possessive. Hemay even be jealous of his wife’s attention to their own childrenor may beat both his children and his wife. By bullyingand physically punishing the family, the abuser often experiencesa sense of power and control, a feeling that eludeshim outside the home. Therefore, the violent behavioroften is rewarding and boosts his self-esteem.Dependency is the trait most commonly found inabused wives who stay with their husbands. Women oftencite personal and financial dependency as reasons whythey find leaving an abusive relationship extremely difficult.Regardless of the victim’s talents or abilities, she perceivesherself as unable to function without her husband.She too often suffers from low self-esteem and defines hersuccess as a person by her ability to remain loyal to hermarriage and “make it work.” Some women internalize thecriticism they receive and mistakenly believe they are toblame. Women also fear their abuser will kill them if they

184UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSFor example, there may be only periodic episodes of violentbehavior with no subsequent honeymoon period, or noobservable period of increasing tension.Cycle of violencetry to leave. This fear is realistic, given that nationalstatistics show 65% of women murdered by spouses orboyfriends were attempting to leave or had left the relationships(Bureau of Justice Statistics, 2007).Cycle of Abuse and ViolenceThe cycle of violence or abuse is another reason oftencited for why women have difficulty leaving abusive relationships.A typical pattern exists: Usually, the initial episodeof battering or violence is followed by a period of theabuser expressing regret, apologizing, and promising itwill never happen again. He professes his love for his wifeand may even engage in romantic behavior (e.g., buyinggifts and flowers). This period of contrition or remorsesometimes is called the honeymoon period. The womannaturally wants to believe her husband and hopes the violencewas an isolated incident. After this honeymoonperiod, the tension-building phase begins; there may bearguments, stony silence, or complaints from the husband.The tension ends in another violent episode after whichthe abuser once again feels regret and remorse and promisesto change. This cycle continually repeats itself. Eachtime, the victim keeps hoping the violence will stop.Initially, the honeymoon period may last weeks or evenmonths, causing the woman to believe that the relationshiphas improved and her husband’s behavior has changed.Over time, however, the violent episodes are more frequent,the period of remorse disappears altogether, and the levelof violence and severity of injuries worsen. Eventually, theviolence is routine—several times a week or even daily.While the cycle of violence is the most common pattern ofintimate partner violence, it does not apply to all situations.Many survivors report only one or two elements of the cycle.AssessmentBecause most abused women do not seek direct help for theproblem, nurses must help identify abused women in varioussettings. Nurses may encounter abused women in emergencyrooms, clinics, or pediatricians’ offices. Some victimsmay be seeking treatment for other medical conditions notdirectly related to the abuse or for pregnancy. Identifyingabused women who need assistance is a top priority of theDepartment of Health and Human Services. The generalistnurse is not expected to deal with this complicated problemalone. He or she can, however, make referrals and contactappropriate health-care professionals experienced in workingwith abused women. Above all, the nurse can offercaring and support throughout. Table 11.1 summarizestechniques for working with victims of partner violence.Many hospitals, clinics, and doctors’ offices ask womenabout safety issues as part of all health histories or intakeinterviews. Because this issue is delicate and sensitive andmany abused women are afraid or embarrassed to admitthe problem, nurses must be skilled in asking appropriatequestions about abuse. Box 11.2 gives an example of questionsto ask using the acronym SAFE (stress/safety, afraid/abused, friends/family, and emergency plan). The first twocategories are designed to detect abuse. The nurse shouldask questions in the other two categories if abuse is present.He or she should ask these questions when the womanis alone; the nurse can paraphrase or edit the questions asneeded for any given situation.Treatment and InterventionEvery state in the United States allows police to make arrestsin cases of domestic violence; more than half the states havelaws requiring police to make arrests for at least somedomestic violence crimes. Sometimes after police have beencalled to the scene, the abuser is allowed to remain at homeafter talking with police and calming down. If an arrest ismade, sometimes the abuser is held only for a few hours orovernight. Often the abuser retaliates upon release; hence,women have a legitimate fear of calling the police. Studieshave shown that arresting the batterer may reduce shorttermviolence but may increase long-term violence.A woman can obtain a restraining order (protectionorder) from her county of residence that legally prohibitsthe abuser from approaching or contacting her. Nevertheless,a restraining order provides only limited protection.The abuser may decide to violate the order andseverely injure or kill the woman before police can intervene.Civil orders of protection are more effective inpreventing future violence when linked with other interventionssuch as advocacy counseling, shelter, or talking

CHAPTER 11 • ABUSE AND VIOLENCE 185Table 11.1DOS AND DON’TS OF WORKING WITH VICTIMS OF PARTNER ABUSEDon’tsDosDon’t tell the victim what to do.Don’t express disgust, disbelief, or anger.Don’t disclose client communications without the client’sconsent.Don’t preach, moralize, or imply that you doubt theclient.Don’t minimize the impact of violence.Don’t express outrage with the perpetrator.Don’t imply that the client is responsible for the abuse.Don’t recommend couples’ counseling.Don’t direct the client to leave the relationship.Don’t take charge and do everything for the client.Do believe the victim.Do ensure and maintain the client’s confidentiality.Do listen, affirm, and say, “I am sorry you have been hurt.”Do express, “I’m concerned for your safety.”Do tell the victim, “You have a right to be safe andrespected.”Do say, “The abuse is not your fault.”Do recommend a support group or an individual counseling.Do identify community resources and encourage the clientto develop a safety plan.Do offer to help the client contact a shelter, the police, orother resources.Do accept and respect the victim’s decision.Do encourage development of a safety plan.with their health-care provider (McCloskey et al., 2006).Women who left their abusive relationships were morelikely to be successful if they were younger aged, had anabuse-related physician visit, had attempted to leaveBox 11.2 SAFE QUESTIONS• Stress/Safety: What stress do you experience in yourrelationships? Do you feel safe in your relationships?Should I be concerned for your safety?• Afraid/Abused: Have there been situations in your relationshipswhere you have felt afraid? Has your partnerever threatened or abused you or your children?Have you ever been physically hurt or threatened byyour partner? Are you in a relationship like that now?Has your partner ever forced you to engage in sexualintercourse that you did not want? People in relationships/marriages often fight; what happens when you andyour partner disagree?• Friends/Family: Are your friends aware that you havebeen hurt? Do your parents or siblings know aboutthis abuse? Do you think you could tell them, andwould they be able to give you support?• Emergency plan: Do you have a safe place to go andthe resources you (and your children) need in anemergency? If you are in danger now, would you likehelp in locating a shelter? Would you like to talk to asocial worker/a counselor/me to develop an emergencyplan?Ashur, M. L. C. (1993). Asking about domestic violence: SAFE questions.JAMA, 269(18), 2367. © American Medical Association.previously, and had a civil order of protection (Koepsell,Kernic, & Holt 2006).Even after a victim of battering has “ended” the relationship,problems may continue. Stalking, or repeatedand persistent attempts to impose unwanted communicationor contact on another person, is a problem. Stalkersusually are “would-be lovers,” pursuing relationships thathave ended or never even existed. Twenty-five percent ofwomen and 10% of men can expect to be victims of ongoingunwanted pursuit. Nearly 1 in 22 adults, almost 10million people, have been stalked in the United States,with 80% of the victims being female (Basile, Swahn, Chen,& Saltzman, 2006).Battered women’s shelters can provide temporary housingand food for abused women and their children whenthey decide to leave the abusive relationship. In many cities,however, shelters are crowded; some have waiting lists,and the relief they provide is temporary. The woman leavingan abusive relationship may have no financial supportand limited job skills or experience. Often she has dependentchildren. These barriers are difficult to overcome, andpublic or private assistance is limited.In addition to the many physical injuries that abusedwomen may experience, there are emotional and psychologicalconsequences. Individual psychotherapy or counseling,group therapy, or support and self-help groups canhelp abused women deal with their trauma and begin tobuild new, healthier relationships. Battering also may resultin PTSD, which is discussed later in this chapter.CHILD ABUSEChild abuse or maltreatment generally is defined as theintentional injury of a child. It can include physical abuseor injuries, neglect or failure to prevent harm, failure to

186UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSCLINICAL VIGNETTE: CHILD ABUSEJohnny, 7 years old, has been sent to the school nursebecause of a large bruise on his face. The teacher saysJohnny is quiet, shy, and reluctant to join games or activitieswith others at recess. He stumbled around with no goodexplanation of what happened to his face when the teacherasked him about it this morning.The nurse has seen Johnny before for a variety of bruises,injuries, and even a burn on his hands. In the past, Johnny’smother has described him as clumsy, always tripping andfalling down. She says he’s a “daredevil,” always trying stuntswith his bike or rollerblades or climbing trees and falling orjumping to the ground. She says she has tried everything butcan’t slow him down.When the nurse talks to Johnny, he is reluctant to discussthe bruise on his face. He does not make eye contact withthe nurse and gives a vague explanation for his bruise: “Iguess I ran into something.” The nurse suspects that someonein the home is abusing Johnny.provide adequate physical or emotional care or supervision,abandonment, sexual assault or intrusion, and overttorture or maiming (Bernet, 2005). In the United States,each state defines child maltreatment, identifies specificreporting procedures, and establishes service deliverysystems. Although similarities exist among the laws ofthe 50 states, there is also a great deal of variation. Forthis reason, accurate data on the type, frequency, andseverity of child maltreatment across the country are difficultto obtain.During 2006 in the United States, 905,000 childrenwere victims of child maltreatment. Sixty-four percentof child maltreatment victims suffered neglect, 16%were physically abused, 8.8% were sexually abused,6.6% were psychologically or emotionally abused, and2.2% were medically neglected. Also, 15% suffered“other” types of maltreatment such as abandonment,physical threats, and congenital drug addiction. Thetotal exceeds 100% because some children are countedin more than one category. Fifteen hundred thirty childrendied from maltreatment: 75% were under age 4 and44% were younger than 1 year (Childhelp, 2008).Fathers, stepfathers, uncles, older siblings, andlive-in partners of the child’s mother often perpetrateabuse on girls. About 75% of reported cases involvefather–daughter incest; mother–son incest is much lessfrequent. Estimates are that 15 million women in theUnited States were sexually abused as children, and onethird of all sexually abused victims were molested whenthey were younger than 9 years of age. Accurate statisticson sexual abuse are difficult to obtain because manyincidences are unreported as a result of shame andembarrassment. In other cases, women do not acknowledgesexual abuse until they are adults. Risk for depression,suicide attempts, marital problems, and marriageto an alcoholic are increased among adults with a historyof childhood sexual abuse (Harris, Lieberman, &Marans, 2007).Types of Child AbusePhysical abuse of children often results from unreasonablysevere corporal punishment or unjustifiable punishmentsuch as hitting an infant for crying or soiling his or herdiapers. Intentional, deliberate assaults on children includeburning, biting, cutting, poking, twisting limbs, or scaldingwith hot water. The victim often has evidence of oldinjuries (e.g., scars, untreated fractures, or multiple bruisesof various ages) that the history given by parents or caregiversdoes not explain adequately.Sexual abuse involves sexual acts performed by anadult on a child younger than 18 years. Examples includeincest, rape, and sodomy performed directly by the personor with an object, oral–genital contact, and acts of molestationsuch as rubbing, fondling, or exposing the adult’sgenitals. Sexual abuse may consist of a single incident ormultiple episodes over a protracted period. A second typeof sexual abuse involves exploitation, such as making,promoting, or selling pornography involving minors, andcoercion of minors to participate in obscene acts.Neglect is malicious or ignorant withholding of physical,emotional, or educational necessities for the child’swell-being. Child abuse by neglect is the most prevalenttype of maltreatment and includes refusal to seek healthcare or delay doing so; abandonment; inadequate supervision;reckless disregard for the child’s safety; punitive,exploitive, or abusive emotional treatment; spousal abusein the child’s presence; giving the child permission to betruant; or failing to enroll the child in school.Psychological abuse (emotional abuse) includes verbalassaults, such as blaming, screaming, name-calling, andusing sarcasm; constant family discord characterized byfighting, yelling, and chaos; and emotional deprivation orwithholding of affection, nurturing, and normal experiencesthat engender acceptance, love, security, and selfworth.Emotional abuse often accompanies other types ofabuse (e.g., physical or sexual abuse). Exposure to parental

CHAPTER 11 • ABUSE AND VIOLENCE 187alcoholism, drug use, or prostitution—and the neglect thatresults—also fall within this category.Clinical PictureParents who abuse their children often have minimal parentingknowledge and skills. They may not understand orknow what their children need, or they may be angry orfrustrated because they are emotionally or financiallyunequipped to meet those needs. Although lack of educationand poverty contribute to child abuse and neglect, theyby no means explain the entire phenomenon. Many incidencesof abuse and violence occur in families who seem tohave everything—the parents are well educated with successfulcareers, and the family is financially stable.Parents who abuse their children often are emotionallyimmature, needy, and incapable of meeting their ownneeds much less those of a child. As in spousal abuse, theabuser frequently views his or her children as propertybelonging to the abusing parent. The abuser does not valuethe children as people with rights and feelings. In someinstances, the parent feels the need to have children toreplace his or her own faulty and disappointing childhood;the parent wants to feel the love between child and parentthat he or she missed as a child. The reality of the tremendousemotional, physical, and financial demands thatcomes with raising children usually shatters these unrealisticexpectations. When the parent’s unrealistic expectationsare not met, he or she often reverts to using the samemethods his or her parents used.This tendency for adults to raise their children in thesame way they were raised perpetuates the cycle of familyviolence. Adults who were victims of abuse as children frequentlyabuse their own children (Bernet, 2005).AssessmentAs with all types of family violence, detection and accurateidentification are the first steps. Box 11.3 lists signs thatmight lead the nurse to suspect neglect or abuse. Burns orscalds may have an identifiable shape, such as cigarettemarks, or may have a “stocking and glove” distribution,indicating scalding. The parent of an infant with a severeskull fracture may report that he or she “rolled off thecouch,” even though the child is too young to do so or theinjury is much too severe for a fall of 20 inches. Bruisesmay have familiar, recognizable shapes such as belt bucklesor teeth marks.Children who have been sexually abused may have urinarytract infections; bruised, red, or swollen genitalia;tears of the rectum or vagina; and bruising. The emotionalresponse of these children varies widely. Often, these childrentalk or behave in ways that indicate more advancedknowledge of sexual issues than would be expected fortheir ages. Other times, they are frightened and anxiousand may either cling to an adult or reject adult attentionBox 11.3WARNING SIGNS OF ABUSED/NEGLECTED CHILDREN• Serious injuries such as fractures, burns, or lacerationswith no reported history of trauma• Delay in seeking treatment for a significant injury• Child or parent giving a history inconsistent with severityof injury, such as a baby with contrecoup injuriesto the brain (shaken baby syndrome) that the parentsclaim happened when the infant rolled off the sofa• Inconsistencies or changes in the child’s history duringthe evaluation by either the child or the adult• Unusual injuries for the child’s age and level of development,such as a fractured femur in a 2-month-oldor a dislocated shoulder in a 2-year-old• High incidence of urinary tract infections; bruised,red, or swollen genitalia; tears or bruising of rectumor vagina• Evidence of old injuries not reported, such as scars,fractures not treated, and multiple bruises thatparent/caregiver cannot explain adequatelyentirely. The key is to recognize when the child’s behavioris outside what is normally expected for his or her age anddevelopmental stage. Seemingly unexplained behavior,from refusal to eat to aggressive behavior with peers, mayindicate abuse.The nurse does not have to decide with certainty thatabuse has occurred. Nurses are responsible for reportingsuspected child abuse with accurate and thorough documentationof assessment data. All 50 states have laws,often called mandatory reporting laws, that require nursesto report suspected abuse. The nurse alone or in consultationwith other health team members (e.g., physicians orsocial workers) may report suspected abuse to appropriatelocal governmental authorities. In some states, that authorityis Child Protective Services, Children and Family Services,or the Department of Health. The number to call canbe located in the local telephone book. The reporting personmay remain anonymous if desired. People who workin such agencies have special education in the investigationof abuse. Questions must be asked in ways that do notfurther traumatize the child or impede any possible legalactions. The generalist nurse should not pursue investigationwith the child: it may do more harm than good.Treatment and InterventionThe first part of treatment for child abuse or neglect is toensure the child’s safety and well-being (Bernet, 2005).This may involve removing the child from the home,which also can be traumatic. Given the high risk for psychologicalproblems, a thorough psychiatric evaluation

188UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSalso is indicated. A relationship of trust between the therapistand the child is crucial to help the child deal with thetrauma of abuse. Depending on the severity and durationof abuse and the child’s response, therapy may be indicatedover a significant period.Long-term treatment for the child usually involves professionalsfrom several disciplines, such as psychiatry,social work, and psychology. The very young child maycommunicate best through play therapy, where he or shedraws or acts out situations with puppets or dolls ratherthan talks about what has happened or his or her feelings.Social service agencies are involved in determining whetherreturning the child to the parental home is possible basedon whether parents can show benefit from treatment. Familytherapy may be indicated if reuniting the family is feasible.Parents may require psychiatric or substance abusetreatment. If the child is unlikely to return home, shorttermor long-term foster care services may be indicated.ELDER ABUSEElder abuse is the maltreatment of older adults by familymembers or caregivers. It may include physical and sexualabuse, psychological abuse, neglect, self-neglect, financialexploitation, and denial of adequate medical treatment.Estimates are that people over age 65 are injured, exploited,abused, or neglected by their caregivers and that only 1 in14 elder maltreatment cases are reported (Muehlbauer &Crane, 2006). Nearly 60% of the perpetrators are spouses,20% are adult children, and 20% are others such as siblings,grandchildren, and boarders.Most victims of elder abuse are 75 years or older; 60%to 65% are women. Abuse is more likely when the elderhas multiple chronic mental and physical health problemsElder abuseand when he or she is dependent on others for food, medicalcare, and various activities of daily living.Persons who abuse elders are almost always in a caregiverposition or the elders depend on them in some way. Mostcases of elder abuse occur when one older spouse is takingCLINICAL VIGNETTE: ELDER ABUSEJosephine is an elderly woman who has moved in with herson, daughter-in-law, and two grandchildren after thedeath of her husband. She lives in a finished basementapartment with her own bath. Friction with her daughterin-lawbegins to develop when Josephine tries to help outaround the house. She comments on the poor manners andoutlandish clothes of her teenaged grandchildren. She addsspices to food her daughter-in-law is cooking on the stove.She comments on how late the children stay out, theirfriends, and how hard her son works. All this is annoyingbut harmless.Josephine’s daughter-in-law gets very impatient, tellingher husband, “I’m the one who has to deal with your motherall day long.” One day, after another criticism from Josephine,the daughter-in-law slaps her. She then tells Josephine to godownstairs to her room and stay out of sight if she wantsto have a place to live. A friend of Josephine’s calls on thephone and the daughter-in-law lies and tells her Josephine issleeping.Josephine spends more time alone in her room, becomesmore isolated and depressed, and is eating and sleepingpoorly. She is afraid she will be placed in a nursing home ifshe doesn’t get along with her daughter-in-law. Her sonseems too busy to notice what is happening, and Josephineis afraid to tell him for fear he won’t believe her or will takehis wife’s side. Her friends don’t seem to call much anymore,and she has no one to talk to about how miserable she is.She just stays to herself most of the day.

CHAPTER 11 • ABUSE AND VIOLENCE 189care of another. This type of spousal abuse usually happensover many years after a disability renders the abused spouseunable to care for himself or herself. When the abuser is anadult child, it is twice as likely to be a son as a daughter. Apsychiatric disorder or a problem with substance abuse alsomay aggravate abuse of elders (Goldstein, 2005).Elders are often reluctant to report abuse, even when theycan, because the abuse usually involves family memberswhom the elder wishes to protect. Victims also often fear losingtheir support and being moved to an institution.No national estimates of abuse of elders living in institutionsare available. However, under a 1978 federal mandate,ombudsmen are allowed to visit nursing homes to check onthe care of the elderly. These ombudsmen report that elderabuse is common in institutions (Goldstein, 2005).Clinical PictureThe victim may have bruises or fractures; may lack neededeyeglasses or hearing aids; may be denied food, fluids, ormedications; or may be restrained in a bed or chair. Theabuser may use the victim’s financial resources for his orher own pleasure while the elder cannot afford food ormedications. Abusers may withhold medical care from anelder with acute or chronic illness. Self-neglect involvesthe elder’s failure to provide for himself or herself.AssessmentCareful assessment of elderly persons and their caregivingrelationships is essential in detecting elder abuse. Often,determining whether the elder’s condition results fromdeterioration associated with a chronic illness or fromabuse is difficult. Several potential indicators of abuserequire further assessment and careful evaluation (Box 11.4).These indicators by themselves, however, do not necessarilysignify abuse or neglect.The nurse should suspect abuse if injuries have beenhidden or untreated or are incompatible with the explanationprovided. Such injuries can include cuts, lacerations,puncture wounds, bruises, welts, or burns. Burns can becigarette burns, scaldings, acid or caustic burns, or frictionburns of the wrists or ankles caused from being restrainedby ropes, clothing, or chains. Signs of physical neglectinclude a pervasive smell of urine or feces, dirt, rashes,sores, lice, or inadequate clothing. Dehydration or malnourishmentnot linked with a specific illness also stronglyindicates abuse.Possible indicators of emotional or psychological abuseinclude an elder who is hesitant to talk openly to the nurseor who is fearful, withdrawn, depressed, and helpless. Theelder also may exhibit anger or agitation for no apparentreason. He or she may deny any problems, even when thefacts indicate otherwise.Possible indicators of self-neglect include inability tomanage money (hoarding or squandering while failing topay bills), inability to perform activities of daily living (personalcare, shopping, food preparation, and cleaning), andchanges in intellectual function (confusion, disorientation,inappropriate responses, and memory loss and isolation).Other indicators of self-neglect include signs of malnutritionor dehydration, rashes or sores on the body, an odor of urineor feces, or failure to keep needed medical appointments.For self-neglect to be diagnosed, the elder must be evaluatedas unable to manage day-to-day life and take care of himselfor herself. Self-neglect cannot be established based solely onfamily members’ beliefs that the elder cannot manage his orher finances. For example, an older adult cannot be consideredto have self-neglect just because he or she gives awaylarge sums of money to a group or charity or invests in someventure of which family members disapprove.Warnings of financial exploitation or abuse may includenumerous unpaid bills (when the client has enough moneyto pay them), unusual activity in bank accounts, checkssigned by someone other than the elder, or recent changes ina will or power of attorney when the elder cannot make suchdecisions. The elder may lack amenities that he or she canafford, such as clothing, personal products, or a television.The elder may report losing valuable possessions and reportthat he or she has no contact with friends or relatives.The nurse also may detect possible indicators of abusefrom the caregiver. The caregiver may complain about howdifficult caring for the elder is, incontinence, difficulties infeeding, or excessive costs of medication. He or she maydisplay anger or indifference toward the elder and try tokeep the nurse from talking with the elder alone. Elderabuse is more likely when the caregiver has a history offamily violence or alcohol or drug problems.All 50 states in the United States, District of Columbia,Guam, Puerto Rico, and the Virgin Islands have laws governingadult protective services. This covers elder citizensand, in most states, includes adults who are considereddependent, disabled, or impaired and who must rely onothers to meet basic needs. These laws provide a systemfor defining, reporting, and investigating abuse, as well asproviding services to victims. However, abuse reportingfor elders or dependent adults is not mandatory in allstates and territories. Nurses should be familiar with thelaws or statutes for reporting abuse in their own states.Many cases remain unreported. The local agency on agingcan provide procedures for reporting abuse in accordancewith state laws. To find a local agency, call the nationalinformation center at 1-800-677-1116.Treatment and InterventionElder abuse may develop gradually as the burden of careexceeds the caregiver’s physical or emotional resources.Relieving the caregiver’s stress and providing additionalresources may help to correct the abusive situation andleave the caregiving relationship intact. In other cases, theneglect or abuse is intentional and designed to provide

190UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSBox 11.4 POSSIBLE INDICATORS OF ELDER ABUSEPHYSICAL ABUSE INDICATORS• Frequent, unexplained injuries accompanied by a habitof seeking medical assistance from various locations• Reluctance to seek medical treatment for injuries or denialof their existence• Disorientation or grogginess indicating misuse ofmedications• Fear or edginess in the presence of family member orcaregiverPSYCHOSOCIAL ABUSE INDICATORS• Change in elder’s general mood or usual behavior• Isolated from previous friends or family• Sudden lack of contact from other people outside theelder’s home• Helplessness• Hesitance to talk openly• Anger or agitation• Withdrawal or depressionMATERIAL ABUSE INDICATORS• Unpaid bills• Standard of living below elder’s means• Sudden sale or disposal of elder’s property/possessions• Unusual or inappropriate activity in bank accounts• Signatures on checks that differ from the elder’s• Recent changes in will or power of attorney when elderis not capable of making those decisions• Missing valuable belongings that are not just misplaced• Lack of television, clothes, or personal items that are easilyaffordable• Unusual concern by the caregiver over the expense ofthe elder’s treatment when it is not the caregiver’s moneybeing spentNEGLECT INDICATORS• Poor personal hygiene• Lack of needed medications or therapies• Dirt, fecal or urine smell, or other health hazards in theelder’s living environment• Rashes, sores, or lice on the elder• Elder has an untreated medical condition or is malnourishedor dehydrated not related to a known illness• Inadequate material items, such as clothing, blankets,furniture, and televisionINDICATORS OF SELF-NEGLECT• Inability to manage personal finances, such as hoarding,squandering, or giving away money while not payingbills• Inability to manage activities of daily living, such as personalcare, shopping, or housework• Wandering, refusing needed medical attention, isolation,and substance use• Failure to keep needed medical appointments• Confusion, memory loss, and unresponsiveness• Lack of toilet facilities, or living quarters infested withanimals or verminWARNING INDICATORS FROM CAREGIVER• Elder is not given opportunity to speak for self, to havevisitors, or to see anyone without the presence of thecaregiver• Attitudes of indifference or anger toward the elder• Blaming the elder for his or her illness or limitations• Defensiveness• Conflicting accounts of elder’s abilities, problems, and soforth• Previous history of abuse or problems with alcohol or drugspersonal gain to the caregiver, such as access to the victim’sfinancial resources. In these situations, removal of theelder or caregiver is necessary.RAPE AND SEXUAL ASSAULTRape is a crime of violence and humiliation of the victimexpressed through sexual means. Rape is the perpetrationof an act of sexual intercourse with a female against herwill and without her consent, whether her will is overcomeby force, fear of force, drugs, or intoxicants. It is alsoconsidered rape if the woman is incapable of exercisingrational judgment because of mental deficiency or whenshe is younger than the age of consent (which variesamong states from 14 to 18 years; van der Kolk, 2005).The crime of rape requires only slight penetration of theouter vulva; full erection and ejaculation are not necessary.Forced acts of fellatio and anal penetration, although theyfrequently accompany rape, are legally considered sodomy.The woman who is raped also may be physically beatenand injured.Rape can occur between strangers, acquaintances, marriedpersons, and persons of the same sex, although sevenstates define domestic violence in a way that excludes

CHAPTER 11 • ABUSE AND VIOLENCE 191CLINICAL VIGNETTE: RAPECynthia is a 22-year-old college student who spent Saturdayafternoon with a group of friends at the football game.Afterward, they were going to attend a few parties to celebratethe victory. Alcohol was served freely at these parties.At one party, Cynthia became separated from her friendsbut started talking to Ron, whom she recognized from herEnglish Lit course. They spent the rest of the evening together,talking, dancing, and drinking. She had had moredrinks than she was used to, as Ron kept bringing her moreevery time her glass was empty. At the end of the night, Ronasked if she wanted him to drive her home. Her friends werestaying longer at the party.When Ron and Cynthia arrived at her apartment, noneof her roommates had returned yet, so she asked Ron tocome in. She was feeling a little tipsy, and they begankissing. She could feel Ron really getting excited. He beganto try to remove her skirt, but she said, “No,” and tried tomove away from him. She remembered him saying, “What’sthe matter with you? Are you a prude or what?” She toldhim she had had a good time but didn’t want to go further.He responded, “Come on, you’ve been trying to turn me onall night. You want this as much as I do.” He forced himselfon top of her and held his arm over her neck and rapedher.When her roommates return in about 1 hour, Cynthia ishuddled in the corner of her room, seems stunned, and iscrying uncontrollably. She feels sick and confused. Did shedo something to cause this whole thing? She keeps askingherself whether she might not have gotten into that situationhad she not been a little tipsy. She is so confused.same-sex victims. Almost two thirds of rapes are committedby someone known to the victim (RAINN, 2009). Aphenomenon called date rape (acquaintance rape) mayoccur on a first date, on a ride home from a party, or whenthe two people have known each other for some time. It ismore prevalent near college and university campuses. Therate of serious injuries associated with dating violenceincreases with increased consumption of alcohol by eitherthe victim or the perpetrator.Rape is a highly underreported crime: Estimates arethat only one rape is reported for every 4 to 10 rapes thatoccur. The underreporting is attributed to the victim’s feelingsof shame and guilt, the fear of further injury, and thebelief that she has no recourse in the legal system. Victimsof rape can be any age: Reported cases have victims rangingin age from 15 months to 82 years. The highest incidenceis in girls and women 16 to 24 years of age. Girlsyounger than 18 years were the victims in 61% of rapesreported (van der Kolk, 2005).Rape most commonly occurs in a woman’s neighborhood,often inside or near her home. Most rapes are premeditated.Strangers perpetrate 43% of rapes, husbandsand boyfriends commit 19%, and other relatives accountfor 38%. Rape results in pregnancy about 10% of the time(van der Kolk, 2005).Male rape is a significantly underreported crime. Itcan occur between gay partners or strangers but is mostprevalent in institutions such as prisons or maximumsecurityhospitals. Estimates are that 2% to 5% of maleinmates are sexually assaulted, but the figure may bemuch higher. This type of rape is particularly violent,and the dynamics of power and control are the same asfor heterosexual rape.Dynamics of RapeMost men who commit rape are between 25 and 44 yearsold. In terms of race, 51% are white and tend to rapewhite victims, and 47% are African American and tend torape African-American victims; the remaining 2% comefrom all other races. Alcohol is involved in 34% of cases.Rape often accompanies another crime. Almost 75% ofarrested rapists have prior criminal histories, includingother rapes, assaults, robberies, and homicides (van derKolk, 2005).Recent research (van der Kolk, 2005) has categorizedmale rapists into four categories:• Sexual sadists who are aroused by the pain of theirvictims• Exploitive predators who impulsively use their victimsas objects for gratification• Inadequate men who believe that no woman would voluntarilyhave sexual relations with them and who areobsessed with fantasies about sex• Men for whom rape is a displaced expression of angerand rage.Feminist theory proposes that women have historicallyserved as objects for aggression, dating back to whenwomen (and children) were legally the property of men. In1982, for the first time, a married man was convicted ofraping his wife, signaling the end of the notion that sexualintercourse could not be denied in the context ofmarriage.Women who are raped are frequently in life-threateningsituations, so their primary motivation is to stay alive. Attimes, attempts to resist or fight the attacker succeed; in

192UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSBox 11.5COMMON MYTHSABOUT RAPE• Rape is about having sex.• When a woman submits to rape, she really wants it tohappen.• Women who dress provocatively are asking fortrouble.• Some women like rough sex but later call it rape.• Once a man is aroused by a woman, he cannot stophis actions.• Walking alone at night is an invitation for rape.• Rape cannot happen between persons who aremarried.• Rape is exciting for some women.• Rape occurs only between heterosexual couples.• If a woman has an orgasm, it can’t be rape.• Rape usually happens between strangers.• Rape is a crime of passion.• Rape happens spontaneously.other situations, fighting and yelling result in more severephysical injuries or even death. Degree of submission ishigher when the attacker has a weapon such as a gun orknife. In addition to forcible penetration, the more violentrapist may urinate or defecate on the woman or insert foreignobjects into her vagina and rectum.The physical and psychological trauma that rape victimssuffer is severe. Related medical problems can includeacute injury, sexually transmitted diseases, pregnancy, andlingering medical complaints. A cross-sectional study ofmedical patients found that women who had been rapedrated themselves as significantly less healthy, visited a physiciantwice as often, and incurred medical costs more thantwice as high as women who had not experienced anycriminal victimization. The level of violence experiencedduring the assault was found to be a powerful predictor offuture use of medical services. Many victims of rape experiencefear, helplessness, shock and disbelief, guilt, humiliation,and embarrassment. They also may avoid the placeor circumstances of the rape; give up previously pleasurableactivities; experience depression, anxiety, PTSD,sexual dysfunction, insomnia, and impaired memory; orcontemplate suicide (RAINN, 2009).Until recently, the rights of rape victims often wereignored. For example, when rape victims reported a rapeto authorities, they often faced doubt and embarrassingquestions from male officers. The courts did not protectthe rights of victims; for example, a woman’s past sexualbehavior was admissible in court—although the past criminalrecord of her accused attacker was not. Laws to correctthese problems have been enacted on a state-by-statebasis since the mid-1980s.Although the treatment of rape victims and the prosecutionof rapists have improved in the past two decades,many people still believe that somehow a woman provokesrape by her behavior and that the woman is partiallyresponsible for this crime. Box 11.5 summarizes commonmyths and misunderstandings about rape.AssessmentTo preserve possible evidence, the physical examinationshould occur before the woman has showered, brushedher teeth, douched, changed her clothes, or had anythingto drink. This may not be possible, because the womanmay have done some of these things before seeking care. Ifthere is no report of oral sex, then rinsing the mouth ordrinking fluids can be permitted immediately.To assess the woman’s physical status, the nurse asks thevictim to describe what happened. If the woman cannot doso, the nurse may ask needed questions gently and with care.Rape kits and rape protocols are available in most emergencyroom settings and provide the equipment and instructionsneeded to collect physical evidence. The physician is primarilyresponsible for this step of the examination.Treatment and InterventionVictims of rape fare best when they receive immediate supportand can express fear and rage to family members,nurses, physicians, and law enforcement officials whobelieve them. Education about rape and the needs of victimsis an ongoing requirement for health-care professionals,law enforcement officers, and the general public.Box 11.6 lists warning signs of relationship violence.These signs, used at the State University of New York atBuffalo (2008) to educate students about date rape, canalert women to the characteristics of men who are likely tocommit dating violence. Examples include expressingnegativity about women, acting tough, engaging in heavydrinking, exhibiting jealousy, making belittling comments,expressing anger, and using intimidation.Rape treatment centers (emergency services that coordinatepsychiatric, gynecologic, and physical trauma servicesin one location and work with law enforcementagencies) are most helpful to the victim. In the emergencysetting, the nurse is an essential part of the team in providingemotional support to the victim. The nurse shouldallow the woman to proceed at her own pace and not rushher through any interview or examination procedures.Giving back to the victim as much control as possible isimportant. Ways to do so include allowing her to makedecisions, when possible, about whom to call, what to donext, what she would like done, and so on. It is the woman’sdecision about whether or not to file charges and testifyagainst the perpetrator. The victim must sign consentforms before any photographs or hair and nail samples aretaken for future evidence.

CHAPTER 11 • ABUSE AND VIOLENCE 193Box 11.6WARNING SIGNS OFRELATIONSHIP VIOLENCE• Emotionally abuses you (insults, makes belittling comments,or acts sulky or angry when you initiate anidea or activity)• Tells you with whom you may be friends or how youshould dress, or tries to control other elements ofyour life• Talks negatively about women in general• Gets jealous for no reason• Drinks heavily, uses drugs, or tries to get you drunk• Acts in an intimidating way by invading your personalspace such as standing too close or touching youwhen you don’t want him to• Cannot handle sexual or emotional frustration withoutbecoming angry• Does not view you as an equal: sees himself as smarteror socially superior• Guards his masculinity by acting tough• Is angry or threatening to the point that you havechanged your life or yourself so you won’t anger him• Goes through extreme highs and lows; is kind oneminute, cruel the next• Berates you for not getting drunk or high, or notwanting to have sex with him• Is physically aggressive, grabbing and holding you, orpushing and shovingAdapted from the State University of New York at Buffalo Counseling Center(2008). Available at: http://ub-counseling.buffalo.edu/warnings.php.Prophylactic treatment for sexually transmitted diseasessuch as chlamydia or gonorrhea is offered. Doing so iscost-effective: many victims of rape will not return to getdefinitive test results for these diseases. HIV testing isstrongly encouraged at specified intervals because seroconversionto positive status does not occur immediately.Women are also encouraged to engage in safe-sex practicesuntil the results of HIV testing are available. Prophylaxiswith ethinyl estradiol and norgestrel (Ovral) can be offeredto prevent pregnancy. Some women may elect to wait toinitiate intervention until they have a positive pregnancytest result or miss a menstrual period.Rape crisis centers, women’s advocacy groups, and otherlocal resources often provide a counselor or volunteer to bewith the victim from the emergency room through longertermfollow-up. This person provides emotional support,serves as an advocate for the woman throughout the process,and can be totally available to the victim. This type ofcomplete and unconditional support is often crucial torecovery.Therapy usually is supportive in approach and focuseson restoring the victim’s sense of control; relieving feelingsof helplessness, dependency, and obsession with the assaultthat frequently follow rape; regaining trust; improvingdaily functioning; finding adequate social support; anddealing with feelings of guilt, shame, and anger. Grouptherapy with other women who have been raped is a particularlyeffective treatment. Some women attend bothindividual and group therapies.It often takes 1 year or more for survivors of rape toregain previous levels of functioning. In some cases, survivorsof rape have long-term consequences, such as PTSD,which is discussed later in this chapter.COMMUNITY VIOLENCEThe National Center for Education Statistics (NCES),Institute of Education Sciences (IES), and the Bureau ofJustice jointly publish an annual report about school crimeand safety. The most recent data published are for the2005–2006 academic year. Fourteen homicides and threesuicides occurred at school in children aged 5 to 18, or1 death per 3.2 million students. There were 1.5 millionnonfatal crimes among children 12 to 18 years old, includingtheft and violent crimes. Eighty-six percent of allschools reported one or more serious violent incidents,theft, or other crimes on school property, or a rate of 46crimes per 1000 students. Among high school (grades 9through 12) students, 14% reported fighting on schoolproperty, 13% carried a weapon to school, 4% consumedalcohol at school, and 5% used marijuana on school property(NCES, 2008).In an effort to combat violence at school, the CDC hasbeen working with schools to develop curricula thatemphasize problem-solving skills, anger management, andsocial skills development. In addition, parenting programsthat promote strong bonding between parents and childrenand conflict management in the home, as well asmentoring programs for young people, show promise indealing with school-related violence. A few people responsiblefor such violence have been diagnosed with a psychiatricdisorder, often conduct disorder, which is discussedin Chapter 20. Often, however, this violence seems tooccur when alienation, disregard for others, and littleregard for self predominate.Bullying is another problem experienced at school,including verbal aggression, physical acts from shoving tobreaking bones, targeting a student to be shunned orignored by others, and cyberbullying involving unwantedemails, text messages, or pictures posted on the Internet(McGuinness, 2007). Nearly one third of U.S. studentsreport they experience bullying, either as a target or as aperpetrator. More than 16% said they’d been bullied occasionally,whereas 8% reported being bullied at least once aweek. The frequency of bullying was highest among sixththrough eighth graders. Children who were bulliedreported more loneliness and difficulty making friends,and those who bullied were more likely to have poor

194UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSgrades and to use alcohol and tobacco. Children with specialphysical health-care needs are bullied more often, andchildren with a chronic emotional, behavioral, or developmentalproblem are more likely to be both a bully and avictim of bullying (Van Cleave & Davis, 2006).Hazing, or initiation rites, is prevalent in both highschool and college. Forty-eight percent of high school studentsreported belonging to groups that involved hazingactivities. Forty-three percent reported being subjected tohumiliating activities, and 30% reported hazing thatinvolved illegal activities. Seventy-one percent of the studentssubjected to hazing reported negative consequencessuch as fighting; being injured; hurting other people; doingpoorly in school; difficulty eating, sleeping, or concentrating;and experiencing feelings of anger, confusion, embarrassment,or guilt (Lipkins, 2006).Exposure to community violence tremendously affectschildren and young adults. When children witness violence,they experience stress-related symptoms thatincrease with the amount of violence they see. In addition,witnessing violence can lead to future problems withaggression, depression, relationships, achievement, andabuse of drugs and alcohol. Addressing the problem of violenceexposure may help to alleviate the cycle of dysfunctionand further violence.On a larger scale, violence such as the terrorist attacksin New York, Washington, and Pennsylvania in 2001 alsohas far-reaching effects on citizens. In the immediateaftermath, children were afraid to go to school or havetheir parents leave them for any reason. Adults had difficultygoing to work, leaving their homes, using publictransportation, and flying. One year later, 1 in 10 NewYork area residents suffered lingering stress and depressionas a result of September 11, and an additional532,240 cases of PTSD had been reported in the NewYork City metropolitan area alone. In addition, peoplereported higher relapse rates of depression and anxietydisorders. There was no increase of PTSD nationwide asa result of individuals watching the attacks and associatedcoverage on television, however, which had been aninitial concern. Three years later, in 2004, the prevalenceof PTSD was 12.6% among Manhattan residents livingnear the World Trade Center. Risk factors for PTSDamong these residents included being injured, witnessinghorrific events, being exposed to dust cloud, and assistingwith evacuation, rescue, and recovery work in theaftermath (DiGrande et al., 2008).Early intervention and treatment are key to dealingwith victims of violence. After several instances of schoolor workplace shootings, counseling, referrals, and ongoingtreatment were instituted immediately to help thoseinvolved deal with the horror of their experiences. Sincethe 2001 terrorist attacks, teams of physicians, therapists,and other health professionals (many associated with universitiesand medical centers) have been working withsurvivors, families, and others affected. Despite suchefforts, many people will continue to experience long-termdifficulties, as described in the next section.PSYCHIATRIC DISORDERS RELATED TOABUSE AND VIOLENCEPosttraumatic Stress DisorderPosttraumatic stress disorder is a disturbing pattern ofbehavior demonstrated by someone who has experienceda traumatic event such as a natural disaster, a combat, oran assault. The person with PTSD was exposed to an eventthat posed a threat of death or serious injury and respondedwith intense fear, helplessness, or terror. Three clusters ofsymptoms are present: reliving the event, avoiding remindersof the event, and being on guard, or experiencinghyperarousal. The person persistently reexperiences thetrauma through memories, dreams, flashbacks, or reactionsto external cues about the event and therefore avoidsstimuli associated with the trauma. The victim feels anumbing of general responsiveness and shows persistentsigns of increased arousal such as insomnia, hyperarousalor hypervigilance, irritability, or angry outbursts. He orshe reports losing a sense of connection and control overhis or her life. In PTSD, the symptoms occur 3 months ormore after the trauma, which distinguishes PTSD fromacute stress disorder. This diagnosis from the Diagnosticand Statistical Manual of Mental Disorders, 4th edition, TextPosttraumatic stress disorder

CHAPTER 11 • ABUSE AND VIOLENCE 195CLINICAL VIGNETTE: POSTTRAUMATIC STRESS DISORDERJulie sat up in bed. She felt her heart pounding, she wasperspiring, and she felt like she couldn’t breathe. She wasgasping for breath and felt the pressure on her throat! Thepicture of that dark figure knocking her to the ground andhis hands around her throat was vivid in her mind. Herheart was pounding and she was reliving it all over again,the pain and the terror of that night! It had been 2 yearssince she was attacked and raped in the park while jogging,but sometimes it felt like just yesterday. She hadnightmares of panic almost every night. She would neverbe rid of that night.Lately, the dread of reliving the nightmare made Julieafraid to fall asleep, and she wasn’t getting much sleep.She felt exhausted. She didn’t feel much like eating andwas losing weight. This ordeal had ruined her life. She wasmissing work more and more. Even while at work, sheoften felt an overwhelming sense of dread. Sometimeseven in the daytime, memories and flashbacks of that nightwould come.Her friends didn’t seem to want to be around her anymorebecause she was often moody and couldn’t seem toenjoy herself. Sure, they were supportive and listened toher for the first 6 months, but now it was 2 years since therape. Before the rape, she was always ready to go to a partyor out to dinner and a movie with friends. Now she just feltlike staying home. She was tired of her mother and friendstelling her she needed to go out and have some fun. Nobodycould understand what she had gone through andhow she felt. Julie had had several boyfriends since then,but the relationships just never seemed to work out. Shewas moody and would often become anxious and depressedfor no reason and cancel dates at the last minute.Everyone was getting tired of her moods, but she felt shehad no control over them.Revision (DSM-IV-TR; American Psychiatric Association[APA], 2000) is appropriate when symptoms appear withinthe first month after the trauma and do not persist longerthan 4 weeks.DSM-IV-TR DIAGNOSTIC CRITERIA:Major Symptoms of PosttraumaticStress Disorder• Recurrent, intrusive, distressing memories of the event• Nightmares• Flashbacks• Avoidance of thoughts, feelings, or conversations associatedwith the trauma• Avoidance of activities, places, or people that arousememories of the trauma• Inability to recall important aspect of the trauma• Marked decrease in interest or participation in significantevents• Feeling detached or estranged from others• Restricted range of affect• Sense of foreshortened future• Difficulty falling or staying asleep• Irritability or anger outbursts• Difficulty concentrating• Hypervigilance• Exaggerated startle responseAdapted from DSM-IV-TR (2000).PTSD can occur at any age, including during childhood.Estimates are that up to 60% of people at risk, such ascombat veterans and victims of violence and natural disasters,develop PTSD. Complete recovery occurs within3 months for about 50% of people. The severity and durationof the trauma and the proximity of the person to theevent are the most important factors affecting the likelihoodof developing PTSD (APA, 2000). One fourth of allvictims of physical assault develop PTSD. Victims of rapehave one of the highest rates of PTSD—approximately70 percent (van der Kolk, 2005).Dissociative DisordersDissociation is a subconscious defense mechanism thathelps a person protect his or her emotional self from recognizingthe full effects of some horrific or traumatic eventby allowing the mind to forget or remove itself from thepainful situation or memory. Dissociation can occur bothduring and after the event. As with any other protectivecoping mechanism, dissociating becomes easier withrepeated use.Dissociative disorders have the essential feature of adisruption in the usually integrated functions of consciousness,memory, identity, or environmental perception.This often interferes with the person’s relationships,ability to function in daily life, and ability to cope with therealities of the abusive or traumatic event. This disturbancevaries greatly in intensity in different people, andthe onset may be sudden or gradual, transient or chronic.Dissociative symptoms are seen in clients with PTSD.

196UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSThe DSM-IV-TR describes different types of dissociativedisorders:• Dissociative amnesia: The client cannot remember importantpersonal information (usually of a traumatic orstressful nature).• Dissociative fugue: The client has episodes of suddenlyleaving the home or place of work without any explanation,traveling to another city, and being unable to rememberhis or her past or identity. He or she mayassume a new identity.• Dissociative identity disorder (formerly multiple personalitydisorder): The client displays two or more distinctidentities or personality states that recurrently takecontrol of his or her behavior. This is accompanied bythe inability to recall important personal information.• Depersonalization disorder: The client has a persistent orrecurrent feeling of being detached from his or hermental processes or body. This is accompanied by intactreality testing; that is, the client is not psychotic or outof touch with reality.Dissociative disorders, relatively rare in the general population,are much more prevalent among those with historiesof childhood physical and sexual abuse. Some believethe recent increase in the diagnosis of dissociative disordersin the United States is the result of more awareness of thisdisorder by mental health professionals (APA, 2000).The media has focused much attention on the theory ofrepressed memories in victims of abuse. Many professionalsbelieve that memories of childhood abuse can be burieddeeply in the subconscious mind or repressed because theyare too painful for the victims to acknowledge and that victimscan be helped to recover or remember such painfulmemories. If a person comes to a mental health professionalexperiencing serious problems in relationships,symptoms of PTSD, or flashbacks involving abuse, themental health professional may help the person rememberor recover those memories of abuse. Some mental healthprofessionals believe there is danger of inducing falseDSM-IV-TR DIAGNOSTIC CRITERIA:Major Symptoms of DissociativeIdentity Disorder• Presence of two or more distinct identities or personalitystates• At least two identities recurrently taking control of theperson’s behavior• Inability to recall important personal information:more extensive than ordinary forgetfulness• Symptoms not related to any substance use or medicalconditionAdapted from DSM-IV-TR (2000).memories of childhood sexual abuse through imaginationin psychotherapy (Rubin & Berndtson, 2007). This socalledfalse memory syndrome has created problems in familieswhen clients made groundless accusations of abuse.Fears exist, however, that people abused in childhood willbe more reluctant to talk about their abuse history because,once again, no one will believe them. Still other therapistsargue that people thought to have dissociative identity disorderare suffering anxiety, terror, and intrusive ideas andemotions and therefore need help, and the therapist shouldremain open-minded about the diagnosis.Treatment and InterventionsSurvivors of trauma and abuse who have PTSD or dissociativedisorders often are involved in group or individualtherapy in the community to address the long-term effectsof their experiences. Cognitive–behavioral therapy is effectivein dealing with the thoughts and subsequent feelingsand behavior of trauma and abuse survivors. Therapy forclients who dissociate focuses on reassociation, or puttingthe consciousness back together. Both paroxetine (Paxil)and sertraline (Zoloft) have been used to treat PTSD successfully.Clients with dissociative disorders may be treatedsymptomatically, that is, with medications for anxiety ordepression or both if these symptoms are predominant.Clients with PTSD and dissociative disorders are foundin all areas of health care, from clinics to primary careoffices. The nurse is most likely to encounter these clientsin acute care settings when there are concerns for theirsafety or the safety of others or when acute symptoms havebecome intense and require stabilization. Treatment inacute care is usually short term, with the client returningto community-based treatment as quickly as possible.APPLICATION OF THE NURSING PROCESSAssessmentThe health history reveals that the client has a history oftrauma or abuse. It may be abuse as a child or in a current orrecent relationship. It generally is not necessary or desirablefor the client to detail specific events of the abuse or trauma;rather, in-depth discussion of the actual abuse is usuallyundertaken during individual psychotherapy sessions.General Appearance and Motor BehaviorThe nurse assesses the client’s overall appearance and motorbehavior. The client often appears hyperalert and reacts toeven small environmental noises with a startle response. Heor she may be very uncomfortable if the nurse is too closephysically and may require greater distance or personalspace than most people. The client may appear anxious oragitated and may have difficulty sitting still, often needingto pace or move around the room. Sometimes the client maysit very still, seeming to curl up with arms around knees.

CHAPTER 11 • ABUSE AND VIOLENCE 197Nursing Care Plan ❘ for a Client With PTSDNursing DiagnosisPosttrauma syndrome: Sustained maladaptive response to a traumatic, overwhelming event.ASSESSMENT DATA• Flashbacks or reexperiencing the traumatic event(s)• Nightmares or recurrent dreams of the event orother trauma• Sleep disturbances (e.g., insomnia, early awakening,or crying out in sleep)• Depression• Denial of feelings or emotional numbness• Projection of feelings• Difficulty in expressing feelings• Anger (may not be overt)• Guilt or remorse• Low self-esteem• Frustration and irritability• Anxiety, panic, or separation anxiety• Fears—may be displaced or generalized (as in fearof men in rape victims)• Decreased concentration• Difficulty expressing love or empathy• Difficulty experiencing pleasure• Difficulty with interpersonal relationships, maritalproblems, and divorce• Abuse in relationships• Sexual problems• Substance use• Employment problems• Physical symptomsIMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)When you approach the client, be nonthreatening andprofessional.Initially, assign the same staff members to the client ifpossible; try to respect the client’s fears and feelings.Gradually increase the number and variety of staffmembers interacting with the client.EXPECTED OUTCOMESImmediateThe client will• Identify the traumatic event• Demonstrate decreased physical symptoms• Verbalize need to grieve loss(es)• Establish an adequate balance of rest, sleep, and activity• Demonstrate decreased anxiety, fear, guilt, and so forth• Participate in treatment program; for example,join in a group activity or talk with staff for at least30 minutes twice a day by a specified dateStabilizationThe client will• Begin the grieving process• Express feelings directly and openly innondestructive ways• Identify strengths and weaknesses realistically• Demonstrate an increased ability to cope with stress• Eliminate substance use• Verbalize knowledge of illness, treatment plan, orsafe use of medications, if anyCommunityThe client will• Demonstrate initial integration of the traumaticexperience into his or her life outside the hospital• Identify support systems in the community; for example,identify specific support groups, friends, or family• Implement plans for follow-up or ongoing therapy,if indicated; for example, identify a therapist andschedule an appointment before dischargeRationaleThe client’s fears may be triggered by authority figuresof other characteristics (e.g., gender and ethnicity).Limiting the number of staff members who interactwith the client at first will facilitate familiarity andtrust. The client may have strong feelings of fear ormistrust about working with staff members withcertain characteristics. These feelings may have beenreinforced in previous encounters with professionalsand may interfere with the therapeutic relationship.(continued)

198UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSNursing Care Plan | for a Client With PTSD, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)*Educate yourself and other staff members aboutthe client’s experience and about posttraumaticbehavior.Examine and remain aware of your own feelings regardingboth the client’s traumatic experience and his orher feelings and behavior. Talk with other staff membersto ventilate and work through your feelings.Remain nonjudgmental in your interactions with theclient.Be consistent with the client; convey acceptance ofhim or her as a person while setting and maintaininglimits regarding behaviors.*Assess the client’s history of substance use (informationfrom significant others might be helpful).Be aware of the client’s use or abuse of substances. Setlimits and consequences for this behavior; it maybe helpful to allow the client or group to have inputinto these decisions.*If substance use is a major problem, refer the client toa substance dependence treatment program.Encourage the client to talk about his or herexperience(s); be accepting and nonjudgmental ofthe client’s accounts and perceptions.Encourage the client to express his or her feelingsthrough talking, writing, crying, or other ways inwhich the client is comfortable.Especially encourage the expression of anger, guilt,and rage.Give the client positive feedback for expressing feelingsand sharing experiences; remain nonjudgmentaltoward the client.*Teach the client and the family or significant othersabout posttraumatic behavior and treatment.*Help the client learn and practice stress managementand relaxation techniques, assertiveness or selfdefensetraining, or other skills as appropriate.*As tolerated, encourage the client to share his orher feelings and experiences in group therapy, in asupport group related to posttrauma, or withother clients informally.RationaleLearning about the client’s experience will help prepareyou for the client’s feelings and the details ofhis or her experience.Traumatic events engender strong feelings in othersand may be quite threatening. You may be remindedof a related experience or of your own vulnerability,or issues related to sexuality, morality, safety, orwell-being. It is essential that you remain aware ofyour feelings so that you do not unconsciouslyproject feelings, avoid issues, or be otherwisenontherapeutic with the client.It is important not to reinforce blame that the clientmay have internalized related to the experience.The client may test limits or the therapeutic relationship.Problems with acceptance, trust, or authorityoften occur with posttraumatic behavior.Client often use substances to help repress (or release)emotions.Substance use undermines therapy and may endangerthe client’s health. Allowing input from the client orgroup may minimize power struggles.Substance use must be dealt with because it may affectall other areas of the client’s life.Retelling the experience can help the client to identifythe reality of what has happened and help to identifyand work through related feelings.Identification and expression of feelings are central tothe grieving process.These feelings often occur in clients who have experiencedtrauma. The client may feel survivor’s guilt that he orshe survived when others did not or guilt about thebehavior he or she undertook to survive (killing othersin combat, enduring a rape, or not saving others).The client may feel that he or she is burdening otherswith his or her problems. It is important not to reinforcethe client’s internalized blame.Knowledge about posttraumatic behavior may help alleviateanxiety or guilt and may increase hope for recovery.The client’s traumatic experience may have resultedin a loss of or decrease in self-confidence, sense ofsafety, or ability to deal with stress.The client needs to know that his or her feelings areacceptable to others and can be shared. Peer or supportgroups can offer understanding, support, andthe opportunity for sharing experiences.(continued)

CHAPTER 11 • ABUSE AND VIOLENCE 199Nursing Care Plan | for a Client With PTSD, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Rationale*If the client has a religious or spiritual orientation,referral to a member of the clergy or a chaplain maybe appropriate.Encourage the client to make realistic plans for thefuture, integrating his or her traumatic experience.*Provide social skills and leisure time counseling, orrefer the client to a recreational therapist as appropriate.*Talk with the client about employment, job-relatedstress, and so forth. Refer the client to vocationalservices as needed.*Help the client arrange for follow-up therapy asneeded.Guilt and forgiveness often are religious or spiritual issuesfor the client.Integrating traumatic experiences and making futureplans are important resolution steps in the griefprocess.Social isolation and lack of interest in recreational activitiesare common problems following trauma.Problems with employment frequently occur in clientswith posttraumatic behavior.Recovering from trauma may be a long-term process.Follow-up therapy can offer continuing support inthe client’s recovery.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.).Philadelphia: Lippincott Williams & Wilkins.Mood and AffectIn assessing mood and affect, the nurse must rememberthat a wide range of emotions is possible, from passivity toanger. The client may look frightened or scared or agitatedand hostile depending on his or her experience. When theclient experiences a flashback, he or she appears terrifiedand may cry, scream, or attempt to hide or run away. Whenthe client is dissociating, he or she may speak in a differenttone of voice or appear numb with a vacant stare. The clientmay report intense rage or anger or feeling dead insideand unable to identify any feelings or emotions.Thought Process and ContentThe nurse asks questions about thought process and content.Clients who have been abused or traumatized reportreliving the trauma, often through nightmares or flashbacks.Intrusive, persistent thoughts about the traumainterfere with the client’s ability to think about other thingsor to focus on daily living. Some clients report hallucinationsor buzzing voices in their heads. Self-destructivethoughts and impulses as well as intermittent suicidal ideationare also common. Some clients report fantasies inwhich they take revenge on their abusers.Sensorium and Intellectual ProcessesDuring assessment of sensorium and intellectual processes,the nurse usually finds that the client is oriented toreality except if the client is experiencing a flashback ordissociative episode. During those experiences, the clientmay not respond to the nurse or may be unable tocommunicate at all. The nurse also may find that clientswho have been abused or traumatized have memory gaps,which are periods for which they have no clear memories.These periods may be short or extensive and are usuallyrelated to the time of the abuse or trauma. Intrusivethoughts or ideas of self-harm often impair the client’sability to concentrate or pay attention.Judgment and InsightThe client’s insight is often related to the duration of his orher problems with dissociation or PTSD. Early in treatment,the client may report little idea about the relationshipof past trauma to his or her current symptoms andproblems. Other clients may be quite knowledgeable if theyhave progressed further in treatment. The client’s ability tomake decisions or solve problems may be impaired.Self-ConceptThe nurse is likely to find these clients have low selfesteem.They may believe they are bad people who somehowdeserve or provoke the abuse. Many clients believethey are unworthy or damaged by their abusive experiencesto the point that they will never be worthwhile orvalued. Clients may believe they are going crazy and areout of control with no hope of regaining control. Clientsmay see themselves as helpless, hopeless, and worthless.Roles and RelationshipsClients generally report a great deal of difficulty with alltypes of relationships. Problems with authority figures often

200UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSlead to problems at work, such as being unable to take directionsfrom another or have another person monitor his orher performance. Close relationships are difficult or impossiblebecause the client’s ability to trust others is severelycompromised. Often the client has quit work or has beenfired, and he or she may be estranged from family members.Intrusive thoughts, flashbacks, or dissociative episodes mayinterfere with the client’s ability to socialize with family orfriends, and the client’s avoidant behavior may keep him orher from participating in social or family events.Physiologic ConsiderationsMost clients report difficulty sleeping because of nightmaresor anxiety over anticipating nightmares. Overeatingor lack of appetite is also common. Frequently, these clientsuse alcohol or other drugs to attempt to sleep or toblot out intrusive thoughts or memories.Data AnalysisNursing diagnoses commonly used in the acute care settingwhen working with clients who dissociate or havePTSD related to trauma or abuse include the following:• Risk for Self-Mutilation• Ineffective Coping• Posttrauma Response• Chronic Low Self-Esteem• PowerlessnessIn addition, the following nursing diagnoses may be pertinentfor clients over longer periods, although not all diagnosesapply to each client:• Disturbed Sleep Pattern• Sexual Dysfunction• Rape-Trauma Syndrome• Spiritual Distress• Social IsolationOutcome IdentificationTreatment outcomes for clients who have survived traumaor abuse may include the following:1. The client will be physically safe.2. The client will distinguish between ideas of self-harmand taking action on those ideas.3. The client will demonstrate healthy, effective ways ofdealing with stress.4. The client will express emotions nondestructively.5. The client will establish a social support system in thecommunity.InterventionPromoting the Client’s SafetyThe client’s safety is a priority. The nurse continually mustassess the client’s potential for self-harm or suicide and takeNURSING INTERVENTIONSPromote Client’s Safety• Discuss self-harm thoughts.• Help client develop plan for going to safe place whenhaving destructive thoughts or impulses.Help Client Cope with Stress and Emotions• Use grounding techniques to help client who isdissociating or experiencing flashbacks.• Validate client’s feelings of fear, but try to increasecontact with reality.• During dissociative experience or flashback, help clientchange body position but do not grab or force client tostand up or move.• Use supportive touch if client responds well to it.• Teach deep breathing and relaxation techniques.• Use distraction techniques such as participating inphysical exercise, listening to music, talking with others,or engaging in a hobby or other enjoyable activity.• Help to make a list of activities and keep materials onhand to engage client when client’s feelings are intense.Help Promote Client’s Self-Esteem• Refer to client as “survivor” rather than “victim.”• Establish social support system in community.• Make a list of people and activities in the community forclient to contact when he or she needs help.action accordingly. The nurse and treatment team mustprovide safety measures when the client cannot do so (seeChapters 10 and 15). To increase the client’s sense of personalcontrol, he or she must begin to manage safety needsas soon as possible. The nurse can talk with the client aboutthe difference between having self-harm thoughts and takingaction on those thoughts: having the thoughts does notmean the client must act on those thoughts. Gradually, thenurse can help the client to find ways to tolerate thethoughts until they diminish in intensity.The nurse can help the client learn to go to a safe placeduring destructive thoughts and impulses so that he or shecan calm down and wait until they pass. Initially, this maymean just sitting with the nurse or around others. Later, theclient can find a safe place at home, often a closet or smallroom, where he or she feels safe. The client may want tokeep a blanket or pillows there for comfort and pictures ora tape recording to serve as reminders of the present.Helping the Client Cope with Stress and EmotionsGrounding techniques are helpful to use with the clientwho is dissociating or experiencing a flashback. Grounding

CHAPTER 11 • ABUSE AND VIOLENCE 201techniques remind the client that he or she is in the present,is an adult, and is safe. Validating what the client isfeeling during these experiences is important: “I know thisis frightening, but you are safe now.” In addition, the nursecan increase contact with reality and diminish the dissociativeexperience by helping the client focus on what he orshe is currently experiencing through the senses:• “What are you feeling?”• “Are you hearing something?”• “What are you touching?”• “Can you see me and the room we’re in?”• “Do you feel your feet on the floor?”• “Do you feel your arm on the chair?”• “Do you feel the watch on your wrist?”For the client experiencing dissociative symptoms, thenurse can use grounding techniques to focus the client on thepresent. For example, the nurse approaches the client andspeaks in a calm reassuring tone. First, the nurse calls the clientby name and then introduces himself or herself by nameand role. If the area is dark, the nurse turns on the lights. Heor she can reorient the client by saying the following:“Hello, Janet, I’m here with you. My nameis Sheila. I’m the nurse working with youtoday. Today is Thursday, February 8, 2010.You’re here in the hospital. This is your roomat the hospital. Can you open your eyes andlook at me? Janet, my name is Sheila.”The nurse repeats this reorienting information asneeded. Asking the client to look around the room encouragesthe client to move his or her eyes and avoid beinglocked in a daze or flashback.As soon as possible, the nurse encourages the client tochange positions. Often during a flashback, the client curls upin a defensive posture. Getting the client to stand and walkaround helps to dispel the dissociative or flashback experience.At this time, the client can focus on his or her feet movingon the floor or the swinging movements of his or her arms.The nurse must not grab the client or attempt to force him orher to stand up or move. The client experiencing a flashbackmay respond to such attempts aggressively or defensively,even striking out at the nurse. Ideally, the nurse asks the clienthow he or she responds to touch when dissociating or experiencinga flashback before one occurs; then the nurse knows ifusing touch is beneficial for that client. Also, the nurse mayask the client to touch the nurse’s arm. If the client does so,then supportive touch is beneficial for this client.Many clients have difficulty identifying or gauging theintensity of their emotions. They also may report thatextreme emotions appear out of nowhere with no warning.The nurse can help clients to get in touch with their feelingsby using a log or journal. Initially, clients may use a“feelings list” so they can select the feeling that most closelymatches their experience. The nurse encourages the clientto write down feelings throughout the day at specifiedintervals, for example, every 30 minutes. Once clients haveidentified their feelings, they can gauge the intensity ofthose feelings, for example, rating each feeling on a scale of1 to 10. Using this process, clients have a greater awarenessof their feelings and the different intensities; this step isimportant in managing and expressing those feelings.After identifying feelings and their intensities, clientscan begin to find triggers, or feelings that precede theflashbacks or dissociative episodes. Clients can then beginto use grounding techniques to diminish or avoid theseepisodes. They can use deep breathing and relaxation,focus on sensory information or stimuli in the environment,or engage in positive distractions until the feelingssubside. Such distractions may include physical exercise,listening to music, talking to others, or engaging in ahobby or activity. Clients must find which distractionswork for them; they should then write them down andkeep the list and the necessary materials for the activitiesclose at hand. When clients begin to experience intensefeelings, they can look at the list and pick up a book, listento a tape, or draw a picture, for instance.Helping to Promote the Client’s Self-EsteemOften it is useful to view the client as a survivor of trauma orabuse rather than as a victim. For these clients, who believethey are worthless and have no power over the situation, ithelps to refocus their view of themselves from being victims tobeing survivors. Defining themselves as survivors allows themto see themselves as strong enough to survive their ordeal. It isa more empowering image than seeing oneself as a victim.Establishing Social SupportThe client needs to find support people or activities in thecommunity. The nurse can help the client to prepare a list ofsupport people. Problem-solving skills are difficult for theseclients when under stress, so having a prepared list eliminatesconfusion or stress. This list should include a local crisishotline to call when the client experiences self-harm thoughtsor urges and friends or family to call when the client is feelinglonely or depressed. The client can also identify local activitiesor groups that provide a diversion and a chance to get outof the house. The client needs to establish community supportsto reduce dependency on health-care professionals.Local support groups can be located by calling thecounty mental health services or the Department of Healthand Human Services. A variety of support groups, bothonline and in person, can be found on the Internet.EvaluationLong-term treatment outcomes for clients who have survivedtrauma or abuse may take years to achieve. Theseclients usually make gradual progress in protectingthemselves, learning to manage stress and emotions, andfunctioning in their daily lives. Although clients learn to

202UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSmanage their feelings and responses, the effects of traumaand abuse can be far reaching and can last a lifetime.SELF-AWARENESS ISSUESNurses sometimes are reluctant to ask womenabout abuse, partly because they may believesome common myths about abuse. They maybelieve that questions about abuse will offendthe client or fear that incorrect interventions will worsenthe situation. Nurses may even believe that a woman whostays in an abusive relationship might deserve or enjoy theabuse or that abuse between husband and wife is private.Some nurses may believe abuse to be a societal or legal,not a health, problem.Listening to stories of family violence or rape is difficult;the nurse may feel horror or revulsion. Because clientsoften watch for the nurse’s reaction, containing these feelingsand focusing on the client’s needs are important. Thenurse must be prepared to listen to the client’s story, nomatter how disturbing, and support and validate the client’sfeelings with comments such as “That must have beenterrifying” or “Sounds like you were afraid for your life.”The nurse must convey acceptance and regard for the clientas a person with worth and dignity regardless of the circumstances.These clients often have low self-esteem andguilt. They must learn to accept and face what has occurred.If the client believes that the nurse can accept him or herafter hearing what has happened, he or she then may gainself-acceptance. Although this acceptance is often painful,it is essential to healing. The nurse must remember that heor she cannot fix or change things; the nurse’s role is tolisten and convey acceptance and support for the client.Nurses with a personal history of abuse or trauma mustseek professional assistance to deal with these issues beforeworking with survivors of trauma or abuse. Such nursescan be very effective and supportive of other survivors butonly after engaging in therapeutic work and accepting andunderstanding their own trauma.Points to Consider When Working withAbused or Traumatized Clients• These clients have many strengths they may not realize.The nurse can help them move from being victims tobeing survivors.• Nurses should ask all women about abuse. Some will beoffended and angry, but it is more important not to missthe opportunity of helping the woman who replies,“Yes. Can you help me?”• The nurse should help the client focus on the presentrather than dwell on horrific things in the past.• Usually, a nurse works best with either the survivors ofabuse or the abusers themselves. Most find it too difficultemotionally to work with both groups.Critical Thinking Questions1. Is spanking a child an acceptable form of discipline,or is it abusive? What determines the appropriatenessof discipline? Who should make these decisions,and why?2. A client has just told the nurse that in the past he haslost his temper and has beaten his child. How shouldthe nurse respond? What factors would affect thenurse’s response?KEY POINTS• The U.S. Department of Health and HumanServices has identified violence and abusivebehavior as national health concerns.• Women and children are the most likelyvictims of abuse and violence.• Characteristics of violent families include an intergenerationaltransmission process, social isolation, powerand control, and the use of alcohol and other drugs.• Spousal abuse can be emotional, physical, sexual, or allthree.• Women have difficulty leaving abusive relationships becauseof financial and emotional dependence on theabusers and because the risk for suffering increased violenceor death.• Nurses in various settings can uncover abuse by askingwomen about their safety in relationships. Many hospitalsand clinics now ask women about safety issues as anintegral part of the intake interview or health history.• Rape is a crime of violence and humiliation throughsexual means. Half of reported cases are perpetrated bysomeone the victim knows.• Child abuse includes neglect and physical, emotional,and sexual abuse. It affects 3 million children in theUnited States.• Elder abuse may include physical and sexual abuse, psychologicalabuse, neglect, exploitation, and medical abuse.• Survivors of abuse and trauma often experience guiltand shame, low self-esteem, substance abuse, depression,PTSD, and dissociative disorders.• PTSD is a response to a traumatic event. It can includeflashbacks, nightmares, insomnia, mistrust, avoidancebehaviors, and intense psychological distress.• Dissociation is a defense mechanism that protects theemotional self from the full reality of abusive or traumaticevents during and after those events.• Dissociative disorders have the essential feature of disruptionin the usually integrated functions of consciousness,memory, identity, and environmental perception. The fourtypes are dissociative amnesia, dissociative fugue, dissociativeidentity disorder, and depersonalization disorder.

CHAPTER 11 • ABUSE AND VIOLENCE 203INTERNET RESOURCESRESOURCES• Domestic Violence Safety Plan• National Domestic Violence Hotline• Domestic Violence• Child Abuse• National Center on Elder AbuseINTERNET ADDRESS*http://www.aardvarc.org/dv/plan.shtmlhttp://www.ndvh.orghttp://www.nlm.nih.gov/medlineplus/domesticviolence.htmlhttp://www.childabuse.comhttp://www.ncea.aoa.gov/NCEAroot/Main_Site/Index.aspx*All of these websites have multiple links to other sites on the topic.• Survivors of trauma and abuse may be admitted to thehospital for safety concerns or stabilization of intensesymptoms such as flashbacks or dissociative episodes.• The nurse can help the client to minimize dissociativeepisodes or flashbacks through grounding techniquesand reality orientation.• Important nursing interventions for survivors of abuseand trauma include protecting the client’s safety, helpingthe client learn to manage stress and emotions, andworking with the client to build a network of communitysupport.• Important self-awareness issues for the nurse includemanaging his or her own feelings and reactions aboutabuse, being willing to ask about abuse, and recognizingand dealing with any abuse issues he or she may haveexperienced personally.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Bacchus, L., Mezey, G., & Bewley, S. (2006). A qualitative exploration ofthe nature of domestic violence in pregnancy. Violence AgainstWomen, 12(6), 558–604.Basile, K. C., Swahn, M. H., Chen, J., & Saltzman, L. E. (2006). Stalkingin the United States: Recent national prevalence rates. AmericanJournal of Preventative Medicine, 31(2), 172–175.Bernet, W. (2005). Child maltreatment. In B. J. Sadock & V. A. Sadock(Eds.), Comprehensive textbook of psychiatry (Vol. 2, 8th ed., pp.3412–3424). Philadelphia: Lippincott Williams & Wilkins.Bureau of Justice Statistics. (2007). Available at: http://www.ojp.usdoj.gov/bjs.Centers for Disease Control and Prevention (CDC). (2008). Available at:http://www.cdc.gov/cdc.html.Childhelp. (2008). National child abuse statistics. Retrieved January 10, 2009,from http://www.childhelp.org/resources/learning-center/statistics.Child Welfare Information Gateway. (2008). Child abuse and neglect.Retrieved January 10, 2009, from http://www.childwelfare.gov/can/index.cfm.DiGrande, L., Perrin, M. A., Thorpe, L. E., Thjalji, L., Murphy, J., Wu, D.,et al. (2008). Posttraumatic stress symptoms, PTSD, and riskfactors among lower Manhattan residents 2–3 years after theSeptember 11, 2001 terrorist attacks. Journal of Traumatic Stress, 21(3),264–273.Goldstein, M. Z. (2005). Elder abuse, neglect, and exploitation. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 2, 8th ed., pp. 3828–3834). Philadelphia: Lippincott Williams& Wilkins.Harris, W. W., Lieberman, A. F., & Marans, S. (2007). In the best interestsof society. Journal of Child Psychology and Psychiatry, 48(3–4),392–411.Koepsell, J. K., Kernic, M. K., & Holt, V. L. (2006). Factors that influencebattered women to leave their abusive relationships. Violence andVictims, 21(2), 131–147.Lipkins, S. (2006). How parents, teachers, and coaches can stop theviolence, harassment, and humiliation. San Francisco: Guilford Press.Marin Institute. (2008). Fact sheet: Violence and alcohol. RetrievedJanuary 5, 2009, from http://www.marininstitute.org/.McCloskey, L. A., Williams, C. M., Lichter, E., Gerber, M., Ganz, M. L., &Sege, R. (2006). Assessing intimate partner violence in health caresettings leads to women’s receipt of interventions and improvedhealth. Public Health Reports, 121(14), 435–444.McGuinness, T. M. (2007). Dispelling the myths of bullying. Journal ofPsychosocial Nursing, 45(10), 19–22.Muehlbauer, M., & Crane, P. A. (2006). Elder abuse and neglect. Journalof Psychosocial Nursing, 44(11), 43–48.National Center for Education Statistics (NCES). (2008). Indicators ofschool crime and safety: 2007. Retrieved January 15, 2009, from http://www.nces.ed.gov/crimeindicators/crimeindicators2007.RAINN (Rape, Abuse, & Incest National Network). (2009). Who are thevictims? The offenders. Retrieved January 19, 2009, from http://www.rainn.org.Rubin, D. C., & Berndtson, D. (2007). People believe it is plausible tohave forgotten memories of childhood sexual abuse. PsychonomicBulletin & Review, 14(4), 776–778.State University of New York at Buffalo Counseling Center. (2008).Available at: http://ub-counseling.buffalo.edu/warnings.php.Van Cleave, J., & Davis M. M. (2006). Bullying and peer victimizationamong children with special health care needs. Pediatrics, 118(4),e1212–e1219.van der Kolk, B. A. (2005). Physical and sexual abuse of adults. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 2, 8th ed., pp. 2393–2398). Philadelphia: Lippincott Williams& Wilkins.ADDITIONAL READINGSBurgess, A. W., Mahoney, M., Visk, J., & Morgenbesser, L. (2008). Cyberchild sexual exploitation. Journal of Psychosocial Nursing, 46(9),38–44.Carretta, C. M. (2008). Domestic violence: A worldwide exploration.Journal of Psychosocial Nursing, 46(3), 26–34.Johnson, D. M., & Zlotnick, C. (2006). A cognitive–behavioral treatmentfor battered women with PTSD in shelters: Findings from a pilotstudy. Journal of Traumatic Stress, 19(4), 559–564.McGuinness, T. M., & Schneider, K. (2007). Poverty, child maltreatment,and foster care. Journal of the American Psychiatric Nurses Association,13(5), 296–301.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following is the best action for the nurseto take when assessing a child who might be abused?a. Confront the parents with the facts and ask themwhat happened.b. Consult with a professional member of the healthteam about making a report.c. Ask the child which of his parents caused this injury.d. Say or do nothing; the nurse has only suspicions, notevidence.2. Which of the following interventions would be mosthelpful for a client with dissociative disorder havingdifficulty expressing feelings?a. Distractionb. Reality orientationc. Journalingd. Grounding techniques3. Which of the following is true about touching a clientwho is experiencing a flashback?a. The nurse should stand in front of the client beforetouching.b. The nurse should never touch a client who is havinga flashback.c. The nurse should touch the client only after receivingpermission to do so.d. The nurse should touch the client to increase feelingsof security.4. Which of the following is true about domestic violencebetween same-sex partners?a. Such violence is less common than that between heterosexualpartners.b. The frequency and intensity of violence are greaterthan between heterosexual partners.c. Rates of violence are about the same as between heterosexualpartners.d. None of the above.5. The nurse working with a client during a flashbacksays, “I know you’re scared, but you’re in a safe place.Do you see the bed in your room? Do you feel the chairyou’re sitting on?” The nurse is using which of the followingtechniques?a. Distractionb. Reality orientationc. Relaxationd. Grounding6. Which of the following assessment findings might indicateelder self-neglect?a. Hesitancy to talk openly with nurseb. Inability to manage personal financesc. Missing valuables that are not misplacedd. Unusual explanations for injuries7. Which type of child abuse can be most difficult to treateffectively?a. Emotionalb. Neglectc. Physicald. Sexual8. Women in battering relationships often remain in thoserelationships as a result of faulty or incorrect beliefs.Which of the following beliefs is valid?a. If she tried to leave, she would be at increased riskfor violence.b. If she would do a better job of meeting his needs, theviolence would stop.c. No one else would put up with her dependent clingingbehavior.d. She often does things that provoke the violent episodes.MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. The nurse who is assessing a client with posttraumaticstress disorder would expect the client to report whichof the following?a. Inability to relaxb. Increased alcohol consumptionc. Insomnia even when very fatiguedd. Suspicion of strangerse. Talking about problems to friendsf. Wanting to sleep all the time2042. A female client comes to an urgent care clinic and says,“I’ve just been raped.” What should the nurse do?a. Allow the client to express whatever she wants.b. Ask the client if staff can call a friend or family memberfor her.c. Offer the client coffee, tea, or whatever she likes to drink.d. Get the examination completed quickly to decreasetrauma to the client.e. Provide the client privacy––let her go to a room tomake phone calls.f. Stay with the client until someone else arrives to be with her.

12 Grief and LossLearning ObjectivesAfter reading this chapter, you should be able to:1. Identify the types of losses for which people may grieve.Key Terms• acculturation• adaptive denial• anticipatory grieving• attachment behaviors• attentive presence• bereavement• complicated grieving• disenfranchised grief• disorganization• grief• grieving• grieving tasks• homeostasis• mourning• outcry• reorganization• recovery• spirituality• theories of grieving• yearning2. Discuss various theories related to understanding the grief process.3. Describe the five dimensions of grieving.4. Discuss universal and culturally specific mourning rituals.5. Discuss disenfranchised grief.6. Identify factors that increase a person’s susceptibility to complicationsrelated to grieving.7. Discuss factors that are critical to integrating loss into life.8. Apply the nursing process to facilitate grieving for clients and families.EXPERIENCES OF LOSS ARE NORMAL and essential in human life. Letting go,relinquishing, and moving on are unavoidable passages as a person movesthrough the stages of growth and development. People frequently saygoodbye to places, people, dreams, and familiar objects. Examples ofnecessary losses accompanying growth include abandoning a favoriteblanket or toy, leaving a first-grade teacher, and giving up the adolescenthope of becoming a famous rock star. Loss allows a person to change,develop, and fulfill innate human potential. It may be planned, expected,or sudden. Although it can be difficult, loss sometimes is beneficial.Other times, it is devastating and debilitating.Grief refers to the subjective emotions and affect that are a normalresponse to the experience of loss. Grieving, also known as bereavement,refers to the process by which a person experiences the grief. It involvesnot only the content (what a person thinks, says, and feels) but also theprocess (how a person thinks, says, and feels). All people grieve when theyexperience life’s changes and losses. Often, grieving is one of the most difficultand challenging processes of human existence; rarely is it comfortableor pleasant. Anticipatory grieving is when people facing an imminentloss begin to grapple with the very real possibility of the loss or death inVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!205

206UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSGriefthe near future (Ziemba & Lynch-Sauer, 2005). Mourningis the outward expression of grief. Rituals of mourninginclude having a wake, sitting Shiva, holding religious ceremonies,and arranging funerals.This chapter examines the human experience of lossand the process by which a person moves through bereavementand integrates loss into his or her life. To supportand care for the grieving client, the nurse must understandthe grieving process as well as cultural responses to loss.At times, grief is the focus of treatment. The nursing processsection outlines the nurse’s role in grieving and givesguidelines for offering support and for teaching copingskills to clients. The chapter also outlines the importanceof the nurse’s self-awareness and competency in helpingclients and families during bereavement.TYPES OF LOSSESOne framework to examine different types of losses isAbraham Maslow’s hierarchy of human needs. Accordingto Maslow (1954), a hierarchy of needs motivates humanactions. The hierarchy begins with physiologic needs(food, air, water, sleep), safety needs (a safe place to liveand work), and security and belonging needs (satisfyingrelationships). The next set of needs includes self-esteemneeds, which lead to feelings of adequacy and confidence.The last and final need is self-actualization, the ability torealize one’s full innate potential. When these humanneeds are taken away or not met for some reason, a personexperiences loss. Examples of losses related to specifichuman needs in Maslow’s hierarchy are as follows:• Physiologic loss: Examples include amputation of alimb, a mastectomy or hysterectomy, or loss ofmobility.• Safety loss: Loss of a safe environment is evident in domesticviolence, child abuse, or public violence. A person’shome should be a safe haven with trust that familymembers will provide protection, not harm or violence.Some public institutions, such as schools and churches,are often associated with safety as well. That feeling ofsafety is shattered when public violence occurs on campusor in a holy place.• Loss of security and a sense of belonging: The loss of aloved one affects the need to love and the feeling ofbeing loved. Loss accompanies changes in relationships,such as birth, marriage, divorce, illness, anddeath; as the meaning of a relationship changes, a personmay lose roles within a family or group.• Loss of self-esteem: Any change in how a person is valuedat work or in relationships or by him or her self canthreaten self-esteem. It may be an actual change or theperson’s perception of a change in value. Death of aloved one, a broken relationship, loss of a job, and retirementare examples of change that represent loss andcan result in a threat to self-esteem.• Loss related to self-actualization: An external or internalcrisis that blocks or inhibits strivings toward fulfillmentmay threaten personal goals and individual potential. Aperson who wanted to go to college, write books, andteach at a university reaches a point in life when it becomesevident that those plans will never materialize.Or a person loses hope that they will find a mate andhave children. These are losses that the person willgrieve.The fulfillment of human needs requires dynamicmovement throughout the various levels in Maslow’s hierarchy.The simultaneous maintenance of needs in the areasof physiologic integrity, safety, security and sense ofbelonging, self-esteem, and self-actualization is challengingand demands flexibility and focus. At times, a focuson protection may take priority over professional or selfactualizationgoals. Likewise, human losses demand agrieving process that can challenge each level of need.THE GRIEVING PROCESSNurses interact with clients responding to myriad lossesalong the continuum of health and illness. Regardless ofthe type of loss, nurses must have a basic understanding ofwhat is involved to meet the challenge that grief brings toclients. By understanding the phenomena that clients

CHAPTER 12 • GRIEF AND LOSS 207experience as they deal with the discomfort of loss, nursesmay promote the expression and release of emotional aswell as physical pain during grieving. Supporting thisprocess means ministering to psychological—andphysical—needs.The therapeutic relationship and therapeutic communicationskills such as active listening are paramount whenassisting grieving clients (see Chapters 5 and 6). Recognizingthe verbal and nonverbal communication content ofthe various stages of grieving can help nurses to selectinterventions that meet the client’s psychological andphysical needs.Theories of GrievingAmong well-known theories of grieving are those posedby Elizabeth Kubler-Ross, John Bowlby, George Engel, andMardi Horowitz.Kubler-Ross’s Stages of GrievingElisabeth Kubler-Ross (1969) established a basis for understandinghow loss affects human life. As she attended toclients with terminal illnesses, a process of dying becameapparent to her. Through her observations and work withdying clients and their families, Kubler-Ross developed amodel of five stages to explain what people experience asthey grieve and mourn:1. Denial is shock and disbelief regarding the loss.2. Anger may be expressed toward God, relatives, friends,or health care providers.3. Bargaining occurs when the person asks God or fate formore time to delay the inevitable loss.4. Depression results when awareness of the loss becomesacute.5. Acceptance occurs when the person shows evidence ofcoming to terms with death.This model became a prototype for care providers as theylooked for ways to understand and assist their clients inthe grieving process.Bowlby’s Phases of GrievingJohn Bowlby, a British psychoanalyst, proposed a theorythat humans instinctively attain and retain affectionalbonds with significant others through attachment behaviors.These attachment behaviors are crucial to thedevelopment of a sense of security and survival. Peopleexperience the most intense emotions when forming abond such as falling in love, maintaining a bond such asloving someone, disrupting a bond such as in a divorce,and renewing an attachment such as resolving a conflictor renewing a relationship (Bowlby, 1980). An attachmentthat is maintained is a source of security; an attachmentthat is renewed is a source of joy. When a bond isthreatened or broken, however, the person respondswith anxiety, protest, and anger.Bowlby described the grieving process as having fourphases:1. Experiencing numbness and denying the loss2. Emotionally yearning for the lost loved one and protestingthe permanence of the loss3. Experiencing cognitive disorganization and emotionaldespair with difficulty functioning in the everydayworld4. Reorganizing and reintegrating the sense of self to pulllife back together.Engel’s Stages of GrievingGeorge Engel (1964) described five stages of grieving asfollows:1. Shock and disbelief: The initial reaction to a loss is astunned, numb feeling accompanied by refusal to acknowledgethe reality of the loss in an attempt to protectthe self against overwhelming stress.2. Developing awareness: As the individual begins to acknowledgethe loss, there may be crying, feelings ofhelplessness, frustration, despair and anger that can bedirected at self or others, including God or the deceasedperson.3. Restitution: Participation in the rituals associated withdeath, such as a funeral, wake, family gathering, or religiousceremonies that help the individual accept the reality ofthe loss and begin the recovery process.4. Resolution of the loss: The individual is preoccupiedwith the loss, the lost person or object is idealized, themourner may even imitate the lost person. Eventually,the preoccupation decreases, usually in a year or perhapsmore.5. Recovery: The previous preoccupation and obsessionends, and the individual is able to go on with life in away that encompasses the loss.Horowitz’s Stages of Loss and AdaptationMardi Horowitz (2001) divides normal grief into fourstages of loss and adaptation:1. Outcry: First realization of the loss. Outcry may be outward,expressed by screaming, yelling, crying, or collapse.Outcry feeling can also be suppressed as theperson appears stoic, trying to maintain emotional control.Either way, outcry feelings take a great deal ofenergy to sustain and tend to be short-lived.2. Denial and intrusion: People move back and forth duringthis stage between denial and intrusion. During denial,the person becomes so distracted or involved inactivities that he or she sometimes isn’t thinking aboutthe loss. At other times, the loss and all it representsintrudes into every moment and activity, and feelingsare quite intense again.3. Working through: As time passes, the person spendsless time bouncing back and forth between denial and

208UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSTable 12.1STAGES OF GRIEVING: COMPARISON OF THEORISTSTheorist/Clinician Phase I Phase II Phase III Phase IVKubler-Ross (1969) Stage I: denial Stage II: angerStage III: bargainingBowlby (1980) Numbness; denial Emotional yearningfor the loved one;protesting permanenceof the lossEngel (1964) Shock and disbelief Developing awareness;crying, frustrated,angryHorowitz (2001) Outcry—outwardly Denial and Intrusion—expressed orfluctuate betweensuppressed feelings not thinking aboutloss to total immersionin lossStage IV: depressionCognitive disorganization;emotionaldespair; difficultyfunctioningRestitution—ritualsResolution—preoccupiedwith lossWorking through—begins to find newways of managinglife and the lossStage V: acceptanceCognitive reorganization;reintegratingsense of selfRecoveryCompletion—life feelsnormal again, butdifferent thanbefore the lossintrusion, and the emotions are not as intense and overwhelming.The person still thinks about the loss, butalso begins to find new ways of managing life after loss.4. Completion: Life begins to feel “normal” again, althoughlife is different after the loss. Memories are less painfuland don’t regularly interfere with day-to-day life. Episodesof intense feelings may occur, especially aroundanniversary dates, but are transient in nature.Table 12.1 compares the stages of grieving theories.Tasks of GrievingGrieving tasks, or mourning, that the bereaved personfaces involve active rather passive participation. It is sometimescalled “grief work” because it is difficult and requirestremendous effort and energy to accomplish.Rando (1984) describes tasks inherent to grieving thatshe calls the “six R’s”:1. Recognize: Experiencing the loss, and understandingthat it is real, it has happened.2. React: Emotional response to loss, feeling the feelings.3. Recollect and re-experience: Memories are reviewed andrelived.4. Relinquish: Accepting that the world has changed (as aresult of the loss), and there is no turning back.5. Readjust: Beginning to return to daily life; loss feels lessacute and overwhelming.6. Reinvest: Accepting changes that have occurred; reenteringthe world, forming new relationships andcommitments.Worden (2008) views the tasks of grieving as follows:1. Accepting the reality of the loss: It is common for peopleinitially to deny that the loss has occurred, it is toopainful to be acknowledged fully. Over time, the personwavers between belief and denial in grappling with thistask. Traditional rituals, such as funerals and wakes, arehelpful to some individuals.2. Working through the pain of grief: A loss causes pain,both physical and emotional, that must be acknowledgedand dealt with. Attempting to avoid or suppressthe pain may delay or prolong the grieving process. Theintensity of pain and the way it is experienced variesamong individuals, but it needs to be experienced forthe person to move forward.3. Adjusting to an environment that has changed becauseof the loss. It may take months for the person to realizewhat life will be like after the loss. When a loved onedies, roles change, relationships are absent or different,lifestyle may change, and the person’s sense or identityand self-esteem may be greatly affected. Feelings of failure,inadequacy, or helplessness at times are common.The individual must develop new coping skills, adaptto the new or changed environment, find meaning inthe new life, and regain some control over life to continueto grow. Otherwise, the person can be in a state ofarrested development and get stuck in mourning.4. Emotionally relocating that which has been lost andmoving on with life. The bereaved person identifies aspecial place for what was lost and the memories. Thelost person or relationship is not forgotten or diminishedin importance, but rather is relocated in the mourner’slife as the person goes on to form new relationships,friends, life rituals, and moves ahead with daily life.DIMENSIONS OF GRIEVINGPeople have many and varied responses to loss. They expresstheir bereavement in their thoughts, words, feelings, and

CHAPTER 12 • GRIEF AND LOSS 209actions as well as through their physiologic responses.Therefore, nurses must use a holistic model of grieving thatencompasses cognitive, emotional, spiritual, behavioral,and physiologic dimensions (Lobb et al., 2006).Cognitive Responses to GriefIn some respects, the pain that accompanies grieving resultsfrom a disturbance in the person’s beliefs. The loss disrupts,if not shatters, basic assumptions about life’s meaning andpurpose. Grieving often causes a person to change beliefsabout self and the world, such as perceptions of the world’sbenevolence, the meaning of life as related to justice, and asense of destiny or life path. Other changes in thinking andattitude include reviewing and ranking values, becomingwiser, shedding illusions about immortality, viewing theworld more realistically, and reevaluating religious or spiritualbeliefs (Zisook & Zisook, 2005).Questioning and Trying to Make Sense of the LossThe grieving person needs to make sense of the loss. He orshe undergoes self-examination and questions acceptedways of thinking. The loss challenges old assumptionsabout life. For example, when a loved one dies prematurely,the grieving person often questions the belief that“life is fair” or that “one has control over life or destiny.”He or she searches for answers to why the trauma occurred.The goal of the search is to give meaning and purpose tothe loss. The nurse might hear the following questions:• “Why did this have to happen? He took such good careof himself!”• “Why did such a young person have to die?”• “He was such a good person! Why did this happen tohim?”Questioning may help the person accept the reality ofwhy someone died. For example, perhaps the death isrelated to the person’s health practices—maybe he did nottake good care of himself and have regular checkups.Questioning may result in realizing that loss and death arerealities that everyone must face one day. Others may discoverexplanations and meaning and even gain comfortfrom a religious or spiritual perspective, such as believingthat the dead person is with God and at peace (Neimeyeret al., 2006).Attempting to Keep the Lost One PresentBelief in an afterlife and the idea that the lost one hasbecome a personal guide are cognitive responses that serveto keep the lost one present. Carrying on an internal dialoguewith the loved one while doing an activity is anexample: “John, I wonder what you would do in this situation.I wish you were here to show me. Let’s see, I thinkyou would probably. . . .” This method of keeping the lostone present helps soften the effects of the loss while assimilatingits reality.Emotional Responses to GriefAnger, sadness, and anxiety are the predominant emotionalresponses to loss. The grieving person may directanger and resentment toward the dead person and his orher health practices, family members, or health care providersor institutions. Common reactions the nurse mighthear are as follows:• “He should have stopped smoking years ago.”• “If I had taken her to the doctor earlier, this might nothave happened.”• “It took you too long to diagnose his illness.”Guilt over things not done or said in the lost relationshipis another painful emotion. Feelings of hatred andrevenge are common when death has resulted from extremecircumstances, such as suicide, murder, or war (Zisook &Zisook, 2005). In addition to despair and anger, some peoplemay also experience feelings of loss of control in theirlives, uncharacteristic feelings of dependency on others,and even anxiety about their own death.Emotional responses are evident throughout the grievingprocess. A common first response to the news of a lossis to be stunned, as though not perceiving reality. Emotionsvacillate in frequency and intensity. The person mayfunction automatically in a state of calm and then suddenlybecome overwhelmed with panic. The outcry ofemotion may involve crying and screaming or suppressedfeelings with a stoic face to the world.Eventually reality begins to set in. He or she often revertsto the behaviors of childhood by acting similar to a childwho loses his or her mother in a store or park. The grievingperson may express irritability, bitterness, and hostilitytoward clergy, medical providers, relatives, comforters, andeven the dead person. The hopeless yet intense desire torestore the bond with the lost person compels the bereavedto search for and recover him or her. The grieving personinterprets sounds, sights, and smells associated with the lostone as signs of the deceased’s presence, which may intermittentlyprovide comfort and ignite hope for a reunion. Forexample, the ring of the telephone at a time in the day whenthe deceased regularly called will trigger the excitement ofhearing his or her voice. Or the scent of the deceased’s perfumewill spur her husband to scan the room for her smilingface. As hopes for the lost one’s return diminish, sadnessand loneliness become constant. Such emotional tumultmay last several months and seems necessary for the personto begin to acknowledge the true permanence of the loss.As the bereaved person begins to understand the loss’spermanence, he or she recognizes that patterns of thinking,feeling, and acting attached to life with the deceasedmust change. As the person relinquishes all hope of recoveringthe lost one, he or she inevitably experiencesmoments of depression, apathy, or despair. The acute sharppain initially experienced with the loss becomes lessintense and less frequent.

210UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSCLINICAL VIGNETTE: GRIEF“If I had known what the grief process was like, I wouldnever have married, or I would have prayed every day ofmy married life that I would be the first to die,” reflectsMargaret, 9 years after the death of her husband.She recalls her initial thought, denying and acknowledgingreality simultaneously, when James was diagnosed withmultiple myeloma in October 1987: “It’s a mistake . . . but Iknow it isn’t.”For 2½ years, Margaret and James diligently followed hisregimen of treatment while taking time for work and play,making the most of their life together in the moment. “Wewere not melodramatic people. We told ourselves, ‘This iswhat’s happening; we’ll deal with it.’”For Margaret, it was a shock to realize that some friendswho had been so readily present for social gatherings wereno longer available. Margaret began to undergo a shift inher thinking: “You begin to evaluate your perceptions ofothers. I asked myself, ‘Who is there for me?’ Friends, arethey really? It can be painful to find out they really aren’t. Itfrees you later, though. You can let them go.”When James died, Margaret remained “level-headedand composed” until one day shortly after the funeralwhen she suddenly became aware of her exhaustion. Whileshopping, she found herself in protest of the emotionalpain and wanting to shout, “Doesn’t anybody know that Ihave just lost my husband?” Surprised with how overwhelmedshe felt, one of her hardest moments was puttingher sister on the plane and going home to “an emptyhouse.” It was at this time that she began to feel the initialshock of her loss. Her body felt like it was “wired withelectricity.” She felt as though she was “just going throughthe motions,” doing routine chores like grocery shoppingand putting gas in the car, all the while feeling numb.Crying spells lasted 6 months. She became “tired ofmourning” and would ask herself, “When is this goingto be relieved?” She also felt anger. “I was upset withJames, wondering why he didn’t go for his completephysical. Maybe James’s death might not have happenedso soon.”After a few months and well into the grief process,Margaret knew she needed to “do something constructive.”She did. She attended support groups, traveled, andbecame involved with church activities.Nearly a decade after James’s death, Margaret views thegrief process as a profound and poignant “search for meaningin life. If he had not gone, I would not have come towhere I am in life. I am content, confident, and happy withhow authentic life is.” Even so, a sense of James’s presenceremains with her as she pictures the way he was before hebecame ill. She states, “This is good for me.”Eventually, the bereaved person begins to reestablish asense of personal identity, direction, and purpose for living.He or she gains independence and confidence. Newways of managing life emerge, new relationships form.The person’s life is reorganized, and seems “normal” again,although different than before the loss. The person stillmisses the deceased, but thinking of him or her no longerevokes painful feelings.Spiritual Responses to GriefClosely associated with the cognitive and emotionaldimensions of grief are the deeply embedded personal valuesthat give meaning and purpose to life. These valuesand the belief systems that sustain them are central componentsof spirituality and the spiritual response to grief.During loss, it is within the spiritual dimension of humanexperience that a person may be most comforted, challenged,or devastated. The grieving person may becomedisillusioned and angry with God or other religious figuresor members of the clergy. The anguish of abandonment,loss of hope, or loss of meaning can cause deep spiritualsuffering.Ministering to the spiritual needs of those grieving is anessential aspect of nursing care. The client’s emotional andspiritual responses become intertwined as he or she grappleswith pain. With an astute awareness of such suffering,nurses can promote a sense of well-being. Providingopportunities for clients to share their suffering assists inthe psychological and spiritual transformation that canevolve through grieving. Finding explanations and meaningthrough religious or spiritual beliefs, the client maybegin to identify positive aspects of grieving. The grievingperson also can experience loss as significant to his or herown growth and development.Behavioral Responses to GriefBehavioral responses to grief are often the easiest toobserve. The grieving person may function “automatically”or routinely without much thought, indicating thatthe person is numb—the reality of the loss has not set in.Tearfully sobbing, crying uncontrollably, showing greatrestlessness, and searching are evidence of the outcry ofemotions. The person actually may call out for the deceasedor visually scan the room for him or her. Irritability and

CHAPTER 12 • GRIEF AND LOSS 211hostility toward others reveal anger and frustration in theprocess. Seeking out as well as avoiding places or activitiesonce shared with the deceased, and keeping or wanting todiscard valuables and belongings of the deceased, illustratefluctuating emotions and perceptions of hope for areconnection.During disorganization or working through grief, thecognitive act of redefining self-identity is essential but difficult.Although superficial at first, efforts made in socialor work activities are behavioral means to support the person’scognitive and emotional shifts. Drug or alcohol abuseindicates a maladaptive behavioral response to the emotionaland spiritual despair. Suicide and homicide attemptsmay be extreme responses if the bereaved person cannotmove through the grieving process.In the phase of reorganization, or recovery, the bereavedperson participates in activities and reflection that are personallymeaningful and satisfying. Redefining the meaningof life, finding new activities and relationships restore theperson’s feeling that life is good again.Physiologic Responses to GriefPhysiologic symptoms and problems associated with griefresponses are often a source of anxiety and concern for thegrieving person as well as for friends or caregivers. Thosegrieving may complain of insomnia, headaches, impairedappetite, weight loss, lack of energy, palpitations, indigestion,and changes in the immune and endocrine systems.Sleep disturbances are among the most frequent and persistentbereavement-associated symptoms (Zisook &Zisook, 2005).Physiologic symptomsCULTURAL CONSIDERATIONSUniversal Reactions to LossAlthough all people grieve for lost loved ones, rituals andhabits surrounding death vary among cultures. Each culturedefines the context in which grieving, mourning, andintegrating loss into life are given meaningful expression.The context for expression is consistent with beliefs aboutlife, death, and an afterlife. Certain aspects of the experienceare more important than other aspects for each culture.Universal reactions include the initial response of shockand social disorientation, attempts to continue a relationshipwith the deceased, anger with those perceived asresponsible for the death, and a time for mourning. Eachculture, however, defines specific acceptable ways toexhibit shock and sadness, display anger, and mourn. Culturalawareness of rituals for mourning can help nursesunderstand an individual’s or a family’s behavior.Culture-Specific RitualsAs people immigrate to the United States and Canada, theymay lose rich ethnic and cultural roots during the adjustmentof acculturation (altering cultural values or behaviorsas a way to adapt to another culture). For example,funeral directors may discourage specific rites of passagethat celebrate or mourn the loss of loved ones, or they maybe reluctant to allow behavioral expressions they perceiveas disruptive. Many such expressions are culturally related,and health care providers must be aware of such instances.For example, the Hmong (people of a mountainous regionof Southeast Asia) believe that the deceased person entersthe next world appearing as she or he did at the time ofdeath. This may lead to a request for removal of needles,tubes, or other “foreign objects” before death.Because cultural bereavement rituals have roots in severalof the world’s major religions (i.e., Buddhism, Christianity,Hinduism, Islam, Judaism), religious or spiritualbeliefs and practices regarding death frequently guide theclient’s mourning. In the United States, various mourningrituals and practices exist. A few of the major ones aresummarized next.African AmericansMost ancestors of today’s African Americans came to theUnited States as slaves and lived under the influence ofEuropean-American and Christian religious practices.Therefore, many mourning rituals are tied to religious traditions.In Catholic and Episcopalian services, hymns maybe sung, poetry read, and a eulogy spoken; less formal Baptistand Holiness traditions may involve singing, speakingin tongues, and liturgical dancing. Typically, the deceased isviewed in church before being buried in a cemetery. Mourningalso may be expressed through public prayers, blackclothing, and decreased social activities. The mourningperiod may last a few weeks to several years.

212UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSMuslim AmericansIslam does not permit cremation. It is important to followthe five steps of the burial procedure, which specify washing,dressing, and positioning of the body. The first step istraditional washing of the body by a Muslim of the samegender (Facing bereavement, 2009).Haitian AmericansSome Haitian Americans practice vodun (voodoo), alsocalled “root medicine.” Derived from Roman Catholic ritualsand cultural practices of western Africa (Benin andTogo) and Sudan, vodun is the practice of calling on agroup of spirits with whom one periodically makes peaceduring specific events in life. The death of a loved one maybe such a time. This practice can be found in several states(Alabama, Louisiana, Florida, North Carolina, SouthCarolina, and Virginia) and in some communities withinNew York City.Chinese AmericansThe largest Asian population in the United States, the Chinesehave strict norms for announcing death, preparingthe body, arranging the funeral and burial, and mourningafter burial. Burning incense and reading scripture areways to assist the spirit of the deceased in the afterlifejourney. If the deceased and family are Buddhists, meditatingbefore a shrine in the room is important. For 1 yearafter death, the family may place bowls of food on a tablefor the spirit.Japanese AmericansBuddhist Japanese Americans view death as a life passage.Close family members may bathe the deceased with warmwater and dress the body in a white kimono after purificationrites. For 2 days, family and friends bearing gifts mayvisit or offer money for the deceased while saying prayersand burning incense.Filipino AmericansMost Filipino Americans are Catholic, and, depending onhow close one was to the deceased, wearing black clothingor armbands is customary during mourning. Family andfriends place wreaths on the casket and drape a broadblack cloth on the home of the deceased. Family memberscommonly place announcements in local newspapers askingfor prayers and blessings on the soul of the deceased.Vietnamese AmericansVietnamese Americans are predominately Buddhists, whobathe the deceased and dress him or her in black clothes.They may put a few grains of rice in the mouth and placemoney with the deceased so that he or she can buy adrink as the spirit moves on in the afterlife. The bodymay be displayed for viewing in the home before burial.When friends enter, music is played as a way to warn thedeceased of the arrival.Hispanic AmericansHispanic or Latino Americans have their origins in Spain,Mexico, Cuba, Puerto Rico, and the Dominican Republic.They are predominately Roman Catholic. They may prayfor the soul of the deceased during a novena (9-day devotion)and a rosary (devotional prayer). They manifest luto(mourning) by wearing black or black and white whilebehaving in a subdued manner. Respect for the deceasedmay include not watching TV, going to the movies, listeningto the radio, or attending dances or other social eventsfor some time. Friends and relatives bring flowers andcrosses to decorate the grave.Guatemalan Americans may include a marimba band inthe funeral procession and services. Lighting candles andblessing the deceased during a wake in the home are commonpractices.Native AmericansAncient beliefs and practices influence the more than 500Native American tribes in the United States even thoughmany are now Christian. A tribe’s medicine man or priestlyhealer, who assists the friends and family of the deceased toregain their spiritual equilibrium, is an essential spiritualguide. Ceremonies of baptism for the spirit of the deceasedseem to help ward off depression of the bereaved. Perceptionsabout the meaning of death and its effects on family andfriends are as varied as the number of tribal communities.Death may be viewed as a state of unconditional love inwhich the spirit of the deceased remains present, comfortsthe tribe, and encourages movement toward life’s purposeof being happy and living in harmony with nature and others.Belief in and fear of ghosts and believing death signifiesthe end of all that is good are other views. Yet anotherview is the belief in a happy afterlife called the “land of thespirits”; proper mourning is essential not only for the soulof the deceased but also for the protection of communitymembers. To designate the end of mourning, a ceremonyat the burial grounds is held during which the grave iscovered with a blanket or cloth for making clothes. Later,the cloth is given to a tribe member. A dinner featuringsinging, speech-making, and contributing money completesthe ceremony.Orthodox Jewish AmericansAn Orthodox Jewish custom is for a relative to stay with adying person so that the soul does not leave the bodywhile the person is alone. To leave the body alone afterdeath is disrespectful. The family of the deceased mayrequest to cover the body with a sheet. The eyes of thedeceased should be closed, and the body should remaincovered and untouched until family, a rabbi, or a Jewishundertaker can begin rites. Although organ donation ispermitted, autopsy is not (unless required by law); burialmust occur within 24 hours unless delayed by theSabbath. Shivah is a 7-day period that begins on the day

CHAPTER 12 • GRIEF AND LOSS 213of the funeral. It represents time for mourners to stepout of day-to-day life, and to reflect on the change thathas occurred (Weinstein, 2003).Nurse’s RoleThe diverse cultural environment of the United Statesoffers nurses many opportunities to individualize carewhen working with grieving clients. In extended families,varying expressions and responses to loss can exist dependingon the degree of acculturation to the dominant cultureof society. Rather than assuming that he or she understandsa particular culture’s grieving behaviors, the nursemust encourage clients to discover and use what is effectiveand meaningful for them. For example, the nursecould ask a Hispanic or Latino client who also is a practicingCatholic if he or she would like to pray for the deceased.If an Orthodox Jew has just died, the nurse could offer tostay with the body while the client notifies relatives.Acculturation may have caused some people to lose, minimize,modify, or set aside specific culture-related rituals.Many Americans, however, have experienced a renewed anddeepened awareness for meaningful mourning through ritual.An example of such awareness is the creation of the AIDSquilt. The planting of a flag in the chaotic debris at GroundZero during the immediate aftermath of the terrorist attackon the World Trade Center in September 2001 signaled thebeginnings of such a ritual. As bodies were recovered andremoved, the caring diligence and attentive presence of thosefacilitating their transport continued this meaningful rite ofpassage. Through the media, the United States and much ofthe world became companions in grief. In April 2000, amemorial was dedicated for the 168 persons who died in thebombing of the Alfred P. Murrah Federal Building in OklahomaCity. During the ceremony, a police chaplain delivereda message to grieving family and friends to “live in the present,dream of the future.” Memorials and public services playan important role in the healing process.DISENFRANCHISED GRIEFDisenfranchised grief is grief over a loss that is not or cannotbe acknowledged openly, mourned publicly, or supportedsocially. Circumstances that can result in disenfranchisedgrief include:• A relationship that has no legitimacy.• The loss itself is not recognized.• The griever is not recognized.• The loss involves social stigma.In each situation, there is an attachment followed by a lossthat leads to grief. The grief process is more complexbecause the usual supports that facilitate grieving andhealing are absent (Schultz & Videbeck, 2009).In U.S. culture, kin-based relationships receive the mostattention in cases of death. Relationships between lovers,friends, neighbors, foster parents, colleagues, and caregiversmay be long-lasting and intense, but people sufferingloss in these relationships may not be able to mourn publiclywith the social support and recognition given to familymembers. In addition, some relationships are not alwaysrecognized publicly or sanctioned socially. Possible examplesinclude same-sex relationships (Smolinski & Colon,2006), cohabitation without marriage, and extramaritalaffairs.Other losses are not recognized or seen as socially significant;thus, accompanying grief is not legitimized,expected, or supported. Examples in this category includeprenatal death, abortion, relinquishing a child for adoption,death of a pet (Kaufman & Kaufman, 2006), or otherlosses not involving death, such as job loss, separation,divorce, and children leaving home. Though these lossescan lead to intense grief for the bereaved, other peoplemay perceive them as minor (Schultz & Videbeck,2009).Some people who experience a loss may not be recognizedor fully supported as grievers. For example, olderadults and children experience limited social recognitionfor their losses and the need to mourn. As people growolder, they “should expect” others their age to die. Adultssometimes view children as “not understanding or comprehending”the loss and may assume wrongly that theirchildren’s grief is minimal. Children may experience theloss of a “nurturing parental figure” from death, divorce,or family dysfunction such as alcoholism or abuse. Theselosses are very significant, yet they may not be recognized.The death of someone who is incarcerated or executed forcrimes carries a social stigma that often prevents familymembers from publicly grieving or receiving support fortheir loss (Beck & Jones, 2008).Nurses may experience disenfranchised grief whentheir need to grieve is not recognized. For example,nurses who work in areas involving organ donation ortransplantation are involved intimately with the death ofclients who may donate organs to another person. Thedaily intensity of relationships between nurses and clients/families creates strong bonds among them. The emotionaleffects of loss are significant for these nurses; however,there is seldom a socially ordained place or time to grieve.The solitude in which the grieving occurs usually provideslittle or no comfort (Doka, 2006).COMPLICATED GRIEVINGSome believe complicated grieving to be a response outsidethe norm, occurring when a person is void of emotion,grieves for prolonged periods, or has expressions ofgrief that seem disproportionate to the event. People maysuppress emotional responses to the loss or become obsessivelypreoccupied with the deceased person or lost object.Others actually may suffer from clinical depression whenthey cannot make progress in the grief process (Zhang,

214UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSFactors of susceptibility: low self-esteem, mistrust,psychiatric disorder, previous suicidal threats or attempts,absent/unhelpful familyFactors of vulnerability: ambivalent attachment, dependentor interdependent attachment to deceased, insecureattachment to parents in childhood, learned helplessnessAvoiders: suppressingor repressingemotional responses tolossBehavioral ResponsesSensitizers: obsessivelypreoccupied with thedeceasedRisk factors: death of child, spouse, parent; sudden, untimelydeaths; multiple deaths; deaths by suicide, murder, ormanslaughterAffective/emotional evidence: depression; anxiety or panicdisorders; delayed, inhibited, chronic griefBehavioral evidence: drug and alcohol abusePhysiologic evidence: immune system impairment,endocrine changes, and mortality from heart diseasePathology: determined only in specific context of person’slifeFigure 12-1. Overview of complicated grief. (Adapted from Groot, Keijser, & Neeleman, 2006; Zhang, El-Jawahri, &Prigerson, 2006; Zisook & Zisook, 2005.)El-Jawahri, & Prigerson, 2006). Figure 12.1 depicts anoverview of complicated grieving.Previously existing psychiatric disorders also may complicatethe grief process, so nurses must be particularlyalert to clients with psychiatric disorders who also aregrieving. Grief can precipitate major depression in a personwith a history of the disorder. These clients also canexperience grief and a sense of loss when they encounterchanges in treatment settings, routine, environment, oreven staff.Although nurses must recognize that complicationsmay arise in the grief process, the process remains uniqueand dynamic for each person. Immense variety exists interms of the cultural determinants in communicating theexperience and the individual differences in emotionalreactions, depth of pain, and time needed to acknowledgeand grasp the personal meaning or assimilate the loss.Characteristics of SusceptibilityFor some, the effects of grief are particularly devastatingbecause their personalities, emotional states, or situationsmake them susceptible to complications during the process.People who are vulnerable to complicated grievinginclude those with the following characteristics:Low self-esteemLow trust in othersA previous psychiatric disorderPrevious suicide threats or attemptsAbsent or unhelpful family membersAn ambivalent, dependent, or insecure attachment tothe deceased person.• In an ambivalent attachment, at least one partner is unclearabout how the couple loves or does not love eachother. For example, when a woman is uncertain aboutand feels pressure from others to have an abortion, sheis experiencing ambivalence about her unborn child.• In a dependent attachment, one partner relies on theother to provide for his or her needs without necessarilymeeting the partner’s needs.• An insecure attachment usually forms during childhood,especially if a child has learned fear and helplessness (i.e.,through intimidation, abuse, or control by parents).A person’s perception is another factor contributing tovulnerability: Perception, or how a person thinks or feelsabout a situation, is not always reality. After the death of aloved one, a person may believe that he or she really cannotcontinue and is at a great disadvantage. He or she maybecome increasingly sad and depressed, not eat or sleep,and perhaps entertain suicidal thoughts.Risk Factors Leading to VulnerabilityZhang, El-Jawahri, and Prigerson (2006) and Zisook andZisook (2005) identified experiences that increase the risk

CHAPTER 12 • GRIEF AND LOSS 215for complicated grieving for the vulnerable parties previouslymentioned. These experiences are related to traumaor individual perceptions of vulnerability and include thefollowing:• Death of a spouse or child• Death of a parent (particularly in early childhood oradolescence)• Sudden, unexpected, and untimely death• Multiple deaths• Death by suicide or murderBased on the experiences previously identified, those mostintimately affected by the terrorist attacks on September 11,2001 could be considered at increased risk for complicatedgrieving.Complicated Grieving as a Uniqueand Varied ExperienceThe person with complicated grieving also can experiencephysiologic and emotional reactions. Physical reactionscan include an impaired immune system, increased adrenocorticalactivity, increased levels of serum prolactin andgrowth hormone, psychosomatic disorders, and increasedmortality from heart disease. Characteristic emotionalresponses include depression, anxiety or panic disorders,delayed or inhibited grief, and chronic grief (Zisook &Zisook, 2005).Panic attackBecause the grieving process is unique to each person,the nurse must assess the degree of impairment within thecontext of the client’s life and experiences—for example, byexamining current coping responses compared with previousexperiences and assessing whether or not the client isengaging in maladaptive behaviors such as drug and alcoholabuse as a means to deal with the painful experience.APPLICATION OF THE NURSING PROCESSBecause the strong emotional attachment created in a significantrelationship is not released easily, the loss of thatrelationship is a major crisis with momentous consequences.Aquilera and Messick (1982) developed a broadapproach to assessment and intervention in their work oncrisis intervention. The state of disequilibrium that a crisisproduces causes great consternation, compelling the personto return to homeostasis, a state of equilibrium or balance.Factors that influence the grieving person’s return tohomeostasis are adequate perception of the situation, adequatesituational support, and adequate coping. These factorshelp the person to regain balance and return to previousfunctioning or even to use the crisis as an opportunityto grow. Because any loss may be perceived as a personalcrisis, it seems appropriate for the nurse to link understandingof crisis theory with the nursing process.For the nurse to support and facilitate the grief processfor clients, he or she must observe and listen for cognitive,emotional, spiritual, behavioral, and physiologic cues.Although the nurse must be familiar with the phases,tasks, and dimensions of human response to loss, he orshe must realize that each client’s experience is unique.Skillful communication is key to performing assessmentand providing interventions.To meet clients’ needs effectively, the nurse must examinehis or her own personal attitudes, maintain an attentivepresence, and provide a psychologically safe environmentfor deeply intimate sharing. Awareness of one’s ownbeliefs and attitudes is essential so that the nurse can avoidimposing them on the client. Attentive presence is beingwith the client and focusing intently on communicatingwith and understanding him or her. The nurse can maintainattentive presence by using open body language suchas standing or sitting with arms down, facing the client,and maintaining moderate eye contact, especially as theclient speaks. Creating a psychologically safe environmentincludes ensuring the client of confidentiality, refrainingfrom judging or giving specific advice, and allowing theclient to share thoughts and feelings freely.AssessmentEffective assessment involves observing all dimensions ofhuman response: what the person is thinking (cognitive), howthe person is feeling (emotional), what the person’s values andbeliefs are (spiritual), how the person is acting (behavioral),

216UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSand what is happening in the person’s body (physiologic) (Box12.1). Effective communication skills during assessment canlead the client toward understanding his or her experience.Thus, assessment facilitates the client’s grief process.While observing for client responses in the dimensionsof grieving, the nurse explores three critical componentsin assessment:• Adequate perception regarding the loss• Adequate support while grieving for the loss• Adequate coping behaviors during the process.Perception of the LossAssessment begins with exploration of the client’s perceptionof the loss. What does the loss mean to the client? Forthe woman who has spontaneously lost her first unbornchild and the woman who has elected to abort a pregnancy,this question could have similar or different answers.Nevertheless, the question is valuable for beginning tofacilitate the grief process.Other questions that assess perception and encouragethe client’s movement through the grief process includethe following:• What does the client think and feel about the loss?• How is the loss going to affect the client’s life?• What information does the nurse need to clarify orshare with the client?Assessing the client’s “need to know” in plain and simplelanguage invites the client to verbalize perceptions that mayneed clarification. This is especially true for the person whois anticipating a loss, such as one facing a life-ending illnessor the loss of a body part. The nurse uses open-ended questionsand helps to clarify any misperceptions.Consider the following. The doctor has just informedMs. Morrison that the lump on her breast is cancerous andBox 12.1 DIMENSIONS (RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENTCognitive responsesEmotional responsesSpiritual responsesBehavioral responsesPhysiologic responsesDisruption of assumptions and beliefsQuestioning and trying to make sense of the lossAttempting to keep the lost one presentBelieving in an afterlife and as though the lost one is a guideAnger, sadness, anxietyResentmentGuiltFeeling numbVacillating emotionsProfound sorrow, lonelinessIntense desire to restore bond with lost one or objectDepression, apathy, despair during phase of disorganizationSense of independence and confidence as phase of reorganization evolvesDisillusioned and angry with GodAnguish of abandonment or perceived abandonmentHopelessness; meaninglessnessFunctioning “automatically”Tearful sobbing; uncontrollable cryingGreat restlessness; searching behaviorsIrritability and hostilitySeeking and avoiding places and activities shared with lost oneKeeping valuables of lost one while wanting to discard themPossibly abusing drugs or alcoholPossible suicidal or homicidal gestures or attemptsSeeking activity and personal reflection during phase of reorganizationHeadaches, insomniaImpaired appetite, weight lossLack of energyPalpitations, indigestionChanges in immune and endocrine systems

CHAPTER 12 • GRIEF AND LOSS 217be able to handle this. Other people have lost their breasts tocancer, and they are doing OK.”Nurse: “You’re pretty upset with yourself, thinking youshould feel differently.” (using reflection)Client: “Yes, exactly. Don’t you think so?”Nurse: “You’ve had to deal with quite a shock today. Soundsto me like you are expecting quite a bit of yourself. What doyou think?” (using reflection; sharing perceptions; seekingvalidation)Client: “I don’t know, maybe. How long is this going to goon? I’m a wreck emotionally.”Nurse: “You are grieving, and there is no fixed timetable forwhat you are dealing with. Everyone has a unique time andway of doing this work.” (informing; validating experience)Three major areas to explore when assessing a grieving clientthat she can be scheduled for a mastectomy in 2 days. Thenurse visits the client after rounds and finds her quietlywatching television.Nurse: “How are you?” (offering presence; givinga broad opening)Client: “Oh, I’m fine. Really, I am.”Nurse: “The doctor was just here. Tell me,what is your understanding of what he said?”(using open-ended questions for description of perception)Client: “Well, I think he said that I will have to havesurgery on my breast.”Nurse: “How do you feel about that news?” (using openendedquestion for what it means to the client)Exploring what the person believes about the grieving processis another important assessment. Does the client have preconceivedideas about when or how grieving should happen?The nurse can help the client realize that grieving is very personaland unique: each person grieves in his or her own way.Later in the shift, the nurse finds Ms. Morrison hittingher pillow and crying. She has eaten little food and hasrefused visitors.Nurse: “Ms. Morrison, I see that you are upset.Tell me, what is happening right now?” (sharingobservation; encouraging description)Client: “Oh, I’m so disgusted with myself.I’m sorry you had to see me act this way. I shouldSupportPurposeful assessment of support systems provides thegrieving client with an awareness of those who can meet hisor her emotional and spiritual needs for security and love.The nurse can help the client to identify his or her supportsystems and reach out and accept what they can offer.Nurse: “Who in your life should or would reallywant to know what you’ve just heard from thedoctor?” (seeking information about situationalsupport)Client: “Oh, I’m really alone. I’m not marriedand don’t have any relatives in town.”Nurse: “There’s no one who would care about this news?”(voicing doubt)Client: “Oh, maybe a friend I talk with on the phone nowand then.”Coping BehaviorsThe client’s behavior is likely to give the nurse the easiestand most concrete information about coping skills. Thenurse must be careful to observe the client’s behaviorthroughout the grief process and never assume that a clientis at a particular phase. The nurse must use effectivecommunication skills to assess how the client’s behaviorreflects coping as well as emotions and thoughts.The following day, the nurse has heard in report that Ms.Morrison had a restless night. She enters Ms. Morrison’s roomand sees her crying with a full tray of food untouched.Nurse: “I wonder if you are upset about yourupcoming surgery.” (making an observation,assuming client was crying as an expectedbehavior of loss and grief)Client: “I’m not having surgery. You have memistaken for someone else.” (using denial to cope)The nurse also must consider several other questionswhen assessing the client’s coping. How has the person dealtwith loss previously? How is the person currently impaired?How does the current experience compare with previousexperiences? What does the client perceive as a problem? Isit related to unrealistic ideas about what he or she should

218UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSfeel or do?. The interaction of the dimensions of humanresponse is fluid and dynamic. What a person thinks aboutduring grieving affects his or her feelings, and those feelingsinfluence his or her behavior. The critical factors of perception,support, and coping are interrelated as well and providea framework for assessing and assisting the client.Data Analysis and PlanningThe nurse must base nursing diagnoses for the personexperiencing loss on subjective and objective assessmentdata. NANDA-I nursing diagnoses (2009) used for clientsexperiencing grief include:• Grieving: A normal complex process that includes emotional,physical, spiritual, social, and intellectual responsesand behaviors by which individuals, families,and communities incorporate an actual, anticipated, orperceived loss into their daily lives.• Complicated grieving: A disorder that occurs after thedeath of a significant other, in which the experience ofdistress accompanying bereavement fails to follow normativeexpectations and manifests in functional impairment(previously titled Dysfunctional grieving).Outcome IdentificationExamples of outcomes are:The client will• Identify the effects of his or her loss.• Identify the meaning of his or her loss.• Seek adequate support while expressing grief.• Develop a plan for coping with the loss.• Apply effective coping strategies while expressing andassimilating all dimensions of human response to lossin his or her life.• Recognize the negative effects of the loss on his or herlife.• Seek or accept professional assistance if needed to promotethe grieving process.InterventionsThe nurse’s guidance helps the client examine and makechanges. Changes imply movement as the client progressesthrough the grief process. Sometimes the client takes onepainful step at a time. Sometimes he or she may seem to goover the same ground repeatedly.Exploring the Perception of LossCognitive responses are connected significantly with theintense emotional turmoil that accompanies grieving.Exploring the client’s perception and meaning of the loss isa first step that can help alleviate the pain of what somewould call the initial emotional overload in grieving. Thenurse might ask what being alone means to the person andexplore the possibility of others being supportive. It is particularlyimportant that the nurse listens to whatever emotionsthe person expresses, even if the nurse doesn’t “agree”with the feelings. For example, anger at the deceased personor God, or criticism of others who aren’t “there for me”or supportive enough, may seem unjustified to the nurse.But it is essential to accept the person’s feelings withouttrying to dissuade them from feeling angry or upset. Thenurse needs to encourage the person to express any and allfeelings without trying to calm or placate them.When loss occurs, especially if it is sudden and withoutwarning, the cognitive defense mechanism of denial actsas a cushion to soften the effects. Typical verbal responsesare, “I can’t believe this has happened,” “It can’t be true,”and “There’s been a mistake.”Adaptive denial, in which the client gradually adjusts tothe reality of the loss, can help the client let go of previous(before the loss) perceptions while creating new ways ofthinking about himself or herself, others, and the world.While taking in the loss in its entirety all at once seems overwhelming,gradually dealing with the loss in smaller incrementsseems much more manageable. The person may havehad assumptions about how others should act or respond tothe loss—but those assumptions prove incorrect.Effective communication skills can be useful in helpingthe client in adaptive denial move toward acceptance. Notethe intervention the nurse makes in the scenario with Ms.Morrison. The nurse enters Ms. Morrison’s room and seesher crying and her full tray of food untouched.Nurse: “You must be quite upset about the newsyou received from your doctor about your surgery.”(using reflection, assuming the clientwas crying as an expected response of grief;focusing on the surgery is an indirect approachregarding the subject of cancer)Client: “I’m not having surgery. You have me mistaken forsomeone else.” (using denial)Nurse: “I saw you crying and wonder what is upsettingyou. I’m interested in how you are feeling.” (focusing on behaviorand sharing observation while indicating concernand accepting the client’s denial)Client: “I’m just not hungry. I don’t have an appetite andI’m not clear about what the doctor said.” (focusing on physiologicresponse; nonresponsive to nurse’s encouragementto talk about feelings; acknowledging doctor’s visit but unsureof what he said—beginning to adjust cognitively toreality of condition)Nurse: “I wonder if not wanting to eat may be related towhat you are feeling. Are there times when you don’t have anappetite and you feel upset about something?” (suggesting aconnection between physiologic response and feelings;promoting adaptive denial)Client: “Well, as a matter of fact, yes. But I can’t thinkwhat I would be upset about.” (acknowledging a connectionbetween behavior and feeling; continuing to deny reality)

CHAPTER 12 • GRIEF AND LOSS 219Nurse: “You said you were unclear about what the doctorsaid. I wonder if things didn’t seem clear because it may haveupset you to hear what he had to say. And now, tonight, youdon’t have an appetite.” (using client’s experience to makeconnection between doctor’s news and client’s physiologicresponse and behavior)Client: “What did he say, do you know?” (requesting information;demonstrating a readiness to hear it again whilecontinuing to adjust to reality)In this example, the nurse gently but persistently guidesthe client toward acknowledging the reality of her impendingloss.Obtaining SupportThe nurse can help the client to reach out and accept whatothers want to give in support of his or her grieving process.Note the assessment is developed into a plan for support.Nurse: “Who in your life would really want toknow what you’ve just heard from the doctor?”(seeking information about situational supportfor the client)Client: “Oh, I’m really alone. I’m not married.”Nurse: “There’s no one who would care about this news?”(voicing doubt)Client: “Oh, maybe a friend I talk with on the phone nowand then.”Nurse: “Why don’t I get the phone book for you and youcan call her right now?” (continuing to offer presence;suggesting an immediate source of support; developing aplan of action providing further support)Many internet resources are available to nurses who wantto help a client find information, support groups, and activitiesrelated to the grieving process. Using the search words“bereavement” and “hospice,” the nurse can link to numerousorganizations that provide support and educationthroughout the United States. If a client does not have internetaccess, most public libraries can help to locate groupsand activities that would serve his or her needs. Dependingon the state in which a person lives, specific groups exist forthose who have lost a child, spouse, or other loved one tosuicide, murder, motor vehicle crash, or cancer.Promoting Coping BehaviorsWhen attempting to focus Ms. Morrison on the reality of hersurgery, the nurse was helping her shift from an unconsciousmechanism of denial to conscious coping with reality. Thenurse used communication skills to encourage Ms. Morrisonto examine her experience and behavior as possible ways inwhich she might be coping with the news of loss.Intervention involves giving the client the opportunityto compare and contrast ways in which he or she has copedwith significant loss in the past and helping him or her toreview strengths and renew a sense of personal power.Remembering and practicing old behaviors in a newfor griefNURSING INTERVENTIONSExplore client’s perception and meaning of his or her loss.Allow adaptive denial.Encourage or assist client to reach out for and acceptsupport.Encourage client to examine patterns of coping in past andpresent situation of loss.Encourage client to review personal strengths and personalpower.Encourage client to care for himself or herself.Offer client food without pressure to eat.Use effective communication:• Offer presence and give broad openings.• Use open-ended questions.• Encourage description.• Share observations.• Use reflection.• Seek validation of perceptions.• Provide information.• Voice doubt.• Use focusing.• Attempt to translate into feelings or verbalize the implied.Establish rapport and maintain interpersonal skills such as• Attentive presence• Respect for client’s unique grieving process• Respect for client’s personal beliefs• Being trustworthy: honest, dependable, consistent• Periodic self-inventory of attitudes and issues relatedto loss.situation may lead to experimentation with new methodsand self-discovery. Having a historical perspective helps theperson’s grief work by allowing shifts in thinking abouthimself or herself, the loss, and perhaps the meaning of theloss.Encouraging the client to care for himself or herself isanother intervention that helps the client cope. The nursecan offer food without pressuring the client to eat. Beingcareful to eat, sleep well, exercise, and take time for comfortingactivities are ways that the client can nourish himselfor herself. Just as the tired hiker needs to stop, rest, andreplenish himself or herself, so must the bereaved persontake a break from the exhausting process of grieving. Goingback to a routine of work or focusing on other members ofthe family may provide that respite. Volunteer activities—volunteering at a hospice or botanical garden, taking partin church activities, or speaking to bereavement educationgroups, for example—can affirm the client’s talents andabilities and can renew feelings of self-worth.

220UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSCommunication and interpersonal skills are tools ofthe effective nurse, just like a stethoscope, scissors, andgloves. The client trusts that the nurse will have what ittakes to assist him or her in grieving. In addition to previouslymentioned skills, these tools include the following:• Using simple nonjudgmental statements to acknowledgeloss: “I want you to know I’m thinking of you.”• Referring to a loved one or object of loss by name (ifacceptable in the client’s culture)• Remembering words are not always necessary; a lighttouch on the elbow, shoulder, or hand or just beingthere indicates caring• Respecting the client’s unique process of grieving• Respecting the client’s personal beliefs• Being honest, dependable, consistent, and worthy ofthe client’s trust.A welcoming smile and eye contact from the client duringintimate conversations usually indicate the nurse’s trustworthiness,but the nurse must be aware that nonverbalbehaviors may have different meanings or connotations inother cultures.Nurses’ toolsNursing Diagnosis | GriefNursing DiagnosisGrieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviorsby which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.ASSESSMENT DATA• Potential loss of health, abilities, or life• Expression of distress regarding potential loss• Anger, hostility, or rage• Guilt• Anhedonia (inability to experience pleasure)• Suicidal ideas or feelings• Depression• Sorrow• Despair• Resentment• Feelings of hopelessness or worthlessness• Feelings of helplessness or powerlessness• Anxiety or fear• Withdrawn behavior• Changes in eating habits• Sleep disturbancesEXPECTED OUTCOMESImmediateThe client will• Be safe and free of self-inflicted harm• Demonstrate decreased suicidal, withdrawn, ordepressive symptomsStabilizationThe client will• Verbalize awareness of his or her illness• Discuss illness with staff members; e.g., talk withstaff about illness for at least 15 minutes at leasttwice per day by a specified date• Discuss illness with significant others• Identify and express feelings, verbally andnonverballyCommunityThe client will• Identify and use sources of social support in thecommunity; e.g., support groups, significant others• Participate in continued therapy if indicated• Progress through the grief process(continued)

CHAPTER 12 • GRIEF AND LOSS 221Nursing Diagnosis | Grief, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Be alert to risk of suicidal behavior. Institute suicideprecautions as needed.Initially, assign the same staff members to the client.Gradually introduce new staff members.Approach the client in a nonjudgmental way. Be sureto deal with your own feelings of discomfort, ifany, related to the client’s situation or grief.Approach the client and initiate interactions;use silence and active listening to facilitatecommunication.*As the client tolerates, encourage discussion of theclient’s illness or situation, first with staff members,then with the client’s significant others and otherclients. Be gentle in your approach to the client; talkabout the situation in simple, matter-of-fact terms.Encourage the client to express his or her feelingsverbally and nonverbally in nondestructive ways.With the client, identify his or her strengths, resources,and sources of hope, pleasure, and support.Give the client honest praise for the things that he orshe is able to do; acknowledge the client’s effortsin the context of the illness, impaired abilities, ordying.Assure the client that the illness is not a form ofpunishment and that he or she does not deserve tohave the illness.*Referral to the facility chaplain, clergy, or otherspiritual resource person may be indicated.*Point out to the client and his or her significant othersthat having a chronic or terminal illness andgrieving are difficult tasks, and give the client positivefeedback for his or her efforts.*Encourage the client to identify and maintain supportiverelationships outside the hospital.*Help the client to identify resources for assistancein the community or via the Internet. Referral to asocial worker may be indicated.*Encourage the client to continue therapy after dischargeif indicated.RationaleClients facing loss of health and functioning may beat increased risk for suicide.The client’s ability to relate to others may beimpaired. Limiting the number of new contactsinitially will promote familiarity and trust anddecrease feelings of being overwhelmed.The client may fear others’ reactions to the illness orterminal situation. Being aware of and dealing withyour own feelings will help prevent them frominterfering in your work with the client.The client may fear rejection from others if he or shetalks about the illness. Your presence indicates caringand acceptance.Acknowledging the illness and loss is necessary tothe grief process. Gentleness demonstrates regardfor the client’s feelings. Being matter-of-fact aboutthe illness can help separate the illness itself fromemotional issues.Ventilation of feelings can help lessen feelings ofdespair and so forth and helps to progress throughthe grief process.The client may feel so overwhelmed that he or she isunable to see anything positive.The client will not benefit from dishonesty or flattery,but small accomplishments may indeed meritpraise in the context of a major illness.The client or others may feel that illness is a punishmentor that the client is to blame.The client may be more comfortable discussing spiritualissues with an advisor who shares his or herbelief system.The client may not realize the difficulty of the workthat he or she is doing to face and live with the illness.The client may fear rejection from others in his orher life and may need encouragement to contactothers.The client may need continued support after discharge.Social workers can help the client to identify and contactresources. Many communities and organizationsprovide information, services, and support groups forclients who have chronic or terminal illnesses.Grieving and chronic or terminal illness may requirelong-term therapy.

222UNIT 3 • CURRENT SOCIAL AND EMOTIONAL CONCERNSINTERNET RESOURCESRESOURCES• Grief support services• Death and dying—site with multiple links• Hospice• The Jewish Bereavement Project• History of funeral customsINTERNET ADDRESShttp://www.griefsupportservices.orghttp://www.righthealth.com/topic/Death_And_Dyinghttp://www.hospicenet.orghttp://www.jewishbereavement.comhttp://www.wyfda.org/basics_2.htmlEvaluationEvaluation of progress depends on the goals establishedfor the client. A review of the tasks and phases of grieving(discussed earlier in the chapter) can be useful in makinga statement about the client’s status at any given moment.The nurse may say the client is still experiencing denial oroutcry emotions. Or that the client is showing signs ofreorganization, recovery or healing.SELF-AWARENESS ISSUESClients who are grieving need more thansomeone who is equipped with skills andbasic knowledge; they need the support ofsomeone they can trust with their emotionsand thoughts. For clients to see nurses as trustworthy,nurses must be willing to examine their personal attitudesabout loss and the grieving process.Points to Consider When Working withClients with Grief and LossTaking a self-awareness inventory means periodic reflectionon questions, such as the following:• What are the losses in my life, and how do they affect me?• Am I currently grieving for a significant loss? How doesmy loss affect my ability to be present to my client?• Who is there for me as I grieve?Critical Thinking Questions1. What are some of the losses that a client mightexperience besides death of a loved one or lifethreateningillness? Among clients in mentalhealth, what are some of the common losses identifiedin their history?2. Think about a significant loss in your own life. Howdid others respond to you? What was helpful? Whatdo you take from that experience that will influencehow you respond to others?• How am I coping with my loss?• Is the pain of my personal grief spilling over as I listenand watch for cues of the client’s grieving?• Am I making assumptions about the client’s experiencebased on my own process?• Can I keep appropriate nurse–client boundaries as Iattend to the client’s needs?• Do I have the strength to be present and to facilitate theclient’s grief?• What does my supervisor or a trusted colleague observeabout my current ability to support a client in the griefprocess?Ongoing self-examination is an effective method ofkeeping the therapeutic relationship goal-directed andacutely attentive to the client’s needs.KEY POINTS• Grief refers to the subjective emotions andaffect that are normal responses to the experienceof loss.• Grieving is the process by which a personexperiences grief.• Types of losses can be identified as unfulfilled or unmethuman needs. Maslow’s hierarchy of human needs is auseful model by which to understand loss as it relates tounfulfilled human needs.• Grief work is one of life’s most difficult challenges. Thechallenge of integrating a loss requires all that the personcan give of mind, body, and spirit.• Because the nurse constantly interacts with clients atvarious points on the health–illness continuum, he orshe must understand loss and the process of grieving.• The process of grieving has been described by many theoristsincluding Kubler-Ross, Bowlby, Engel, and Horowitz.• Dimensions of human response include cognitive, emotional,spiritual, behavioral, and physiologic. Peoplemay be experiencing more than one phase of the grievingprocess at a time.• Culturally bound reactions to loss are often lost in theacculturation to dominant societal norms. Both universaland culture-specific rituals facilitate grieving.

CHAPTER 12 • GRIEF AND LOSS 223• Disenfranchised grief often involves deaths, mourners,or situations that are not socially supported or sanctioned,or carry a stigma for the mourners.• Complicated grieving is a response that lies outside thenorm. The person may be void of emotion, grieve for aprolonged period, or express feelings that seem out ofproportion.• Low self-esteem, distrust of others, a psychiatric disorder,previous suicide threats or attempts, and absent orunhelpful family members increase the risk for complicatedgrieving.• Situations considered risk factors for complicated griefin those already vulnerable include death of a spouse orchild, a sudden unexpected death, and murder.• During assessment, the nurse observes and listens forcues in what the person thinks and feels and how he orshe behaves and then uses these relevant data to guidethe client in the grieving process.• Crisis theory can be used to help the nurse workingwith a grieving client. Adequate perception, adequatesupport, and adequate coping are critical factors.• Effective communication skills are the key to successfulassessment and interventions.• Interventions focused on the perception of loss includeexploring the meaning of the loss and allowing adaptivedenial, which is the process of gradually adjusting to thereality of a loss.• Being there to help the client while assisting him or herto seek other sources of support is an essentialintervention.• Encouraging the client to care for himself or herself promotesadequate coping.• To earn the client’s trust, the nurse must examine his orher own attitudes about loss and periodically take a selfawarenessinventory.REFERENCESAquilera, D. C., & Messick, J. M. (1982). Crisis intervention: Theory andmethodology. St. Louis: C. V. Mosby.Beck, E., & Jones, S. J. (2008). Children of the condemned: Grieving theloss of a father to death row. Omega, 56(2), 191–215.Bowlby, J. (1980). Attachment and loss, Vol. 3: Loss, sadness, and depression.New York: Basic Books.Doka, K. J. (2006). Grief: The constant companion of illness.Anesthesiology Clinics, 24(1), 205–212.Engel, G. L. (1964). Grief and grieving. American Journal of Nursing,64(9), 93–98.Facing bereavement. Muslim funeral. (2009). Retrieved January 13,2009: http://www.facingbereavement.co.uk/muslim-funeral.html.Groot, M. H., Keijser, J., & Neeleman, J. (2006). Grief shortly after suicideand natural death: A comparative study among spouses andfirst-degree relatives. Suicide & Life-threatening Behavior, 36(4),418–431.Horowitz, M. J. (2001). Stress response syndromes: Personality styles andinterventions. Lanham, MD: Jason Aronson Publishers/Rowman &Littlefield Publishing Group.Kaufman, K. R., & Kaufman, N. D. (2006). And then the dog died. DeathStudies, 30(1), 61–76.Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.Lobb, E. A., Clayton, J. M., & Price, M. A. (2006). Suffering, loss andgrief in palliative care. Australian Family Physician, 35(10), 772–775.Maslow, A. H. (1954). Motivation and personality. New York: Harper.Neimeyer, R. A., Baldwin, S. A., & Gillies, J. (2006) Continuing bondsand reconstructing meaning: Mitigating complications in bereavement.Death Studies, 30(8), 715–738.North American Nursing Diagnosis Association. (2007). Nursing diagnosis:Definitions & Classifications 2007–2009. Philadelphia: NANDAInternational.Rando, T. A. (1984). Grief, dying, and death: Clinical interventions forcaregivers. Champaign, IL: Research Press.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Smolinski, K. M., & Colon, Y. (2006). Silent voices and invisible walls:Exploring end of life care with lesbians and gay men. Journal ofPsychosocial Oncology, 24(1), 51–64.Weinstein, L. B. (2003). Bereaved orthodox Jewish families and theircommunity: A cross-cultural perspective. Journal of CommunityHealth Nursing, 20(4), 233–243.Worden, J. W. (2008). Grief counseling and grief therapy: A handbook forthe mental health practitioner (4th ed.). New York: Springer.Zhang, B., El-Jawahri, A., & Prigerson, H. G. (2006). Update on bereavementresearch: Evidence-based guidelines for the diagnosis and treatmentof complicated bereavement. Journal of Palliative Medicine,9(5), 1188–1203.Ziemba, R. A., Lynch-Sauer, J. M. (2005). Preparedness for taking care ofelderly parents: “First, you get ready to cry.” Journal of Women &Aging, 17(1–2), 99–113.Zisook, S., & Zisook, S. A. (2005). Death, dying, and bereavement. In B.J. Sadock & V. A. Sadock (Eds.), Comprehensive Textbook of Psychiatry(Vol. 2., 8th ed., pp. 2367–2393). Philadelphia: Lippincott Williams& Wilkins.ADDITIONAL READINGSStroebe, M. S., Folkman, S., Hansson, R. O., & Schut, H. (2006). Theprediction of bereavement outcome: Development of an integrativerisk factor framework. Social Science & Medicine, 63(9), 2440–2451.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following give cues to the nurse that a clientmay be grieving for a loss?a. Sad affect, anger, anxiety, and sudden changes inmoodb. Thoughts, feelings, behavior, and physiologiccomplaintsc. Hallucinations, panic level of anxiety, and sense ofimpending doomd. Complaints of abdominal pain, diarrhea, and loss ofappetite2. Situations that are considered risk factors for complicatedgrief area. Inadequate support and old ageb. Childbirth, marriage, and divorcec. Death of a spouse or child, death by suicide, andsudden and unexpected deathd. Inadequate perception of the grieving crisis3. Physiologic responses of complicated grieving includea. Tearfulness when recalling significant memories ofthe lost oneb. Impaired appetite, weight loss, lack of energy,palpitationsc. Depression, panic disorders, chronic griefd. Impaired immune system, increased serum prolactinlevel, increased mortality rate from heart disease4. Critical factors for successful integration of loss duringthe grieving process area. The client’s adequate perception, adequate support,and adequate copingb. The nurse’s trustworthiness and healthy attitudesabout griefc. Accurate assessment and intervention by the nurseor helping persond. The client’s predictable and steady movement fromone stage of the process to the nextMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Rando’s Six R’s of grieving tasks include:a. Reactb. Readc. Readjustd. Recovere. Reinvestf. Restitution2. Nursing interventions that are helpful for the grievingclient include:a. Allowing denial when it is usefulb. Assuring the client that it will get betterc. Correcting faulty assumptionsd. Discouraging negative, pessimistic conversatione. Providing attentive presencef. Reviewing past coping behaviors224

NURSING PRACTICEFOR PSYCHIATRICDISORDERSUnit 4Chapter 13Chapter 14Chapter 15Chapter 16Chapter 17Chapter 18Chapter 19Chapter 20Chapter 21Anxiety, Anxiety Disorders,and Stress-Related IllnessSchizophreniaMood DisordersPersonality DisordersSubstance AbuseEating DisordersSomatoform DisordersChild and Adolescent DisordersCognitive Disorders

226UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS13Anxiety, AnxietyDisorders, andStress-Related IllnessLearning ObjectivesAfter reading this chapter, you should be able to:1. Describe anxiety as a response to stress.Key Terms• agoraphobia• anxiety• anxiety disorders• assertiveness training• automatisms• avoidance behavior• compulsions• decatastrophizing• defense mechanisms• depersonalization• derealization• exposure• fear• flooding• mild anxiety• moderate anxiety• obsessions• panic anxiety• panic attacks• panic disorder• phobia• positive reframing• primary gain• response prevention• secondary gain• severe anxiety• stress• systematic desensitization2262. Describe the levels of anxiety with behavioral changes related to each level.3. Discuss the use of defense mechanisms by people with anxiety disorders.4. Describe the current theories regarding the etiologies of major anxietydisorders.5. Evaluate the effectiveness of treatment including medications for clientswith anxiety disorders.6. Apply the nursing process to the care of clients with anxiety and anxietydisorders.7. Provide teaching to clients, families, caregivers, and communities to increaseunderstanding of anxiety and stress-related disorders.8. Examine your feelings, beliefs, and attitudes regarding clients with anxietydisorders.ANXIETY IS A VAGUE FEELING of dread or apprehension; it is a response toexternal or internal stimuli that can have behavioral, emotional, cognitive,and physical symptoms. Anxiety is distinguished from fear, which isfeeling afraid or threatened by a clearly identifiable external stimulus thatrepresents danger to the person. Anxiety is unavoidable in life and canserve many positive functions such as motivating the person to take actionto solve a problem or to resolve a crisis. It is considered normal whenit is appropriate to the situation and dissipates when the situation hasbeen resolved.Anxiety disorders comprise a group of conditions that share a keyfeature of excessive anxiety with ensuing behavioral, emotional, cognitive,and physiologic responses. Clients suffering from anxiety disorderscan demonstrate unusual behaviors such as panic without reason, unwarrantedfear of objects or life conditions, uncontrollable repetitive actions,reexperiencing of traumatic events, or unexplainable or overwhelmingworry. They experience significant distress over time, and the disorderVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 227significantly impairs their daily routines, social lives, andoccupational functioning.This chapter discusses anxiety as an expected responseto stress. It also explores anxiety disorders, with particularemphasis on panic disorder and obsessive–compulsivedisorder (OCD).ANXIETY AS A RESPONSE TO STRESSStress is the wear and tear that life causes on the body(Selye, 1956). It occurs when a person has difficulty dealingwith life situations, problems, and goals. Each personhandles stress differently: One person can thrive in a situationthat creates great distress for another. For example,many people view public speaking as scary, but for teachersand actors, it is an everyday, enjoyable experience.Marriage, children, airplanes, snakes, a new job, a newschool, and leaving home are examples of stress-causingevents.Hans Selye (1956, 1974), an endocrinologist, identifiedthe physiologic aspects of stress, which he labeled the generaladaptation syndrome. He used laboratory animals toassess biologic system changes; the stages of the body’sphysical responses to pain, heat, toxins, and restraint; and,later, the mind’s emotional responses to real or perceivedstressors. He determined three stages of reaction to stress:• In the alarm reaction stage, stress stimulates the body tosend messages from the hypothalamus to the glands(such as the adrenal gland, to send out adrenaline andThree reactions or stages of stressnorepinephrine for fuel) and organs (such as the liver,to reconvert glycogen stores to glucose for food) to preparefor potential defense needs.• In the resistance stage, the digestive system reducesfunction to shunt blood to areas needed for defense.The lungs take in more air, and the heart beats fasterand harder so it can circulate this highly oxygenatedand highly nourished blood to the muscles to defendthe body by fight, flight, or freeze behaviors. If the personadapts to the stress, the body responses relax, andthe gland, organ, and systemic responses abate.• The exhaustion stage occurs when the person has respondednegatively to anxiety and stress: body storesare depleted or the emotional components are not resolved,resulting in continual arousal of the physiologicresponses and little reserve capacity.Autonomic nervous system responses to fear and anxietygenerate the involuntary activities of the body that areinvolved in self-preservation. Sympathetic nerve fibers“charge up” the vital signs at any hint of danger to preparethe body’s defenses. The adrenal glands release adrenalin(epinephrine), which causes the body to take in more oxygen,dilate the pupils, and increase arterial pressure andheart rate while constricting the peripheral vessels andshunting blood from the gastrointestinal and reproductivesystems and increasing glycogenolysis to free glucose forfuel for the heart, muscles, and central nervous system.When the danger has passed, parasympathetic nerve fibersreverse this process and return the body to normal operatingconditions until the next sign of threat reactivates thesympathetic responses.Anxiety causes uncomfortable cognitive, psychomotor,and physiologic responses, such as difficulty with logicalthought, increasingly agitated motor activity, and elevatedvital signs. To reduce these uncomfortable feelings, theperson tries to reduce the level of discomfort by implementingnew adaptive behaviors or defense mechanisms.Adaptive behaviors can be positive and help the person tolearn, for example, using imagery techniques to refocusattention on a pleasant scene, practicing sequential relaxationof the body from head to toe, and breathing slowlyand steadily to reduce muscle tension and vital signs. Negativeresponses to anxiety can result in maladaptive behaviorssuch as tension headaches, pain syndromes, andstress-related responses that reduce the efficiency of theimmune system.People can communicate anxiety to others both verballyand nonverbally. If someone yells “fire,” othersaround them can become anxious as they picture a fire andthe possible threat that represents. Viewing a distraughtmother searching for her lost child in a shopping mall cancause anxiety in others as they imagine the panic she isexperiencing. They can convey anxiety nonverballythrough empathy, which is the sense of walking in anotherperson’s shoes for a moment in time (Sullivan, 1952).

228UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSLevels of anxietyPhysiologic responseExamples of nonverbal empathetic communication arewhen the family of a client undergoing surgery can tellfrom the physician’s body language that their loved onehas died, when the nurse reads a plea for help in a client’seyes, or when a person feels the tension in a room wheretwo people have been arguing and are now not speaking toeach other.Levels of AnxietyAnxiety has both healthy and harmful aspects dependingon its degree and duration as well as on how well the personcopes with it. Anxiety has four levels: mild, moderate,severe, and panic (Table 13.1). Each level causes bothphysiologic and emotional changes in the person.Mild anxiety is a sensation that something is differentand warrants special attention. Sensory stimulation increasesand helps the person focus attention to learn, solve problems,think, act, feel, and protect himself or herself. Mildanxiety often motivates people to make changes or to engagein goal-directed activity. For example, it helps students tofocus on studying for an examination.Moderate anxiety is the disturbing feeling that somethingis definitely wrong; the person becomes nervous or agitated.In moderate anxiety, the person can still process information,solve problems, and learn new things with assistance fromothers. He or she has difficulty concentrating independentlybut can be redirected to the topic. For example, the nursemight be giving preoperative instructions to a client who isanxious about the upcoming surgical procedure. As the nurseis teaching, the client’s attention wanders but the nurse canregain the client’s attention and direct him or her back to thetask at hand.As the person progresses to severe anxiety and panic,more primitive survival skills take over, defensive responsesensue, and cognitive skills decrease significantly. A personwith severe anxiety has trouble thinking and reasoning.Muscles tighten and vital signs increase. The person paces;is restless, irritable, and angry; or uses other similaremotional–psychomotor means to release tension. Inpanic, the emotional–psychomotor realm predominateswith accompanying fight, flight, or freeze responses.Adrenaline surge greatly increases vital signs. Pupilsenlarge to let in more light, and the only cognitive processfocuses on the person’s defense.Working with Anxious ClientsNurses encounter anxious clients and families in a widevariety of situations such as before surgery and in emergencydepartments, intensive care units, offices, and clinics.First and foremost, the nurse must assess the person’sanxiety level because that determines what interventionsare likely to be effective.Mild anxiety is an asset to the client and requires nodirect intervention. People with mild anxiety can learn andsolve problems and are even eager for information. Teachingcan be very effective when the client is mildly anxious.In moderate anxiety, the nurse must be certain that theclient is following what the nurse is saying. The client’s

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 229Table 13.1LEVELS OF ANXIETYAnxiety Level Psychological Responses Physiologic ResponsesMildModerateSeverePanicWide perceptual fieldSharpened sensesIncreased motivationEffective problem-solvingIncreased learning abilityIrritabilityPerceptual field narrowed to immediate taskSelectively attentiveCannot connect thoughts or events independentlyIncreased use of automatismsPerceptual field reduced to one detail or scattereddetailsCannot complete tasksCannot solve problems or learn effectivelyBehavior geared toward anxiety relief and is usuallyineffectiveDoesn’t respond to redirectionFeels awe, dread, or horrorCriesRitualistic behaviorPerceptual field reduced to focus on selfCannot process any environmental stimuliDistorted perceptionsLoss of rational thoughtDoesn’t recognize potential dangerCan’t communicate verballyPossible delusions and hallucinationMay be suicidalRestlessnessFidgetingGI “butterflies”Difficulty sleepingHypersensitivity to noiseMuscle tensionDiaphoresisPounding pulseHeadacheDry mouthHigh voice pitchFaster rate of speechGI upsetFrequent urinationSevere headacheNausea, vomiting, and diarrheaTremblingRigid stanceVertigoPaleTachycardiaChest painMay bolt and runORTotally immobile and muteDilated pupilsIncreased blood pressure andpulseFlight, fight, or freezeattention can wander, and he or she may have some difficultyconcentrating over time. Speaking in short, simple, and easyto-understandsentences is effective; the nurse must stop toensure that the client is still taking in information correctly.The nurse may need to redirect the client back to the topic ifthe client goes off on an unrelated tangent.When anxiety becomes severe, the client no longer canpay attention or take in information. The nurse’s goal mustbe to lower the person’s anxiety level to moderate or mildbefore proceeding with anything else. It is also essential toremain with the person because anxiety is likely to worsenif he or she is left alone. Talking to the client in a low, calm,and soothing voice can help. If the person cannot sit still,walking with him or her while talking can be effective.What the nurse talks about matters less than how he orshe says the words. Helping the person to take deep evenbreaths can help lower anxiety.During panic-level anxiety, the person’s safety is the primaryconcern. He or she cannot perceive potential harmand may have no capacity for rational thought. The nursemust keep talking to the person in a comforting manner,even though the client cannot process what the nurse issaying. Going to a small, quiet, and nonstimulating environmentmay help to reduce anxiety. The nurse can reassurethe person that this is anxiety, that it will pass, and thathe or she is in a safe place. The nurse should remain withthe client until the panic recedes. Panic-level anxiety is notsustained indefinitely but can last from 5–30 minutes.

230UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 13.2ANXIOLYTIC DRUGSGeneric (Trade) Name Speed of Onset Half-Life(Hours)Side EffectsNursing ImplicationsBenzodiazepinesDiazepam (Valium)Alprazolam (Xanax)Chlordiazepoxide(Librium)Lorazepam (Ativan)Clonazepam(Klonopin)Oxazepam (Serax)NonbenzodiazepinesBuspirone (BuSpar)Meprobamate(Miltown, Equanil)FastIntermediateIntermediateIntermediateSlowSlowVery slowRapid20–1006–125–3010–2018–504–15Dizziness, clumsiness,sedation, headache,fatigue, sexualdysfunction, blurredvision, dry throatand mouth,constipation, highpotential for abuseand dependenceDizziness, restlessness,agitation, drowsiness,headache,weakness, nausea,vomiting, paradoxicalexcitement oreuphoriaAvoid other CNS depressants, suchas antihistamines and alcohol.Avoid caffeine.Take care with potentially hazardousactivities such as driving.Rise slowly from lying or sittingposition.Use sugar-free beverages or hardcandy.Drink adequate fluids.Take only as prescribed.Do not stop taking the drug abruptly.Rise slowly from sitting position.Take care with potentially hazardousactivities such as driving.Take with food.Report persistent restlessness, agitation,excitement, or euphoria tophysician.Nursing Care Plan ❘ Anxious BehaviorNursing DiagnosisAnxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response(the source often nonspecific or unknown to the individual); a feeling of apprehension caused byanticipation of danger. It is an alerting signal that warns of impending danger and enables theindividual to take measures to deal with the threat.ASSESSMENT DATAEXPECTED OUTCOMES• Decreased attention span• Restlessness, irritability• Poor impulse control• Feelings of discomfort, apprehension, or helplessness• Hyperactivity, pacing• Wringing hands• Perceptual field deficits• Decreased ability to communicate verballyIn addition, in panic anxiety• Inability to discriminate harmful stimuli or situations• Disorganized thought processes• Delusions.ImmediateThe client will• Be free from injury• Discuss feelings of dread, anxiety, and so forth• Respond to relaxation techniques with a decreasedanxiety levelStabilizationThe client will• Demonstrate the ability to perform relaxation techniques• Reduce own anxiety levelCommunityThe client will• Be free from anxiety attacks• Manage the anxiety response to stress effectively(continued)

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 231Nursing Care Plan | Anxious Behavior cont.IMPLEMENTATIONNursing Interventions (*denotes collaborativeinterventions)Remain with the client at all times when levels ofanxiety are high (severe or panic).Move the client to a quiet area with minimal or decreasedstimuli such as a small room or seclusion area.PRN medications may be indicated for high levels ofanxiety, delusions, disorganized thoughts, and so forth.Remain calm in your approach to the client.Use short, simple, and clear statements.Avoid asking or forcing the client to make choices.Be aware of your own feelings and level of discomfort.Encourage the client’s participation in relaxationexercises such as deep breathing, progressivemuscle relaxation, meditation, and imagining beingin a quiet, peaceful place.Teach the client to use relaxation techniquesindependently.Help the client see that mild anxiety can be a positivecatalyst for change and does not need to be avoided.RationaleThe client’s safety is a priority. A highly anxious clientshould not be left alone—his or her anxiety willescalate.Anxious behavior can be escalated by externalstimuli. In a large area, the client can feel lost andpanicked, but a smaller room can enhance a senseof security.Medication may be necessary to decrease anxiety to alevel at which the client can feel safe.The client will feel more secure if you are calm and ifthe client feels you are in control of the situation.The client’s ability to deal with abstractions orcomplexity is impaired.The client may not make sound decisions or may beunable to make decisions or solve problems.Anxiety is communicated interpersonally. Being withan anxious client can raise your own anxietylevel.Relaxation exercises are effective, nonchemical ways toreduce anxiety.Using relaxation techniques can give the clientconfidence in having control over anxiety.The client may feel that all anxiety is bad and notuseful.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric care plans(8th ed.). Philadelphia: Lippincott Williams & Wilkins.When working with an anxious person, the nurse mustbe aware of his or her own anxiety level. It is easy for thenurse to become increasingly anxious. Remaining calmand in control is essential if the nurse is going to workeffectively with the client.Short-term anxiety can be treated with anxiolyticmedications (Table 13.2). Most of these drugs are benzodiazepines,which are commonly prescribed for anxiety.Benzodiazepines have a high potential for abuse anddependence, however, so their use should be short-term,ideally no longer than 4 to 6 weeks. These drugs aredesigned to relieve anxiety so that the person can dealmore effectively with whatever crisis or situation is causingstress. Unfortunately, many people see these drugs asa “cure” for anxiety and continue to use them instead oflearning more effective coping skills or making neededchanges. Chapter 2 contains additional informationabout anxiolytic drugs.Stress-Related IllnessStress-related illness is a broad term that covers a spectrumof illnesses that result from or worsen because of chronic,long-term, or unresolved stress. Chronic stress that isrepressed can cause eating disorders, such as anorexia nervosaand bulimia, which are discussed in depth in Chapter 18.Repressed stress can cause physical symptoms with noactual organic disease, called somatoform disorders (seeChapter 19). Stress can also exacerbate the symptoms ofmany medical illness, such as hypertension and ulcerativecolitis. Chronic or recurrent anxiety resulting from stressmay also be diagnosed as an anxiety disorder.

232UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSOVERVIEW OF ANXIETY DISORDERSAnxiety disorders are diagnosed when anxiety no longerfunctions as a signal of danger or a motivation for neededchange but becomes chronic and permeates major portionsof the person’s life, resulting in maladaptive behaviorsand emotional disability. Anxiety disorders have manymanifestations, but anxiety is the key feature of each(American Psychiatric Association [APA], 2000). Types ofanxiety disorders include the following:• Agoraphobia with or without panic disorder• Panic disorder• Specific phobia• Social phobia• OCD• Generalized anxiety disorder (GAD)• Acute stress disorder• Posttraumatic stress disorder.Panic disorder and OCD are the most common and are thefocus of this chapter. Posttraumatic stress disorder isaddressed in Chapter 11.INCIDENCEAnxiety disorders have the highest prevalence rates ofall mental disorders in the United States. Nearly one infour adults in the United States is affected, and the magnitudeof anxiety disorders in young people is similar (Merikangas,2005). Anxiety disorders are more prevalent inwomen, people younger than age 45 years, people who aredivorced or separated, and people of lower socioeconomicstatus. The exception is OCD, which is equally prevalentin men and women but is more common among boys thanamong girls.ONSET AND CLINICAL COURSEThe onset and clinical course of anxiety disorders areextremely variable depending on the specific disorder.These aspects are discussed later in this chapter within thecontext of each disorder.RELATED DISORDERSAnxiety disorder due to a general medical condition is diagnosedwhen the prominent symptoms of anxiety are judgedto result directly from a physiologic condition. The personmay have panic attacks, generalized anxiety, or obsessionsor compulsions. Medical conditions causing this disordercan include endocrine dysfunction, chronic obstructivepulmonary disease, congestive heart failure, and neurologicconditions.Substance-induced anxiety disorder is anxiety directlycaused by drug abuse, a medication, or exposure to a toxin.Symptoms include prominent anxiety, panic attacks, phobias,obsessions, or compulsions.Separation anxiety disorder is excessive anxiety concerningseparation from home or from persons, parents, orcaregivers to whom the client is attached. It occurs whenit is no longer developmentally appropriate and before18 years of age.Adjustment disorder is an emotional response to astressful event, such as one involving financial issues,medical illness, or a relationship problem, that results inclinically significant symptoms such as marked distress orimpaired functioning.ETIOLOGYBiologic TheoriesGenetic TheoriesAnxiety may have an inherited component because firstdegreerelatives of clients with increased anxiety have higherrates of developing anxiety. Heritability refers to the proportionof a disorder that can be attributed to genetic factors:• High heritabilities are greater than 0.6 and indicate thatgenetic influences dominate.• Moderate heritabilities are 0.3 to 0.5 and suggest an evengreater influence of genetic and nongenetic factors.• Heritabilities less than 0.3 mean that genetics arenegligible as a primary cause of the disorder.Panic disorder and social and specific phobias, includingagoraphobia, have moderate heritability. GAD and OCDtend to be more common in families, indicating a stronggenetic component, but still require further in-depth study(McMahon & Kassem, 2005). At this point, current re -search indicates a clear genetic susceptibility to or vulnerabilityfor anxiety disorders; however, additional factors arenecessary for these disorders to actually develop.Neurochemical TheoriesGamma-aminobutyric acid (-aminobutyric acid [GABA])is the amino acid neurotransmitter believed to be dysfunctionalin anxiety disorders. GABA, an inhibitory neurotransmitter,functions as the body’s natural antianxiety agent byreducing cell excitability, thus decreasing the rate of neuronalfiring. It is available in one third of the nerve synapses,especially those in the limbic system and in the locusceruleus, the area where the neurotransmitter norepinephrine,which excites cellular function, is produced. BecauseGABA reduces anxiety and norepinephrine increases it,researchers believe that a problem with the regulation ofthese neurotransmitters occurs in anxiety disorders.Serotonin, the indolamine neurotransmitter usuallyimplicated in psychosis and mood disorders, has many

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 233DSM-IV-TR DIAGNOSTIC CRITERIA: Symptoms of Anxiety DisordersDISORDERAgoraphobia is anxiety about or avoidance ofplaces or situations from which escape mightbe difficult or in which help might beunavailable.Panic disorder is characterized by recurrent,unexpected panic attacks that cause constantconcern. Panic attack is the suddenonset of intense apprehension, fearfulness,or terror associated with feelings of impendingdoom.Specific phobia is characterized by significantanxiety provoked by a specific feared objector situation, which often leads to avoidancebehavior.Social phobia is characterized by anxiety provokedby certain types of social or performancesituations, which often leads toavoidance behavior.Obsessive–compulsive disorder involves obsessions(thoughts, impulses, or images) thatcause marked anxiety and/or compulsions(repetitive behaviors or mental acts) that attemptto neutralize anxiety.Generalized anxiety disorder is characterizedby at least 6 months of persistent andexcessive worry and anxiety.Acute stress disorder is the development ofanxiety, dissociation, and other symptomswithin 1 month of exposure to an extremelytraumatic stressor; it lasts 2 days to 4 weeks.Posttraumatic stress disorder is characterizedby the reexperiencing of an extremelytraumatic event, avoidance of stimuli associatedwith the event, numbing of responsiveness,and persistent increased arousal; itbegins within 3 months to years after theevent and may last a few months or years.SYMPTOMSAvoids being outside alone or at home alone; avoids traveling in vehicles;impaired ability to work; difficulty meeting daily responsibilities(e.g., grocery shopping or going to appointments); knowsresponse is extremeA discrete episode of panic lasting 15 to 30 minutes with four or moreof the following: palpitations, sweating, trembling or shaking,shortness of breath, choking or smothering sensation, chest pain ordiscomfort, nausea, derealization or depersonalization, fear of dyingor going crazy, paresthesias, chills or hot flashesMarked anxiety response to the object or situation; avoidance or sufferedendurance of object or situation; significant distress or impairmentof daily routine, occupation, or social functioning; adolescentsand adults recognize their fear as excessive or unreasonable.Fear of embarrassment or inability to perform; avoidance or dreadedendurance of behavior or situation; recognition that response is irrationalor excessive; belief that others are judging him or her negatively;significant distress or impairment in relationships, work, orsocial life; anxiety can be severe or panic level.Recurrent, persistent, unwanted, intrusive thoughts, impulses, orimages beyond worrying about realistic life problems; attempts toignore, suppress, or neutralize obsessions with compulsions that aremostly ineffective; adults and adolescents recognize that obsessionsand compulsions are excessive and unreasonable.Apprehensive expectations more days than not for 6 months or moreabout several events or activities; uncontrollable worrying; significantdistress or impaired social or occupational functioning; three ofthe following symptoms: restlessness, easily fatigued, difficulty concentratingor mind going blank, irritability, muscle tension, sleepdisturbanceExposure to traumatic event causing intense fear, helplessness, or horror;marked anxiety symptoms or increased arousal; significant distressor impaired functioning; persistent reexperiencing of the event;three of the following symptoms: sense of emotional numbing ordetachment, feeling dazed, derealization, depersonalization, dissociativeamnesia (inability to recall important aspect of the event)Exposure to traumatic event involving intense fear, helplessness, orhorror; reexperiencing (intrusive recollections or dreams, flashbacks,physical and psychological distress over reminders of the event);avoidance of memory-provoking stimuli and numbing of generalresponsiveness (avoidance of thoughts, feelings, conversations,people, places, amnesia, diminished interest or participation in lifeevents, feeling detached or estranged from others, restricted affect,sense of foreboding); increased arousal (sleep disturbance, irritabilityor angry outbursts, difficulty concentrating, hypervigilance,exaggerated startle response); significant distress or impairmentAdapted from American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., text revision).Washington, DC: Author.

234UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSsubtypes. 5-Hydroxytryptamine type 1a plays a role inanxiety, and it also affects aggression and mood. Serotoninis believed to play a distinct role in OCD, panic disorder,and GAD. An excess of norepinephrine is suspected inpanic disorder, GAD, and posttraumatic stress disorder(Neumeister, Bonne, & Charney, 2005).Psychodynamic TheoriesIntrapsychic /Psychoanalytic TheoriesFreud (1936) saw a person’s innate anxiety as the stimulusfor behavior. He described defense mechanisms as thehuman’s attempt to control awareness of and to reduce anxiety(see Chapter 3). Defense mechanisms are cognitivedistortions that a person uses unconsciously to maintain asense of being in control of a situation, to lessen discomfort,and to deal with stress. Because defense mechanismsarise from the unconscious, the person is unaware of usingthem. Some people overuse defense mechanisms, whichstops them from learning a variety of appropriate methodsto resolve anxiety-producing situations. The dependenceon one or two defense mechanisms also can inhibit emotionalgrowth, lead to poor problem-solving skills, and createdifficulty with relationships.Interpersonal TheoryHarry Stack Sullivan (1952) viewed anxiety as being generatedfrom problems in interpersonal relationships. Caregiverscan communicate anxiety to infants or childrenthrough inadequate nurturing, agitation when holding orhandling the child, and distorted messages. Such communicatedanxiety can result in dysfunction such as failure toachieve age-appropriate developmental tasks. In adults,anxiety arises from the person’s need to conform to thenorms and values of his or her cultural group. The higherthe level of anxiety, the lower the ability to communicateand to solve problems and the greater the chance for anxietydisorders to develop.Hildegard Peplau (1952) understood that humansexist in interpersonal and physiologic realms; thus, thenurse can better help the client to achieve health by attendingto both areas. She identified the four levels of anxietyand developed nursing interventions and interpersonalcommunication techniques based on Sullivan’s interpersonalview of anxiety. Nurses today use Peplau’s interpersonaltherapeutic communication techniques to developand to nurture the nurse–client relationship and to applythe nursing process.Behavioral TheoryBehavioral theorists view anxiety as being learned throughexperiences. Conversely, people can change or “unlearn”behaviors through new experiences. Behaviorists believethat people can modify maladaptive behaviors without gaininginsight into their causes. They contend that disturbingbehaviors that develop and interfere with a person’s life canbe extinguished or unlearned by repeated experiencesguided by a trained therapist.CULTURAL CONSIDERATIONSEach culture has rules governing the appropriate ways toexpress and deal with anxiety. Culturally competent nursesshould be aware of them while being careful not to stereotypeclients.People from Asian cultures often express anxietythrough somatic symptoms such as headaches, backaches,fatigue, dizziness, and stomach problems. One intenseanxiety reaction is koro, or a man’s profound fear that hispenis will retract into the abdomen and he will then die.Accepted forms of treatment include having the personfirmly hold his penis until the fear passes, often with assistancefrom family members or friends, and clamping thepenis to a wooden box. In women, koro is the fear that thevulva and nipples will disappear (Spector, 2008).Susto is diagnosed in some Hispanics (Peruvians,Bolivians, Colombians, and Central and South AmericanIndians) during cases of high anxiety, sadness, agitation,weight loss, weakness, and heart rate changes. The symptomsare believed to occur because supernatural spirits or badair from dangerous places and cemeteries invades the body.TREATMENTTreatment for anxiety disorders usually involves medicationand therapy. This combination produces betterresults than either one alone (Charney, 2005). Drugsused to treat anxiety disorders are listed in Table 13.3.Antidepressants are discussed in detail in Chapter 15.Cognitive–behavioral therapy is used successfully to treatanxiety disorders. Positive reframing means turning negativemessages into positive messages. The therapistteaches the person to create positive messages for useduring panic episodes. For example, instead of thinking,“My heart is pounding. I think I’m going to die!” the clientthinks, “I can stand this. This is just anxiety. It will goaway.” The client can write down these messages andkeep them readily accessible such as in an address book,a calendar, or a wallet.Decatastrophizing involves the therapist’s use of questionsto more realistically appraise the situation. The therapistmay ask, “What is the worst thing that could happen?Is that likely? Could you survive that? Is that as bad as youimagine?” The client uses thought-stopping and distractiontechniques to jolt himself or herself from focusing onnegative thoughts. Splashing the face with cold water, snappinga rubber band worn on the wrist, or shouting are alltechniques that can break the cycle of negative thoughts.Assertiveness training helps the person take morecontrol over life situations. Techniques help the personnegotiate interpersonal situations and foster self- assurance.They involve using “I” statements to identify feelings and

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 235Table 13.3DRUGS USED TO TREAT ANXIETY DISORDERSGeneric (Trade) Drug Name Classification Used to TreatAlprazolam (Xanax)Buspirone (BuSpar)Chlorazepate (Tranxene)Chlordiazepoxide (Librium)Clomipramine (Anafranil)Clonazepam (Klonopin)Clonidine (Catapres)Diazepam (Valium)Fluoxetine (Prozac)Fluvoxamine (Luvox)Hydroxyzine (Vistaril, Atarax)Imipramine (Tofranil)Meprobamate (Miltown, Equanil)Oxazepam (Serax)Paroxetine (Paxil)Propranolol (Inderal)Sertraline (Zoloft)BenzodiazepineNonbenzodiazepine anxiolyticBenzodiazepineBenzodiazepineTricyclic antidepressantBenzodiazepineBeta-blockerBenzodiazepineSSRI antidepressantSSRI antidepressantAntihistamineTricyclic antidepressantNonbenzodiazepine anxiolyticBenzodiazepineSSRI antidepressantAlpha-adrenergic agonistSSRI antidepressantAnxiety, panic disorder, OCD, socialphobia, agoraphobiaAnxiety, OCD, social phobia, GADAnxietyAnxietyOCDAnxiety, panic disorder, OCDAnxiety, panic disorderAnxiety, panic disorderPanic disorder, OCD, GADOCDAnxietyAnxiety, panic disorder, agoraphobiaAnxietyAnxietySocial phobia, GADAnxiety, panic disorder, GADPanic disorder, OCD, social phobia, GADGAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder; SSRI, selective serotonin reuptake inhibitor.to communicate concerns or needs to others. Examplesinclude “I feel angry when you turn your back while I’mtalking,” “I want to have 5 minutes of your time for anuninterrupted conversation about something important,”and “I would like to have about 30 minutes in the eveningto relax without interruption.”ELDER CONSIDERATIONSAnxiety that starts for the first time in late life is frequentlyassociated with another condition such as depression,dementia, physical illness, or medication toxicity or withdrawal.Phobias, particularly agoraphobia, and GAD arethe most common late-life anxiety disorders. Most peoplewith late-onset agoraphobia attribute the start of the disorderto the abrupt onset of a physical illness or as aresponse to a traumatic event such as a fall or mugging.Late-onset GAD is usually associated with depression.Though less common, panic attacks can occur in later lifeand are often related to depression or a physical illnesssuch as cardiovascular, gastrointestinal, or chronic pulmonarydiseases. Ruminative thoughts are common inlate-life depression and can take the form of obsessionssuch as contamination fears, pathologic doubt, or fear ofharming others. The treatment of choice for anxiety disordersin the elderly is selective serotonin reuptake inhibitor(SSRI) antidepressants. Initial treatment involvesdoses lower than the usual starting doses for adults toensure the elderly client can tolerate the medication: ifstarted on too high a dose, SSRIs can exacerbate anxietysymptoms in elderly clients (Sakauye, 2008).COMMUNITY-BASED CARENurses encounter many people with anxiety disorders incommunity settings rather than in inpatient settings. Formaltreatment for these clients usually occurs in community mentalhealth clinics and in the offices of physicians, psychiatricclinical specialists, psychologists, or other mental healthcounselors. Because the person with an anxiety disorder oftenbelieves the sporadic symptoms are related to medical problems,the family practitioner or advanced practice nurse canbe the first health-care professional to evaluate him or her.Knowledge of community resources helps the nurseguide the client to appropriate referrals for assessment,diagnosis, and treatment. The nurse can refer the client toa psychiatrist or to an advanced practice psychiatric nursefor diagnosis, therapy, and medication. Other communityresources such as anxiety disorder groups or self-helpgroups can provide support and help the client feel lessisolated and lonely.MENTAL HEALTH PROMOTIONToo often, anxiety is viewed negatively as something toavoid at all costs. Actually, for many people, anxiety is awarning they are not dealing with stress effectively.

236UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSLearning to heed this warning and to make needed changesis a healthy way to deal with the stress of daily events.Stress and resulting anxiety are not associated exclusivelywith life problems. Events that are “positive” ordesired, such as going away to college, getting a first job,getting married, and having children, are stressful andcause anxiety. Managing the effects of stress and anxiety inone’s life is important to being healthy. Tips for managingstress include the following:• Keep a positive attitude and believe in yourself.• Accept there are events you cannot control.• Communicate assertively with others: talk about yourfeelings to others and express your feelings throughlaughing, crying, and so forth.• Learn to relax.• Exercise regularly.• Eat well-balanced meals.• Limit intake of caffeine and alcohol.• Get enough rest and sleep.• Set realistic goals and expectations and find an activitythat is personally meaningful.• Learn stress management techniques, such as relaxation,guided imagery, and meditation; practice them aspart of your daily routine.For people with anxiety disorders, it is important toemphasize that the goal is effective management of stressand anxiety, not the total elimination of anxiety. Althoughmedication is important to relieve excessive anxiety, itdoes not solve or eliminate the problem entirely. Learninganxiety management techniques and effective methods forcoping with life and its stresses is essential for overallimprovement in life quality.PANIC DISORDERPanic disorder is composed of discrete episodes of panicattacks, that is, 15 to 30 minutes of rapid, intense, escalatinganxiety in which the person experiences great emotionalfear as well as physiologic discomfort. During apanic attack, the person has overwhelmingly intense anxietyand displays four or more of the following symptoms:palpitations, sweating, tremors, shortness of breath, senseof suffocation, chest pain, nausea, abdominal distress, dizziness,paresthesias, chills, or hot flashes.Panic disorder is diagnosed when the person hasrecurrent, unexpected panic attacks followed by at least1 month of persistent concern or worry about futureattacks or their meaning or a significant behavioral changerelated to them. Slightly more than 75% of people withpanic disorder have spontaneous initial attacks with noenvironmental trigger. Half of those with panic disorderhave accompanying agoraphobia. Panic disorder is morecommon in people who have not graduated from collegeand are not married. The risk increases by 18% in peoplewith depression (Merikangas, 2005).Panic attackClinical CourseThe onset of panic disorder peaks in late adolescence andthe mid-30s. Although panic anxiety might be normal insomeone experiencing a life-threatening situation, a personwith panic disorder experiences these emotional and physiologicresponses without this stimulus. The memory of thepanic attack coupled with the fear of having more can leadto avoidance behavior. In some cases, the person becomeshomebound or stays in a limited area near home such as onthe block or within town limits. This behavior is known asagoraphobia (“fear of the marketplace” or fear of beingoutside). Some people with agoraphobia fear stepping outsidethe front door because a panic attack may occur assoon as they leave the house. Others can leave the housebut feel safe from the anticipatory fear of having a panicattack only within a limited area. Agoraphobia also canoccur alone without panic attacks.The behavior patterns of people with agoraphobiaclearly demonstrate the concepts of primary and secondarygain associated with many anxiety disorders. Primarygain is the relief of anxiety achieved by performing thespecific anxiety-driven behavior such as staying in thehouse to avoid the anxiety of leaving a safe place. Secondarygain is the attention received from others as a result ofthese behaviors. For instance, the person with agoraphobiamay receive attention and caring concern from familymembers, who also assume all the responsibilities of

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 237CLINICAL VIGNETTE: PANIC DISORDERNancy spent as much time in her friend Jen’s condo as shedid in her own home. It was at Jen’s place that Nancy hadher first panic attack. For no reason at all, she felt the wallsclosing in on her, no air to breathe, and her heart poundingout of her chest. She needed to get out—Hurry! Run!—soshe could live. While a small, still-rational part of her mindassured her there was no reason to run, the need to flee wasoverwhelming. She ran out of the apartment and down thehall, repeatedly smashing the elevator button with the heelof her hand in hopes of instant response. “What if the elevatordoesn’t come?” “Where were the stairs she so desperatelywanted but couldn’t find?”The elevator door slid open. Scurrying into the elevatorand not realizing she had been holding her breath, Nancyexhaled with momentary relief. She had the faint perceptionof someone following her to ask, “What’s wrong?” Shecouldn’t answer! She still couldn’t breathe. She held ontothe rail on the wall of the elevator because it was the onlyway to keep herself from falling. “Breathe,” she told herselfas she forced herself to inhale. She searched for the rightbutton to push, the one for the ground floor. She couldn’tmake a mistake, couldn’t push the wrong button, couldn’thave the elevator take more time, because she might notmake it. Heart pounding, no air, run, run!!! When the elevatordoors opened, she ran outside and then bent forward,her hands on her knees. It took 5 minutes for her to realizeshe was safe and would be all right. Sliding onto a bench,breathing more easily, she sat there long enough for herheart rate to decrease. Exhausted and scared, she wondered,“Am I having a heart attack? Am I going crazy?What’s happening to me?”Instead of returning to Jen’s, Nancy walked across thestreet to her own apartment. She couldn’t face going intoJen’s place until she recovered. She sincerely hoped she wouldnever have this happen to her again; in fact, it might not be agood idea to go to Jen’s for a few days. As she sat in her apartment,she thought about what had happened to her that afternoonand how to prevent it from ever happening again.family life outside the home (e.g., work and shopping).Essentially, these compassionate significant others becomeenablers of the self-imprisonment of the person withagoraphobia.TreatmentPanic disorder is treated with cognitive–behavioral techniques,deep breathing and relaxation, and medicationssuch as benzodiazepines, SSRI antidepressants, tricyclicantidepressants, and antihypertensives such as clonidine(Catapres) and propranolol (Inderal).APPLICATION OF THE NURSING PROCESS:PANIC DISORDERAssessmentBox 13.1 presents the Hamilton Rating Scale for Anxiety.The nurse can use this tool along with the followingdetailed discussion to guide his or her assessment of theclient with panic disorder.HistoryThe client usually seeks treatment for panic disorder afterhe or she has experienced several panic attacks. The clientmay report, “I feel like I’m going crazy. I thought I washaving a heart attack, but the doctor says it’s anxiety.”Usually, the client cannot identify any trigger for theseevents.General Appearance and Motor BehaviorThe nurse assesses the client’s general appearance andmotor behavior. The client may appear entirely “normal”or may have signs of anxiety if he or she is apprehensiveabout having a panic attack in the next few moments. Ifthe client is anxious, speech may increase in rate, pitch,and volume, and he or she may have difficulty sitting in achair. Automatisms––which are automatic, unconsciousmannerisms––may be apparent. Examples include tappingfingers, jingling keys, or twisting hair. Automatisms aregeared toward anxiety relief and increase in frequency andintensity with the client’s anxiety level.Mood and AffectAssessment of mood and affect may reveal that the client isanxious, worried, tense, depressed, serious, or sad. Whendiscussing the panic attacks, the client may be tearful. Heor she may express anger at himself or herself for being“unable to control myself.” Most clients are distressedabout the intrusion of anxiety attacks in their lives. Duringa panic attack, the client may describe feelings of beingdisconnected from himself or herself ( depersonalization)or sensing that things are not real (derealization).Thought Processes and ContentDuring a panic attack, the client is overwhelmed, believingthat he or she is dying, losing control, or “going insane.” Theclient may even consider suicide. Thoughts are disorganized,and the client loses the ability to think rationally. At other

238UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 13.1 HAMILTON RATING SCALE FOR ANXIETYInstructions: This checklist is to assist the physician or psychiatrist in evaluating each patient as to his or her degree of anxietyand pathological condition. Please fill in the appropriate rating:NONE 0 MILD 1 MODERATE 2 SEVERE 3 SEVERE, GROSSLY DISABLING 4ItemRatingAnxious mood Worries, anticipation of the worst, fearful anticipation, irritability ________TensionFeelings of tension, fatigability, startle response, moved to tears easily, ________trembling, feelings of restlessness, inability to relaxFears Of dark, of strangers, of being left alone, of animals, of traffic, of crowds ________InsomniaDifficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on ________waking, dreams, nightmares, night terrorsIntellectual (cognitive) Difficulty in concentration, poor memory ________Depressed moodLoss of interest, lack of pleasure in hobbies, depression, early waking, ________diurnal swingSomatic (muscular)Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, ________unsteady voice, increased muscular toneSomatic (sensory)Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, ________picking sensationCardiovascular symptoms Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings,________missing beatRespiratory symptoms Pressure or constriction in chest, choking feelings, sighing, dyspnea ________Gastrointestinal symptoms Difficulty in swallowing, wind, abdominal pain, burning sensations, abdominal________fullness, nausea, vomiting, borborygmi, looseness of bowels,loss of weight, constipationGenitourinary symptoms Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia,________development of frigidity, premature ejaculation, loss of libido,impotenceAutonomic symptoms Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache,________raising of hairBehavior at interview Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strainedface, sighing or rapid respiration, facial pallor, swallowing, belching, brisktendon jerks, dilated pupils, exophthalmos________Additional Comments:Investigator’s Signature:Reprinted with permission from the British Journal of Medical Psychology (1959), 32, 50–55. © British PsychologicalSociety.times, the client may be consumed with worry about whenthe next panic attack will occur or how to deal with it.Sensorium and Intellectual ProcessesDuring a panic attack, the client may become confusedand disoriented. He or she cannot take in environmentalcues and respond appropriately. These functions arerestored to normal after the panic attack subsides.Judgment and InsightJudgment is suspended during panic attacks; in an effortto escape, the person can run out of a building and intothe street in front of a speeding car before the ability toassess safety has returned. Insight into panic disorderoccurs only after the client has been educated about thedisorder. Even then, clients initially believe they are helplessand have no control over their anxiety attacks.Self-ConceptIt is important for the nurse to assess self-concept in clientswith panic disorder. These clients often make selfblamingstatements such as “I can’t believe I’m so weakand out of control” or “I used to be a happy, well-adjustedperson.” They may evaluate themselves negatively in all

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 239aspects of their lives. They may find themselves consumedwith worry about impending attacks and may beunable to do many things they did before having panicattacks.Roles and RelationshipsBecause of the intense anticipation of having another panicattack, the person may report alterations in his or hersocial, occupational, or family life. The person typicallyavoids people, places, and events associated with previouspanic attacks. For example, the person may no longer ridethe bus if he or she has had a panic attack on a bus.Although avoiding these objects does not stop the panicattacks, the person’s sense of helplessness is so great thathe or she may take even more restrictive measures to avoidthem, such as quitting work and remaining at home.Physiologic and Self-Care ConcernsThe client often reports problems with sleeping and eating.The anxiety of apprehension between panic attacks mayinterfere with adequate, restful sleep even though the personmay spend hours in bed. Clients may experience loss ofappetite or eat constantly in an attempt to ease the anxiety.Data AnalysisThe following nursing diagnoses may apply to the clientwith panic disorder:• Risk for Injury• Anxiety• Situational Low Self-Esteem (Panic Attacks)• Ineffective Coping• Powerlessness• Ineffective Role Performance• Disturbed Sleep PatternOutcome IdentificationOutcomes for clients with panic disorders include thefollowing:• The client will be free from injury.• The client will verbalize feelings.• The client will demonstrate use of effective copingmechanisms.• The client will demonstrate effective use of methods tomanage anxiety response.• The client will verbalize a sense of personal control.• The client will reestablish adequate nutritional intake.• The client will sleep at least 6 hours per night.InterventionPromoting Safety and ComfortDuring a panic attack, the nurse’s first concern is to providea safe environment and to ensure the client’s privacy.for Panic DisorderNURSING INTERVENTIONS• Provide a safe environment and ensure client’s privacyduring a panic attack.• Remain with the client during a panic attack.• Help client to focus on deep breathing.• Talk to client in a calm, reassuring voice.• Teach client to use relaxation techniques.• Help client to use cognitive restructuring techniques.• Engage client to explore how to decrease stressors andanxiety-provoking situations.If the environment is overstimulating, the client shouldmove to a less stimulating place. A quiet place reducesanxiety and provides privacy for the client.The nurse remains with the client to help calm him orher down and to assess client behaviors and concerns.After getting the client’s attention, the nurse uses a soothing,calm voice and gives brief directions to assure the clientthat he or she is safe:“John, look around. It’s safe, and I’m here withyou. Nothing is going to happen. Take a deepbreath.”Reassurances and a calm demeanor can helpto reduce anxiety. When the client feels out ofcontrol, the nurse can let the client know that the nurse isin control until the client regains self-control.Using Therapeutic CommunicationClients with anxiety disorders can collaborate with thenurse in the assessment and planning of their care; thus,rapport between nurse and client is important. Communicationshould be simple and calm because the client withsevere anxiety cannot pay attention to lengthy messagesand may pace to release energy. The nurse can walk withthe client who feels unable to sit and talk. The nurseshould evaluate carefully the use of touch because clientswith high anxiety may interpret touch by a stranger as athreat and pull away abruptly.As the client’s anxiety diminishes, cognition begins toreturn. When anxiety has subsided to a manageable level,the nurse uses open-ended communication techniques todiscuss the experience:Nurse: “It seems your anxiety is subsiding. Isthat correct?” or “Can you share with me whatit was like a few minutes ago?”At this point, the client can discuss his or her emotionalresponses to physiologic processes and behaviors and can tryto regain a sense of control.

240UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSManaging AnxietyThe nurse can teach the client relaxation techniques to usewhen he or she is experiencing stress or anxiety. Deep breathingis simple; anyone can do it. Guided imagery and progressiverelaxation are methods to relax taut muscles: Guidedimagery involves imagining a safe, enjoyable place to relax.In progressive relaxation, the person progressively tightens,holds, and then relaxes muscle groups while letting tensionflow from the body through rhythmic breathing. Cognitiverestructuring techniques (discussed earlier in text) also mayhelp the client to manage his or her anxiety response.For any of these techniques, it is important for the clientto learn and to practice them when he or she is relativelycalm. When adept at these techniques, the client ismore likely to use them successfully during panic attacksor periods of increased anxiety. Clients are likely to believethat self-control is returning when using these techniqueshelps them to manage anxiety. When clients believe theycan manage the panic attack, they spend less time worryingabout and anticipating the next one, which reducestheir overall anxiety level.Providing Client and Family EducationClient and family education is of primary importancewhen working with clients who have anxiety disorders.The client learns ways to manage stress and to cope withreactions to stress and stress-provoking situations. Witheducation about the efficacy of combined psychotherapyand medication and the effects of the prescribed medication,the client can become the chief treatment manager ofthe anxiety disorder. It is important for the nurse to educatethe client and family members about the physiologyof anxiety and the merits of using combined psychotherapyand drug management. Such a combined treatmentapproach along with stress reduction techniques can helpthe client to manage these drastic reactions and allow himor her to gain a sense of self-control. The nurse shouldCLIENT/FAMILY EDUCATIONfor Panic Disorder• Review breathing control and relaxation techniques.• Discuss positive coping strategies.• Encourage regular exercise.• Emphasize the importance of maintaining prescribedmedication regimen and regular follow-up.• Describe time management techniques such as creating“to do” lists with realistic estimated deadlines for eachactivity, crossing off completed items for a sense ofaccomplishment, and saying “no.”• Stress the importance of maintaining contact withcommunity and participating in supportiveorganizations.help the client to understand that these therapies anddrugs do not “cure” the disorder but are methods to helphim or her to control and manage it. Client and familyeducation regarding medications should include the recommendeddosage and dosage regimen, expected effects,side effects and how to handle them, and substances thathave a synergistic or antagonistic effect with the drug.The nurse encourages the client to exercise regularly.Routine exercise helps to metabolize adrenaline, reducespanic reactions, and increases production of endorphins;all these activities increase feelings of well-being.EvaluationEvaluation of the plan of care must be individualized.Ongoing assessment provides data to determine whetherthe client’s outcomes were achieved. The client’s perceptionof the success of treatment also plays a part in evaluation.Even if all outcomes are achieved, the nurse must ask if theclient is comfortable or satisfied with the quality of life.Evaluation of the treatment of panic disorder is basedon the following:• Does the client understand the prescribed medicationregimen, and is he or she committed to adhering to it?• Have the client’s episodes of anxiety decreased in frequencyor intensity?• Does the client understand various coping methods andwhen to use them?• Does the client believe that his or her quality of life issatisfactory?PHOBIASA phobia is an illogical, intense, and persistent fear of aspecific object or a social situation that causes extreme distressand interferes with normal functioning. Phobias usuallydo not result from past negative experiences. In fact,the person may never have had contact with the object ofthe phobia. People with phobias understand that their fearis unusual and irrational and may even joke about how“silly” it is. Nevertheless, they feel powerless to stop it(Andreasen & Black, 2006).People with phobias develop anticipatory anxiety evenwhen thinking about possibly encountering the dreadedphobic object or situation. They engage in avoidancebehavior that often severely limits their lives. Such avoidancebehavior usually does not relieve the anticipatoryanxiety for long.There are three categories of phobias:• Agoraphobia (discussed earlier in text)• Specific phobia, which is an irrational fear of an objector a situation• Social phobia, which is anxiety provoked by certain socialor performance situations.

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 241people. Examples include making a speech, attending asocial engagement alone, interacting with the opposite sexor with strangers, and making complaints. The fear isrooted in low self-esteem and concern about others’ judgments.The person fears looking socially inept, appearinganxious, or doing something embarrassing such as burpingor spilling food. Other social phobias include fear ofeating in public, using public bathrooms, writing in public,or becoming the center of attention. A person mayhave one or several social phobias; the latter is known asgeneralized social phobia (Culpepper, 2006).Onset and Clinical CourseSpecific phobias usually occur in childhood or adolescence.In some cases, merely thinking about or handling a plasticmodel of the dreaded object can create fear. Specific phobiasthat persist into adulthood are lifelong 80% of the time.The peak age of onset for social phobia is middle adolescence;it sometimes emerges in a person who was shy asa child. The course of social phobia is often continuous,although the disorder may become less severe duringadulthood. Severity of impairment fluctuates with lifestress and demands.Specific phobiasMany people express “phobias” about snakes, spiders,rats, or similar objects. These fears are very specific, easyto avoid, and cause no anxiety or worry. The diagnosis of aphobic disorder is made only when the phobic behaviorsignificantly interferes with the person’s life by creatingmarked distress or difficulty in interpersonal or occupationalfunctioning.Specific phobias are subdivided into the followingcategories:• Natural environmental phobias: fear of storms, water,heights, or other natural phenomena• Blood-injection phobias: fear of seeing one’s own or others’blood, traumatic injury, or an invasive medical proceduresuch as an injection• Situational phobias: fear of being in a specific situationsuch as on a bridge or in a tunnel, elevator, small room,hospital, or airplane• Animal phobia: fear of animals or insects (usually a specifictype; often this fear develops in childhood and cancontinue through adulthood in both men and women;cats and dogs are the most common phobic objects)• Other types of specific phobias: for example, fear of gettinglost while driving if not able to make all right (andno left) turns to get to one’s destination.In social phobia, also known as social anxiety disorder,the person becomes severely anxious to the point of panicor incapacitation when confronting situations involvingTreatmentBehavioral therapy works well. Behavioral therapists initiallyfocus on teaching what anxiety is, helping the clientto identify anxiety responses, teaching relaxation techniques,setting goals, discussing methods to achieve thosegoals, and helping the client to visualize phobic situations.Therapies that help the client to develop self-esteem andself-control are common and include positive reframingand assertiveness training (explained earlier in text).One behavioral therapy often used to treat phobias issystematic (serial) desensitization, in which the therapistprogressively exposes the client to the threatening objectin a safe setting until the client’s anxiety decreases. Duringeach exposure, the complexity and intensity of exposuregradually increase, but the client’s anxiety decreases. Thereduced anxiety serves as a positive reinforcement untilthe anxiety is ultimately eliminated. For example, for theclient who fears flying, the therapist would encourage theclient to hold a small model airplane while talking abouthis or her experiences; later, the client would hold a largermodel airplane and talk about flying. Even later exposuresmight include walking past an airport, sitting in a parkedairplane, and, finally, taking a short ride in a plane. Eachsession’s challenge is based on the success achieved in previoussessions (Andreasen & Black, 2006).Flooding is a form of rapid desensitization in which abehavioral therapist confronts the client with the phobicobject (either a picture or the actual object) until it nolonger produces anxiety. Because the client’s worst fear hasbeen realized and the client did not die, there is little

242UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLINICAL VIGNETTE: OCDSam had just returned home from work. He immediatelygot undressed and entered the shower. As he showered, hesoaped and resoaped his washcloth and rubbed it vigorouslyover every inch of his body. “I can’t miss anything! I mustget off all the germs,” he kept repeating to himself. Hespent 30 minutes scrubbing and scrubbing. As he steppedout of the shower, Sam was very careful to step on theclean, white bath towel on the floor. He dried himself thoroughly,making sure his towel didn’t touch the floor or sink.He had intended to put on clean clothes after his showerand fix something to eat. But now he wasn’t sure he hadgotten clean. He couldn’t get dressed if he wasn’t clean.Slowly, Sam turned around, got back in the shower, andstarted all over again.reason to fear the situation anymore. The goal is to rid theclient of the phobia in one or two sessions. This method ishighly anxiety producing and should be conducted onlyby a trained psychotherapist under controlled circumstancesand with the client’s consent.Drugs used to treat phobias are listed in Table 13.3.OBSESSIVE–COMPULSIVE DISORDERObsessions are recurrent, persistent, intrusive, andunwanted thoughts, images, or impulses that causemarked anxiety and interfere with interpersonal, social,or occupational function. The person knows thesethoughts are excessive or unreasonable but believes he orshe has no control over them. Compulsions are ritualisticor repetitive behaviors or mental acts that a personcarries out continuously in an attempt to neutralize anxiety.Usually, the theme of the ritual is associated with thatof the obsession, such as repetitive hand-washing whensomeone is obsessed with contamination or repeatedprayers or confession for someone obsessed with blasphemousthoughts. Common compulsions include thefollowing:• Checking rituals (repeatedly making sure the door islocked or the coffee pot is turned off)• Counting rituals (each step taken, ceiling tiles, concreteblocks, or desks in a classroom)• Washing and scrubbing until the skin is raw• Praying or chanting• Touching, rubbing, or tapping (feeling the texture ofeach material in a clothing store; touching people,doors, walls, or oneself)• Hoarding items (for fear of throwing away somethingimportant)• Ordering (arranging and rearranging furniture or itemson a desk or shelf into perfect order; vacuuming the rugpile in one direction)• Exhibiting rigid performance (getting dressed in an unvaryingpattern)• Having aggressive urges (for instance, to throw one’schild against a wall).OCD is diagnosed only when these thoughts, images,and impulses consume the person or he or she is compelledto act out the behaviors to a point at which theyinterfere with personal, social, and occupational function.Examples include a man who can no longer workbecause he spends most of his day aligning and realigningall items in his apartment or a woman who feels compelledto wash her hands after touching any object orperson.OCD can be manifested through many behaviors, allof which are repetitive, meaningless, and difficult to conquer.The person understands that these rituals areunusual and unreasonable but feels forced to performthem to alleviate anxiety or to prevent terrible thoughts.Obsessions and compulsions are a source of distress andshame to the person, who may go to great lengths to keepthem secret.Onset and Clinical CourseOCD can start in childhood, especially in males. Infemales, it more commonly begins in the 20s. Overall,distribution between the sexes is equal. Onset is usuallygradual, although there have been cases of acute onsetwith periods of waxing and waning symptoms. Exacerbationof symptoms may be related to stress. Eighty percentof those treated with behavior therapy and medicationreport success in managing obsessions andcompulsions, whereas 15% show progressive deteriorationin occupational and social functioning (APA,2000).TreatmentLike for other anxiety disorders, optimal treatment forOCD combines medication and behavior therapy.Table 13.3 lists drugs used to treat OCD. Behavior therapyspecifically includes exposure and response prevention:Exposure involves assisting the client to deliberately confrontthe situations and stimuli that he or she usuallyavoids. Response prevention focuses on delaying or avoidingperformance of rituals. The person learns to tolerate

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 243the anxiety and to recognize that it will recede without thedisastrous imagined consequences. Other techniques discussedpreviously, such as deep breathing and relaxation,also can assist the person to tolerate and eventually managethe anxiety (Bandelow, 2008).APPLICATION OF THE NURSING PROCESS:OBSESSIVE–COMPULSIVE DISORDERAssessmentBox 13.2 presents the Yale-Brown Obsessive–CompulsiveScale. The nurse can use this tool along with the followingdetailed discussion to guide his or her assessment of theclient with OCD.HistoryThe client usually seeks treatment only when obsessionsbecome too overwhelming or when compulsions interferewith daily life (e.g., going to work, cooking meals, or participatingin leisure activities with family or friends) orboth. Clients are hospitalized only when they have becomecompletely unable to carry out their daily routines. Mosttreatment is outpatient. The client often reports that ritualsbegan many years before; some begin as early as childhood.The more responsibility the client has as he or shegets older, the more the rituals interfere with the ability tofulfill those responsibilities.General Appearance and Motor BehaviorThe nurse assesses the client’s appearance and behavior.Clients with OCD often seem tense, anxious, worried, andfretful. They may have difficulty relating symptoms becauseof embarrassment. Their overall appearance is unremarkable;that is, nothing observable seems to be “out of theordinary.” The exception is the client who is almost immobilizedby his or her thoughts and the resulting anxiety.Mood and AffectDuring assessment of mood and affect, clients report ongoing,overwhelming feelings of anxiety in response to theobsessive thoughts, images, or urges. They may look sadand anxious.Thought Processes and ContentThe nurse explores the client’s thought processes and content.Many clients describe the obsessions as arising fromnowhere during the middle of normal activities. The harderthe client tries to stop the thought or image, the moreintense it becomes. The client describes how these obsessionsare not what he or she wants to think about and thathe or she would never willingly have such ideas or images.Assessment reveals intact intellectual functioning.The client may describe difficulty concentrating or payingattention when obsessions are strong. There is no impairmentof memory or sensory functioning.Judgment and InsightThe nurse examines the client’s judgment and insight. Theclient recognizes that the obsessions are irrational, but heor she cannot stop them. He or she can make sound judgments(e.g., “I know the house is safe”) but cannot act onthem. The client still engages in ritualistic behavior whenthe anxiety becomes overwhelming.Self-ConceptDuring exploration of self-concept, the client voices concernthat he or she is “going crazy.” Feelings of powerlessnessto control the obsessions or compulsions contributeto low self-esteem. The client may believe that if he or shewere “stronger” or had more will power, he or she couldpossibly control these thoughts and behaviors.Roles and RelationshipsIt is important for the nurse to assess the effects of OCD onthe client’s roles and relationships. As the time spent performingrituals increases, the client’s ability to fulfill liferoles successfully decreases. Relationships also suffer asfamily and friends tire of the repetitive behavior, and theclient is less available to them as he or she is more consumedwith anxiety and ritualistic behavior.Physiologic and Self-Care ConsiderationsThe nurse examines the effects of OCD on physiology andself-care. As with other anxiety disorders, clients withOCD may have trouble sleeping. Performing rituals maytake time away from sleep, or anxiety may interfere withthe ability to go to sleep and wake refreshed. Clients alsomay report a loss of appetite or unwanted weight loss. Insevere cases, personal hygiene may suffer because the clientcannot complete needed tasks.Data AnalysisDepending on the particular obsession and its accompanyingcompulsions, clients have varying symptoms. Nursingdiagnoses can include the following:• Anxiety• Ineffective Coping• Fatigue• Situational Low Self-Esteem• Impaired Skin Integrity (If Scrubbing or Washing Rituals)Outcome IdentificationOutcomes for clients with OCD include the following:• The client will complete daily routine activities withina realistic time frame.• The client will demonstrate effective use of relaxationtechniques.• The client will discuss feelings with another person.• The client will demonstrate effective use of behaviortherapy techniques.• The client will spend less time performing rituals.

244UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 13.2 YALE-BROWN OBSESSIVE–COMPULSIVE SCALEFor each item, circle the number identifying the response that best characterizes the patient.1. Time occupied by obsessive thoughtsHow much of your time is occupied by obsessivethoughts?How frequently do the obsessive thoughts occur?0 None1 Mild (less than 1 hour/day) or occasional (intrusionoccurring no more than eight times a day)2 Moderate (1–3 hours/day) or frequent (intrusion occurringmore than eight times a day, but most of thehours of the day are free of obsessions)3 Severe (greater than 3 and up to 8 hours/day) or veryfrequent (intrusion occurring more than eight times aday and occurring during most of the hours of the day)4 Extreme (greater than 8 hours/day) or near-consistentintrusion (too numerous to count and an hour rarelypasses without several obsessions occurring)2. Interference due to obsessive thoughtsHow much do your obsessive thoughts interfere withyour social or work (or role) functioning?Is there anything that you don’t do because of them?0 None1 Mild: slight interference with social or occupationalactivities, but overall performance not impaired2 Moderate: definite interference with social or occupationalperformance but still manageable3 Severe: causes substantial impairment in social oroccupational performance4 Extreme: incapacitating3. Distress associated with obsessive thoughtsHow much distress do your obsessive thoughts cause you?0 None1 Mild, infrequent, and not too disturbing2 Moderate, frequent, and disturbing but stillmanageable3 Severe, very frequent, and very disturbing4 Extreme, near constant, and disabling distress4. Resistance against obsessionsHow much of an effort do you make to resist the obsessivethoughts?How often do you try to disregard or turn your attentionaway from these thoughts as they enter your mind?0 Makes an effort to always resist, or symptoms so minimaldoesn’t need to actively resist1 Tries to resist most of the time2 Makes some effort to resist3 Yields to all obsessions without attempting to controlthem, but does so with some reluctance4 Completely and willingly yields to all obsessions5. Degree of control over obsessive thoughtsHow much control do you have over your obsessivethoughts?How successful are you in stopping or diverting your obsessivethinking?0 Complete control1 Much control: usually able to stop or divert obsessionswith some effort and concentration2 Moderate control: sometimes able to stop or divertobsessions3 Little control: rarely successful in stopping obsessions4 No control: experienced as completely involuntary,rarely able to even momentarily divert thinking6. Time spent performing compulsive behaviorsHow much time do you spend performing compulsivebehaviors?How frequently do you perform compulsions?0 None1 Mild (less than 1 hour/day performing compulsions)or occasional (performance of compulsions occurringno more than eight times a day)2 Moderate (1–3 hours/day performing compulsions) orfrequent (performance of compulsions occurringmore than eight times a day, but most of the hours ofthe day are free of compulsive behaviors)3 Severe (greater than 3 and up to 8 hours/day performingcompulsions) or very frequent (performanceof compulsions occurring more than eight times a dayand occurring during most of the hours of the day)4 Extreme (greater than 8 hours/day performing compulsions)or near-consistent performance of compulsions(too numerous to count and an hour rarelypasses without several compulsions being performed)7. Interference due to compulsive behaviorsHow much do your compulsive behaviors interfere withyour social or work (or role) functioning? Is there anythingthat you don’t do because of the compulsions?0 None1 Mild: slight interference with social or occupationalactivities, but overall performance not impaired2 Moderate: definite interference with social or occupationalperformance but still manageable3 Severe: causes substantial impairment in social oroccupational performance4 Extreme: incapacitating8. Distress associated with compulsive behaviorHow would you feel if prevented from performing yourcompulsions?continued on page 245

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 245Box 13.2 YALE-BROWN OBSESSIVE–COMPULSIVE SCALE ContinuedHow anxious would you become? How anxious do youget while performing compulsions until you are satisfiedthey are completed?0 None1 Mild: only slightly anxious if compulsions preventedor only slightly anxious during performance ofcompulsions2 Moderate: reports that anxiety would mount but remainmanageable if compulsions prevented or thatanxiety increases but remains manageable during performanceof compulsions3 Severe: prominent and very disturbing increase inanxiety if compulsions interrupted or prominent andvery disturbing increases in anxiety during performanceof compulsions4 Extreme: incapacitating anxiety from any interventionaimed at modifying activity or incapacitating anxietyduring performance of compulsions9. Resistance against compulsionsHow much of an effort do you make to resist thecompulsions?0 Makes an effort to always resist, or symptoms sominimal doesn’t need to actively resist1 Tries to resist most of the time2 Makes some effort to resist3 Yields to all compulsions without attempting tocontrol them, but does so with some reluctance4 Completely and willingly yields to all compulsions10. Degree of control over compulsive behavior0 Complete control1 Much control: experiences pressure to perform thebehavior but usually able to exercise voluntary controlover it2 Moderate control: strong pressure to perform behavior;can control it only with difficulty3 Little control: very strong drive to perform behavior;must be carried to completion; can only delay withdifficulty4 No control: drive to perform behavior experienced ascompletely involuntaryReprinted with permission from Goodman, W. K., Price, L. H., Rasmussen, S. A., et al. (1989). The Yale-Brown Obsessive–Compulsive Scale, I: Development, use,and reliability. Archives of General Psychiatry, 46, 1006.InterventionUsing Therapeutic CommunicationOffering support and encouragement to the client is importantto help him or her manage anxiety responses. Thenurse can validate the overwhelming feelings the clientexperiences while indicating the belief that the client canmake needed changes and regain a sense of control. Thenurse encourages the client to talk about the feelings andto describe them in as much detail as the client can tolerate.Because many clients try to hide their rituals and tokeep obsessions secret, discussing these thoughts, behaviors,and resulting feelings with the nurse is an importantstep. Doing so can begin to relieve some of the “burden”the client has been keeping to himself or herself.Teaching Relaxation and Behavioral TechniquesThe nurse can teach the client about relaxation techniquessuch as deep breathing, progressive musclerelaxation, and guided imagery. This interventionshould take place when the client’s anxiety is low so heor she can learn more effectively. Initially, the nurse candemonstrate and practice the techniques with the client.Then, the nurse encourages the client to practicethese techniques until he or she is comfortable doingthem alone. When the client has mastered relaxationtechniques, he or she can begin to use them when anxietyincreases. In addition to decreasing anxiety, theclient gains an increased sense of control that can leadto improved self-esteem.To manage anxiety and ritualistic behaviors, a baselineof frequency and duration is necessary. The client cankeep a diary to chronicle situations that trigger obsessions,the intensity of the anxiety, the time spent performingrituals, and the avoidance behaviors. This record providesa clear picture for both client and nurse. The clientthen can begin to use exposure and response preventionbehavioral techniques. Initially, the client can decreasethe time he or she spends performing the ritual or delayperforming the ritual while experiencing anxiety. Eventually,the client can eliminate the ritualistic response ordecrease it significantly to the point that interference withdaily life is minimal. Clients can use relaxation techniquesto assist them in managing and tolerating the anxiety theyare experiencing.It is important to note that the client must be willingto engage in exposure and response prevention. These arenot techniques that can be forced on the client.

246UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNURSING INTERVENTIONSCLIENT/FAMILY EDUCATIONfor OCD• Offer encouragement, support, and compassion.• Be clear with the client that you believe he or she canchange.• Encourage the client to talk about feelings, obsessions,and rituals in detail.• Gradually decrease time for the client to carry outritualistic behaviors.• Assist client to use exposure and response preventionbehavioral techniques.• Encourage client to use techniques to manage andtolerate anxiety responses.• Assist client to complete daily routine and activitieswithin agreed-on time limits.• Encourage the client to develop and follow a writtenschedule with specified times and activities.Completing a Daily RoutineTo accomplish tasks efficiently, the client initially mayneed additional time to allow for rituals. For example, ifbreakfast is at 8:00 AM and the client has a 45-minute ritualbefore eating, the nurse must plan that time into theclient’s schedule. It is important for the nurse not to interruptor to attempt to stop the ritual because doing so willescalate the client’s anxiety dramatically. Again, the clientmust be willing to make changes in his or her behavior.The nurse and client can agree on a plan to limit the timespent performing rituals. They may decide to limit themorning ritual to 40 minutes, then to 35 minutes, and soforth, taking care to decrease this time gradually at a ratethe client can tolerate. When the client has completed theritual or the time allotted has passed, the client then mustengage in the expected activity. This may cause anxietyand is a time when the client can use relaxation and stressreduction techniques. At home, the client can continue tofollow a daily routine or written schedule that helps himor her to stay on tasks and accomplish activities andresponsibilities.Providing Client and Family EducationIt is important for both the client and the family to learnabout OCD. They often are relieved to find the client isnot “going crazy” and that the obsessions are unwanted,rather than a reflection of any “dark side” to the client’spersonality. Helping the client and family to talk openlyabout the obsessions, anxiety, and rituals eliminates theclient’s need to keep these things secret and to carry theguilty burden alone. Family members also can better givefor OCD• Teach about OCD.• Review the importance of talking openly aboutobsessions, compulsions, and anxiety.• Emphasize medication compliance as an important partof treatment.• Discuss necessary behavioral techniques for managinganxiety and decreasing prominence of obsessions.the client needed emotional support when they are fullyinformed.Teaching about the importance of medication complianceto combat OCD is essential. The client may need totry different medications until his or her response is satisfactory.The chances for improved OCD symptoms areenhanced when the client takes medication and usesbehavioral techniques.EvaluationTreatment has been effective when OCD symptoms nolonger interfere with the client’s ability to carry out responsibilities.When obsessions occur, the client managesresulting anxiety without engaging in complicated or timeconsumingrituals. He or she reports regained control overhis or her life and the ability to tolerate and manage anxietywith minimal disruption.GENERALIZED ANXIETY DISORDERA person with GAD worries excessively and feels highlyanxious at least 50% of the time for 6 months or more.Unable to control this focus on worry, the person has threeor more of the following symptoms: uneasiness, irritability,muscle tension, fatigue, difficulty thinking, and sleepalterations. More people with this chronic disorder areseen by family physicians than by psychiatrists. The qualityof life is diminished greatly in older adults with GAD.Buspirone (BuSpar) and SSRI antidepressants are the mosteffective treatments (Starcevic, 2006).POST TRAUMATIC STRESS DISORDERPosttraumatic stress disorder can occur in a person whohas witnessed an extraordinarily terrifying and potentiallydeadly event. After the traumatic event, the personreexperiences all or some of it through dreams or wakingrecollections and responds defensively to these flashbacks.New behaviors develop related to the trauma,

CHAPTER 13 • ANXIETY, ANXIETY DISORDERS, AND STRESS-RELATED ILLNESS 247such as sleep difficulties, hypervigilance, thinking difficulties,severe startle response, and agitation (APA, 2000;see Chapter 11).ACUTE STRESS DISORDERAcute stress disorder is similar to posttraumatic stress disorderin that the person has experienced a traumatic situationbut the response is more dissociative. The person hasa sense that the event was unreal, believes he or she isunreal, and forgets some aspects of the event throughamnesia, emotional detachment, and muddled obliviousnessto the environment (APA, 2000).SELF-AWARENESS ISSUESWorking with people who have anxiety disordersis a different kind of challenge for thenurse. These clients are usually average peoplein other respects who know that theirsymptoms are unusual but feel unable to stop them. Theyexperience much frustration and feelings of helplessnessand failure. Their lives are out of their control, and theylive in fear of the next episode. They go to extreme measuresto try to prevent episodes by avoiding people andplaces where previous events occurred.It may be difficult for nurses and others to understandwhy the person cannot simply stop performing the bizarrebehaviors interfering with his or her life. Why does thehand-washer who has scrubbed himself raw keep washinghis poor sore hands every hour on the hour? Nurses mustunderstand what and how anxiety behaviors work, notjust for client care but to help understand the role anxietyplays in performing nursing responsibilities. Nurses areexpected to function at a high level and to avoid allowingtheir own feelings and needs to hinder the care of theirclients. But as emotional beings, nurses are just as vulnerableto stress and anxiety as others, and they have needs oftheir own.Points to Consider When Workingwith Clients with Anxiety andStress-Related Illness• Remember that everyone occasionally suffers from stressand anxiety that can interfere with daily life and work.• Avoid falling into the pitfall of trying to “fix” the client’sproblems.• Discuss any uncomfortable feelings with a more experiencednurse for suggestions on how to deal with yourfeelings toward these clients.• Remember to practice techniques to manage stress andanxiety in your own life.Critical Thinking Questions1. Because all people occasionally have anxiety, it is importantfor nurses to be aware of their own copingmechanisms. Do a self-assessment: What causes youanxiety? What physical, emotional, and cognitive responsesoccur when you are anxious? What copingmechanisms do you use? Are they healthy?2. Clients with anxiety disorders often engage in avoidancebehaviors, hoping to escape environmentaltriggers and thereby avoid future anxiety attacks.How can the nurse ensure that these clients remainengaged in their daily lives? What interventions orteaching might be effective?INTERNET RESOURCESRESOURCES• Anxiety Disorders Association of America• Obsessive Compulsive Foundation• OCD Online Home Page• Panic Anxiety Disorders Help and Support• Phobia List• Social Anxiety Network Home Page• Social Phobia/Social Anxiety AssociationINTERNET ADDRESShttp://www.adaa.orghttp://www.ocfoundation.orghttp://www.ocdonline.comhttp://www.panicdisorder.about.comhttp://www.phobia-fear-release.com/phobia-list.htmlhttp://www.social-anxiety-network.comhttp://www.socialphobia.org

248UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSKEY POINTS• Anxiety is a vague feeling of dread or apprehension.It is a response to external or internalstimuli that can have behavioral, emotional,cognitive, and physical symptoms.• Anxiety has positive and negative side effects. The positiveeffects produce growth and adaptive change. Thenegative effects produce poor self-esteem, fear, inhibition,and anxiety disorders (in addition to otherdisorders).• The four levels of anxiety are mild anxiety (helps peoplelearn, grow, and change); moderate anxiety (increasesfocus on the alarm; learning is still possible); severeanxiety (greatly decreases cognitive function, increasespreparation for physical responses, and increases spaceneeds); and panic (fight, flight, or freeze response; nolearning is possible; the person is attempting to freehimself or herself from the discomfort of this high stageof anxiety).• Defense mechanisms are intrapsychic distortions that aperson uses to feel more in control. It is believed thatthese defense mechanisms are overused when a persondevelops an anxiety disorder.• Current etiologic theories and studies of anxiety disordershave shown a familial incidence and have implicatedthe neurotransmitters GABA, norepinephrine, andserotonin.• Treatment for anxiety disorders involves medication(anxiolytics, SSRI and tricyclic antidepressants, and clonidineand propranolol) and therapy.• Cognitive–behavioral techniques include positive reframing,decatastrophizing, thought stopping, and distraction.Behavioral techniques for OCD include exposure andresponse prevention.• In a panic attack, the person feels as if he or she is dying.Symptoms can include palpitations, sweating, tremors,shortness of breath, a sense of suffocation, chest pain,nausea, abdominal distress, dizziness, paresthesias, andvasomotor lability. The person has a fight, flight, orfreeze response.• Phobias are excessive anxiety about being in public oropen places (agoraphobia), a specific object, or socialsituations.• OCD involves recurrent, persistent, intrusive, and unwantedthoughts, images, or impulses (obsessions) andritualistic or repetitive behaviors or mental acts (compulsions)carried out to eliminate the obsessions or toneutralize anxiety.• Self-awareness about one’s anxiety and responses toit greatly improves both personal and professionalrelationships.REFERENCESAmerican Psychiatric Association. (2000). DSM-IV-TR: Diagnostic andstatistical manual of mental disorders (4th ed., text revision).Washington, DC: American Psychiatric Association.Andreasen, N. C., & Black, D. W. (2006). Introductory textbook of psychiatry(4th ed.). Washington, DC: American PsychiatricPublishing.Bandelow, B. (2008). The medical treatment of obsessive–compulsivedisorder and anxiety. CNS Spectrums, 13(9 Suppl. 14), 37–46.Charney, D. S. (2005). Anxiety disorders: Introduction and overview. InB. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1718–1719). Philadelphia: LippincottWilliams & Wilkins.Culpepper, L. (2006). Social anxiety disorder in the primary care setting.Journal of Clinical Psychiatry, 67(Suppl. 12), 31–37.Freud, S. (1936). The problem of anxiety. New York: W. W. Norton.McMahon, F. J., & Kassem, L. (2005). Anxiety disorders: Genetics. In B.J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1759–1762). Philadelphia: Lippincott Williams& Wilkins.Merikangas, K. R. (2005). Anxiety disorders: Epidemiology. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1720–1728). Philadelphia: Lippincott Williams& Wilkins.Neumeister, A., Bonne, O., & Charney, D. S. (2005). Anxiety disorders:Neurochemical aspects. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1739–1748).Philadelphia: Lippincott Williams & Wilkins.Peplau, H. (1952). Interpersonal relations. New York: Putnam.Sakauye, K. (2008). Geriatric Psychiatry basics. New York: WW Norton.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Selye, H. (1956). The stress life. St. Louis: McGraw-Hill.Selye, H. (1974). Stress without distress. Philadelphia: J. B. Lippincott.Spector, R. E. (2008). Cultural diversity in health and illness (7th ed.).Upper Saddle River, NJ: Prentice-Hall Health.Starcevic, V. (2006). Anxiety states: A review of conceptual and treatmentissues. Current Opinion in Psychiatry, 19(1), 79–83.Sullivan, H. S. (1952). Interpersonal theory of psychiatry. New York: W. W.Norton.ADDITIONAL READINGSIancu, I., Levin, J., Hermesh, H., Dannon, P., Poreh, A., Ben-Yehuda, Y.,et al. (2006). Social phobia symptoms: Prevalence, sociodemographiccorrelates, and overlap with specific phobia symptoms. ComprehensivePsychiatry, 47(5), 399–405.Mataix-Cois, D., do Rosario-Campos, M. C., & Leckman, J. F. (2005). Amultidimensional model of obsessive–compulsive disorder. AmericanJournal of Psychiatry, 162(2), 228–238.Uhlenhuth, E. H., Leon, A. C., & Matuzas, W. (2006). Psychopathologyof panic attacks in panic disorder. Journal of Affective Disorders, 92(1),55–62.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The nurse observes a client who is becoming increasinglyupset. He is rapidly pacing, hyperventilating,clenching his jaw, wringing his hands, and trembling.His speech is high pitched and random; he seems preoccupiedwith his thoughts. He is pounding his fist intohis other hand. The nurse identifies his anxiety level asa. Mildb. Moderatec. Severed. Panic2. When assessing a client with anxiety, the nurse’s questionsshould bea. Avoided until the anxiety is goneb. Open endedc. Postponed until the client volunteers informationd. Specific and direct3. During the assessment, the client tells the nurse thatshe cannot stop worrying about her appearance andthat she often removes “old” makeup and applies freshmakeup every hour or two throughout the day. Thenurse identifies this behavior as indicative of a(n)a. Acute stress disorderb. Generalized anxiety disorderc. Panic disorderd. Obsessive–compulsive disorder4. The best goal for a client learning a relaxation techniqueis that the client willa. Confront the source of anxiety directlyb. Experience anxiety without feeling overwhelmedc. Report no episodes of anxietyd. Suppress anxious feelings5. Which of the four classes of medications used forpanic disorder is considered the safest because of lowincidence of side effects and lack of physiologicdependence?a. Benzodiazepinesb. Tricyclicsc. Monoamine oxidase inhibitorsd. Selective serotonin reuptake inhibitors6. Which of the following would be the best interventionfor a client having a panic attack?a. Involve the client in a physical activity.b. Offer a distraction such as music.c. Remain with the client.d. Teach the client a relaxation technique.7. A client with generalized anxiety disorder states, “I havelearned that the best thing I can do is to forget my worries.”How would the nurse evaluate this statement?a. The client is developing insight.b. The client’s coping skills have improved.c. The client needs encouragement to verbalize feelings.d. The client’s treatment has been successful.8. A client with anxiety is beginning treatment with lorazepam(Ativan). It is most important for the nurse toassess the client’sa. Motivation for treatmentb. Family and social supportc. Use of coping mechanismsc. Use of alcoholMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Interventions for a client with obsessive–compulsivedisorder would includea. Encouraging the client to verbalize feelingsb. Helping the client to avoid obsessive thinkingc. Interrupting rituals with appropriate distractionsd. Planning with the client to limit ritualse. Teaching relaxation exercises to the clientf. Telling the client to tolerate any anxious feelings2. When working with a client with moderate anxiety, thenurse would expect to seea. Cannot complete tasksb. Failure to respond to redirectionc. Increased automatisms or gesturesd. Narrowed perceptual fielde. Selective attentionf. Unable to connect thoughts independently249

250 UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLINICAL EXAMPLEMartha Cummings contacted Visiting Nurses Association (VNA) to discuss her concernsabout her 29-year-old daughter Susan, who is a graphic designer. Martha explains thatSusan has always been a shy person, has one or two close friends, and has difficulty dealingwith new situations. Over the past 4 months, Martha reports, Susan has been increasinglyreluctant to leave her apartment, making excuses about not visiting her family and askingher mother to run errands and even purchase groceries for her. Martha also states thatSusan has quit going to the office, but has continued her job by working at home. Heremployer has allowed her to do this for several weeks but is becoming more impatient withSusan. Martha fears Susan may lose her job.When Martha attempts to talk to Susan about this situation, Susan becomes very anxiousand agitated. She doesn’t want to discuss her problems, and keeps insisting she can’t “goout there” anymore. Martha has not been able to convince Susan to see a doctor, so shecontacted VNA to see if they would go to Susan’s apartment to see her. Susan has agreed totalk to the nurse if the nurse comes to her apartment.1. What assessments would the nurse need to make during the initial visit with Susan?2. What type(s) of treatment are available for Susan?3. How is Martha’s behavior affecting Susan’s situation? What suggestions might the nursemake to Martha?

14SchizophreniaLearning ObjectivesAfter reading this chapter, you should be able to:1. Discuss various theories of the etiology of schizophrenia.Key Terms• Abnormal InvoluntaryMovement Scale (AIMS)• akathisia• alogia• anhedonia• blunted affect• catatonia• command hallucinations• delusions• depersonalization• dystonic reactions• echolalia• echopraxia• extrapyramidal side effects• flat affect• hallucinations• ideas of reference• latency of response• neuroleptic malignant syndrome(NMS)• neuroleptics• polydipsia2. Describe the positive and negative symptoms of schizophrenia.3. Describe a functional and mental status assessment for a client withschizophrenia.4. Apply the nursing process to the care of a client with schizophrenia.5. Evaluate the effectiveness of antipsychotic medications for clients withschizophrenia.6. Provide teaching to clients, families, caregivers, and community membersto increase knowledge and understanding of schizophrenia.7. Describe the supportive and rehabilitative needs of clients with schizophreniawho live in the community.8. Evaluate your own feelings, beliefs, and attitudes regarding clients withschizophrenia.• pseudoparkinsonism• psychomotor retardation• psychosis• tardive dyskinesia• thought blocking• thought broadcasting• thought insertion• thought withdrawal• waxy flexibility• word saladVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!251

252UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSDSM-IV-TR DIAGNOSTIC CRITERIA: Positive and Negative Symptoms of SchizophreniaPOSITIVE OR HARD SYMPTOMSAmbivalence: Holding seemingly contradictory beliefs orfeelings about the same person, event, or situationAssociative looseness: Fragmented or poorly relatedthoughts and ideasDelusions: Fixed false beliefs that have no basis in realityEchopraxia: Imitation of the movements and gestures ofanother person whom the client is observingFlight of ideas: Continuous flow of verbalization in whichthe person jumps rapidly from one topic to anotherHallucinations: False sensory perceptions or perceptual experiencesthat do not exist in realityIdeas of reference: False impressions that external eventshave special meaning for the personPerseveration: Persistent adherence to a single idea ortopic; verbal repetition of a sentence, word, or phrase; resistingattempts to change the topicNEGATIVE OR SOFT SYMPTOMSAlogia: Tendency to speak very little or to convey little substanceof meaning (poverty of content)Anhedonia: Feeling no joy or pleasure from life or any activitiesor relationshipsApathy: Feelings of indifference toward people, activities,and eventsBlunted affect: Restricted range of emotional feeling, tone,or moodCatatonia: Psychologically induced immobility occasionallymarked by periods of agitation or excitement; the clientseems motionless, as if in a tranceFlat affect: Absence of any facial expression that would indicateemotions or moodLack of volition: Absence of will, ambition, or drive to takeaction or accomplish tasksAdapted from DSM-IV-TR (2000).SCHIZOPHRENIA CAUSES DISTORTED and bizarre thoughts, perceptions,emotions, movements, and behavior. It cannot bedefined as a single illness; rather, schizophrenia is thought ofas a syndrome or as disease process with many different varietiesand symptoms, much like the varieties of cancer. For decades,the public vastly misunderstood schizophrenia, fearingit as dangerous and uncontrollable and causing wild disturbancesand violent outbursts. Many people believed that thosewith schizophrenia needed to be locked away from societyand institutionalized. Only recently has the mental health industrycome to learn and educate the community at large thatschizophrenia has many different symptoms and presentationsand is an illness that medication can control. Thanks tothe increased effectiveness of newer atypical antipsychoticdrugs and advances in community-based treatment, many clientswith schizophrenia live successfully in the community.Clients whose illness is medically supervised and whose treatmentis maintained often continue to live and sometimes workin the community with family and outside support.Schizophrenia usually is diagnosed in late adolescenceor early adulthood. Rarely does it manifest in childhood.The peak incidence of onset is 15 to 25 years of age formen and 25 to 35 years of age for women (American PsychiatricAssociation [APA], 2000). The prevalence ofschizophrenia is estimated at about 1% of the total population.In the United States, this translates to nearly 3 millionpeople who are, have been, or will be affected by thedisease. The incidence and the lifetime prevalence areroughly the same throughout the world (Buchanan &Carpenter, 2005).The symptoms of schizophrenia are divided into twomajor categories: positive or hard symptoms/signs, whichinclude delusions, hallucinations, and grossly disorganizedthinking, speech, and behavior; and negative or softsymptoms/signs, which include flat affect, lack of volition,and social withdrawal or discomfort. For Diagnostic andStatistical Manual of Mental Disorders, 4th edition, Text Revision(DSM-IV-TR; APA, 2000) diagnostic criteria for schizophrenia,please refer to the DSM-IV-TR Diagnostic Criteria.Medication can control the positive symptoms, but frequentlythe negative symptoms persist after positive symptomshave abated. The persistence of these negative symptomsover time presents a major barrier to recovery andimproved functioning in the client’s daily life.The following are the types of schizophrenia accordingto the DSM-IV-TR (APA, 2000). The diagnosis is madeaccording to the client’s predominant symptoms:• Schizophrenia, paranoid type: characterized by persecutory(feeling victimized or spied on) or grandiose delusions,hallucinations, and, occasionally, excessivereligiosity (delusional religious focus) or hostile andaggressive behavior• Schizophrenia, disorganized type: characterized bygrossly inappropriate or flat affect, incoherence, looseassociations, and extremely disorganized behavior• Schizophrenia, catatonic type: characterized by markedpsychomotor disturbance, either motionless or excessivemotor activity. Motor immobility may be manifestedby catalepsy (waxy flexibility) or stupor. Excessivemotor activity is apparently purposeless and is notinfluenced by external stimuli. Other features includeextreme negativism, mutism, peculiarities of voluntarymovement, echolalia, and echopraxia.

CHAPTER 14 • SCHIZOPHRENIA 253CLINICAL VIGNETTE: SCHIZOPHRENIARicky was staying with his father for a few weeks on avisit. During the first week, things had gone pretty well, butRicky forgot to take his medication for a few days. His fatherknew Ricky wasn’t sleeping well at night, and he could hearRicky talking to himself in the next room.One day while his father was at work, Ricky began tohear some voices outside the apartment. The voices grewlouder, saying, “You’re no good; you can’t do anythingright. You can’t take care of yourself or protect your dad.We’re going to get you both.” Ricky grew more frightenedand went to the closet where his dad kept his tools. Hegrabbed a hammer and ran outside. When his father camehome from work early, Ricky wasn’t in the apartment thoughhis coat and wallet were still there. Ricky’s father called aneighbor, and they drove around the apartment complexlooking for Ricky. They finally found Ricky crouched behindsome bushes. Although it was 45ºF (7ºC), he was wearingonly a T-shirt and shorts and no shoes. Ricky’s neighborcalled emergency services. Meanwhile Ricky’s father tried tocoax Ricky into the car, but Ricky wouldn’t come. The voiceshad grown louder, and Ricky was convinced that the devilhad kidnapped his father and was coming for him too. Hesaw someone else in the car with his dad. The voices saidthey would crash the car if he got in. They were laughing athim! He couldn’t get into the car; it was only a trap. His dadhad tried his best, but he was trapped, too. The voices toldRicky to use the hammer and to destroy the car to kill thedevil. He began to swing the hammer into the windshield,but someone held him back.The emergency services staff arrived and spoke quietlyand firmly as they removed the hammer from Ricky’s hands.They told Ricky they were taking him to the hospital wherehe and his father would be safe. They gently put him on astretcher with restraints, and his father rode in the emergencyvan with him to the hospital.• Schizophrenia, undifferentiated type: characterized bymixed schizophrenic symptoms (of other types) alongwith disturbances of thought, affect, and behavior• Schizophrenia, residual type: characterized by at leastone previous, though not a current, episode; socialwithdrawal; flat affect; and looseness of associationsSchizoaffective disorder is diagnosed when the client hasthe psychotic symptoms of schizophrenia and meets thecriteria for a major affective or mood disorder. The mooddisorder can be mania, depression, or mixed moods. Thereis disagreement among psychiatrists about the validity ofthis diagnosis, with many believing that a diagnosis of psychoticmood disorder is more appropriate (Lake & Hurwitz,2007). Other clinicians believe it would be more beneficialto diagnose the client with schizophrenia and a mooddisorder, such as bipolar disorder (Mahli, Green, Fagiolini,Peselow, & Kumari, 2008), rather than try to combine thetwo diagnoses.CLINICAL COURSEAlthough the symptoms of schizophrenia are always severe,the long-term course does not always involve progressivedeterioration. The clinical course varies among clients.OnsetOnset may be abrupt or insidious, but most clients slowly andgradually develop signs and symptoms such as social withdrawal,unusual behavior, loss of interest in school or work,and neglected hygiene. The diagnosis of schizophrenia usuallyis made when the person begins to display more activelypositive symptoms of delusions, hallucinations, and disorderedthinking (psychosis). Regardless of when and how theillness begins and the type of schizophrenia, consequences formost clients and their families are substantial and enduring.When and how the illness develops seems to affect theoutcome. Age at onset appears to be an important factor inhow well the client fares: Those who develop the illnessearlier show worse outcomes than those who develop itlater. Younger clients display a poorer premorbid adjustment,more prominent negative signs, and greater cognitiveimpairment than do older clients. Those who experience agradual onset of the disease (about 50%) tend to have bothpoorer immediate and long-term course than those whoexperience an acute and sudden onset (Buchanan & Carpenter,2005). Approximately one third of clients withschizophrenia relapse within 1 year of an acute episode(Ucok, Polat, Cakir, & Genc, 2006).Immediate CourseIn the years immediately after the onset of psychotic symptoms,two typical clinical patterns emerge. In one pattern,the client experiences ongoing psychosis and never fullyrecovers, although symptoms may shift in severity overtime. In another pattern, the client experiences episodes ofpsychotic symptoms that alternate with episodes of relativelycomplete recovery from the psychosis.Long-Term CourseThe intensity of psychosis tends to diminish with age.Many clients with long-term impairment regain some

254UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSdegree of social and occupational functioning. Over time,the disease becomes less disruptive to the person’s life andeasier to manage, but rarely can the client overcome theeffects of many years of dysfunction (Buchanan & Carpenter,2005). In later life, these clients may live independently orin a structured family-type setting and may succeed at jobswith stable expectations and a supportive work environment.However, most clients with schizophrenia have difficultyfunctioning in the community, and few lead fully independentlives (Carter, 2006). This is primarily due to persistentnegative symptoms, impaired cognition, or treatmentrefractorypositive symptoms.Antipsychotic medications play a crucial role in thecourse of the disease and individual outcomes. They do notcure the disorder; however, they are crucial to its successfulmanagement. The more effective the client’s response andadherence to his or her medication regimen, the better theclient’s outcome. Marshall and Rathbone (2006) found thatearly detection and aggressive treatment of the first psychoticepisode were associated with improved outcomes.RELATED DISORDERSOther disorders are related to, but distinguished from,schizophrenia in terms of presenting symptoms and theduration or magnitude of impairment. The DSM-IV-TR(APA, 2000) categorizes these disorders as follows:• Schizophreniform disorder: The client exhibits the symptomsof schizophrenia but for less than the 6 monthsnecessary to meet the diagnostic criteria for schizophrenia.Social or occupational functioning may or may notbe impaired.• Delusional disorder: The client has one or more nonbizarredelusions—that is, the focus of the delusion is believable.Psychosocial functioning is not markedlyimpaired, and behavior is not obviously odd or bizarre.• Brief psychotic disorder: The client experiences the suddenonset of at least one psychotic symptom, such asdelusions, hallucinations, or disorganized speech or behavior,which lasts from 1 day to 1 month. The episodemay or may not have an identifiable stressor or may followchildbirth.• Shared psychotic disorder (folie à deux): Two peopleshare a similar delusion. The person with this diagnosisdevelops this delusion in the context of a close relationshipwith someone who has psychotic delusions.Two other diagnoses, schizoid personality disorder andschizotypal personality disorder, are not psychotic disordersand should not be confused with schizophrenia eventhough the names sound similar. These two diagnoses arecovered in Chapter 16.ETIOLOGYWhether schizophrenia is an organic disease with underlyingphysical brain pathology has been an importantquestion for researchers and clinicians for as long as theyhave studied the illness. In the first half of the 20th century,studies focused on trying to find a particular pathologicstructure associated with the disease, largely throughautopsy. Such a site was not discovered. In the 1950s and1960s, the emphasis shifted to examination of psychologicaland social causes. Interpersonal theorists suggestedthat schizophrenia resulted from dysfunctional relationshipsin early life and adolescence. None of the interpersonaltheories has been proved, and newer scientific studies arefinding more evidence to support neurologic/neurochemicalcauses. However, some therapists still believe thatschizophrenia results from dysfunctional parenting orfamily dynamics. For parents or family members of personsdiagnosed with schizophrenia, such beliefs causeagony over what they did “wrong” or what they could havedone to help prevent it.Newer scientific studies began to demonstrate thatschizophrenia results from a type of brain dysfunction. Inthe 1970s, studies began to focus on possible neurochemicalcauses, which remain the primary focus of research andtheory today. These neurochemical/neurologic theories aresupported by the effects of antipsychotic medications,which help to control psychotic symptoms, and neuroimagingtools such as computed tomography, which have shownthat the brain of people with schizophrenia differs in structureand function from the brain of control subjects.Genetics plays a role in mental illness

CHAPTER 14 • SCHIZOPHRENIA 255Biologic TheoriesThe biologic theories of schizophrenia focus on geneticfactors, neuroanatomic and neurochemical factors (structureand function of the brain), and immunovirology (thebody’s response to exposure to a virus).Genetic FactorsMost genetic studies have focused on immediate families(i.e., parents, siblings, and offspring) to examine whetherschizophrenia is genetically transmitted or inherited. Fewhave focused on more distant relatives. The most importantstudies have centered on twins; these findings have demonstratedthat identical twins have a 50% risk for schizophrenia;that is, if one twin has schizophrenia, the other has a50% chance of developing it as well. Fraternal twins haveonly a 15% risk (Kirkpatrick & Tek, 2005). This findingindicates that schizophrenia is at least partially inherited.Other important studies have shown that children withone biologic parent with schizophrenia have a 15% risk; therisk rises to 35% if both biologic parents have schizophrenia.Children adopted at birth into a family with no historyof schizophrenia but whose biologic parents have a historyof schizophrenia still reflect the genetic risk of their biologicparents. All these studies have indicated a genetic risk ortendency for schizophrenia, but genetics cannot be the onlyfactor: identical twins have only a 50% risk even thoughtheir genes are 100% identical (Riley & Kendler, 2005).Neuroanatomic and Neurochemical FactorsWith the development of noninvasive imaging techniquessuch as computed tomography, magnetic resonance imaging,and positron emission tomography in the past 25 years,scientists have been able to study the brain structure (neuroanatomy)and activity (neurochemistry) of people withschizophrenia. Findings have demonstrated that peoplewith schizophrenia have relatively less brain tissue andcerebrospinal fluid than those who do not have schizophrenia(Schneider-Axmann et al., 2006); this could represent afailure in the development or a subsequent loss of tissue.Computed tomography scans have shown enlarged ventriclesin the brain and cortical atrophy. Positron emissiontomography studies suggest that glucose metabolism andoxygen are diminished in the frontal cortical structures ofthe brain. The research consistently shows decreased brainvolume and abnormal brain function in the frontal andtemporal areas of persons with schizophrenia. This pathologycorrelates with the positive signs of schizophrenia(temporal lobe), such as psychosis, and the negative signsof schizophrenia (frontal lobe), such as lack of volition ormotivation and anhedonia. It is unknown whether thesechanges in the frontal and temporal lobes are the result of afailure of these areas to develop properly or if a virus,trauma, or immune response has damaged them. Intrauterineinfluences such as poor nutrition, tobacco, alcohol, andother drugs, and stress also are being studied as possiblecauses of the brain pathology found in people with schizophrenia(Buchanan & Carpenter, 2005).Neurochemical studies have consistently demonstratedalterations in the neurotransmitter systems of the brain inpeople with schizophrenia. The neuronal networks thattransmit information by electrical signals from a nerve cellthrough its axon and across synapses to postsynaptic receptorson other nerve cells seem to malfunction. The transmissionof the signal across the synapse requires a complexseries of biochemical events. Studies have implicated theactions of dopamine, serotonin, norepinephrine, acetylcholine,glutamate, and several neuromodulary peptides.Currently, the most prominent neurochemical theoriesinvolve dopamine and serotonin. One prominent theorysuggests excess dopamine as a cause. This theory was developedbased on two observations: First, drugs that increaseactivity in the dopaminergic system, such as amphetamineand levodopa, sometimes induce a paranoid psychotic reactionsimilar to schizophrenia. Second, drugs blocking postsynapticdopamine receptors reduce psychotic symptoms;in fact, the greater the ability of the drug to block dopaminereceptors, the more effective it is in decreasing symptoms ofschizophrenia (Buchanan & Carpenter, 2005).More recently, serotonin has been included among theleading neurochemical factors affecting schizophrenia. Thetheory regarding serotonin suggests that serotonin modulatesand helps to control excess dopamine. Some believethat excess serotonin itself contributes to the developmentof schizophrenia. Newer atypical antipsychotics, such asclozapine (Clozaril), are both dopamine and serotoninantagonists. Drug studies have shown that clozapine candramatically reduce psychotic symptoms and amelioratethe negative signs of schizophrenia (Kane & Marder,2005).Researchers also are exploring the possibility thatschizophrenia may have three separate symptom complexesor syndromes: hallucinations/delusions, disorganizationof thought and behavior, and negative symptoms(Buchanan & Carpenter, 2005). Investigations show thatthe three syndromes relate to neurobiologic differences inthe brain. It is postulated that schizophrenia has (thesethree) subgroups, which may be homogeneous relative tocourse, pathophysiology, and, therefore, treatment.Immunovirologic FactorsPopular theories have emerged stating that exposure to avirus or the body’s immune response to a virus could alterthe brain physiology of people with schizophrenia.Although scientists continue to study these possibilities,few findings have validated them.Cytokines are chemical messengers between immunecells, mediating inflammatory and immune responses.Specific cytokines also play a role in signaling the brainto produce behavioral and neurochemical changesneeded in the face of physical or psychological stress tomaintain homeostasis. It is believed that cytokines may

256UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERShave a role in the development of major psychiatric disorderssuch as schizophrenia (Brown, Bresnahan, &Susser, 2005).Recently, researchers have been focusing on infectionsin pregnant women as a possible origin for schizophrenia.Waves of schizophrenia in England, Wales, Denmark,Finland, and other countries have occurred a generationafter influenza epidemics. Also, there are higher rates ofschizophrenia among children born in crowded areas incold weather, conditions that are hospitable to respiratoryailments (Brown, Bresnahan, & Susser, 2005).CULTURAL CONSIDERATIONSAwareness of cultural differences is important when assessingfor symptoms of schizophrenia. Ideas that are considereddelusional in one culture, such as beliefs in sorcery orwitchcraft, may be commonly accepted by other cultures.Also, auditory or visual hallucinations, such as seeing theVirgin Mary or hearing God’s voice, may be a normal partof religious experiences in some cultures. The assessmentof affect requires sensitivity to differences in eye contact,body language, and acceptable emotional expression; thesevary across cultures (APA, 2000).Psychotic behavior observed in countries other thanthe United States or among particular ethnic groups hasbeen identified as a “culture-bound” syndrome. Althoughthese episodes exist primarily in certain countries, theymay be seen in other places as people visit or immigrate toother countries or areas. Mojtabai (2005) summarizedsome of these psychotic behaviors:• Bouffée délirante, a syndrome found in West Africa andHaiti, involves a sudden outburst of agitated and aggressivebehavior, marked confusion, and psychomotorexcitement. It is sometimes accompanied by visual andauditory hallucinations or paranoid ideation.• Ghost sickness is preoccupation with death and the deceasedfrequently observed among members of some NativeAmerican tribes. Symptoms include bad dreams,weakness, feelings of danger, loss of appetite, fainting, dizziness,fear, anxiety, hallucinations, loss of consciousness,confusion, feelings of futility, and a sense of suffocation.• Locura refers to a chronic psychosis experienced byLatinos in the United States and Latin America. Symptomsinclude incoherence, agitation, visual and auditoryhallucinations, inability to follow social rules,unpredictability, and, possibly, violent behavior.• Qi-gong psychotic reaction is an acute, time-limited episodecharacterized by dissociative, paranoid, or otherpsychotic symptoms that occur after participating inthe Chinese folk health-enhancing practice of qi-gong.Especially vulnerable are those who become overly involvedin the practice.• Zar, an experience of spirits possessing a person, is seenin Ethiopia, Somalia, Egypt, Sudan, Iran, and otherNorth African and Middle Eastern societies. The afflictedperson may laugh, shout, wail, bang her or hishead on a wall, or be apathetic and withdrawn, refusingto eat or carry out daily tasks. Locally, such behavior isnot considered pathologic.Ethnicity also may be a factor in the way a person respondsto psychotropic medications. This difference in response isprobably the result of the person’s genetic makeup. Somepeople metabolize certain drugs more slowly, so the druglevel in the bloodstream is higher than desired. AfricanAmericans, white Americans, and Hispanic Americansappear to require comparable therapeutic doses of antipsychoticmedications. Asian clients, however, need lower dosesof drugs such as haloperidol (Haldol) to obtain the sameeffects; therefore, they would be likely to experience moresevere side effects if given the traditional or usual doses.TREATMENTPsychopharmacologyThe primary medical treatment for schizophrenia is psychopharmacology.In the past, electroconvulsive therapy,insulin shock therapy, and psychosurgery were used, butsince the creation of chlorpromazine (Thorazine) in 1952,other treatment modalities have become all but obsolete.Antipsychotic medications, also known as neuroleptics,are prescribed primarily for their efficacy in decreasing psychoticsymptoms. They do not cure schizophrenia; rather,they are used to manage the symptoms of the disease.The older, or conventional, antipsychotic medicationsare dopamine antagonists. The newer, or atypical, antipsychoticmedications are both dopamine and serotonin antagonists(see Chapter 2). These medications, usual daily dosages,and their common side effects are listed in Table 14.1.The conventional antipsychotics target the positive signs ofschizophrenia, such as delusions, hallucinations, disturbedthinking, and other psychotic symptoms, but have noobservable effect on the negative signs. The atypical antipsychoticsnot only diminish positive symptoms but also,for many clients, lessen the negative signs of lack of volitionand motivation, social withdrawal, and anhedonia.Maintenance TherapyTwo antipsychotics are available in depot injection formsfor maintenance therapy: fluphenazine (Prolixin) indecanoate and enanthate preparations and haloperidol(Haldol) in decanoate. The vehicle for depot injections issesame oil; therefore, the medications are absorbed slowlyover time into the client’s system. The effects of the medicationslast 2 to 4 weeks, eliminating the need for dailyoral antipsychotic medication (see Chapter 2). The durationof action is 7 to 28 days for fluphenazine and 4 weeksfor haloperidol. It may take several weeks of oral therapywith these medications to reach a stable dosing level beforethe transition to depot injections can be made. Therefore,

CHAPTER 14 • SCHIZOPHRENIA 257Table 14.1ANTIPSYCHOTIC DRUGS, USUAL DAILY DOSAGES, AND INCIDENCEOF SIDE EFFECTSGeneric (Trade) NameUsual DailyDosage* (mg) Sedation Hypotension EPS AnticholinergicConventional AntipsychoticsChlorpromazine (Thorazine) 200–1,600 Perphenazine (Trilafon) 16–32 Fluphenazine (Prolixin) 2.5–20 Thioridazine (Mellaril) 200–600 Mesoridazine (Serentil) 75–300 Thiothixene (Navane) 6–30 Haloperidol (Haldol) 2–20 /0Loxapine (Loxitane) 60–100 Molindone (Moban) 50–100 /0 Perphenazine (Etrafon) 16–32 Trifluoperazine (Stelazine) 6–50 Atypical AntipsychoticsClozapine (Clozaril) 150–500 /0 Risperidone (Risperdal) 2–8 Olanzapine (Zyprexa) 5–20 Quetiapine (Seroquel) 150–500 /0 Ziprasidone (Geodon) 40–160 /0 Paliperidone (Invega) 6 Aripiprazole (Abilify) 10–40 *Oral dosage only.EPS, extrapyramidal side effects., very significant; , significant; , moderate; , mild; / 0, rare or absent.these preparations are not suitable for the management ofacute episodes of psychosis. They are, however, very usefulfor clients requiring supervised medication complianceover an extended period.Side EffectsThe side effects of antipsychotic medications are significantand can range from mild discomfort to permanent movementdisorders (Kane & Marder, 2005). Because many ofthese side effects are frightening and upsetting to clients,they are frequently cited as the primary reason that clientsdiscontinue or reduce the dosage of their medications. Seriousneurologic side effects include extrapyramidal sideeffects (EPS) (acute dystonic reactions, akathisia, and parkinsonism),tardive dyskinesia, seizures, and neurolepticmalignant syndrome (NMS; discussion to follow). Nonneurologicside effects include weight gain, sedation, photosensitivity,and anticholinergic symptoms such as dry mouth,blurred vision, constipation, urinary retention, and orthostatichypotension. Table 14.2 lists the side effects of antipsychoticmedications and appropriate nursing interventions.Extrapyramidal Side Effects. EPS are reversible movementdisorders induced by neuroleptic medication. They includedystonic reactions, parkinsonism, and akathisia.Dystonic reactions to antipsychotic medications appearearly in the course of treatment and are characterized byspasms in discrete muscle groups such as the neck muscles(torticollis) or eye muscles (oculogyric crisis). These spasmsalso may be accompanied by protrusion of the tongue, dysphagia,and laryngeal and pharyngeal spasms that can compromisethe client’s airway, causing a medical emergency.Dystonic reactions are extremely frightening and painfulfor the client. Acute treatment consists of diphenhydramine(Benadryl) given either intramuscularly or intravenously, orbenztropine (Cogentin) given intramuscularly.Pseudoparkinsonism, or neuroleptic-induced parkinsonism,includes a shuffling gait, mask-like facies, musclestiffness (continuous) or cogwheeling rigidity (ratchet-likemovements of joints), drooling, and akinesia (slowness anddifficulty initiating movement). These symptoms usuallyappear in the first few days after starting or increasing thedosage of an antipsychotic medication. Treatment of pseudoparkinsonismand prevention of further dystonic reactionsare achieved with the medications listed in Table 14.3.Akathisia is characterized by restless movement, pacing,inability to remain still, and the client’s report of innerrestlessness. Akathisia usually develops when the antipsychoticis started or when the dose is increased. Clients arevery uncomfortable with these sensations and may stoptaking the antipsychotic medication to avoid these side

258UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 14.2Side EffectSIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS AND NURSINGINTERVENTIONSNursing InterventionDystonic reactionsTardive dyskinesiaNeuroleptic malignant syndromeAkathisiaExtrapyramidal side effects orneuroleptic-induced parkinsonismSeizuresSedationPhotosensitivityWeight gainAnticholinergic symptomsDry mouthBlurred visionConstipationUrinary retentionOrthostatic hypotensionAdminister medications as ordered; assess for effectiveness; reassure client ifhe or she is frightened.Assess using tool such as AIMS; report occurrence or score increase tophysician.Stop all antipsychotic medications; notify physician immediately.Administer medications as ordered; assess for effectiveness.Administer medications as ordered; assess for effectiveness.Stop medication; notify physician; protect client from injury during seizure;provide reassurance and privacy for client after seizure.Caution about activities requiring client to be fully alert, such as driving a car.Caution client to avoid sun exposure; advise client when in the sun to wearprotective clothing and sun-blocking lotion.Encourage balanced diet with controlled portions and regular exercise; focuson minimizing gain.Use ice chips or hard candy for relief.Assess side effect, which should improve with time; report to physicianif no improvement.Increase fluid and dietary fiber intake; client may need a stool softenerif unrelieved.Instruct client to report any frequency or burning with urination; report tophysician if no improvement over time.Instruct client to rise slowly from sitting or lying position; wait to ambulateuntil no longer dizzy or light-headed.Table 14.3EFFICACY OF DRUGS USED TO TREAT EXTRAPYRAMIDAL SIDE EFFECTSAND NURSING INTERVENTIONSGeneric (Trade) Name Akathisia Dystonia Rigidity Tremor Nursing InterventionsBenztropine (Cogentin)Trihexyphenidyl (Artane)Biperiden (Akineton)Procyclidine (Kemadrin)2211233333332333Increase fluid and fiber intake to avoidconstipation; use ice chips or hardcandy for dry mouth; assess formemory impairment (another sideeffect).Amantadine (Symmetrel) 3 2 3 2 Use ice chips or hard candy for drymouth; assess for worseningpsychosis (an occasional side effect).Diphenhydramine (Benadryl) 2 2–3 1 2 Use ice chips or hard candy for drymouth; observe for sedation.Diazepam (Valium) 2 1–2 1–2 0–1 Observe for sedation; potential formisuse or abuse.Lorazepam (Ativan) 2 1–2 1–2 0–1 Observe for sedation; potential formisuse or abuse.Propranolol (Inderal) 3 0 0 1–2 Assess for palpitations, dizziness, coldhands and feet.

CHAPTER 14 • SCHIZOPHRENIA 259Box 14.1 ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) EXAMINATION PROCEDUREClient identification: _______________________________________________________ Date: ___________________Rated by: ________________________________________________________________________________________________Either before or after completing the examination procedure, observe the client unobtrusively at rest (e.g., in waiting room).The chair to be used in this examination should be a hard, firm one without arms.After observing the client, he or she may be rated on a scale of 0 (none), 1 (minimal), 2 (mild), 3 (moderate), and 4 (severe)according to the severity of symptoms.Ask the client if there is anything in his/her mouth (i.e., gum, candy, etc.) and, if there is, to remove it.Ask client about the current condition of his/her teeth. Ask client if he/she wears dentures. Do teeth or dentures bother client now?Ask client whether he/she notices any movement in mouth, face, hands, or feet. If yes, ask to describe and to what extentthe movements currently bother patient or interfere with his/her activities.0 1 2 3 4Have client sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire body formovements while in this position.)0 1 2 3 4 Ask client to sit with hands hanging unsupported. If male, hands between legs; if female and wearing adress, hands hanging over knees. (Observe hands and other body areas.)0 1 2 3 4 Ask client to open mouth. (Observe tongue at rest within mouth.) Do this twice.0 1 2 3 4 Ask client to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice.0 1 2 3 4Ask client to tap thumb with each finger as rapidly as possible for 10–15 seconds; separately with right hand,then with left hand. (Observe facial and leg movements.)0 1 2 3 4 Flex and extend client’s left and right arms. (One at a time.)0 1 2 3 4 Ask client to stand up. (Observe in profile. Observe all body areas again, hips included.)0 1 2 3 4 ∗ Ask client to extend both arms outstretched in front with palms down. (Observe trunk, legs, and mouth.)0 1 2 3 4 ∗ Have client walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice.∗Activated movements.effects. Beta-blockers such as propranolol have been mosteffective in treating akathisia, whereas benzodiazepineshave provided some success as well.The early detection and successful treatment of EPS isvery important in promoting the client’s compliance withmedication. The nurse is most often the person whoobserves these symptoms or the person to whom the clientreports symptoms. To provide consistency in assessmentamong nurses working with the client, a standardizedrating scale for extrapyramidal symptoms is useful. TheSimpson–Angus scale for EPS is one tool that can be used.Tardive Dyskinesia. Tardive dyskinesia, a late-appearingside effect of antipsychotic medications, is characterizedby abnormal, involuntary movements such as lip smacking,tongue protrusion, chewing, blinking, grimacing, andchoreiform movements of the limbs and feet. These involuntarymovements are embarrassing for clients and maycause them to become more socially isolated. Tardivedyskinesia is irreversible once it appears, but decreasing ordiscontinuing the medication can arrest the progression.Clozapine (Clozaril), an atypical antipsychotic drug, hasnot been found to cause this side effect, so it often is recommendedfor clients who have experienced tardive dyskinesiawhile taking conventional antipsychotic drugs.Screening clients for late-appearing movement disorderssuch as tardive dyskinesia is important. The AbnormalInvoluntary Movement Scale (AIMS) is used to screenfor symptoms of movement disorders. The client isobserved in several positions, and the severity of symptomsis rated from 0 to 4. The AIMS can be administeredevery 3 to 6 months. If the nurse detects an increased scoreon the AIMS, indicating increased symptoms of tardivedyskinesia, he or she should notify the physician so thatthe client’s dosage or drug can be changed to preventadvancement of tardive dyskinesia. The AIMS examinationprocedure is presented in Box 14.1.

260UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSSeizures. Seizures are an infrequent side effect associatedwith antipsychotic medications. The incidence is 1%of people taking antipsychotics. The notable exception isclozapine, which has an incidence of 5%. Seizures may beassociated with high doses of the medication. Treatment isa lowered dosage or a different antipsychotic medication.Neuroleptic Malignant Syndrome. Neuroleptic malignantsyndrome (NMS) is a serious and frequently fatal conditionseen in those being treated with antipsychotic medications.It is characterized by muscle rigidity, high fever,increased muscle enzymes (particularly creatine phosphokinase),and leukocytosis (increased leukocytes). It is estimatedthat 0.1% to 1% of all clients taking antipsychoticsdevelop NMS. Any of the antipsychotic medications cancause NMS, which is treated by stopping the medication.The client’s ability to tolerate other antipsychotic medicationsafter NMS varies, but use of another antipsychoticappears possible in most instances.Agranulocytosis. Clozapine has the potentially fatal sideeffect of agranulocytosis (failure of the bone marrow toproduce adequate white blood cells). Agranulocytosisdevelops suddenly and is characterized by fever, malaise,ulcerative sore throat, and leukopenia. This side effect maynot be manifested immediately but can occur as long as18 to 24 weeks after the initiation of therapy. The drugmust be discontinued immediately. Clients taking this antipsychoticmust have weekly white blood cell counts forthe first 6 months of clozapine therapy and every 2 weeksthereafter. Clozapine is dispensed every 7 or 14 days only,and evidence of a white cell count above 3,500 cells/mm 3is required before a refill is furnished.Psychosocial TreatmentIn addition to pharmacologic treatment, many other modesof treatment can help the person with schizophrenia. Individualand group therapies, family therapy, family education,and social skills training can be instituted for clientsin both inpatient and community settings.Individual and group therapy sessions are often supportivein nature, giving the client an opportunity forsocial contact and meaningful relationships with otherpeople. Groups that focus on topics of concern such asmedication management, use of community supports, andfamily concerns also have been beneficial to clients withschizophrenia (Pfammatter, Junghan, & Brenner, 2006).Clients with schizophrenia can improve their social competencewith social skill training, which translates into moreeffective functioning in the community. Basic social skilltraining involves breaking complex social behavior intosimpler steps, practicing through role-playing, and applyingthe concepts in the community or real-world setting.Cognitive adaptation training using environmental supportsis designed to improve adaptive functioning in the homesetting. Individually tailored environmental supports suchas signs, calendars, hygiene supplies, and pill containers cuethe client to perform associated tasks (Velligan et al., 2006).Moriana, Alarcon, and Herruzo (2006) found that psychosocialskill training was more effective when carried outduring in-home visits in the client’s own environment ratherthan in an outpatient setting.A new therapy, cognitive enhancement therapy (CET),combines computer-based cognitive training with groupsessions that allow clients to practice and develop socialskills. This approach is designed to remediate or improvethe clients’ social and neurocognitive deficits, such asattention, memory, and information processing. The experientialexercises help the client to take the perspective ofanother person, rather than focus entirely on self. Positiveresults of CET include increased mental stamina, activerather than passive information processing, and spontaneousand appropriate negotiation of unrehearsed socialchallenges (Hogarty, Greenwald, & Eack, 2006).Family education and therapy are known to diminishthe negative effects of schizophrenia and reduce the relapserate (Penn, Waldheter, Perkins, Mueser, & Lieberman,2005). Although inclusion of the family is a factor thatimproves outcomes for the client, family involvementoften is neglected by health-care professionals. Familiesoften have a difficult time coping with the complexitiesand ramifications of the client’s illness. This creates stressamong family members that is not beneficial for the clientor family members. Family education helps to make familymembers part of the treatment team. See Chapter 3 fora discussion of the National Alliance for the Mentally IllFamily to Family Education course.In addition, family members can benefit from a supportiveenvironment that helps them cope with the many difficultiespresented when a loved one has schizophrenia.These concerns include continuing as a caregiver for thechild who is now an adult; worrying about who will carefor the client when the parents are gone; dealing with thesocial stigma of mental illness; and possibly facing financialproblems, marital discord, and social isolation. Such supportis available through the National Alliance for the MentallyIll and local support groups. The client’s health-careprovider can make referrals to meet specific family needs.APPLICATION OF THE NURSING PROCESSAssessmentSchizophrenia affects thought processes and content, perception,emotion, behavior, and social functioning; however,it affects each individual differently. The degree ofimpairment in both the acute or psychotic phase and thechronic or long-term phase varies greatly; thus, so do theneeds of and the nursing interventions for each affectedclient. The nurse must not make assumptions about theclient’s abilities or limitations based solely on the medicaldiagnosis of schizophrenia.For example, the nurse may care for a client in an acuteinpatient setting. The client may appear frightened, hearvoices (hallucinate), make no eye contact, and mumble constantly.The nurse would deal with the positive, or psychotic,

CHAPTER 14 • SCHIZOPHRENIA 261signs of the disease. Another nurse may encounter a clientwith schizophrenia in a community setting who is not experiencingpsychotic symptoms; rather, this client lacks energyfor daily tasks and has feelings of loneliness and isolation(negative signs of schizophrenia). Although both clients havethe same medical diagnosis, the approach and interventionsthat each nurse takes would be very different.HistoryThe nurse first elicits information about the client’s previoushistory with schizophrenia to establish baseline data. He orshe asks questions about how the client functioned beforethe crisis developed, such as “How do you usually spend yourtime?” and “Can you describe what you do each day?”The nurse assesses the age at onset of schizophrenia,knowing that poorer outcomes are associated with an earlierage at onset. Learning the client’s previous history ofhospital admissions and response to hospitalization also isimportant.The nurse also assesses the client for previous suicideattempts. Ten percent of all people with schizophrenia eventuallycommit suicide. The nurse might ask, “Have you everattempted suicide?” or “Have you ever heard voices tellingyou to hurt yourself?” Likewise, it is important to elicitinformation about any history of violence or aggressionbecause a history of aggressive behavior is a strong predictorof future aggression. The nurse might ask, “What do you dowhen you are angry, frustrated, upset, or scared?”The nurse assesses whether the client has been usingcurrent support systems by asking the client or significantothers the following questions:• Has the client kept in contact with family or friends?• Has the client been to scheduled groups or therapyappointments?• Does the client seem to run out of money betweenpaychecks?• Have the client’s living arrangements changed recently?Finally, the nurse assesses the client’s perception of hisor her current situation—that is, what the client believesto be significant present events or stressors. The nurse cangather such information by asking, “What do you see asthe primary problem now?” or “What do you need helpmanaging now?”General Appearance, Motor Behavior, and SpeechAppearance may vary widely among different clients withschizophrenia. Some appear normal in terms of beingdressed appropriately, sitting in a chair conversing withthe nurse and exhibiting no strange or unusual postures orgestures. Others exhibit odd or bizarre behavior. They mayappear disheveled and unkempt with no obvious concernfor their hygiene, or they may wear strange or inappropriateclothing (for instance, a heavy wool coat and stockingcap in hot weather).Overall motor behavior also may appear odd. The clientmay be restless and unable to sit still, exhibit agitationand pacing, or appear unmoving (catatonia). He or shealso may demonstrate seemingly purposeless gestures(stereotypic behavior) and odd facial expressions such asgrimacing. The client may imitate the movements andgestures of someone whom he or she is observing (echopraxia).Rambling speech that may or may not make senseto the listener is likely to accompany these behaviors.Conversely, the client may exhibit psychomotor retardation(a general slowing of all movements). Sometimesthe client may be almost immobile, curled into a ball (fetalposition). Clients with the catatonic type of schizophreniacan exhibit waxy flexibility: they maintain any position inwhich they are placed, even if the position is awkward oruncomfortable.The client may exhibit an unusual speech pattern. Twotypical patterns are word salad (jumbled words and phrasesthat are disconnected or incoherent and make no sense tothe listener) and echolalia (repetition or imitation of whatsomeone else says). Speech may be slowed or acceleratedin rate and volume: the client may speak in whispers orhushed tones or may talk loudly or yell. Latency of responserefers to hesitation before the client responds to questions.This latency or hesitation may last 30 or 45 seconds andusually indicates the client’s difficulty with cognition orthought processes. Box 14.2 lists and gives examples ofthese unusual speech patterns.Mood and AffectClients with schizophrenia report and demonstrate widevariances in mood and affect. They often are described ashaving flat affect (no facial expression) or blunted affect(few observable facial expressions). The typical facialexpression often is described as mask-like. The affect alsomay be described as silly, characterized by giddy laughterfor no apparent reason. The client may exhibit an inappropriateexpression or emotions incongruent with thecontext of the situation. This incongruence ranges frommild or subtle to grossly inappropriate. For example, theclient may laugh and grin while describing the death of afamily member or weep while talking about the weather.The client may report feeling depressed and having nopleasure or joy in life (anhedonia). Conversely, he or shemay report feeling all-knowing, all-powerful, and not at allconcerned with the circumstance or situation. It is morecommon for the client to report exaggerated feelings ofwell-being during episodes of psychotic or delusionalthinking and a lack of energy or pleasurable feelings duringthe chronic, or long-term, phase of the illness.Thought Process and ContentSchizophrenia often is referred to as a thought disorderbecause that is the primary feature of the disease: thoughtprocesses become disordered, and the continuity of thoughtsand information processing is disrupted. The nurse canassess thought process by inferring from what the client says.He or she can assess thought content by evaluating what theclient actually says. For example, clients may suddenly stop

262UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 14.2 UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIAClang associations are ideas that are related to one another based on sound or rhyming rather than meaning.Example: “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill.”Neologisms are words invented by the client.Example: “I’m afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?”Verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener.Example: “I want to go home, go home, go home, go home.”Echolalia is the client’s imitation or repetition of what the nurse says.Example: Nurse: “Can you tell me how you’re feeling?” Client: “Can you tell me how you’re feeling, how you’re feeling?”Stilted language is use of words or phrases that are flowery, excessive, and pompous.Example: “Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just awee bit of refreshment, perhaps in the form of some clear spring water?”Perseveration is the persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, evenwhen another person attempts to change the topic.Example: Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Wheredo you live?” Client: “At my place people have been following me.” Nurse: “What do you like to do in your free time?”Client: “Nothing because people are following me.”Word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to thelistener.Example: “Corn, potatoes, jump up, play games, grass, cupboard.”talking in the middle of a sentence and remain silent forseveral seconds to 1 minute (thought blocking). They alsomay state that they believe others can hear their thoughtsThought broadcasting(thought broadcasting), that others are taking their thoughts(thought withdrawal), or that others are placing thoughts intheir mind against their will (thought insertion).Clients also may exhibit tangential thinking, which isveering onto unrelated topics and never answering theoriginal question:Nurse: “How have you been sleeping lately?”Client: “Oh, I try to sleep at night. I like to listento music to help me sleep. I really like countrywesternmusic best. What do you like? Can I havesomething to eat pretty soon? I’m hungry.”Nurse: “Can you tell me how you’ve been sleeping?Circumstantiality may be evidenced if the client givesunnecessary details or strays from the topic but eventuallyprovides the requested information:Nurse: “How have you been sleeping lately?”Client: “Oh, I go to bed early, so I can getplenty of rest. I like to listen to music or readbefore bed. Right now I’m reading a goodmystery. Maybe I’ll write a mystery someday. Butit isn’t helping, reading I mean. I have been getting only 2 or3 hours of sleep at night.”Poverty of content (alogia) describes the lack of any realmeaning or substance in what the client says:Nurse: “How have you been sleeping lately?”Client: “Well, I guess, I don’t know, hardto tell.”

CHAPTER 14 • SCHIZOPHRENIA 263DelusionsClients with schizophrenia usually experience delusions(fixed, false beliefs with no basis in reality) in the psychoticphase of the illness. A common characteristic ofschizophrenic delusions is the direct, immediate, and totalcertainty with which the client holds these beliefs. Becausethe client believes the delusion, he or she therefore actsaccordingly. For example, the client with delusions of persecutionis probably suspicious, mistrustful, and guardedabout disclosing personal information; he or she mayexamine the room periodically or speak in hushed, secretivetones.The theme or content of the delusions may vary. Box 14.3describes and provides examples of the various types ofdelusions. External contradictory information or facts cannotalter these delusional beliefs. If asked why he or shebelieves such an unlikely idea, the client often replies, “I justknow it.”Initially, the nurse assesses the content and depth of thedelusion to know what behaviors to expect and to try toestablish reality for the client. When eliciting informationabout the client’s delusional beliefs, the nurse must becareful not to support or challenge them. The nurse mightask the client to explain what he or she believes by saying“Please explain that to me” or “Tell me what you’re thinkingabout that.”Delusions of grandeurNursing Care Plan | Client with DelusionsNursing DiagnosisDisturbed Thought Processes: Disruption in cognitive operations and activities.ASSESSMENT DATA• Thinking not based in reality• Disorientation• Labile affect• Short attention span• Impaired judgment• DistractibilityEXPECTED OUTCOMESImmediateThe client will• Be free of injury• Demonstrate decreased anxiety level• Respond to reality-based interactions initiated byothers, for example, verbally interact with staff forspecified time periodStabilizationThe client will• Interact on reality-based topics such as dailyactivities or local events• Sustain attention and concentration to completetasks or activities(continued)

264UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Diagnosis | Client with Delusions, cont.IMPLEMENTATIONCommunityThe client will• Verbalize recognition of delusional thoughts if theypersist• Be free from delusions or demonstrate the ability tofunction without responding to persistent delusionalthoughtsNursing Interventions (* denotes collaborative interventions)Be sincere and honest when communicating with theclient. Avoid vague or evasive remarks.Be consistent in setting expectations, enforcing rules,and so forth.Do not make promises that you cannot keep.Encourage the client to talk with you, but do not pryfor information.Explain procedures, and try to be sure the clientunderstands the procedures before carrying them out.Give positive feedback for the client’s successes.Recognize the client’s delusions as the client’s perceptionof the environment.Initially, do not argue with the client or try to convincethe client that the delusions are false or unreal.Interact with the client on the basis of real things; donot dwell on the delusional material.Engage the client in one-to-one activities at first, thenactivities in small groups, and gradually activities inlarger groups.Recognize and support the client’s accomplishments(projects completed, responsibilities fulfilled, interactionsinitiated).Show empathy regarding the client’s feelings; reassurethe client of your presence and acceptance.Do not be judgmental or belittle or joke about the client’sbeliefs.Never convey to the client that you accept the delusionsas reality.Directly interject doubt regarding delusions as soonas the client seems ready to accept this (e.g., “I findthat hard to believe.”). Do not argue but present afactual account of the situation as you see it.Ask the client if he or she can see that the delusionsinterfere with or cause problems in his or her life.RationaleDelusional clients are extremely sensitive about othersand can recognize insincerity. Evasive comments orhesitation reinforces mistrust or delusions.Clear, consistent limits provide a secure structure forthe client.Broken promises reinforce the client’s mistrust of others.Probing increases the client’s suspicion and interfereswith the therapeutic relationship.When the client has full knowledge of procedures, heor she is less likely to feel tricked by the staff.Positive feedback for genuine success enhances the client’ssense of well-being and helps to make nondelusionalreality a more positive situation for the client.Recognizing the client’s perceptions can help youunderstand the feelings he or she is experiencing.Logical argument does not dispel delusional ideas andcan interfere with the development of trust.Interacting about reality is healthy for the client.A distrustful client can best deal with one person initially.Gradual introduction of others as the clienttolerates is less threatening.Recognizing the client’s accomplishments can lessenanxiety and the need for delusions as a source ofself-esteem.The client’s delusions can be distressing. Empathyconveys your caring, interest, and acceptance of theclient.The client’s delusions and feelings are not funny tohim or her. The client may not understand or mayfeel rejected by attempts at humor.Indicating belief in the delusions reinforces the delusion(and the client’s illness).As the client begins to trust you, he or she maybecome willing to doubt the delusion if you expressyour doubt.Discussion of the problems caused by the delusions isa focus on the present and is reality based.Adapted from Schultz, J. M., & Videbeck, S. L (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.).Philadelphia: Lippincott Williams & Wilkins.

CHAPTER 14 • SCHIZOPHRENIA 265Box 14.3 TYPES OF DELUSIONSPersecutory/paranoid delusions involve the client’s belief that “others” are planning to harm the client or are spying, following,ridiculing, or belittling the client in some way. Sometimes the client cannot define who these “others” are.Examples: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimesthe “persecutor” is the government, FBI, or other powerful organization. Occasionally, specific individuals, even familymembers, may be named as the “persecutor.”Grandiose delusions are characterized by the client’s claim to association with famous people or celebrities, or the client’sbelief that he or she is famous or capable of great feats.Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming tobe the daughter of the president of the United States, or he or she may claim to have found a cure for cancer.Religious delusions often center around the second coming of Christ or another significant religious figure or prophet.These religious delusions appear suddenly as part of the client’s psychosis and are not part of his or her religious faith orthat of others.Examples: Client claims to be the Messiah or some prophet sent from God; believes that God communicates directly to himor her or that he or she has a “special” religious mission in life or special religious powers.Somatic delusions are generally vague and unrealistic beliefs about the client’s health or bodily functions. Factual informationor diagnostic testing does not change these beliefs.Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain.Referential delusions or ideas of reference involve the client’s belief that television broadcasts, music, or newspaper articleshave special meaning for him or her.Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messagesare sent through newspaper articles.Sensorium and Intellectual ProcessesOne hallmark symptom of schizophrenic psychosis ishallucinations (false sensory perceptions, or perceptualexperiences that do not exist in reality). Hallucinationscan involve the five senses and bodily sensations. Theycan be threatening and frightening for the client;less frequently, clients report hallucinations as pleasant.Initially, the client perceives hallucinations as real, butlater in the illness, he or she may recognize them ashallucinations.Hallucinations are distinguished from illusions,which are misperceptions of actual environmental stimuli.For example, while walking through the woods, aperson believes he sees a snake at the side of the path.On closer examination, however, he discovers it is onlya curved stick. Reality or factual information correctedthis illusion. Hallucinations, however, have no suchbasis in reality.The following are the various types of hallucinations(Kirkpatrick & Tek, 2005):• Auditory hallucinations, the most common type, involvehearing sounds, most often voices, talking to or aboutthe client. There may be one or multiple voices; a familiaror unfamiliar person’s voice may be speaking. Commandhallucinations are voices demanding that theclient take action, often to harm self or others, and areconsidered dangerous.• Visual hallucinations involve seeing images that do notexist at all, such as lights or a dead person, or distortionssuch as seeing a frightening monster instead of the nurse.They are the second most common type of hallucination.• Olfactory hallucinations involve smells or odors. Theymay be a specific scent such as urine or feces or a moregeneral scent such as a rotten or rancid odor. In additionto clients with schizophrenia, this type of hallucinationoften occurs with dementia, seizures, or cerebrovascularaccidents.• Tactile hallucinations refer to sensations such as electricityrunning through the body or bugs crawling on theskin. Tactile hallucinations are found most often in clientsundergoing alcohol withdrawal; they rarely occurin clients with schizophrenia.• Gustatory hallucinations involve a taste lingering in themouth or the sense that food tastes like something else.The taste may be metallic or bitter or may be representedas a specific taste.• Cenesthetic hallucinations involve the client’s report thathe or she feels bodily functions that are usually undetectable.Examples would be the sensation of urineforming or impulses being transmitted through thebrain.• Kinesthetic hallucinations occur when the client is motionlessbut reports the sensation of bodily movement.Occasionally, the bodily movement is something unusual,such as floating above the ground.

266UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSDuring episodes of psychosis, clients are commonlydisoriented to time and sometimes place. The most extremeform of disorientation is depersonalization, in which theclient feels detached from her or his behavior. Althoughthe client can state her or his name correctly, she or hefeels as if her or his body belongs to someone else or thather or his spirit is detached from the body.Assessing the intellectual processes of a client withschizophrenia is difficult if he or she is experiencing psychosis.The client usually demonstrates poor intellectualfunctioning as a result of disordered thoughts. Nevertheless,the nurse should not assume that the client haslimited intellectual capacity based on impaired thoughtprocesses. It may be that the client cannot focus, concentrate,or pay adequate attention to demonstrate his or herintellectual abilities accurately. The nurse is more likely toobtain accurate assessments of the client’s intellectual abilitieswhen the client’s thought processes are clearer.Clients often have difficulty with abstract thinking andmay respond in a very literal way to other people and theenvironment. For example, when asked to interpret theproverb, “A stitch in time saves nine,” the client may explainit by saying, “I need to sew up my clothes.” The client maynot understand what is being said and can easily misinterpretinstructions. This can pose serious problems duringmedication administration. For example, the nurse may tellthe client, “It is always important to take all your medications.”The client may misinterpret the nurse’s statement and takethe entire supply of medication at one time.Judgment and InsightJudgment is frequently impaired in the client with schizophrenia.Because judgment is based on the ability to interpretthe environment correctly, it follows that the clientwith disordered thought processes and environmentalmisinterpretations will have great difficulty with judgment.At times, lack of judgment is so severe that clientscannot meet their needs for safety and protection and placethemselves in harm’s way. This difficulty may range fromfailing to wear warm clothing in cold weather to failing toseek medical care even when desperately ill. The clientalso may fail to recognize needs for sleep or food.Insight also can be severely impaired, especially earlyin the illness, when the client, family, and friends do notunderstand what is happening. Over time, some clientscan learn about the illness, anticipate problems, and seekappropriate assistance as needed. However, chronic difficultiesresult in clients who fail to understand schizophreniaas a long-term health problem requiring consistentmanagement.Self-ConceptDeterioration of the concept of self is a major problem inschizophrenia. The phrase loss of ego boundaries describesthe client’s lack of a clear sense of where his or her ownbody, mind, and influence end and where those aspects ofother animate and inanimate objects begin. This lack ofego boundaries is evidenced by depersonalization, derealization(environmental objects become smaller or larger orseem unfamiliar), and ideas of reference. Clients maybelieve they are fused with another person or object, maynot recognize body parts as their own, or may fail to knowwhether they are male or female. These difficulties are thesource of many bizarre behaviors such as public undressingor masturbating, speaking about oneself in the thirdperson, or physically clinging to objects in the environment.Body image distortion also may occur.Roles and RelationshipsSocial isolation is prevalent in clients with schizophrenia,partly as a result of positive signs such as delusions, hallucinations,and loss of ego boundaries. Relating to othersis difficult when one’s self-concept is not clear. Clients alsohave problems with trust and intimacy, which interferewith the ability to establish satisfactory relationships. Lowself-esteem, one of the negative signs of schizophrenia,further complicates the client’s ability to interact with othersand the environment. These clients lack confidence,feel strange or different from other people, and do notbelieve they are worthwhile. The result is avoidance ofother people.The client may experience great frustration in attemptingto fulfill roles in the family and community. Success inschool or at work can be severely compromised becausethe client has difficulty thinking clearly, remembering,paying attention, and concentrating. Subsequently, he orshe lacks motivation. Clients who develop schizophreniaat young ages have more difficulties than those whose illnessdeveloped later in life because they did not have theopportunity to succeed in these areas before the illness.Fulfilling family roles, such as that of son or daughteror sibling, is difficult for these clients. Often, their erraticor unpredictable behavior frightens or embarrasses familymembers, who become unsure what to expect next. Familiesalso may feel guilty or responsible, believing theysomehow failed to provide a loving supportive home life.These clients also may believe they have disappointedtheir families because they cannot become independent orsuccessful.Physiologic and Self-Care ConsiderationsClients with schizophrenia may have significant self-caredeficits. Inattention to hygiene and grooming needs iscommon, especially during psychotic episodes. The clientcan become so preoccupied with delusions or hallucinationsthat he or she fails to perform even basic activities ofdaily living.Clients also may fail to recognize sensations such ashunger or thirst, and food or fluid intake may be inadequate.This can result in malnourishment and constipation. Constipationis also a common side effect of antipsychoticmedications, compounding the problem. Paranoia or

CHAPTER 14 • SCHIZOPHRENIA 267Self-care deficitsexcessive fears that food and fluids have been poisoned arecommon and may interfere with eating. If the client is agitatedand pacing, he or she may be unable to sit down longenough to eat.Occasionally, clients develop polydipsia (excessivewater intake), which leads to water intoxication. Serumsodium levels can become dangerously low, leading toseizures. Polydipsia usually is seen in clients who havehad severe and persistent mental illness for many years aswell as long-term therapy with antipsychotic medications.It may be caused by the behavioral state itself or may beprecipitated by the use of antidepressant or antipsychoticmedications (Dundas, Harris, & Narasimhan, 2007).Sleep problems are common. Hallucinations may stimulateclients, resulting in insomnia. Other times, clients aresuspicious and believe harm will come to them if theysleep. As in other self-care areas, the client may notcorrectly perceive or acknowledge physical cues such asfatigue.To assist the client with community living, the nurseassesses daily living skills and functional abilities. Suchskills—having a bank account and paying bills, buying foodand preparing meals, and using public transportation—areoften difficult tasks for the client with schizophrenia. He orshe might never have learned such skills or may be unableto accomplish them consistently.Data AnalysisThe nurse must analyze assessment data for clients withschizophrenia to determine priorities and establish an effectiveplan of care. Not all clients have the same problems andneeds, nor is it likely that any individual client has all theproblems that can accompany schizophrenia. Levels of familyand community support and available services also vary,all of which influence the client’s care and outcomes.The analysis of assessment data generally falls into twomain categories: data associated with the positive signs ofthe disease and data associated with the negative signs.The North American Nursing Diagnosis Association’snursing diagnoses commonly established based on theassessment of psychotic symptoms or positive signs are asfollows:• Risk for Other-Directed Violence• Risk for Suicide• Disturbed Thought Processes• Disturbed Sensory Perception• Disturbed Personal Identity• Impaired Verbal CommunicationThe North American Nursing Diagnosis Association’snursing diagnoses based on the assessment of negativesigns and functional abilities include the following:• Self-Care Deficits• Social Isolation• Deficient Diversional Activity• Ineffective Health Maintenance• Ineffective Therapeutic Regimen ManagementOutcome IdentificationIt is likely that the client with an acute psychotic episodeof schizophrenia will receive treatment in an intensive settingsuch as an inpatient hospital unit. During this phase,the focus of care is stabilizing the client’s thought processesand reality orientation as well as ensuring safety. This isalso the time to evaluate resources, make referrals, andbegin planning for the client’s rehabilitation and return tothe community.Examples of outcomes appropriate to the acute, psychoticphase of treatment are as follows:1. The client will not injure self or others.2. The client will establish contact with reality.3. The client will interact with others in the environment.4. The client will express thoughts and feelings in a safeand socially acceptable manner.5. The client will participate in prescribed therapeuticinterventions.Once the crisis or the acute, psychotic symptoms havebeen stabilized, the focus is on developing the client’s abilityto live as independently and successfully as possible in

268UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSthe community. This usually requires continued follow-upcare and participation of the client’s family in communitysupport services. Prevention and early recognition andtreatment of relapse symptoms are important parts of successfulrehabilitation. Dealing with the negative signs ofschizophrenia, which medication generally does not affect,is a major challenge for the client and caregivers. Examplesof treatment outcomes for continued care after thestabilization of acute symptoms are as follows:1. The client will participate in the prescribed regimen(including medications and follow-up appointments).2. The client will maintain adequate routines for sleepingand food and fluid intake.3. The client will demonstrate independence in self-careactivities.4. The client will communicate effectively with others inthe community to meet his or her needs.5. The client will seek or accept assistance to meet his orher needs when indicated.The nurse must appreciate the severity of schizophreniaand the profound and sometimes devastating effects it hason the lives of clients and their families. It is equally importantto avoid treating the client as a “hopeless case,” someonewho no longer is capable of having a meaningful andsatisfying life. It is not helpful to expect either too much ortoo little from the client. Careful ongoing assessment isnecessary so that appropriate treatment and interventionsaddress the client’s needs and difficulties while helping theclient to reach his or her optimal level of functioning.InterventionPromoting the Safety of Client and OthersSafety for both the client and the nurse is the priority whenproviding care for the client with schizophrenia. The clientmay be paranoid and suspicious of the nurse and theenvironment and may feel threatened and intimidated.Although the client’s behavior may be threatening to thenurse, the client also is feeling unsafe and may believe hisor her well-being to be in jeopardy. Therefore, the nursemust approach the client in a nonthreatening manner.Making demands or being authoritative only increasesthe client’s fears. Giving the client ample personal spaceusually enhances his or her sense of security.A fearful or agitated client has the potential to harm self orothers. The nurse must observe for signs of building agitationor escalating behavior such as increased intensity of pacing,loud talking or yelling, and hitting or kicking objects. Thenurse must institute interventions to protect the client, nurse,and others in the environment. This may involve administeringmedication; moving the client to a quiet, less stimulatingenvironment; and, in extreme situations, temporarily usingseclusion or restraints. See Chapter 10 for a discussion ofhow to deal with anger and hostility and Chapter 15 for howto deal with clients who are suicidal.NURSING INTERVENTIONSfor Clients with Schizophrenia• Promoting safety of client and others and right toprivacy and dignity• Establishing therapeutic relationship by establishingtrust• Using therapeutic communication (clarifying feelingsand statements when speech and thoughts aredisorganized or confused)• Interventions for delusions:Do not openly confront the delusion or argue withthe client.Establish and maintain reality for the client.Use distracting techniques.Teach the client positive self-talk, positive thinking,and to ignore delusional beliefs.• Interventions for hallucinations:Help present and maintain reality by frequent contactand communication with client.Elicit description of hallucination to protect clientand others. The nurse’s understanding of thehallucination helps him or her know how to calmor reassure the client.Engage client in reality-based activities such as cardplaying, occupational therapy, or listening to music.• Coping with socially inappropriate behaviors:Redirect client away from problem situations.Deal with inappropriate behaviors in a nonjudgmentaland matter-of-fact manner; give factual statements;do not scold.Reassure others that the client’s inappropriatebehaviors or comments are not his or her fault(without violating client confidentiality).Try to reintegrate the client into the treatment milieuas soon as possible.Do not make the client feel punished or shunned forinappropriate behaviors.Teach social skills through education, role modeling,and practice.• Client and family teaching• Establishing community support systems and careEstablishing a Therapeutic RelationshipEstablishing trust between the client and the nurse alsohelps to allay the fears of a frightened client. Initially, theclient may tolerate only 5 or 10 minutes of contact at onetime. Establishing a therapeutic relationship takes time,and the nurse must be patient. The nurse provides explanationsthat are clear, direct, and easy to understand. Bodylanguage should include eye contact but not staring, arelaxed body posture, and facial expressions that conveygenuine interest and concern. Telling the client one’s name

CHAPTER 14 • SCHIZOPHRENIA 269and calling the client by name are helpful in establishingtrust as well as reality orientation.The nurse must assess carefully the client’s response tothe use of touch. Sometimes gentle touch conveys caringand concern. At other times, the client may misinterpretthe nurse’s touch as threatening and therefore undesirable.As the nurse sits near the client, does he or she move orlook away? Is the client frightened or wary of the nurse’spresence? If so, that client may not be reassured by touchbut frightened or threatened by it.Using Therapeutic CommunicationCommunicating with clients experiencing psychoticsymptoms can be difficult and frustrating. The nurse triesto understand and make sense of what the client is saying,but this can be difficult if the client is hallucinating, withdrawnfrom reality, or relatively mute. The nurse mustmaintain nonverbal communication with the client, especiallywhen verbal communication is not very successful.This involves spending time with the client, perhapsthrough fairly lengthy periods of silence. The presence ofthe nurse is a contact with reality for the client and alsocan demonstrate the nurse’s genuine interest and caringto the client. Calling the client by name, making referencesto the day and time, and commenting on the environmentare all helpful ways to continue to make contact with a clientwho is having problems with reality orientation andverbal communication. Clients who are left alone for longperiods become more deeply involved in their psychosis,so frequent contact and time spent with a client are importanteven if the nurse is unsure that the client is aware ofthe nurse’s presence.Active listening is an important skill for the nurse tryingto communicate with a client whose verbalizations aredisorganized or nonsensical. Rather than dismissing whatthe client says because it is not clear, the nurse must makeefforts to determine the meaning the client is trying toconvey. Listening for themes or recurrent statements, askingclarifying questions, and exploring the meaning of theclient’s statements are all useful techniques to increaseunderstanding.The nurse must let the client know when his or hermeaning is not clear. It is never useful to pretend to understandor just to agree or go along with what the client issaying: this is dishonest and violates trust between clientand nurse.Nurse: “How are you feeling today?” (using abroad opening statement)Client: “Invisible.”Nurse: “Can you explain that to me?” (seekingclarification)Client: “Oh, it doesn’t matter.”Nurse: “I’m interested in how you feel; I’m just not sure Iunderstand.” (offering self/seeking clarification)Client: “It doesn’t mean much.”Nurse: “Let me see if I can understand. Do you feel likeyou’re being ignored, that no one is really listening?” (verbalizingthe implied)Implementing Interventionsfor Delusional ThoughtsThe client experiencing delusions utterly believes themand cannot be convinced they are false or untrue. Suchdelusions powerfully influence the client’s behavior. Forexample, if the client’s delusion is that he or she is beingpoisoned, he or she will be suspicious, mistrustful, andprobably resistant to providing information and takingmedications.The nurse must avoid openly confronting the delusionor arguing with the client about it. The nurse also mustavoid reinforcing the delusional belief by “playing along”with what the client says. It is the nurse’s responsibility topresent and maintain reality by making simple statementssuch as“I have seen no evidence of that.” (presentingreality)or“It doesn’t seem that way to me.” (castingdoubt)As antipsychotic medications begin to have a therapeuticeffect, it will be possible for the nurse to discuss the delusionalideas with the client and identify ways in which thedelusions interfere with the client’s daily life.The nurse also can help the client minimize the effectsof delusional thinking. Distraction techniques, such as listeningto music, watching television, writing, or talking tofriends, are useful. Direct action, such as engaging in positiveself-talk and positive thinking and ignoring the delusionalthoughts, may be beneficial as well.Implementing Interventions for HallucinationsIntervening when the client experiences hallucinationsrequires the nurse to focus on what is real and to help shiftthe client’s response toward reality. Initially, the nurse mustdetermine what the client is experiencing—that is, whatthe voices are saying or what the client is seeing. Doing soincreases the nurse’s understanding of the nature of theclient’s feelings and behavior. In command hallucinations,the client hears voices directing him or her to do something,often to hurt self or someone else. For this reason,the nurse must elicit a description of the content of thehallucination so that health-care personnel can take precautionsto protect the client and others as necessary. Thenurse might say,“I don’t hear any voices; what are you hearing?”(presenting reality/seeking clarification)This also can help the nurse understandhow to relieve the client’s fears or paranoia.

270UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSFor example, the client might be seeing ghosts or monsterlikeimages, and the nurse could respond,“I don’t see anything, but you must be frightened.You are safe here in the hospital.” (presentingreality/translating into feelings)This acknowledges the client’s fear but reassuresthe client that no harm will come to him or her.Clients do not always report or identify hallucinations.At times, the nurse must infer from the client’s behaviorthat hallucinations are occurring. Examples of behaviorthat indicate hallucinations include alternately listeningand then talking when no one else is present, laughinginappropriately for no observable reason, and mumbling ormouthing words with no audible sound.A helpful strategy for intervening with hallucinations isto engage the client in a reality-based activity such as playingcards, participating in occupational therapy, or listeningto music. It is difficult for the client to pay attention tohallucinations and reality-based activity at the same time,so this technique of distracting the client is often useful.It also may be useful to work with the client to identifycertain situations or a particular frame of mind that mayprecede or trigger auditory hallucinations. Intensity ofhallucinations often is related to anxiety levels; therefore,monitoring and intervening to lower a client’s anxiety maydecrease the intensity of hallucinations. Clients who recognizethat certain moods or patterns of thinking precedethe onset of voices may eventually be able to manage orcontrol the hallucinations by learning to manage or avoidparticular states of mind. This may involve learning torelax when voices occur, engaging in diversions, correctingnegative self-talk, and seeking out or avoiding socialinteraction.Teaching the client to talk back to the voices forcefullyalso may help him or her manage auditory hallucinations.The client should do this in a relatively private place ratherthan in public. There is an international self-help movementof “voice-hearer groups,” developed to assist peopleto manage auditory hallucinations. One group devised thestrategy of carrying a cell phone (fake or real) to cope withvoices when in public places. With cell phones, memberscan carry on conversations with their voices in the street—and tell them to shut up—while avoiding ridicule by lookinglike a normal part of the street scene. Being able toverbalize resistance can help the client feel empoweredand capable of dealing with the hallucinations (Farhall,Greenwood, & Jackson, 2007).Clients can also benefit from openly discussing thevoice-hearing experience with designated others. Talkingwith other clients who have similar experiences with auditoryhallucinations has proved helpful (McLeod, Morris,Birchwood, & Dovey, 2007), so the client doesn’t feel soisolated and alone with the hallucination experience. Someclients wanted to discuss the hallucinations with theircommunity mental health nurse (Coffey & Hewitt, 2008)to better understand the hallucinations and what theymight mean.Coping with Socially Inappropriate BehaviorsClients with schizophrenia often experience a loss of egoboundaries, which poses difficulties for themselves andothers in their environment and community. Potentiallybizarre or strange behaviors include touching others withoutwarning or invitation, intruding into others’ livingspaces, talking to or caressing inanimate objects, andengaging in such socially inappropriate behaviors asundressing, masturbating, or urinating in public. Clientsmay approach others and make provocative, insulting, orsexual statements. The nurse must consider the needs ofothers as well as the needs of clients in these situations.Protecting the client is a primary nursing responsibilityand includes protecting the client from retaliation by otherswho experience the client’s intrusions and sociallyunacceptable behavior. Redirecting the client away fromsituations or others can interrupt the undesirable behaviorand keep the client from further intrusive behaviors. Thenurse also must try to protect the client’s right to privacyand dignity. Taking the client to his or her room or to aquiet area with less stimulation and fewer people oftenhelps. Engaging the client in appropriate activities also isindicated. For example, if the client is undressing in frontof others, the nurse might say,“Let’s go to your room and you can put yourclothes back on.” (encouraging collaboration/redirecting to appropriate activity)If the client is making verbal statements toothers, the nurse might ask the client to go for awalk or move to another area to listen to music. The nurseshould deal with socially inappropriate behavior nonjudgmentallyand matter-of-factly. This means making factualstatements with no overtones of scolding and not talkingto the client as if he or she were a naughty child.Some behaviors may be so offensive or threatening thatothers respond by yelling at, ridiculing, or even takingaggressive action against the client. Although providingphysical protection for the client is the nurse’s first consideration,helping others affected by the client’s behavior alsois important. Usually, the nurse can offer simple and factualstatements to others that do not violate the client’s confidentiality.The nurse might make statements, such as“You didn’t do anything to provoke that behavior.Sometimes people’s illnesses cause them to actin strange and uncomfortable ways. It is importantnot to laugh at behaviors that are partof someone’s illness.” (presenting reality/givinginformation)The nurse reassures the client’s family that these behaviorsare part of the client’s illness and not personallydirected at them. Such situations present an opportunity

CHAPTER 14 • SCHIZOPHRENIA 271to educate family members about schizophrenia and to helpallay their feelings of guilt, shame, or responsibility.Reintegrating the client into the treatment milieu assoon as possible is essential. The client should not feelshunned or punished for inappropriate behavior. Healthcarepersonnel should introduce limited stimulation gradually.For example, when the client is comfortable anddemonstrating appropriate behavior with the nurse, one ortwo other people can be engaged in a somewhat structuredactivity with the client. The client’s involvement is graduallyincreased to small groups and then to larger, less structuredgroups as he or she can tolerate the increased level ofstimulation without decompensating (regressing to previous,less effective coping behaviors).Teaching Client and FamilyCoping with schizophrenia is a major adjustment for boththe clients and their families. Understanding the illness,the need for continuing medication and follow-up, and theuncertainty of the prognosis or recovery are key issues.Clients and families need help to cope with the emotionalupheaval that schizophrenia causes. See Client/FamilyEducation for Schizophrenia for education points.Identifying and managing one’s own health needs areprimary concerns for everyone, but this is a particularchallenge for clients with schizophrenia because theirhealth needs can be complex and their ability to managethem may be impaired. The nurse helps the client to managehis or her illness and health needs as independently aspossible. This can be accomplished only through educationand ongoing support.Teaching the client and family members to prevent ormanage relapse is an essential part of a comprehensiveCLIENT / FAMILY EDUCATIONfor Schizophrenia• How to manage illness and symptoms• Recognizing early signs of relapse• Developing a plan to address relapse signs• Importance of maintaining prescribed medicationregimen and regular follow-up• Avoiding alcohol and other drugs• Self-care and proper nutrition• Teaching social skills through education, role modeling,and practice• Seeking assistance to avoid or manage stressfulsituations• Counseling and educating family/significant othersabout the biologic causes and clinical course ofschizophrenia and the need for ongoing support• Importance of maintaining contact with community andparticipating in supportive organizations and careBox 14.4 EARLY SIGNS OF RELAPSE• Impaired cause-and-effect reasoning• Impaired information processing• Poor nutrition• Lack of sleep• Lack of exercise• Fatigue• Poor social skills, social isolation, loneliness• Interpersonal difficulties• Lack of control, irritability• Mood swings• Ineffective medication management• Low self-concept• Looks and acts different• Hopeless feelings• Loss of motivation• Anxiety and worry• Disinhibition• Increased negativity• Neglecting appearance• Forgetfulnessplan of care. This includes providing facts about schizophrenia,identifying the early signs of relapse, and teachinghealth practices to promote physical and psychologicalwell-being. Early identification of these relapse signs(Box 14.4) has been found to reduce the frequency ofrelapse; when relapse cannot be prevented, early identificationprovides the foundation for interventions to managethe relapse. For example, if the nurse finds that theclient is fatigued or lacks adequate sleep or proper nutrition,interventions to promote rest and nutrition may preventa relapse or minimize its intensity and duration.The nurse can use the list of relapse risk factors in severalways. He or she can include these risk factors in dischargeteaching before the client leaves the inpatient settingso that the client and family know what to watch forand when to seek assistance. The nurse also can use thelist when assessing the client in an outpatient or clinic settingor when working with clients in a community supportprogram. The nurse also can provide teaching to ancillarypersonnel who may work with the client so they knowwhen to contact a mental health professional. Taking medicationsas prescribed, keeping regular follow-up appointments,and avoiding alcohol and other drugs have beenassociated with fewer and shorter hospital stays. In addition,clients who can identify and avoid stressful situationsare less likely to suffer frequent relapses. Using a list ofrelapse risk factors is one way to assess the client’s progressin the community.

272UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSFamilies experience a wide variety of responses to theillness of their loved one. Some family members might beashamed or embarrassed or frightened of the client’sstrange or threatening behaviors. They worry about arelapse. They may feel guilty for having these feelings orfear for their own mental health or well-being. If the clientexperiences repeated and profound problems with schizophrenia,the family members may become emotionallyexhausted or even alienated from the client, feeling theycan no longer deal with the situation. Family membersneed ongoing support and education, including reassurancethat they are not the cause of schizophrenia. Participatingin organizations such as the Alliance for the MentallyIll may help families with their ongoing needs.Teaching Self-Care and Proper Nutrition. Because of apathyor lack of energy over the course of the illness, poor personalhygiene can be a problem for clients who are experiencingpsychotic symptoms as well as for all clients withschizophrenia. When the client is psychotic, he or she maypay little attention to hygiene or may be unable to sustainthe attention or concentration required to completegrooming tasks. The nurse may need to direct the clientthrough the necessary steps for bathing, shampooing,dressing, and so forth. The nurse gives directions in short,clear statements to enhance the client’s ability to completethe tasks. The nurse allows ample time for grooming andperforming hygiene and does not attempt to rush or hurrythe client. In this way, the nurse encourages the client tobecome more independent as soon as possible—that is,when he or she is better oriented to reality and betterable to sustain the concentration and attention needed forthese tasks.If the client has deficits in hygiene and grooming resultingfrom apathy or lack of energy for tasks, the nurse mayvary the approach used to promote the client’s independencein these areas. The client is most likely to performtasks of hygiene and grooming if they become a part of hisor her daily routine. The client who has an establishedstructure that incorporates his or her preferences has agreater chance for success than the client who waits todecide about hygiene tasks or performs them randomly.For example, the client may prefer to shower and shampooon Monday, Wednesday, and Friday upon getting upin the morning. This nurse can assist the client to incorporatethis plan into the client’s daily routine, which leads toit becoming a habit. The client thus avoids making dailydecisions about whether or not to shower or whether he orshe feels like showering on a particular day.Adequate nutrition and fluids are essential to the client’sphysical and emotional well-being. Careful assessmentof the client’s eating patterns and preferences allowsthe nurse to determine whether the client needs assistancein these areas. As with any type of self-care deficit, thenurse provides assistance as long as needed and then graduallypromotes the client’s independence as soon as theclient is capable.When the client is in the community, factors other thanthe client’s illness may contribute to inadequate nutritionalintake. Examples include lack of money to buy food, lackof knowledge about a nutritious diet, inadequate transportation,or limited abilities to prepare food. A thoroughassessment of the client’s functional abilities for communityliving helps the nurse to plan appropriate interventions.See the section “Community-Based Care.”Teaching Social Skills. Clients may be isolated from othersfor a variety of reasons. The bizarre behavior or statementsof the client who is delusional or hallucinating mayfrighten or embarrass family or community members. Clientswho are suspicious or mistrustful may avoid contactwith others. Other times, clients may lack the social orconversation skills they need to make and maintain relationshipswith others. Also, a stigma remains attached tomental illness, particularly for clients for whom medicationfails to relieve the positive signs of the illness.The nurse can help the client develop social skillsthrough education, role modeling, and practice. The clientmay not discriminate between the topics suitable for sharingwith the nurse and those suitable for using to initiate aconversation on a bus. The nurse can help the client learnneutral social topics appropriate to any conversation, suchas the weather or local events. The client also can benefitfrom learning that he or she should share certain details ofhis or her illness, such as the content of delusions or hallucinations,only with a health-care provider.Modeling and practicing social skills with the client canhelp him or her experience greater success in social interactions.Specific skills such as eye contact, attentive listening,and taking turns talking can increase the client’sabilities and confidence in socializing.Medication Management. Maintaining the medicationregimen is vital to a successful outcome for clients withschizophrenia. Failing to take medications as prescribed isone of the most frequent reasons for recurrence ofpsychotic symptoms and hospital admission (Kane &Marder, 2005). Clients who respond well to and maintainan antipsychotic medication regimen may lead relativelynormal lives with only an occasional relapse. Those whodo not respond well to antipsychotic agents may face alifetime of dealing with delusional ideas and hallucinations,negative signs, and marked impairment. Many clientsfind themselves somewhere between these twoextremes. See Client Education for Medication Management:Antipsychotics.There are many reasons why clients may not maintainthe medication regimen. The nurse must determine thebarriers to compliance for each client. Sometimes clientsintend to take their medications as prescribed but havedifficulty remembering when and if they did so. They mayfind it difficult to adhere to a routine schedule for medications.Several methods are available to help clients rememberwhen to take medications. One is using a pillbox withcompartments for days of the week and times of the day.

CHAPTER 14 • SCHIZOPHRENIA 273CLIENT / FAMILY EDUCATIONfor Medication Management: Antipsychotics• Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth.• Avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little torelieve dry mouth.• Constipation can be prevented or relieved by increasing intake of water and bulk-forming foods in the diet and byexercising.• Stool softeners are permissible, but laxatives should be avoided.• Use sunscreen to prevent burning. Avoid long periods of time in the sun, and wear protective clothing. Photosensitivity cancause you to burn easily.• Rising slowly from a lying or sitting position prevents falls from orthostatic hypotension or dizziness due to a drop in bloodpressure. Wait until any dizziness has subsided before you walk.• Monitor the amount of sleepiness or drowsiness you experience. Avoid driving a car or performing other potentiallydangerous activities until your response time and reflexes seem normal.• If you forget a dose of antipsychotic medication, take it if the dose is only 3 to 4 hours late. If the missed dose is more than4 hours late or the next dose is due, omit the forgotten dose.• If you have difficulty remembering your medication, use a chart to record doses when taken, or use a pillbox labeled withdosage times and/or days of the week to help you remember when to take medication.After the box has been filled, perhaps with assistance fromthe nurse or case manager, the client often has no moredifficulties. It is also helpful to make a chart of all administrationtimes so that the client can cross off each time heor she has taken the medications.Clients may have practical barriers to medication compliance,such as inadequate funds to obtain expensivemedications, lack of transportation or knowledge abouthow to obtain refills for prescriptions, or inability to planahead to get new prescriptions before current supplies runout. Clients usually can overcome all these obstacles oncethey have been identified.Sometimes clients decide to decrease or discontinuetheir medications because of uncomfortable or embarrassingside effects. Unwanted side effects are frequentlyreported as the reason clients stop taking medications(Kane & Marder, 2005). Interventions, such as eating aproper diet and drinking enough fluids, using a stool softenerto avoid constipation, sucking on hard candy to minimizedry mouth, or using sunscreen to avoid sunburn, canhelp to control some of these uncomfortable side effects(see Table 13.2). Some side effects, such as dry mouth andblurred vision, improve with time or with lower doses ofmedication. Medication may be warranted to combat commonneurologic side effects such as EPS or akathisia.Some side effects, such as those affecting sexual functioning,are embarrassing for the client to report, and theclient may confirm these side effects only if the nursedirectly inquires about them. This may require a call to theclient’s physician or primary provider to obtain a prescriptionfor a different type of antipsychotic.Sometimes a client discontinues medications because he orshe dislikes taking them or believes he or she does not needthem. The client may have been willing to take the medicationswhen experiencing psychotic symptoms but may believethat medication is unnecessary when he or she feels well. Byrefusing to take the medications, the client may be denyingthe existence or severity of schizophrenia. These issues ofnoncompliance are much more difficult to resolve. The nursecan teach the client about schizophrenia, the nature of chronicillness, and the importance of medications in managing symptomsand preventing recurrence. For example, the nurse couldsay, “This medication helps you think more clearly” or “Takingthis medication will make it less likely that you’ll heartroubling voices in your mind again.”Even after education, some clients continue to refuse totake medication; they may understand the connection betweenmedication and prevention of relapse only after experiencinga return of psychotic symptoms. A few clients still do notunderstand the importance of consistently taking medicationand, even after numerous relapses, continue to experiencepsychosis and hospital admission fairly frequently.EvaluationThe nurse must consider evaluation of the plan of care inthe context of each client and family. Ongoing assessmentprovides data to determine whether the client’s individualoutcomes were achieved. The client’s perception of thesuccess of treatment also plays a part in evaluation. Evenif all outcomes are achieved, the nurse must ask if the clientis comfortable or satisfied with the quality of life.

274UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSIn a global sense, evaluation of the treatment of schizophreniais based on the following:• Have the client’s psychotic symptoms disappeared? Ifnot, can the client carry out his or her daily life despitethe persistence of some psychotic symptoms?• Does the client understand the prescribed medicationregimen? Is he or she committed to adherence to theregimen?• Does the client possess the necessary functional abilitiesfor community living?• Are community resources adequate to help the clientlive successfully in the community?• Is there a sufficient after-care or crisis plan in place todeal with recurrence of symptoms or difficulties encounteredin the community?• Are the client and family adequately knowledgeableabout schizophrenia?• Does the client believe that he or she has a satisfactoryquality of life?ELDER CONSIDERATIONSLate-onset schizophrenia refers to development of the diseaseafter age 45; schizophrenia is not initially diagnosedin elder clients. Psychotic symptoms that appear in laterlife are usually associated with depression or dementia,not schizophrenia. People with schizophrenia do surviveinto old age, with a variety of long-term outcomes. Approximatelyone fourth of the clients experienced dementia,resulting in a steady, deteriorating decline in health;another 25% actually have a reduction in positive symptoms,somewhat like a remission; and schizophreniaremains mostly unchanged in the remaining clients(Sakauye, 2008).COMMUNITY-BASED CAREClients with schizophrenia are no longer hospitalized forlong periods. Most return to live in the community withassistance provided by family and support services. Clientsmay live with family members, independently, or in aresidential program such as a group home where they canreceive needed services without being admitted to thehospital. Assertive community treatment programs haveshown success in reducing the rate of hospital admissionsby managing symptoms and medications; assisting clientswith social, recreational, and vocational needs; and providingsupport to clients and their families. The psychiatricnurse is a member of the multidisciplinary team thatworks with clients in assertive community treatment programs,focusing on the management of medications andtheir side effects and the promotion of health and wellness.Behavioral home health care also is expanding, withnurses providing care to persons with schizophrenia (aswell as other mental illnesses) using the holistic approachto integrate clients into the community. Although muchhas been done to give these clients the support they needto live in the community, there is still a need to increaseservices to homeless persons and those in prison withschizophrenia.Community support programs often are an importantlink in helping persons with schizophrenia and theirfamilies. A case manager may be assigned to the client toprovide assistance in handling the wide variety of challengesthat the client in community settings faces. Theclient who has had schizophrenia for some time mayhave a case manager in the community. Other clients mayneed assistance to obtain a case manager. Depending onthe type of funding and agencies available in a particularcommunity, the nurse may refer the client to a socialworker or may directly refer the client to case managementservices.Case management services often include helping theclient with housing and transportation, money management,and keeping appointments as well as with socializationand recreation. Frequent face-to-face and telephonecontact with clients in the community helps address clients’immediate concerns and avoid relapse and rehospitalization.Common concerns of clients include difficultieswith treatment and after-care, dealing with psychiatricsymptoms, environmental stresses, and financial issues.Although the support of professionals in the community isvital, the nurse must not overlook the client’s need forautonomy and potential abilities to manage his or her ownhealth.MENTAL HEALTH PROMOTIONPsychiatric rehabilitation has the goal of recovery for clientswith major mental illness that goes beyond symptomcontrol and medication management (see Chapter 4).Working with clients to manage their own lives, makeeffective treatment decisions, and have an improved qualityof life—from the client’s point of view—are centralcomponents of such programs. Mental health promotioninvolves strengthening the client’s ability to bounce backfrom adversity and to manage the inevitable obstaclesencountered in life. Strategies include fostering selfefficacyand empowering the client to have control overhis or her life; improving the client’s resiliency, or ability tobounce back emotionally from stressful events; andimproving the client’s ability to cope with the problems,stress, and strains of everyday living. See Chapter 7 for afull discussion of resiliency and self-efficacy.Early intervention in schizophrenia is an emerging goalof research investigating the earliest signs of the illnessthat occur predominately in adolescence and young adulthood(Borgmann-Winter, Calkins, Kniele, & Gur, 2006).Accurate identification of individuals at greatest risk isthe key to early intervention. Initiatives of early detection,

CHAPTER 14 • SCHIZOPHRENIA 275intervention, and prevention of psychosis have beenestablished to work with primary care providers to recognizeprodromal signs that are predictive of later psychoticepisodes, such as sleep difficulties, change in appetite, lossof energy and interest, odd speech, hearing voices, peculiarbehavior, inappropriate expression of feelings, paucityof speech, ideas of reference, and feelings of unreality.After these high-risk individuals are identified, individualizedintervention is implemented that may include education,stress management, or neuroleptic medication or acombination of these. Treatment also includes familyinvolvement, individual and vocational counseling, andcoping strategies to enhance self-mastery. Interventionsare intensive, using home visits and daily sessions ifneeded.Studies in Switzerland (Simon et al., 2006) focusedon identifying at-risk individuals demonstrating a coredeficit of prodromal symptoms, including cognitiveimpairment, affective symptoms, social isolation, and adecline in social functioning. In Germany, comprehensivecognitive–behavioral therapy has been developedfor patients in the early initial prodromal phase, whereasthose in the late initial prodromal phase receive lowdoseantipsychotic medication along with cognitive–behavioral therapy (Bechdolf, Ruhrmann, & Wagner,2006b; Hafner & Maurer, 2006). These early interventionsimplemented in Germany, Australia, and the UnitedKingdom have resulted in improvement of prodromalsymptoms, prevention of social stagnation or decline,and prevention or delay of progression to psychosis(Bechdolf, Phillips, & Francey, 2006a).SELF-AWARENESS ISSUESWorking with clients with schizophrenia canpresent many challenges for the nurse. Clientshave many experiences that are difficultfor the nurse to relate to, such as delusionsand hallucinations. Suspicious or paranoid behavior onthe client’s part may make the nurse feel as though he orshe is not trustworthy or that his or her integrity is beingquestioned. The nurse must recognize this type of behavioras part of the illness and not interpret or respond to itas a personal affront. Taking the client’s statements orbehavior as a personal accusation only causes the nurse torespond defensively, which is counterproductive to theestablishment of a therapeutic relationship.The nurse also may be genuinely frightened or threatenedif the client’s behavior is hostile or aggressive. Thenurse must acknowledge these feelings and take measuresto ensure his or her safety. This may involve talking to theclient in an open area rather than in a more isolated locationor having an additional staff person present ratherthan being alone with the client. If the nurse pretends tobe unafraid, the client may sense the fear anyway and feelless secure, leading to a greater potential for the client tolose personal control.As with many chronic illnesses, the nurse may becomefrustrated if the client does not follow the medication regimen,fails to keep needed appointments, or experiencesrepeated relapses. The nurse may feel as though a greatdeal of hard work has been wasted or that the situation isfutile or hopeless. Schizophrenia is a chronic illness, andclients may suffer numerous relapses and hospital admissions.The nurse must not take responsibility for the successor failure of treatment efforts or view the client’s status asa personal success or failure. Nurses should look to theircolleagues for helpful support and discussion of theseself-awareness issues.Points to Consider When Working withClients with Schizophrenia• Remember that although these clients often suffer numerousrelapses and return for repeated hospital stays,they do return to living and functioning in the community.Focusing on the amount of time the client is outsidethe hospital setting may help decrease the frustrationthat can result when working with clients with a chronicillness.• Visualize the client not at his or her worst but as he orshe gets better and symptoms become less severe.• Remember that the client’s remarks are not directed atyou personally but are a byproduct of the disorderedand confused thinking that schizophrenia causes.• Discuss these issues with a more experienced nurse forsuggestions on how to deal with your feelings and actionstoward these clients. You are not expected to haveall the answers.Critical Thinking Questions1. Clients who fail to take medications regularly areoften admitted to the hospital repeatedly, and thiscan become quite expensive. How do you reconcilethe client’s rights (to refuse treatment or medications)with the need to curtail avoidable healthcarecosts?2. What is the quality of life for the client with schizophreniawho has a minimal response to antipsychoticmedications and therefore poor treatmentoutcomes?3. If a client with schizophrenia who experiences frequentrelapses has a young child, should the childremain with the parent? What factors influence thisdecision? Who should be able to make such adecision?

276UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSINTERNET RESOURCESRESOURCES• National Alliance for the Mentally III• National Schizophrenia Foundation• Schizophrenia• Schizophrenia Information and Support• Schizophrenia National Mental Health InformationCenter• Schizophrenia Society of Canada• Schizophrenics AnonymousINTERNET ADDRESShttp://www.nami.orghttp://www.nsfoundation.orghttp://imh.nih.gov/health/topics/schizophrenia/index.shtmlhttp://www.schizophrenia.comhttp:mentalhealth.samhsa.gov/publications/allpubs/ken98-0052/default.asphttp://www.schizophrenia.cahttp://sanonymousKEY POINTS• Schizophrenia is a chronic illness requiringlong-term management strategies and copingskills. It is a disease of the brain, a clinicalsyndrome that involves a person’sthoughts, perceptions, emotions, movements, andbehaviors.• The effects of schizophrenia on the client may be profound,involving all aspects of the client’s life: social interactions,emotional health, and ability to work andfunction in the community.• Schizophrenia is conceptualized in terms of positivesigns such as delusions, hallucinations, and disorderedthought processes as well as negative signs such as socialisolation, apathy, anhedonia, and lack of motivationand volition.• The clinical picture, prognosis, and outcomes for clientswith schizophrenia vary widely. Therefore, it is importantthat each client is carefully and individually assessed,with appropriate needs and interventionsdetermined.• Careful assessment of each client as an individual is essentialto planning an effective plan of care.• Families of clients with schizophrenia may experiencefear, embarrassment, and guilt in response to their familymember’s illness. Families must be educated aboutthe disorder, the course of the disorder, and how it canbe controlled.• Failure to comply with treatment and the medicationregimen and the use of alcohol and other drugs are associatedwith poorer outcomes in the treatment ofschizophrenia.• For clients with psychotic symptoms, key nursing interventionsinclude helping to protect the client’ssafety and right to privacy and dignity, dealing withsocially inappropriate behaviors in a nonjudgmentaland matter-of-fact manner, helping present and maintainreality for the client by frequent contact andcommunication, and ensuring appropriate medicationadministration.• For the client whose condition is stabilized with medication,key nursing interventions include continuingto offer a supportive, nonconfrontational approach,maintaining the therapeutic relationship by establishingtrust and trying to clarify the client’s feelings andstatements when speech and thoughts are disorganizedor confused, helping to develop social skills bymodeling and practicing, and helping to educate theclient and family about schizophrenia and the importanceof maintaining a therapeutic regimen and otherself-care habits.• Self-awareness issues for the nurse working with clientswith schizophrenia include dealing with psychoticsymptoms, fear for personal safety, andfrustration as a result of relapses and repeated hospitaladmissions.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Bechdolf, A., Phillips, L. J., Francey, S. M., et al. (2006a). Recentapproaches to psychological interventions for people at risk of psychosis.European Archives of Psychiatry and Clinical Neuroscience,256(3), 159–173.Bechdolf, A., Ruhrmann, S., Wagner, M., et al. (2006b). Interventions inthe prodromal states of psychosis in Germany: Concept and recruitment.British Journal of Psychiatry, 48(Suppl.), s45–s48.Borgmann-Winter, K., Calkins, M. E., Kniele, K., & Gur, R. E. (2006).Assessment of adolescents at risk for psychosis. Current PsychiatryReports, 8(4), 313–321.Brown, A. S., Bresnahan, M., & Susser, E. S. (2005). Schizophrenia:Environmental epidemiology. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1371–1380).Philadelphia: Lippincott Williams & Wilkins.Buchanan, R. W., & Carpenter, W. T. (2005). Concept of schizophrenia.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1329–1345). Philadelphia: LippincottWilliams & Wilkins.Carter, C. S. (2006). Editorial: Understanding the glass ceiling for functionaloutcome in schizophrenia. American Journal of Psychiatry,163(3), 356–358.

CHAPTER 14 • SCHIZOPHRENIA 277Coffey, M., & Hewitt, J. (2008). “You don’t talk about the voices”: Voicehearers and community mental health nurses talk about respondingto voice hearing experiences. Journal of Clinical Nursing, 17(12),1591–1600.Dundas, B., Harris, M., & Narasimhan, M. (2007). Psychogenic polydipsiareview: Etiology, differential, and treatment. Current PsychiatryReports, 9(3), 236–241.Farhall, J., Greenwood, K. M., & Jackson, H. J. (2007). Coping with hallucinatedvoices in schizophrenia: A review of self-initiated strategiesand therapeutic interventions. Clinical Psychology Review, 27(4),476–493.Hafner, H., & Maurer, K. (2006). Early detection of schizophrenia:Current evidence and future perspectives. World Psychiatry, 5(3),130–138.Hogarty, G. E., Greenwald, D. P., & Eack, S. M. (2006). Durability andmechanism of effects of cognitive enhancement therapy. PsychiatricServices, 57(12), 1751–1757.Kane, J. M., & Marder, S. R. (2005). Schizophrenia: Somatic treatment.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1467–1476). Philadelphia: LippincottWilliams & Wilkins.Kirkpatrick, B., & Tek, C. (2005). Schizophrenia: Clinical features andpsychopathology concepts. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1416–1436).Philadelphia: Lippincott Williams & Wilkins.Lake, C. R., & Hurwitz, N. (2007). Schizoaffective disorder mergesschizophrenia and bipolar disorders as one disease—there isno schizoaffective disorder. Current Opinion in Psychiatry, 20(4),365–379.Mahli, G. S., Green, M., Fagiolini, A., Peselow, E. D., & Kumari, V.(2008). Schizoaffective disorder: Diagnostic issues and future recommendations.Bipolar Disorders, 10(1), 215–230.Marshall, M., & Rathbone, J. (2006). Early intervention for psychosis.Cochrane Database of Systematic Review (online), 4(CD004718).McLeod, T., Morris, M., Birchwood, M., & Dovey, A. (2007). Cognitivebehavioural therapy group work with voice hearers. Part 1. BritishJournal of Nursing, 16(4), 248–252.Mojtabai, R. (2005). Culture-bound syndromes with psychotic features.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1538–1541). Philadelphia: LippincottWilliams & Wilkins.Moriana, J. A., Alarcon, E., & Herruzo, J. (2006). In-home psychosocialtraining for patients with schizophrenia. Psychiatric Services, 57(2),260–262.Penn, D. L., Waldheter, E. J., Perkins, D. O., Mueser, K. T., & Lieberman,J. A. (2005). Psychosocial treatment for first-episode psychosis:A research update. American Journal of Psychiatry, 162(12),2220–2232.Pfammatter, M., Junghan, U. M., & Brenner, H. D. (2006). Efficacy ofpsychological therapy in schizophrenia: Conclusions from metaanalysis.Schizophrenia Bulletin, 32(Suppl. 1), S64–S80.Riley, B. P., & Kendler, K. S. (2005). Schizophrenia: Genetics. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1354–1371). Philadelphia: Lippincott Williams& Wilkins.Sakauye, K. (2008). Geriatric psychiatry basics. New York: W. W.Norton.Schneider-Axmann, T., Kamer, T., Moroni, M., et al. (2006). Relationbetween cerebrospinal fluid, gray matter and white matter changes infamilies with schizophrenia. Journal of Psychiatric Research, 40(7),646–655.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Simon, A. E., Dvorsky, D. N., Boesch, J., Roth, B., Isler, E., Schueler, P.,et al. (2006). Defining subjects at risk for psychosis: A comparison oftwo approaches. Schizophrenia Research, 81(1), 83–90.Ucok, A., Polat, A., Cakir, S., & Genc, A. (2006). One year outcome infirst episode schizophrenia: Predictors of relapse. European Archivesof Psychiatry and Neuroscience, 256(1), 37–43.Velligan, D. I., Mueller, J., Wang, M., Dicocco, M., Diamond, P. M.,Maples, N. J., et al. (2006). Use of environmental supports amongpatients with schizophrenia. Psychiatric Services, 57(2), 219–224.ADDITIONAL READINGSHunt, I. M., Kapur, N., Windfuhr, K., Robinson, J., Bickley, H., Flynn, S.,et al. (2006). Suicide in schizophrenia: Findings from a nationalclinical survey. Journal of Psychiatric Practice, 12(3), 139–147.Kane, J. M. (2006). Utilization of long-acting antipsychotic medicationin patient care. CNS Spectrums, 11(12 Suppl. 14), 1–8.Klam, J., McLay, M., & Grabke, D. (2006). Personal empowerment program:Addressing health concerns in people with schizophrenia.Journal of Psychosocial Nursing, 44(8), 20–28.Kopelwicz, A., Liberman, R. P., & Zarate, R. (2006). Recent advances insocial skills training for schizophrenia. Schizophrenia Bulletin,32(Suppl. 1), S12–S23.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The family of a client with schizophrenia asks the nurseabout the difference between conventional and atypicalantipsychotic medications. The nurse’s answer is basedon which of the following?a. Atypical antipsychotics are newer medications butact in the same ways as conventional antipsychotics.b. Conventional antipsychotics are dopamine antagonists;atypical antipsychotics inhibit the reuptake ofserotonin.c. Conventional antipsychotics have serious side effects;atypical antipsychotics have virtually no sideeffects.d. Atypical antipsychotics are dopamine and serotoninantagonists; conventional antipsychotics are onlydopamine antagonists.2. The nurse is planning discharge teaching for a clienttaking clozapine (Clozaril). Which of the following isessential to include?a. Caution the client not to be outdoors in the sunshinewithout protective clothing.b. Remind the client to go to the lab to have blooddrawn for a white blood cell count.c. Instruct the client about dietary restrictions.d. Give the client a chart to record a daily pulse rate.3. The nurse is caring for a client who has been takingfluphenazine (Prolixin) for 2 days. The client suddenlycries out, his neck twists to one side, and his eyesappear to roll back in the sockets. The nurse finds thefollowing PRN medications ordered for the client.Which one should the nurse administer?a. Benztropine (Cogentin), 2 mg PO, bid, PRNb. Fluphenazine (Prolixin), 2 mg PO, tid, PRNc. Haloperidol (Haldol), 5 mg IM, PRN extremeagitationd. Diphenhydramine (Benadryl), 25 mg IM, PRN4. Which of the following statements would indicate thatfamily teaching about schizophrenia had been effective?a. “If our son takes his medication properly, he won’thave another psychotic episode.”b. “I guess we’ll have to face the fact that our daughterwill eventually be institutionalized.”c. “It’s a relief to find out that we did not cause ourson’s schizophrenia.”d. “It is a shame our daughter will never be able to havechildren.”5. When the client describes fear of leaving his apartmentas well as the desire to get out and meet others, it iscalleda. Ambivalenceb. Anhedoniac. Alogiad. Avoidance6. The client who hesitates 30 seconds before respondingto any question is described as havinga. Blunted affectb. Latency of responsec. Paranoid delusionsd. Poverty of speech7. The overall goal of psychiatric rehabilitation is for theclient to gaina. Control of symptomsb. Freedom from hospitalizationc. Management of anxietyd. Recovery from the illnessMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. A teaching plan for the client taking an antipsychoticmedication will includea. Apply sun block lotion before going outdoors.b. Drink sugar-free beverages for dry mouth.c. Have serum blood levels drawn once a month.d. Rise slowly from a sitting position.e. Skip any dose that is not taken on time.f. Take medication with food to avoid nausea.2. Which of the following are considered to be positivesigns of schizophrenia?a. Anhedoniab. Delusionsc. Hallucinationsd. Disorganized thinkinge. Illusionsf. Social withdrawal278

CHAPTER 14 • SCHIZOPHRENIA279CLINICAL EXAMPLEJohn Jones, 33, has been admitted to the hospital for the third time with a diagnosis ofparanoid schizophrenia. John had been taking haloperidol (Haldol) but stopped taking it2 weeks ago, telling his case manager it was “the poison that is making me sick.” Yesterday,John was brought to the hospital after neighbors called the police because he had been upall night yelling loudly in his apartment. Neighbors reported him saying, “I can’t do it!They don’t deserve to die!” and similar statements.John appears guarded and suspicious and has very little to say to anyone. His hair ismatted, he has a strong body odor, and he is dressed in several layers of heavy clothingeven though the temperature is warm. So far, John has been refusing any offers of food orfluids. When the nurse approached John with a dose of haloperidol, he said, “Do you wantme to die?”1. What additional assessment data does the nurse need to plan care for John?2. Identify the three priorities, nursing diagnoses, and expected outcomes for John’s care,with your rationales for the choices.3. Identify at least two nursing interventions for the three priorities listed above.4. What community referrals or supports might be beneficial for John when he isdischarged?

15 Mood DisordersLearning ObjectivesAfter reading this chapter, you should be able to:1. Discuss etiologic theories of depression and bipolar disorder.Key Terms• anergia• anhedonia• electroconvulsive therapy (ECT)• euthymic• flight of ideas• hypertensive crisis• hypomania• kindling• labile emotions• latency of response• mania• mood disorders• pressured speech• psychomotor agitation• psychomotor retardation• ruminate• seasonal affective disorder(SAD)• suicidal ideation• suicide• suicide precautions2. Describe the risk factors for and characteristics of mood disorders.3. Apply the nursing process to the care of clients and families with mooddisorders.4. Provide education to clients, families, caregivers, and community membersto increase knowledge and understanding of mood disorders.5. Identify populations at risk for suicide.6. Apply the nursing process to the care of a suicidal client.7. Evaluate your feelings, beliefs, and attitudes regarding mood disorders andsuicide.EVERYONE OCCASIONALLY FEELS sad, low, and tired, with the desire to stay inbed and shut out the world. These episodes often are accompanied byanergia (lack of energy), exhaustion, agitation, noise intolerance, andslowed thinking processes, all of which make decisions difficult.Work, family, and social responsibilities drive most people to proceedwith their daily routines, even when nothing seems to go right and theirirritable mood is obvious to all. Such “low periods” pass in a few days, andenergy returns. Fluctuations in mood are so common to the human conditionthat we think nothing of hearing someone say, “I’m depressed becauseI have too much to do.” Everyday use of the word depressed doesn’t actuallymean that the person is clinically depressed but, rather, that the personis just having a bad day. Sadness in mood also can be a response to misfortune:death of a friend or relative, financial problems, or loss of a job maycause a person to grieve (see Chapter 12).At the other end of the mood spectrum are episodes of exaggeratedlyenergetic behavior. The person has the sure sense that he or she can takeon any task or relationship. In an elated mood, stamina for work, family,and social events is untiring. This feeling of being “on top of the world”also recedes in a few days to a euthymic mood (average affect and activity).280Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 15 • MOOD DISORDERS 281Vincent Van Gogh; philosopher Frederic Nietzsche; televisioncommentator and host of 60 Minutes Mike Wallace;and actress Patty Duke.Until the mid-1950s, no treatment was available to helppeople with serious depression or mania. These peoplesuffered through their altered moods, thinking they werehopelessly weak to succumb to these devastating symptoms.Family and mental health professionals tended toagree, seeing sufferers as egocentric or viewing life negatively.Although there are still no cures for mood disorders,effective treatments for both depression and mania arenow available.Mood disorders are the most common psychiatric diagnosesassociated with suicide; depression is one of themost important risk factors for it (Sudak, 2005). For thatreason, this chapter focuses on major depression, bipolardisorder, and suicide. It is important to note that clientswith schizophrenia, substance use disorders, antisocial andborderline personality disorders, and panic disorders alsoare at increased risk for suicide and suicide attempts.AnergiaHappy events stimulate joy and enthusiasm. These moodalterations are normal and do not interfere meaningfullywith the person’s life.Mood disorders, also called affective disorders, are pervasivealterations in emotions that are manifested bydepression, mania, or both. They interfere with a person’slife, plaguing him or her with drastic and long-term sadness,agitation, or elation. Accompanying self-doubt, guilt,and anger alter life activities, especially those that involveself-esteem, occupation, and relationships.From early history, people have suffered from mooddisturbances. Archeologists have found holes drilled intoancient skulls to relieve the “evil humors” of those sufferingfrom sad feelings and strange behaviors. Babyloniansand ancient Hebrews believed that overwhelming sadnessand extreme behavior were sent to people through the willof God or other divine beings. Biblical notables King Saul,King Nebuchadnezzar, and Moses suffered overwhelminggrief of heart, unclean spirits, and bitterness of soul, all ofwhich are symptoms of depression. Abraham Lincoln andQueen Victoria had recurrent episodes of depression.Other famous people with mood disorders were writersVirginia Woolf, Sylvia Plath, and Eugene O’Neill; composerGeorge Frideric Handel; musician Jerry Garcia; artistCATEGORIES OF MOOD DISORDERSThe primary mood disorders are major depressive disorderand bipolar disorder (formerly called manic-depressiveillness). A major depressive episode lasts at least 2 weeks,during which the person experiences a depressed mood orloss of pleasure in nearly all activities. In addition, four ofthe following symptoms are present: changes in appetiteor weight, sleep, or psychomotor activity; decreasedenergy; feelings of worthlessness or guilt; difficulty thinking,concentrating, or making decisions; or recurrentthoughts of death or suicidal ideation, plans, or attempts.These symptoms must be present every day for 2 weeksand result in significant distress or impair social, occupational,or other important areas of functioning (AmericanPsychiatric Association [APA], 2000). Some people alsohave delusions and hallucinations; the combination isreferred to as psychotic depression.Bipolar disorder is diagnosed when a person’s moodcycles between extremes of mania and depression (asdescribed previously). Mania is a distinct period duringwhich mood is abnormally and persistently elevated,expansive, or irritable. Typically, this period lasts about1 week (unless the person is hospitalized and treatedsooner), but it may be longer for some individuals. Atleast three of the following symptoms accompany themanic episode: inflated self-esteem or grandiosity;decreased need for sleep; pressured speech (unrelenting,rapid, often loud talking without pauses); flight of ideas(racing, often unconnected, thoughts); distractibility;increased involvement in goal-directed activity or psychomotoragitation; and excessive involvement in pleasure-seekingactivities with a high potential for painfulconsequences (APA, 2000). Some people also exhibitdelusions and hallucinations during a manic episode.

282UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSHypomania is a period of abnormally and persistentlyelevated, expansive, or irritable mood lasting 4 days andincluding three or four of the additional symptomsdescribed earlier. The difference is that hypomanic episodesdo not impair the person’s ability to function (infact, he or she may be quite productive), and there are nopsychotic features (delusions and hallucinations). Amixed episode is diagnosed when the person experiencesboth mania and depression nearly every day for at least 1week. These mixed episodes often are called rapid cycling.For the purpose of medical diagnosis, bipolar disordersare described as follows:• Bipolar I disorder—one or more manic or mixed episodesusually accompanied by major depressive episodes.• Bipolar II disorder—one or more major depressive episodesaccompanied by at least one hypomanic episode.People with bipolar disorder may experience a euthymicor normal mood and affect between extreme episodes,or they may have a depressed mood swing after a manicepisode before returning to a euthymic mood. For some,euthymic periods between extremes are quite short. Forothers, euthymia lasts months or even years.RELATED DISORDERSOther disorders classified in the Diagnostic and StatisticalManual of Mental Disorders, 4th edition, Text Revision (APA,2000) as mood disorders but with symptoms that are lesssevere or of shorter duration include the following:• Dysthymic disorder is characterized by at least 2 yearsof depressed mood for more days than not with someadditional, less severe symptoms that do not meet thecriteria for a major depressive episode.• Cyclothymic disorder is characterized by 2 years ofnumerous periods of both hypomanic symptoms thatdo not meet the criteria for bipolar disorder.• Substance-induced mood disorder is characterized by aprominent and persistent disturbance in mood that isjudged to be a direct physiologic consequence of ingestedsubstances such as alcohol, other drugs, or toxins.• Mood disorder due to a general medical condition ischaracterized by a prominent and persistent disturbancein mood that is judged to be a direct physiologicconsequence of a medical condition such as degenerativeneurologic conditions, cerebrovascular disease,metabolic or endocrine conditions, autoimmune disorders,human immunodeficiency virus (HIV) infections,or certain cancers.Other disorders that involve changes in mood include thefollowing:• Seasonal affective disorder (SAD) has two subtypes. Inone, most commonly called winter depression or fallonsetSAD, people experience increased sleep, appetite,Seasonal affective disorderand carbohydrate cravings; weight gain; interpersonalconflict; irritability; and heaviness in the extremitiesbeginning in late autumn and abating in spring andsummer. The other subtype, called spring-onset SAD, isless common, with symptoms of insomnia, weight loss,and poor appetite lasting from late spring or early summeruntil early fall. SAD is often treated with light therapy(Rastad, Ulfberg, & Lindberg, 2008).• Postpartum or “maternity” blues are a frequent normalexperience after delivery of a baby. They are characterizedby labile mood and affect, crying spells, sadness,insomnia, and anxiety. Symptoms begin approximately1 day after delivery, usually peak in 3 to 7 days, and subsiderapidly with no medical treatment (Sit, Rothschild,& Wisner, 2006).• Postpartum depression meets all the criteria for amajor depressive episode, with onset within 4 weeks ofdelivery.• Postpartum psychosis is a psychotic episode developingwithin 3 weeks of delivery and beginning with fatigue,sadness, emotional lability, poor memory, andconfusion and progressing to delusions, hallucinations,poor insight and judgment, and loss of contact with reality.This medical emergency requires immediate treatment(Sit et al., 2006).

CHAPTER 15 • MOOD DISORDERS 283ETIOLOGYVarious theories for the etiology of mood disorders exist.The most recent research focuses on chemical biologicimbalances as the cause. Nevertheless, psychosocial stressorsand interpersonal events appear to trigger certainphysiologic and chemical changes in the brain, which significantlyalter the balance of neurotransmitters (Akiskal,2005). Effective treatment addresses both the biologic andpsychosocial components of mood disorders. Thus, nursesneed a basic knowledge of both perspectives when workingwith clients experiencing these disorders.Biologic TheoriesGenetic TheoriesGenetic studies implicate the transmission of major depressionin first-degree relatives, who are at twice the risk fordeveloping depression compared with the general population(APA, 2000). First-degree relatives of people with bipolardisorder have a 3% to 8% risk for developing bipolardisorder compared with a 1% risk in the general population.For all mood disorders, monozygotic (identical) twins havea concordance rate (both twins having the disorder) two tofour times higher than that of dizygotic (fraternal) twins.Although heredity is a significant factor, the concordancerate for monozygotic twins is not 100%, so genetics alonedo not account for all mood disorders (Kelsoe, 2005).Markowitz and Milrod (2005) discussed indications ofa genetic overlap between early-onset bipolar disorder andearly-onset alcoholism. They noted that people with bothproblems have a higher rate of mixed and rapid cycling,poorer response to lithium, slower rate of recovery, andmore hospital admissions. Mania displayed by these clientsinvolves more agitation than elation; clients mayrespond better to anticonvulsants than to lithium.Neurochemical TheoriesNeurochemical influences of neurotransmitters (chemicalmessengers) focus on serotonin and norepinephrine as thetwo major biogenic amines implicated in mood disorders.Serotonin has many roles in behavior: mood, activity,aggressiveness and irritability, cognition, pain, biorhythms,and neuroendocrine processes (i.e., growth hormone, cortisol,and prolactin levels are abnormal in depression).Deficits of serotonin, its precursor tryptophan, or a metabolite(5-hydroxyindole acetic acid, or 5-HIAA) of serotoninfound in the blood or cerebrospinal fluid occur in peoplewith depression. Positron emission tomography demonstratesreduced metabolism in the prefrontal cortex, whichmay promote depression (Tecott & Smart, 2005).Norepinephrine levels may be deficient in depressionand increased in mania. This catecholamine energizes thebody to mobilize during stress and inhibits kindling.Kindling is the process by which seizure activity in a specificarea of the brain is initially stimulated by reaching athreshold of the cumulative effects of stress, low amountsof electric impulses, or chemicals such as cocaine that sensitizenerve cells and pathways. These highly sensitizedpathways respond by no longer needing the stimulus toinduce seizure activity, which now occurs spontaneously.It is theorized that kindling may underlie the cycling ofmood disorders as well as addiction. Anticonvulsantsinhibit kindling; this may explain their efficacy in thetreatment of bipolar disorder (Akiskal, 2005).Dysregulation of acetylcholine and dopamine also isbeing studied in relation to mood disorders. Cholinergicdrugs alter mood, sleep, neuroendocrine function, andthe electroencephalographic pattern; therefore, acetylcholineseems to be implicated in depression and mania.The neurotransmitter problem may not be as simple asunderproduction or depletion through overuse duringstress. Changes in the sensitivity as well as the numberof receptors are being evaluated for their roles in mooddisorders (Tecott & Smart, 2005).Neuroendocrine InfluencesHormonal fluctuations are being studied in relation todepression. Mood disturbances have been documented inpeople with endocrine disorders such as those of the thyroid,adrenal, parathyroid, and pituitary glands. Elevatedglucocorticoid activity is associated with the stressresponse, and evidence of increased cortisol secretion isapparent in about 40% of clients with depression, with thehighest rates found among older clients. Postpartum hormonealterations precipitate mood disorders such as postpartumdepression and psychosis. About 5% to 10% ofpeople with depression have thyroid dysfunction, notablyan elevated thyroid-stimulating hormone. This problemmust be corrected with thyroid treatment, or treatment forthe mood disorder is affected adversely (Thase, 2005).Psychodynamic TheoriesMany psychodynamic theories about the cause of mooddisorders seemed to “blame the victim” and his or herfamily (Markowitz & Milrod, 2005):• Freud looked at the self-depreciation of people withdepression and attributed that self-reproach to angerturned inward related to either a real or perceived loss.Feeling abandoned by this loss, people became angrywhile both loving and hating the lost object.• Bibring believed that one’s ego (or self) aspired to beideal (i.e., good and loving, superior or strong) and thatto be loved and worthy, one must achieve these highstandards. Depression results when, in reality, the personwas not able to achieve these ideals all the time.• Jacobson compared the state of depression with a situationin which the ego is a powerless, helpless child victimizedby the superego, much like a powerful andsadistic mother who takes delight in torturing the child.

284UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS• Most psychoanalytical theories of mania view manicepisodes as a “defense” against underlying depression,with the id taking over the ego and acting as an undisciplinedhedonistic being (child).• Meyer viewed depression as a reaction to a distressinglife experience such as an event with psychic causality.• Horney believed that children raised by rejecting or unlovingparents were prone to feelings of insecurity andloneliness, making them susceptible to depression andhelplessness.• Beck saw depression as resulting from specific cognitivedistortions in susceptible people. Early experiencesshaped distorted ways of thinking about one’s self, theworld, and the future; these distortions involve magnificationof negative events, traits, and expectations andsimultaneous minimization of anything positive.CULTURAL CONSIDERATIONSOther behaviors considered age appropriate can maskdepression, which makes the disorder difficult to identifyand diagnose in certain age groups. Children with depressionoften appear cranky. They may have school phobia,hyperactivity, learning disorders, failing grades, and antisocialbehaviors. Adolescents with depression may abusesubstances, join gangs, engage in risky behavior, be underachievers,or drop out of school. In adults, manifestationsof depression can include substance abuse, eating disorders,compulsive behaviors such as workaholism and gambling,and hypochondriasis. Older adults who are crankyand argumentative may actually be depressed.Many somatic ailments (physiologic ailments) accompanydepression. This manifestation varies among culturesand is more apparent in cultures that avoid verbalizingemotions. For example, Asians who are anxious ordepressed are more likely to have somatic complaints ofheadache, backache, or other symptoms. Latin culturescomplain of “nerves” or headaches; Middle Eastern culturescomplain of heart problems (Andrews & Boyle, 2007).MAJOR DEPRESSIVE DISORDERMajor depressive disorder typically involves 2 or moreweeks of a sad mood or lack of interest in life activitieswith at least four other symptoms of depression such asanhedonia and changes in weight, sleep, energy, concentration,decision making, self-esteem, and goals. Majordepression is twice as common in women and has a 1.5 to3 times greater incidence in first-degree relatives than inthe general population. Incidence of depression decreaseswith age in women and increases with age in men. Singleand divorced people have the highest incidence. Depressionin prepubertal boys and girls occurs at an equal rate(Kelsoe, 2005).Onset and Clinical CourseAn untreated episode of depression can last 6 to 24 monthsbefore remitting. Fifty to sixty percent of people who haveone episode of depression will have another. After a secondepisode of depression, there is a 70% chance of recurrence.Depressive symptoms can vary from mild to severe.The degree of depression is comparable with the person’ssense of helplessness and hopelessness. Some peoplewith severe depression (9%) have psychotic features(APA, 2000).CLINICAL VIGNETTE: DEPRESSION“Just get out! I am not interested in food,” said Chris to herhusband Matt, who had come into their bedroom to invite herto the dinner he and their daughters had prepared. “Can’tthey leave me alone?” thought Chris to herself as she miserablypulled the covers over her shoulders. Yet she felt guiltyabout the way she’d snapped at Matt. She knew she’d disparagedher family’s efforts to help, but she couldn’t stop.Chris was physically and emotionally exhausted. “I can’tremember when I felt well . . . maybe last year sometime, ormaybe never,” she thought fretfully. She’d always workedhard to get things done; lately, she could not do anything atall except complain. Kathy, her 13-year-old, accused her ofhating everything and everybody, including her family. Linda,11 years old, said, “Everything has to be your way, Mom.You snap at us for every little thing. You never listen anymore.”Matt had long ago withdrawn from her moodiness,acid tongue, and disinterest in sex. One day, she overheardMatt tell his brother that Chris was “crabby, agitated, andself-centered and if it wasn’t for the girls, I don’t know whatI’d do. I’ve tried to get her to go to a doctor, but she says it’sall our fault; then she sulks for days. What is our fault? Idon’t know what to do for her. I feel as if I am living in aminefield and never know what will set off an explosion. Itry to remember the love we had together, but her behavioris getting old.”Chris has lost 12 pounds in the past 2 months, has difficultysleeping, and is hostile, angry, and guilty about it.She has no desire for any pleasure. “Why bother? There isnothing to enjoy. Life is bleak.” She feels stuck, worthless,hopeless, and helpless. Hoping against hope, Chris thinksto herself, “I wish I were dead. I’d never have to do anythingagain.”

CHAPTER 15 • MOOD DISORDERS 285DSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of MajorDepressive Disorder• Depressed mood• Anhedonism (decreased attention to and enjoymentfrom previously pleasurable activities)• Unintentional weight change of 5% or more in amonth• Change in sleep pattern• Agitation or psychomotor retardation• Tiredness• Worthlessness or guilt inappropriate to the situation(possibly delusional)• Difficulty thinking, focusing, or making decisions• Hopelessness, helplessness, and/or suicidal ideationAdapted from DSM-IV-TR, 2000.Treatment and PrognosisPsychopharmacologyMajor categories of antidepressants include cyclic antidepressants,monoamine oxidase inhibitors (MAOIs), selectiveserotonin reuptake inhibitors (SSRIs), and atypicalantidepressants. Chapter 2 details biologic treatments. Thechoice of which antidepressant to use is based on the client’ssymptoms, age, and physical health needs; drugs thathave or have not worked in the past or that have workedfor a blood relative with depression; and other medicationsthat the client is taking.Researchers believe that levels of neurotransmitters,especially norepinephrine and serotonin, are decreased indepression. Usually, presynaptic neurons release theseneurotransmitters to allow them to enter synapses andlink with postsynaptic receptors. Depression results if toofew neurotransmitters are released, if they linger too brieflyin synapses, if the releasing presynaptic neurons reabsorbthem too quickly, if conditions in synapses do not supportlinkage with postsynaptic receptors, or if the number ofpostsynaptic receptors has decreased. The goal is toincrease the efficacy of available neurotransmitters and theabsorption by postsynaptic receptors. To do so, antidepressantsestablish a blockade for the reuptake of norepinephrineand serotonin into their specific nerve terminals.This permits them to linger longer in synapses and to bemore available to postsynaptic receptors. Antidepressantsalso increase the sensitivity of the postsynaptic receptorsites (Rush, 2005).In clients who have acute depression with psychoticfeatures, an antipsychotic is used in combination with anantidepressant. The antipsychotic treats the psychotic features;several weeks into treatment, the client is reassessedto determine whether the antipsychotic can be withdrawnand the antidepressant maintained.Evidence is increasing that antidepressant therapyshould continue for longer than the 3 to 6 months originallybelieved necessary. Fewer relapses occur in peoplewith depression who receive 18 to 24 months of antidepressanttherapy. As a rule, the dosage of antidepressantsshould be tapered before being discontinued.Selective Serotonin Reuptake Inhibitors. SSRIs, the newestcategory of antidepressants (Table 15.1), are effective formost clients. Their action is specific to serotonin reuptakeinhibition; these drugs produce few sedating, anticholinergic,and cardiovascular side effects, which make them safer foruse in older adults. Because of their low side effects andrelative safety, people using SSRIs are more apt to be compliantwith the treatment regimen than clients using more troublesomemedications. Insomnia decreases in 3 to 4 days,appetite returns to a more normal state in 5 to 7 days, andenergy returns in 4 to 7 days. In 7 to 10 days, mood, concentration,and interest in life improve.Fluoxetine (Prozac) produces a slightly higher rate ofmild agitation and weight loss but less somnolence. It hasa half-life of more than 7 days, which differs from the25-hour half-life of other SSRIs.Cyclic Antidepressants. Tricyclics, introduced for the treatmentof depression in the mid-1950s, are the oldestantidepressants. They relieve symptoms of hopelessness,helplessness, anhedonia, inappropriate guilt, suicidal ideation,and daily mood variations (cranky in the morning andbetter in the evening). Other indications include panic disorder,obsessive–compulsive disorder, and eating disorders.Each drug has a different degree of efficacy in blocking theactivity of norepinephrine and serotonin or increasing thesensitivity of postsynaptic receptor sites. Tricyclic and heterocyclicantidepressants have a lag period of 10 to 14 daysbefore reaching a serum level that begins to alter symptoms;they take 6 weeks to reach full effect. Because they have along serum half-life, there is a lag period of 1 to 4 weeks beforesteady plasma levels are reached and the client’s symptomsbegin to decrease. They cost less primarily because theyhave been around longer and generic forms are available.Tricyclic antidepressants are contraindicated in severeimpairment of liver function and in myocardial infarction(acute recovery phase). They cannot be given concurrentlywith MAOIs. Because of their anticholinergic side effects,tricyclic antidepressants must be used cautiously in clientswho have glaucoma, benign prostatic hypertrophy, urinaryretention or obstruction, diabetes mellitus, hyperthyroidism,cardiovascular disease, renal impairment, or respiratorydisorders (Table 15.2).Overdosage of tricyclic antidepressants occurs over severaldays and results in confusion, agitation, hallucinations,hyperpyrexia, and increased reflexes. Seizures, coma,and cardiovascular toxicity can occur with ensuingtachycardia, decreased output, depressed contractility, andatrioventricular block. Because many older adults have

286UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 15.1SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) ANTIDEPRESSANTSGeneric (Trade) Name Side Effects Nursing ImplicationsFluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)Headache, nervousness, anxiety, sedation,tremor, sexual dysfunction, anorexia,constipation, nausea, diarrhea, andweight lossDizziness, sedation, headache, insomnia,tremor, sexual dysfunction, diarrhea,dry mouth and throat, nausea,vomiting, and sweatingDizziness, sedation, headache, insomnia,weakness, fatigue, constipation, drymouth and throat, nausea, vomiting,diarrhea, and sweatingDrowsiness, sedation, insomnia, nausea,vomiting, weight gain, constipation,and diarrheaDrowsiness, dizziness, weight gain, sexualdysfunction, restlessness, dry mouth,headache, nausea, and diarrheaAdminister in AM (if nervous) or PM (if drowsy).Monitor for hyponatremia.Encourage adequate fluids.Report sexual difficulties to physician.Administer in PM if client is drowsy.Encourage use of sugar-free beverages or hardcandy.Drink adequate fluids.Monitor hyponatremia; report sexual difficultiesto physician.Administer with food.Administer in PM if client is drowsy.Encourage use of sugar-free hard candy orbeverages.Encourage adequate fluids.Monitor for hyponatremia.Administer with food.Administer dose at 6 PM or later.Promote balanced nutrition and exercise.Check orthostatic blood pressure.Assist client to rise slowly from sitting position.Encourage use of sugar-free beverages or hardcandy.Administer with food.concomitant health problems, cyclic antidepressants areused less often in the geriatric population than newer typesof antidepressants that have fewer side effects and lessdrug interactions.Tetracyclic Antidepressants. Amoxapine (Asendin) maycause extrapyramidal symptoms, tardive dyskinesia, andneuroleptic malignant syndrome. It can create tolerance in1 to 3 months. It increases appetite and causes weight gainand cravings for sweets.Maprotiline (Ludiomil) carries a risk for seizures (especiallyin heavy drinkers), severe constipation and urinaryretention, stomatitis, and other side effects; this leads topoor compliance. The drug is started and withdrawn gradually.Central nervous system depressants can increase theeffects of this drug.Atypical Antidepressants. Atypical antidepressants areused when the client has an inadequate response to or sideeffects from SSRIs. Atypical antidepressants include venlafaxine(Effexor), duloxetine (Cymbalta), bupropion (Wellbutrin),nefazodone (Serzone), and mirtazapine (Remeron)(Table 15.3).Venlafaxine blocks the reuptake of serotonin, norepinephrine,and dopamine (weakly). Duloxetine selectively blocksboth serotonin and norepinephrine. Bupropion modestlyinhibits the reuptake of norepinephrine, weakly inhibits thereuptake of dopamine, and has no effects on serotonin.Bupropion is marketed as Zyban for smoking cessation.Nefazodone inhibits the reuptake of serotonin and norepinephrineand has few side effects. Its half-life is 4 hours,and it can be used in clients with liver and kidney disease.It increases the action of certain benzodiazepines (alprazolam,estazolam, and triazolam) and the H2 blocker terfenadine.Remeron also inhibits the reuptake of serotonin andnorepinephrine, and it has few sexual side effects; however,its use comes with a higher incidence of weight gain,sedation, and anticholinergic side effects (Facts andComparisons, 2009).Monoamine Oxidase Inhibitors. MAOIs are used infrequentlybecause of potentially fatal side effects and interactionswith numerous drugs, both prescription andover-the-counter preparations (Table 15.4). The most seriousside effect is hypertensive crisis, a life-threatening conditionthat can result when a client taking MAOIs ingeststyramine-containing foods (see Chapter 2, Box 2.1) and fluidsor other medications. Symptoms are occipital headache,hypertension, nausea, vomiting, chills, sweating, restlessness,nuchal rigidity, dilated pupils, fever, and motor agitation.These can lead to hyperpyrexia, cerebral hemorrhage,

CHAPTER 15 • MOOD DISORDERS 287Table 15.2TRICYCLIC ANTIDEPRESSANT MEDICATIONSGeneric (Trade) Name Side Effects Nursing ImplicationsAmitriptyline (Elavil)Amoxapine (Asendin)Doxepin (Sinequan)Imipramine (Tofranil)Desipramine(Norpramine)Nortriptyline (Pamelor)Dizziness, orthostatic hypotension,tachycardia, sedation, headache,tremor, blurred vision, constipation,dry mouth and throat, weight gain,urinary hesitancy, and sweatingDizziness, orthostatic hypotension,sedation, insomnia, constipation,dry mouth and throat, and rashesDizziness, orthostatic hypotension,tachycardia, sedation, blurredvision, constipation, dry mouth andthroat, weight gain, and sweatingDizziness, orthostatic hypotension,weakness, fatigue, blurred vision,constipation, dry mouth andthroat, and weight gainCardiac dysrhythmias, dizziness,orthostatic hypotension, excitement,insomnia, sexual dysfunction, drymouth and throat, and rashesCardiac dysrhythmias, tachycardia,confusion, excitement, tremor,constipation, and dry mouth andthroatAssist client to rise slowly from sitting position.Administer at bedtime.Encourage use of sugar-free beverages and hardcandy.Ensure adequate fluids and balanced nutrition.Encourage exercise.Monitor cardiac function.Assist client to rise slowly from sitting position.Administer at bedtime if client is sedated.Ensure adequate fluids.Encourage use of sugar-free beverages and hardcandy.Report rashes to physician.Assist client to rise slowly from sitting position.Administer at bedtime if client is sedated.Ensure adequate fluids and balanced nutrition.Encourage use of sugar-free beverages and hardcandy.Encourage exercise.Assist client to rise slowly from sitting or supineposition.Ensure adequate fluids and balanced nutrition.Encourage use of sugar-free beverages and hardcandy.Encourage exercise.Monitor cardiac function.Assist client to rise slowly from sitting position.Administer in AM if client is having insomnia.Encourage sugar-free beverages and hard candy.Report rashes or sexual difficulties to physician.Monitor cardiac function.Administer in AM if stimulated.Ensure adequate fluids.Encourage use of sugar-free beverages and hardcandy.Report confusion to physician.and death. The MAOI–tyramine interaction produces symptomswithin 20 to 60 minutes after ingestion. For hypertensivecrisis, transient antihypertensive agents, such as phentolaminemesylate, are given to dilate blood vessels and decrease vascularresistance (Facts and Comparisons, 2009).There is a 2- to 4-week lag period before MAOIs reachtherapeutic levels. Because of the lag period, adequatewashout periods of 5 to 6 weeks are recommended betweenthe times that the MAOI is discontinued and another classof antidepressant is started.Other Medical Treatments and PsychotherapyElectroconvulsive Therapy. Psychiatrists may use electroconvulsivetherapy (ECT) to treat depression in selectgroups, such as clients who do not respond to antidepressantsor those who experience intolerable side effects attherapeutic doses (particularly true for older adults). Inaddition, pregnant women can safely have ECT with noharm to the fetus. Clients who are actively suicidal may begiven ECT if there is concern for their safety while waitingweeks for the full effects of antidepressant medication.ECT involves application of electrodes to the head ofthe client to deliver an electrical impulse to the brain; thiscauses a seizure. It is believed that the shock stimulatesbrain chemistry to correct the chemical imbalance ofdepression. Historically, clients did not receive any anestheticor other medication before ECT, and they had fullblowngrand mal seizures that often resulted in injuries

288UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 15.3ATYPICAL ANTIDEPRESSANTSGeneric (Trade) Name Side Effects Nursing ImplicationsVenlafaxine (Effexor)Duloxetine (Cymbalta)Bupropion (Wellbutrin)Nefazodone (Serzone)Mirtazapine (Remeron)Increased blood pressure and pulse, nausea,vomiting, headache, dizziness, drowsiness,dry mouth, and sweating; can alter manylab tests, e.g., AST, ALT, alkaline phosphatase,creatinine, glucose, andelectrolytesIncreased blood pressure and pulse, nausea,vomiting, drowsiness or insomnia,headache, dry mouth, constipation,lowered seizure threshold, and sexualdysfunctionNausea, vomiting, lowered seizure threshold,agitation, restlessness, insomnia, may altertaste, blurred vision, weight gain, andheadacheHeadache; dizziness; drowsiness; alters resultsof AST, ALT, LDH, cholesterol, glucose, andhematocritSedation, dizziness, dry mouth and throat,weight gain, sexual dysfunction, andconstipationAdminister with food.Ensure adequate fluids.Give in PM.Encourage use of sugar-free beveragesor hard candy.Administer with food.Ensure adequate fluids.Encourage use of sugar-free beveragesor hard candy.Give with food.Administer dose in AM.Ensure balanced nutrition and exercise.Administer before meal (food inhibitsabsorption).Monitor liver and kidney functions.Administer in PM.Encourage use of sugar-free beveragesand hard candy.Ensure adequate fluids and balancednutrition.Report sexual difficulties to physician.ALT, alanine aminotransferase; AST, aspartite aminotransferase; LDH, lactate dehydrogenase.Table 15.4MONOAMINE OXIDASE INHIBITOR (MAOI) ANTIDEPRESSANTSGeneric (Trade) Name Side Effects Nursing ImplicationsIsocarboxazid (Marplan)Phenelzine (Nardil)Tranylcypromine (Parnate)Drowsiness, dry mouth, overactivity,insomnia, nausea, anorexia,constipation, urinary retention,and orthostatic hypotensionAssist client to rise slowly from sitting position.Administer in AM.Administer with food.Ensure adequate fluids.Perform essential teaching on importance oflow-tyramine diet.ranging from biting the tongue to breaking bones. ECT fellinto disfavor for a period and was seen as “barbaric.”Today, although ECT is administered in a safe and humaneway with almost no injuries, there are still critics of thetreatment.Clients usually receive a series of 6 to 15 treatmentsscheduled thrice a week. Generally, a minimum of sixtreatments are needed to see sustained improvement indepressive symptoms. Maximum benefit is achieved in 12to 15 treatments.Preparation of a client for ECT is similar to preparationfor any outpatient minor surgical procedure: The clientreceives nothing by mouth (or, is NPO) after midnight,removes any fingernail polish, and voids just before theprocedure. An intravenous line is started for the administrationof medication.Initially, the client receives a short-acting anesthetic sohe or she is not awake during the procedure. Next, he or shereceives a muscle relaxant/paralytic, usually succinylcholine,which relaxes all muscles to reduce greatly the outward

CHAPTER 15 • MOOD DISORDERS 289Serotonin SyndromeSerotonin syndrome occurs when there is an inadequatewashout period between taking MAOIs and SSRIs or whenMAOIs are combined with meperidine. Symptoms of serotoninsyndrome include:• Change in mental state: confusion and agitation• Neuromuscular excitement: muscle rigidity, weakness,sluggish pupils, shivering, tremors, myoclonic jerks,collapse, and muscle paralysis• Autonomic abnormalities: hyperthermia, tachycardia,tachypnea, hypersalivation, and diaphoresisOverdose of MAOI and Cyclic AntidepressantsBoth the cyclic compounds and MAOIs are potentially lethalwhen taken in overdose. To decrease this risk, depressed orimpulsive clients who are taking any antidepressants inthese two categories may need to have prescriptions andrefills in limited amounts.MAOI Drug InteractionsThere are numerous drugs that interact with MAOIs. Thefollowing drugs cause potentially fatal interactions:• Amphetamines• Ephedrine• Fenfluramine• Isoproterenol• Meperidine• Phenylephrine• Phenylpropanolamine• Pseudoephedrine• SSRI antidepressants• Tricyclic antidepressants• Tyraminesigns of the seizure (e.g., clonic–tonic muscle contractions).Electrodes are placed on the client’s head: one on either side(bilateral) or both on one side (unilateral). The electricalstimulation is delivered, which causes seizure activity in thebrain that is monitored by an electroencephalogram, orEEG. The client receives oxygen and is assisted to breathewith an Ambu bag. He or she generally begins to wakenafter a few minutes. Vital signs are monitored, and the clientis assessed for the return of a gag reflex.After ECT treatment, the client may be mildly confusedor briefly disoriented. He or she is very tired and often hasa headache. The symptoms are just like those of anyonewho has had a grand mal seizure. In addition, the clientwill have some short-term memory impairment. After atreatment, the client may eat as soon as he or she is hungryand usually sleeps for a period. Headaches are treatedsymptomatically.Unilateral ECT results in less memory loss for the client,but more treatments may be needed to see sustainedimprovement. Bilateral ECT results in more rapid improvementbut with increased short-term memory loss.The literature continues to be divided about the effectivenessof ECT. Some studies report that ECT is as effective asmedication for depression, whereas other studies report onlyshort-term improvement. Likewise, some studies report thatmemory loss side effects of ECT are short lived, whereas othersreport they are serious and long term (Fenton, Fasula,Ostroff, & Sanacora, 2006; Ross, 2006).ECT is also used for relapse prevention in depression.Clients may continue to receive treatments, such as oneper month, to maintain their mood improvement. Often,clients are given antidepressant therapy after ECT to preventrelapse. Studies have found maintenance ECT to beeffective in relapse prevention (Frederikse, Petrides, &Kellner, 2006).Psychotherapy. A combination of psychotherapy andmedications is considered the most effective treatment fordepressive disorders. There is no one specific type of therapythat is better for the treatment of depression (Rush,2005). The goals of combined therapy are symptom remission,psychosocial restoration, prevention of relapse orrecurrence, reduced secondary consequences such asmarital discord or occupational difficulties, and increasingtreatment compliance.Interpersonal therapy focuses on difficulties in relationships,such as grief reactions, role disputes, and role transitions.For example, a person who, as a child, neverlearned how to make and trust a friend outside the familystructure has difficulty establishing friendships as an adult.Interpersonal therapy helps the person to find ways toaccomplish this developmental task.Behavior therapy seeks to increase the frequency of theclient’s positively reinforcing interactions with the environmentand to decrease negative interactions. It also mayfocus on improving social skills.Cognitive therapy focuses on how the person thinksabout the self, others, and the future and interprets his or herexperiences. This model focuses on the person’s distortedthinking, which, in turn, influences feelings, behavior, andfunctional abilities. Table 15.5 describes the cognitive distortionsthat are the focus of cognitive therapy.

290UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 15.5DISTORTIONS ADDRESSED BY COGNITIVE THERAPYCognitive DistortionDefinitionAbsolute, dichotomous thinkingArbitrary inferenceSpecific abstractionOvergeneralizationMagnification and minimizationPersonalizationTendency to view everything in polar categories, i.e., all or none, black or whiteDrawing a specific conclusion without sufficient evidence, i.e., jumping to(negative) conclusionsFocusing on a single (often minor) detail while ignoring other, more significantaspects of the experience, i.e., concentrating on one small (negative) detailwhile discounting positive aspectsForming conclusions based on too little or too narrow experience, i.e., if oneexperience was negative, then all similar experiences will be negativeOver- or undervaluing the significance of a particular event, i.e., one smallnegative event is the end of the world or a positive experience is totallydiscountedTendency to self-reference external events without basis, i.e., believing thatevents are directly related to one’s self, whether they are or notInvestigational Treatments. Other treatments for depressionare being tested. These include transcranial magneticstimulation (TMS), magnetic seizure therapy, deep brainstimulation, and vagal nerve stimulation. TMS is the closestto approval for clinical use. These novel brain-stimulationtechniques seem to be safe, but their efficacy in relievingdepression needs to be established (Eitan & Lerer, 2006).APPLICATION OF THE NURSING PROCESS:DEPRESSIONAssessmentHistoryThe nurse can collect assessment data from the client andfamily or significant others, previous chart information,and others involved in the support or care. It may takeseveral short periods to complete the assessment becauseclients who are severely depressed feel exhausted andoverwhelmed. It can take time for them to process thequestion asked and to formulate a response. It is importantthat the nurse does not try to rush clients because doing soleads to frustration and incomplete assessment data.To assess the client’s perception of the problem, thenurse asks about behavioral changes: when they started,what was happening when they began, their duration, andwhat the client has tried to do about them. Assessing thehistory is important to determine any previous episodes ofdepression, treatment, and client’s response to treatment.The nurse also asks about family history of mood disorders,suicide, or attempted suicide.General Appearance and Motor BehaviorMany people with depression look sad; sometimes theyjust look ill. The posture often is slouched with headdown, and they make minimal eye contact. They havepsychomotor retardation (slow body movements, slowcognitive processing, and slow verbal interaction).Responses to questions may be minimal, with only one ortwo words. Latency of response is seen when clients takeup to 30 seconds to respond to a question. They mayanswer some questions with “I don’t know” because theyare simply too fatigued and overwhelmed to think of ananswer or respond in any detail. Clients also may exhibitsigns of agitation or anxiety such as wringing their handsand having difficulty sitting still. These clients are said tohave psychomotor agitation (increased body movementsand thoughts), which includes pacing, accelerated thinking,and argumentativeness.Mood and AffectClients with depression may describe themselves as hopeless,helpless, down, or anxious. They also may say theyare a burden on others or are a failure at life, or they maymake other similar statements. They are easily frustrated,are angry with themselves, and can be angry with others(APA, 2000). They experience anhedonia, losing any senseof pleasure from activities they formerly enjoyed. Clientsmay be apathetic, that is, not caring about self, activities,or much of anything.Their affect is sad or depressed or may be flat with noemotional expressions. Typically, depressed clients sit alone,staring into space or lost in thought. When addressed,they interact minimally with a few words or a gesture. Theyare overwhelmed by noise and people who might makedemands on them, so they withdraw from the stimulationof interaction with others.Thought Process and ContentClients with depression experience slowed thinking processes:their thinking seems to occur in slow motion. With

CHAPTER 15 • MOOD DISORDERS 291Nursing Care Plan | DepressionNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices ofpracticed responses, and/or inability to use available resources.ASSESSMENT DATA• Suicidal ideas or behavior• Slowed mental processes• Disordered thoughts• Feelings of despair, hopelessness, and worthlessness• Guilt• Anhedonia (inability to experience pleasure)• Disorientation• Generalized restlessness or agitation• Sleep disturbances: early awakening, insomnia, orexcessive sleeping• Anger or hostility (may not be overt)• Rumination• Delusions, hallucinations, or other psychoticsymptoms• Diminished interest in sexual activity• Fear of intensity of feelings• AnxietyEXPECTED OUTCOMESImmediateThe client will• Be free from self-inflicted harm• Engage in reality-based interactions• Be oriented to person, place, and time• Express anger or hostility outwardly in a safemanner, e.g., talking with staff membersStabilizationThe client will• Express feelings directly with congruent verbal andnonverbal messages• Be free from psychotic symptoms• Demonstrate functional level of psychomotoractivityCommunityThe client will• Demonstrate compliance with and knowledge ofmedications, if any• Demonstrate an increased ability to cope withanxiety, stress, or frustration• Verbalize or demonstrate acceptance of loss orchange, if any• Identify a support system in the communityIMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Provide a safe environment for the client.Continually assess the client’s potential for suicide.Remain aware of this suicide potential at all times.Observe the client closely, especially under the followingcircumstances:• After antidepressant medication begins to raise theclient’s mood.• Unstructured time on the unit or times when thenumber of staff on the unit is limited.• After any dramatic behavioral change (suddencheerfulness, relief, or giving away personalbelongings).RationalePhysical safety of the client is a priority. Many commonitems may be used in a self-destructive manner.Depressed clients may have a potential for suicidethat may or may not be expressed and that maychange with time.You must be aware of the client’s activities at alltimes when there is a potential for suicide or selfinjury.Risk for suicide increases as the client’senergy level is increased by medication, when theclient’s time is unstructured, and when observationof the client decreases. These changes may indicatethat the client has come to a decision to commitsuicide.(continued)

292UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Depression, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Reorient the client to person, place, and time as indicated(call the client by name, tell the client yourname, tell the client where he or she is, and so forth).Spend time with the client.If the client is ruminating, tell him or her that youwill talk about reality or about the client’s feelings,but limit the attention given to repeated expressionsof rumination.Initially assign the same staff members to work withthe client whenever possible.When approaching the client, use a moderate, leveltone of voice. Avoid being overly cheerful.Use silence and active listening when interacting withthe client. Let the client know that you are concernedand that you consider the client a worthwhile person.Be comfortable sitting with the client in silence. Letthe client know you are available to converse, butdo not require the client to talk.When first communicating with the client, use simple,direct sentences; avoid complex sentences or directions.Avoid asking the client many questions, especiallyquestions that require only brief answers.Do not cut off interactions with cheerful remarks orplatitudes (e.g., “No one really wants to die,” or“You’ll feel better soon.”). Do not belittle the client’sfeelings. Accept the client’s verbalizations offeelings as real, and give support for expressions ofemotions, especially those that may be difficult forthe client (like anger).Encourage the client to ventilate feelings in whateverway is comfortable—verbal and nonverbal. Letthe client know you will listen and accept what isbeing expressed.Allow (and encourage) the client to cry. Stay withand support the client if he or she desires. Provideprivacy if the client desires and it is safe to do so.Interact with the client on topics with which heor she is comfortable. Do not probe forinformation.RationaleRepeated presentation of reality is concrete reinforcementfor the client.Your physical presence is reality.Minimizing attention may help decrease rumination.Providing reinforcement for reality orientationand expression of feelings will encourage thesebehaviors.The client’s ability to respond to others may beimpaired. Limiting the number of new contacts initiallywill facilitate familiarity and trust.However, the number of people interacting with theclient should increase as soon as possible to minimizedependency and to facilitate the client’s abilitiesto communicate with a variety of people.Being overly cheerful may indicate to the client thatbeing cheerful is the goal and that other feelingsare not acceptable.The client may not communicate if you are talkingtoo much. Your presence and use of active listeningwill communicate your interest and concern.Your silence will convey your expectation that theclient will communicate and your acceptance ofthe client’s difficulty with communication.The client’s ability to perceive and respond to complexstimuli is impaired.Asking questions and requiring only brief answersmay discourage the client from expressing feelings.You may be uncomfortable with certain feelings theclient expresses. If so, it is important for you torecognize this and discuss it with another staffmember rather than directly or indirectly communicatingyour discomfort to the client. Proclaimingthe client’s feelings to be inappropriate or belittlingthem is detrimental.Expressing feelings may help relieve despair, hopelessness,and so forth. Feelings are not inherently goodor bad. You must remain nonjudgmental about theclient’s feelings and express this to the client.Crying is a healthy way of expressing feelings of sadness,hopelessness, and despair. The client may notfeel comfortable crying and may need encouragementor privacy.Topics that are uncomfortable for the client andprobing may be threatening and discourage communication.After trust has been established, theclient may be able to discuss more difficult topics.(continued)

CHAPTER 15 • MOOD DISORDERS 293Nursing Care Plan | Depression, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Teach the client about the problem-solving process:explore possible options, examine the consequencesof each alternative, select and implementan alternative, and evaluate the results.Provide positive feedback at each step of the process.If the client is not satisfied with the chosen alternative,assist the client to select another alternative.RationaleThe client may be unaware of a systematic methodfor solving problems. Successful use of the problem-solvingprocess facilitates the client’s confidencein the use of coping skills.Positive feedback at each step will give the client manyopportunities for success, encourage him or her to persistin problem solving, and enhance confidence. Theclient also can learn to “survive” making a mistake.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.severe depression, they may not respond verbally to questions.Clients tend to be negative and pessimistic in theirthinking, that is, they believe that they will always feel thisbad, things will never get any better, and nothing will help.Clients make self-deprecating remarks, criticizing themselvesharshly and focusing only on failures or negativeattributes. They tend to ruminate, which is repeatedly goingover the same thoughts. Those who experience psychoticsymptoms have delusions; they often believe they areresponsible for all the tragedies and miseries in the world.Often clients with depression have thoughts of dying orcommitting suicide. It is important to assess suicidal ideationby asking about it directly. The nurse may ask, “Are youthinking about suicide?” or “What suicidal thoughts are youhaving?” Most clients readily admit to suicidal thinking. Suicideis discussed more fully later in this chapter.Sensorium and Intellectual ProcessesSome clients with depression are oriented to person, time,and place; others experience difficulty with orientation,especially if they experience psychotic symptoms or arewithdrawn from their environment. Assessing generalknowledge is difficult because of their limited ability torespond to questions. Memory impairment is common.Clients have extreme difficulty concentrating or payingattention. If psychotic, clients may hear degrading andbelittling voices or they may even have command hallucinationsthat order them to commit suicide.Judgment and InsightClients with depression experience impaired judgmentbecause they cannot use their cognitive abilities to solveproblems or to make decisions. They often cannot makedecisions or choices because of their extreme apathy ortheir negative belief that it “doesn’t matter anyway.”Insight may be intact, especially if clients have beendepressed previously. Others have very limited insight andRuminationare totally unaware of their behavior, feelings, or even theirillness.Self-ConceptSense of self-esteem is greatly reduced; clients often usephrases such as “good for nothing” or “just worthless” to

294UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSdescribe themselves. They feel guilty about not being ableto function and often personalize events or take responsibilityfor incidents over which they have no control. Theybelieve that others would be better off without them, abelief which leads to suicidal thoughts.Roles and RelationshipsClients with depression have difficulty fulfilling roles andresponsibilities. The more severe the depression, thegreater the difficulty. They have problems going to work orschool; when there, they seem unable to carry out theirresponsibilities. The same is true with family responsibilities.Clients are less able to cook, clean, or care for children.In addition to the inability to fulfill roles, clientsbecome even more convinced of their “worthlessness” forbeing unable to meet life responsibilities.Depression can cause great strain in relationships. Familymembers who have limited knowledge about depressionmay believe clients should “just get on with it.” Clientsoften avoid family and social relationships because they feeloverwhelmed, experience no pleasure from interactions,and feel unworthy. As clients withdraw from relationships,the strain increases.Physiologic and Self-Care ConsiderationsClients with depression often experience pronouncedweight loss because of lack of appetite or disinterest in eating.Sleep disturbances are common: either clients cannotsleep, or they feel exhausted and unrefreshed no matterhow much time they spend in bed. They lose interest insexual activities, and men often experience impotence.Some clients neglect personal hygiene because they lackthe interest or energy. Constipation commonly resultsfrom decreased food and fluid intake as well as from inactivity.If fluid intake is severely limited, clients also may bedehydrated.Depression Rating ScalesClients complete some rating scales for depression; mentalhealth professionals administer others. These assessmenttools, along with evaluation of behavior, thought processes,history, family history, and situational factors, helpto create a diagnostic picture. Self-rating scales of depressivesymptoms include the Zung Self-Rating DepressionScale and the Beck Depression Inventory. Self-rating scalesare used for case finding in the general public and may beused over the course of treatment to determine improvementfrom the client’s perspective.The Hamilton Rating Scale for Depression (Table 15.6)is a clinician-rated depression scale used like a clinicalinterview. The clinician rates the range of the client’sbehaviors such as depressed mood, guilt, suicide, andinsomnia. There is also a section to score diurnal variations,depersonalization (sense of unreality about the self),paranoid symptoms, and obsessions.Data AnalysisThe nurse analyzes assessment data to determine prioritiesand to establish a plan of care. Nursing diagnoses commonlyestablished for the client with depression includethe following:• Risk for Suicide• Imbalanced Nutrition: Less Than Body Requirements• Anxiety• Ineffective Coping• Hopelessness• Ineffective Role Performance• Self-Care Deficit• Chronic Low Self-Esteem• Disturbed Sleep Pattern• Impaired Social InteractionOutcome IdentificationOutcomes for clients with depression relate to how thedepression is manifested—for instance, whether or not theperson is slow or agitated, sleeps too much or too little, oreats too much or too little. Examples of outcomes for aclient with the psychomotor retardation form of depressioninclude the following:• The client will not injure himself or herself.• The client will independently carry out activities ofdaily living (showering, changing clothing, grooming).• The client will establish a balance of rest, sleep, andactivity.• The client will establish a balance of adequate nutrition,hydration, and elimination.• The client will evaluate self-attributes realistically.• The client will socialize with staff, peers, and family/friends.• The client will return to occupation or schoolactivities.• The client will comply with antidepressant regimen.• The client will verbalize symptoms of a recurrence.InterventionProviding for SafetyThe first priority is to determine whether a client withdepression is suicidal. If a client has suicidal ideation orhears voices commanding him or her to commit suicide,measures to provide a safe environment are necessary. Ifthe client has a suicide plan, the nurse asks additionalquestions to determine the lethality of the intent andplan. The nurse reports this information to the treatmentteam. Health care personnel follow hospital or agencypolicies and procedures for instituting suicide precautions(e.g., removal of harmful items, increased supervision).A thorough discussion is presented later in thechapter.

CHAPTER 15 • MOOD DISORDERS 295Table 15.6HAMILTON RATING SCALE FOR DEPRESSIONFor each item select the “cue” that best characterizes the patient.1: Depressed mood (sadness, hopeless, helpless, worthless)0 Absent1 These feeling states indicated only on questioning2 These feeling states spontaneously reported verbally3 Communicates feeling states nonverbally—i.e.,through facial expression, posture, voice, andtendency to weep4 Patient reports VIRTUALLY ONLY these feelingstates in his spontaneous verbal and nonverbalcommunication2: Feelings of guilt0 Absent1 Self-reproach, feels he has let people down2 Ideas of guilt or rumination over past errors orsinful deeds3 Present illness is a punishment. Delusions of guilt4 Hears accusatory or denunciatory voices and/orexperiences threatening visual hallucinations3: Suicide0 Absent1 Feels life is not worth living2 Wishes he were dead or any thoughts of possibledeath to self3 Suicide ideas or gesture4 Attempts at suicide (any serious attempt rates 4)4: Insomnia early0 No difficulty falling asleep1 Complains of occasional difficulty falling asleep—i.e., more than ¼ hour2 Complains of nightly difficulty falling asleep5: Insomnia middle0 No difficulty1 Patient complains of being restless and disturbedduring the night2 Waking during the night—any getting out of bedrates 2 (except for purpose of voiding)6: Insomnia late0 No difficulty1 Waking in early hours of the morning but goesback to sleep2 Unable to fall asleep again if gets out of bed7: Work and activities0 No difficulty1 Thoughts and feelings of incapacity, fatigue orweakness related to activities, work, or hobbies2 Loss of interest in activity, hobbies, or work—either directly reported by patient, or indirect inlistlessness, indecision and vacillation (feels he hasto push self to work or activities)3 Decrease in actual time spent in activities ordecrease in productivity. In hospital, rate 3 ifpatient does not spend at least 3 hours a day inactivities (hospital job or hobbies) exclusive ofward chores4 Stopped working because of present illness. Inhospital, rate 4 if patient engages in no activitiesexcept ward chores, or if patient fails to performward chores unassisted8: Retardation (slowness of thought and speech; impairedability to concentrate; decreased motor activity)0 Normal speech and thought1 Slight retardation at interview2 Obvious retardation at interview3 Interview difficult4 Complete stupor9: Agitation0 None1 “Playing with” hands, hair, etc.2 Hand wringing, nail biting, hair pulling, biting of lips10: Anxiety psychic0 No difficulty1 Subjective tension and irritability2 Worrying about minor matters3 Apprehensive attitude apparent in face or speech4 Fears expressed without questioning11: Anxiety somatic0 Absent Physiologic concomitants ofanxiety, such as:1 Mild Gastrointestinal—dry mouth,wind, indigestion, diarrhea,cramps, belching2 Moderate Cardiovascular—palpitations,headaches3 Severe Respiratory—hyperventilation,sighing4 Incapacitating Urinary frequency Sweating12: Somatic symptoms gastrointestinal0 None1 Loss of appetite but eating without staff encouragement.Heavy feelings in abdomen.2 Difficulty eating without staff urging. Requestsor requires laxatives or medication for bowels ormedication for GI symptoms13: Somatic symptoms general0 None1 Heaviness in limbs, back or head. Backaches, headache,muscle aches. Loss of energy and fatigability2 Any clear cut symptom rates 214: Genital symptoms0 Absent Symptoms such as:1 Mild Loss of libido2 Severe Menstrual disturbances15: Hypochondriasis0 Not present1 Self-absorption (bodily)2 Preoccupation with health3 Frequent complaints, requests for help, etc.4 Hypochondriacal delusions(continued)

296UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 15.6HAMILTON RATING SCALE FOR DEPRESSION (Continued)16: Loss of weightA: When rating by history0 No weight loss1 Probable weight loss associated with presentillness2 Definite (according to patient) weight lossB: On weekly ratings by ward psychiatrist, whenactual weight changes are measured0 Less than 1 pound weight loss in week1 Greater than 1 pound weight loss in week2 Greater than 2 pounds weight loss in week17: Insight0 Acknowledges being depressed and ill1 Acknowledges illness but attributes cause to badfood, climate, overwork, virus, need for rest, etc.2 Denies being ill at all18: Diurnal variationAM PM If symptoms are worse in the0 0 Absent morning or evening, note which1 1 Mild it is and rate severity of variation2 2 Severe19: Depersonalization and derealization0 Absent1 Mild Such as:2 Moderate Feeling of unreality3 Severe Nihilistic ideas4 Incapacitating20: Paranoid symptoms0 None12 Suspiciousness3 Ideas of reference4 Delusions of reference and persecution21: Obsessional and compulsive symptoms0 Absent1 Mild2 Severe22: Helplessness0 Not present1 Subjective feelings that are elicited only by inquiry2 Patient volunteers his helpless feelings3 Requires urging, guidance, and reassurance toaccomplish ward chores or personal hygiene4 Requires physical assistance for dress, grooming,eating, bedside tasks, or personal hygiene23: Hopelessness0 Not present1 Intermittently doubts that “things will improve”but can be reassured2 Consistently feels “hopeless” but accepts reassurances3 Expresses feelings of discouragement, despair, pessimismabout future, which cannot be dispelled4 Spontaneously and inappropriately perseverates“I’ll never get well” or its equivalent24: Worthlessness (ranges from mild loss of esteem,feelings of inferiority, self-depreciation to delusionalnotions of worthlessness)0 Not present1 Indicates feelings of worthlessness (loss of selfesteem)only on questioning2 Spontaneously indicates feelings of worthlessness(loss of self-esteem)3 Different from 2 by degree. Patient volunteersthat he is “no good,” “inferior,” etc.4 Delusional notions of worthlessness—i.e., “I am aheap of garbage” or its equivalentReprinted with permission from Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56.Promoting a Therapeutic RelationshipIt is important to have meaningful contact with clients whohave depression and to begin a therapeutic relationshipregardless of the state of depression. Some clients are quiteopen in describing their feelings of sadness, hopelessness,helplessness, or agitation. Clients may be unable to sustaina long interaction, so several shorter visits help the nurse toassess status and to establish a therapeutic relationship.The nurse may find it difficult to interact with these clientsbecause of empathy with such sadness and depression.The nurse also may feel unable to “do anything” for clientswith limited responses. Clients with psychomotor retardation(slow speech, slow movement, slow thought processes)are very noncommunicative or may even be mute. Thenurse can sit with such clients for a few minutes at intervalsthroughout the day. The nurse’s presence conveys genuineinterest and caring. It is not necessary for the nurse to talkto clients the entire time; rather, silence can convey that clientsare worthwhile even if they are not interacting.“My name is Sheila. I’m your nurse today. I’mgoing to sit with you for a few minutes. If youneed anything, or if you would like to talk,please tell me.”After time has elapsed, the nurse would say the following:“I’m going now. I will be back in an hour to seeyou again.”

CHAPTER 15 • MOOD DISORDERS 297for DepressionNURSING INTERVENTIONS• Provide for the safety of the client and others.• Institute suicide precautions if indicated.• Begin a therapeutic relationship by spendingnondemanding time with the client.• Promote completion of activities of daily living byassisting the client only as necessary.• Establish adequate nutrition and hydration.• Promote sleep and rest.• Engage the client in activities.• Encourage the client to verbalize and describeemotions.• Work with the client to manage medications and sideeffects.It is also important that the nurse avoids being overlycheerful or trying to “cheer up” clients. It is impossible tocoax or to humor clients out of their depression. In fact, anoverly cheerful approach may make clients feel worse orconvey a lack of understanding of their despair.Promoting Activities of Daily Livingand Physical CareThe ability to perform daily activities is related to the levelof psychomotor retardation. To assess ability to performactivities of daily living independently, the nurse first asksthe client to perform the global task. For example,“Martin, it’s time to get dressed.” (global task)If a client cannot respond to the global request, the nursebreaks the task into smaller segments. Clients with depressioncan become overwhelmed easily with a task that hasseveral steps. The nurse can use success in small, concretesteps as a basis to increase self-esteem and to build competencyfor a slightly more complex task the next time.If clients cannot choose between articles of clothing,the nurse selects the clothing and directs clients to putthem on. For example,“Here are your gray slacks. Put them on.”This still allows clients to participate in dressing. If thisis what clients are capable of doing at this point, thisactivity will reduce dependence on staff. This request isconcrete, and if clients cannot do this, the nurse has informationabout the level of psychomotor retardation.If a client cannot put on slacks, the nurse assists bysaying,“Let me help you with your slacks, Martin.”The nurse helps clients to dress only when they cannotperform any of the above steps. This allows clients to do asmuch as possible for themselves and to avoid becomingdependent on the staff. The nurse can carry out this sameprocess with clients when they eat, take a shower, and performroutine self-care activities.Because abilities change over time, the nurse mustassess them on an ongoing basis. This continual assessmenttakes more time than simply helping clients to dress.Nevertheless, it promotes independence and providesdynamic assessment data about psychomotor abilities.Often, clients decline to engage in activities becausethey are too fatigued or have no interest. The nurse canvalidate these feelings yet still promote participation. Forexample,“I know you feel like staying in bed, but it is timeto get up for breakfast.”Often, clients may want to stay in bed until they “feellike getting up” or engaging in activities of daily living.The nurse can let clients know they must become moreactive to feel better rather than waiting passively forimprovement. It may be helpful to avoid asking “yes-orno”questions. Instead of asking, “Do you want to get upnow?” the nurse would say, “It is time to get up now.”Reestablishing balanced nutrition can be challengingwhen clients have no appetite or don’t feel like eating. Thenurse can explain that beginning to eat helps stimulate appetite.Food offered frequently and in small amounts can preventoverwhelming clients with a large meal that they feelunable to eat. Sitting quietly with clients during meals canpromote eating. Monitoring food and fluid intake may benecessary until clients are consuming adequate amounts.Promoting sleep may include the short-term use of asedative or giving medication in the evening if drowsinessor sedation is a side effect. It is also important to encourageclients to remain out of bed and active during the day tofacilitate sleeping at night. It is important to monitor thenumber of hours clients sleep as well as whether they feelrefreshed on awakening.Using Therapeutic CommunicationClients with depression are often overwhelmed by theintensity of their emotions. Talking about these feelings

298UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERScan be beneficial. Initially, the nurse encourages clientsto describe in detail how they are feeling. Sharing theburden with another person can provide some relief. Atthese times, the nurse can listen attentively, encourageclients, and validate the intensity of their experience. Forexample,Nurse: “How are you feeling today?” (broadopening)Client: “I feel so awful . . . terrible.”Nurse: “Tell me more. What is that like foryou?” (using a general lead; encouragingdescription)Client: “I don’t feel like myself. I don’t know what to do.”Nurse: “That must be frightening.” (validating)It is important at this point that the nurse does notattempt to “fix” the client’s difficulties or offer clichés suchas “Things will get better” or “But you know your familyreally needs you.” Although the nurse may have goodintentions, remarks of this type belittle the client’s feelingsor make the client feel more guilty and worthless.As clients begin to improve, the nurse can help them tolearn or rediscover more effective coping strategies such astalking to friends, spending leisure time to relax, takingpositive steps to deal with stressors, and so forth. Improvedcoping skills may not prevent depression but may assist clientsto deal with the effects of depression more effectively.Managing MedicationsThe increased activity and improved mood that antidepressantsproduce can provide the energy for suicidal clients tocarry out the act. Thus, the nurse must assess suicide riskeven when clients are receiving antidepressants. It is alsoimportant to ensure that clients ingest the medication andare not saving it in attempt to commit suicide. As clientsbecome ready for discharge, careful assessment of suicidepotential is important because they will have a supply ofantidepressant medication at home. SSRIs are rarely fatal inoverdose, but cyclic and MAOI antidepressants are potentiallyfatal. Prescriptions may need to be limited to only a1-week supply at a time if concerns linger about overdose.An important component of client care is managementof side effects. The nurse must make careful observationsand ask clients pertinent questions to determine how theyare tolerating medications. Tables 15.1 through 15.4 givespecific interventions to manage side effects of antidepressantmedications.Clients and family must learn how to manage the medicationregimen because clients may need to take thesemedications for months, years, or even a lifetime. Educationpromotes compliance. Clients must know how oftenthey need to return for monitoring and diagnostic tests.Providing Client and Family TeachingTeaching clients and family about depression is important.They must understand that depression is an illness, not aCLIENT FAMILY EDUCATIONfor Depression• Teach about the illness of depression.• Identify early signs of relapse.• Discuss the importance of support groups and assist inlocating resources.• Teach the client and family about the benefits oftherapy and follow-up appointments.• Encourage participation in support groups.• Teach the action, side effects, and special instructionsregarding medications.• Discuss methods to manage side effects of medication.lack of willpower or motivation. Learning about the beginningsymptoms of relapse may assist clients to seek treatmentearly and avoid a lengthy recurrence.Clients and family should know that treatment outcomesare best when psychotherapy and antidepressantsare combined. Psychotherapy helps clients to exploreanger, dependence, guilt, hopelessness, helplessness,object loss, interpersonal issues, and irrational beliefs. Thegoal is to reverse negative views of the future, improveself-image, and help clients gain competence and self-mastery.The nurse can help clients to find a therapist throughmental health centers in specific communities.Support group participation also helps some clients andtheir families. Clients can receive support and encouragementfrom others who struggle with depression, and familymembers can offer support to one another. The NationalAlliance for the Mentally Ill is an organization that canhelp clients and families connect with local supportgroups.EvaluationEvaluation of the plan of care is based on achievement ofindividual client outcomes. It is essential that clients feelsafe and do not experience uncontrollable urges to commitsuicide. Participation in therapy and medication complianceproduce more favorable outcomes for clients withdepression. Being able to identify signs of relapse and toseek treatment immediately can significantly decrease theseverity of a depressive episode.BIPOLAR DISORDERBipolar disorder involves extreme mood swings from episodesof mania to episodes of depression. (Bipolar disorder was formerlyknown as manic-depressive illness.) During manicphases, clients are euphoric, grandiose, energetic, and sleepless.They have poor judgment and rapid thoughts, actions,and speech. During depressed phases, mood, behavior, and

CHAPTER 15 • MOOD DISORDERS 299CLINICAL VIGNETTE: MANIC EPISODE“Everyone is stupid! What is the matter? Have you alltaken dumb pills? Dumb pills, rum pills, shlummy shlum lumpills!” Mitch screamed as he waited for his staff to snap toattention and get with the program. He had started thePickle Barn 10 years ago and now had a money-makingbusiness canning and delivering gourmet pickles.He knew how to do everything in this place and, runningfrom person to person to watch what each was doing, hedidn’t like what he saw. It was 8 AM, and he’d already firedthe supervisor, who had been with him for 5 years.By 8:02 am, Mitch had fired six pickle assistants becausehe did not like the way they looked. Then, Mitch threw potsand paddles at them because they weren’t leaving fastenough. Rich, his brother, walked in during this melee andquietly asked everyone to stay, then invited Mitch outsidefor a walk.“Are you nuts?” Mitch screamed at his brother. “Everyonehere is out of control. I have to do everything.” Mitchwas trembling, shaking. He hadn’t slept in 3 days and didn’tneed to. The only time he’d left the building in these 3 dayswas to have sex with any woman who had agreed. He felteuphoric, supreme, able to leap tall buildings in a singlebound. He glared at Rich. “I feel good! What are you buggingme for?” He slammed out the door, shrilly reciting,“Rich and Mitch! Rich and Mitch! Pickle king rich!”“Rich and Mitch, Rich and Mitch. With dear old auntie,now we’re rich.” Mitch couldn’t stop talking and speedwalking. Watching Mitch, Rich gently said, “Aunt Jen calledme last night. She says you are manic again. When did youstop taking your lithium?”“Manic? Who’s manic? I’m just feeling good. Who needsthat stuff? I like to feel good. It is wonderful, marvelous,stupendous. I am not manic,” shrieked Mitch as he swervedaround to face his brother. Rich, weary and sad, said, “I amtaking you to the emergency psych unit. If you do not agreeto go, I will have the police take you. I know you don’t seethis in yourself, but you are out of control and gettingdangerous.”thoughts are the same as in people diagnosed with majordepression (see previous discussion). In fact, if a person’sfirst episode of bipolar illness is a depressed phase, he or shemight be diagnosed with major depression; a diagnosis ofbipolar disorder may not be made until the person experiencesa manic episode. To increase awareness about bipolardisorder, health care professionals can use tools such as theMood Disorder Questionnaire (Box 15.1).Bipolar disorder ranks second only to major depressionas a cause of worldwide disability. The lifetime risk forbipolar disorder is at least 1.2%, with a risk of completedsuicide for 15%. Young men early in the course of theirillness are at highest risk for suicide, especially those witha history of suicide attempts or alcohol abuse as well asthose recently discharged from the hospital (Rihmer &Angst, 2005).Whereas a person with major depression slowly slidesinto depression that can last for 6 months to 2 years, theperson with bipolar disorder cycles between depressionand normal behavior (bipolar depressed) or mania andnormal behavior (bipolar manic). A person with bipolarmixed episodes alternates between major depressive andmanic episodes interspersed with periods of normal behavior.Each mood may last for weeks or months before thepattern begins to descend or ascend once again. Figure 15.1shows the three categories of bipolar cycles.Bipolar disorder occurs almost equally among men andwomen. It is more common in highly educated people.Because some people with bipolar illness deny their mania,prevalence rates may actually be higher than reported.Onset and Clinical CourseThe mean age for a first manic episode is the early 20s, butsome people experience onset in adolescence, whereas othersstart experiencing symptoms when they are older than50 (APA, 2000). Currently, debate exists about whether ornot some children diagnosed with attention deficit hyperactivitydisorder actually have a very early onset of bipolardisorder. Manic episodes typically begin suddenly, withrapid escalation of symptoms over a few days, and they lastfrom a few weeks to several months. They tend to be brieferand to end more suddenly than depressive episodes. Adolescentsare more likely to have psychotic manifestations.The diagnosis of a manic episode or mania requires atleast 1 week of unusual and incessantly heightened, grandiose,or agitated mood in addition to three or more of thefollowing symptoms: exaggerated self-esteem; sleeplessness;pressured speech; flight of ideas; reduced ability tofilter extraneous stimuli; distractibility; increased activitieswith increased energy; and multiple, grandiose, highriskactivities involving poor judgment and severe consequences,such as spending sprees, sex with strangers, andimpulsive investments (APA, 2000).Clients often do not understand how their illness affectsothers. They may stop taking medications because they likethe euphoria and feel burdened by the side effects, bloodtests, and physicians’ visits needed to maintain treatment.Family members are concerned and exhausted by their lovedones’ behaviors; they often stay up late at night for fear themanic person may do something impulsive and dangerous.

300UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 15.1 MOOD DISORDER QUESTIONNAIREThe following questionnaire can be used as a starting point to help you recognize the signs/symptoms of bipolar disorder butis not meant to be a substitute for a full medical evaluation. Bipolar disorder is complex and an accurate, thorough diagnosiscan be made through a personal evaluation by your doctor. However, a positive screening may suggest that youmight benefit from seeking such an evaluation from your doctor. Regardless of the questionnaire results, if you or your familyhas concerns about your mental health, please contact your physician and/or other health care professional.When completed, you may want to print out your responses.Instructions: Please answer each question as best you can.1. Has there ever been a period of time when you were not your usual self and . . . YES NO. . . you felt so good or so hyper that other people thought you were not your normal self or youwere so hyper that you got into trouble?■■. . . you were so irritable that you shouted at people or started fights or arguments? ■ ■. . . you felt much more self-confident than usual? ■ ■. . . you got much less sleep than usual and found you didn’t really miss it? ■ ■. . . you were much more talkative or spoke much faster than usual? ■ ■. . . thoughts raced through your head or you couldn’t slow your mind down? ■ ■. . . you were so easily distracted by things around you that you had trouble concentrating orstaying on track?■■. . . you had much more energy than usual? ■ ■. . . you were much more active or did many more things than usual? ■ ■. . . you were much more social or outgoing than usual, for example, you telephoned friends inthe middle of the night?■■. . . you were much more interested in sex than usual? ■ ■. . . you did things that were unusual for you or that other people might have thought wereexcessive, foolish, or risky?■■. . . spending money got you or your family into trouble? ■ ■2. If you checked YES to more than one of the above, have several of these ever happened duringthe same period of time?3. How much of a problem did any of these cause you—like being unable to work; having family,money or legal troubles; getting into arguments or fights? Please select one response only.[ ■ ] No [ ■ ] Minor [ ■ ] Moderate [ ■ ] Seriousproblem problem problem problem4. Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) hadmanic-depressive illness or bipolar disorder?5. Has a health care professional ever told you that you have manic-depressive illness or bipolardisorder?■■■■■■From Hirschfeld, R. M. A., Williams, J. B., Spitzer, R. L., et al. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: TheMood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873–1875.

CHAPTER 15 • MOOD DISORDERS 301ManiaHypomaniaNormal moodDepression1. Bipolarmixed2. Bipolartype I3. Bipolartype II1. Bipolar mixed—Cycles alternate between periods of mania, normal mood, depression,normal mood, mania, and so forth.2. Bipolar type I—Manic episodes with at least one depressive episode.3. Bipolar type II—Recurrent depressive episodes with at least one hypomanic episode.Figure 15-1. Graphic depiction of mood cycles.DSM-IV-TR DIAGNOSTIC CRITERIA:Typical Symptoms of Mania• Heightened, grandiose, or agitated mood• Exaggerated self-esteem• Sleeplessness• Pressured speech• Flight of ideas• Reduced ability to filter out extraneous stimuli; easilydistractible• Increased number of activities with increased energy• Multiple, grandiose, high-risk activities, using poorjudgment, with severe consequencesAdapted from DSM-IV-TR, 2000.TreatmentPsychopharmacologyTreatment for bipolar disorder involves a lifetime regimenof medications: either an antimanic agent called lithium oranticonvulsant medications used as mood stabilizers (seeChapter 2). This is the only psychiatric disorder in whichmedications can prevent acute cycles of bipolar behavior.Once thought to help reduce manic behavior only, lithiumand these anticonvulsants also protect against the effectsof bipolar depressive cycles. If a client in the acute stage ofmania or depression exhibits psychosis (disordered thinkingas seen with delusions, hallucinations, and illusions),an antipsychotic agent is administered in addition to thebipolar medications. Some clients keep taking both bipolarmedications and antipsychotics.Lithium. Lithium is a salt contained in the human body;it is similar to gold, copper, magnesium, manganese, andother trace elements. Once believed to be helpful for bipolarmania only, investigators quickly realized that lithiumalso could partially or completely mute the cycling towardbipolar depression. The response rate in acute mania tolithium therapy is 70% to 80%. In addition to treating therange of bipolar behaviors, lithium also can stabilize bipolardisorder by reducing the degree and frequency of cyclingor eliminating manic episodes (Freeman, Wiegand,& Gelenberg, 2006).Lithium not only competes for salt receptor sites butalso affects calcium, potassium, and magnesium ions aswell as glucose metabolism. Its mechanism of action isunknown, but it is thought to work in the synapses to hastendestruction of catecholamines (dopamine, norepinephrine),inhibit neurotransmitter release, and decreasethe sensitivity of postsynaptic receptors (Facts and Comparisons,2009).Lithium’s action peaks in 30 minutes to 4 hours forregular forms and in 4 to 6 hours for the slow-release form.It crosses the blood–brain barrier and placenta and is distributedin sweat and breast milk. Lithium use duringpregnancy is not recommended because it can lead to firsttrimesterdevelopmental abnormalities. Onset of action is5 to 14 days; with this lag period, antipsychotic or antidepressantagents are used carefully in combination withlithium to reduce symptoms in acutely manic or acutelydepressed clients. The half-life of lithium is 20 to 27 hours(Facts and Comparisons, 2009).Anticonvulsant Drugs. Lithium is effective in about 75%of people with bipolar illness. The rest do not respond or

302UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERShave difficulty taking lithium because of side effects, problemswith the treatment regimen, drug interactions, ormedical conditions such as renal disease that contraindicateuse of lithium. Several anticonvulsants traditionallyused to treat seizure disorders have proved helpful in stabilizingthe moods of people with bipolar illness. Thesedrugs are categorized as miscellaneous anticonvulsants.Their mechanism of action is largely unknown, but theymay raise the brain’s threshold for dealing with stimulation;this prevents the person from being bombarded withexternal and internal stimuli (Table 15.7).Carbamazepine (Tegretol), which had been used forgrand mal and temporal lobe epilepsy as well as for trigeminalneuralgia, was the first anticonvulsant found to havemood-stabilizing properties, but the threat of agranulocytosiswas of great concern. Clients taking carbamazepineneed to have drug serum levels checked regularly to monitorfor toxicity and to determine whether the drug hasreached therapeutic levels, which are generally 4 to 12 µg/mL (Ketter, Wang & Post, 2006). Baseline and periodiclaboratory testing must also be done to monitor for suppressionof white blood cells.Valproic acid (Depakote), also known as divalproexsodium or sodium valproate, is an anticonvulsant used forsimple absence and mixed seizures, migraine prophylaxis,and mania. The mechanism of action is unclear. Therapeuticlevels are monitored periodically to remain at 50 to125 µg/mL, as are baseline and ongoing liver functiontests, including serum ammonia levels and platelet andbleeding times (Bowden, 2006).Gabapentin (Neurontin), lamotrigine (Lamictal), andtopiramate (Topamax) are other anticonvulsants sometimesused as mood stabilizers, but they are used less frequentlythan valproic acid. Value ranges for therapeuticlevels are not established.Clonazepam (Klonopin) is an anticonvulsant and abenzodiazepine (a schedule IV controlled substance) usedin simple absence and minor motor seizures, panic disorder,and bipolar disorder. Physiologic dependence candevelop with long-term use. This drug may be used inlithium or other mood stabilizers but is not used alone tomanage bipolar disorder.PsychotherapyPsychotherapy can be useful in the mildly depressive ornormal portion of the bipolar cycle. It is not useful duringacute manic stages because the person’s attention span isbrief and he or she can gain little insight during times ofTable 15.7ANTICONVULSANTS USED AS MOOD STABILIZERSGeneric (Trade) Name Side Effects Nursing ImplicationsCarbamazepine (Tegretol)Divalproex (Depakote)Gabapentin (Neurontin)Lamotrigine (Lamictal)Topiramate (Topamax)Oxcarbazepine (Trileptal)Dizziness, hypotension, ataxia, sedation,blurred vision, leukopenia, and rashesAtaxia, drowsiness, weakness, fatigue,menstrual changes, dyspepsia, nausea,vomiting, weight gain, and hair lossDizziness, hypotension, ataxia, coordination,sedation, headache, fatigue,nystagmus, nausea, and vomitingDizziness, hypotension, ataxia, coordination,sedation, headache, weakness,fatigue, menstrual changes, sore throat,flu-like symptoms, blurred or doublevision, nausea, vomiting, and rashesDizziness, hypotension, anxiety, ataxia,incoordination, confusion, sedation,slurred speech, tremor, weakness,blurred or double vision, anorexia,nausea, and vomitingDizziness, fatigue, ataxia, confusion,nausea, vomiting, anorexia, headache,tremor, confusion, and rashesAssist client to rise slowly from sitting position.Monitor gait and assist as necessary.Report rashes to physician.Monitor gait and assist as necessary.Provide rest periods.Give with food.Establish balanced nutrition.Assist client to rise slowly from sitting position.Provide rest periods.Give with food.Assist client to rise slowly from sitting position.Monitor gait and assist as necessary.Provide rest periods.Monitor physical health.Give with food.Report rashes to physician.Assist client to rise slowly from sitting position.Monitor gait and assist as necessary.Orient client.Protect client from potential injury.Give with food.Assist client to rise slowly from sitting position.Monitor gait and assist as necessary.Give with food.Orient client and protect from injury.Report rashes to physician.

CHAPTER 15 • MOOD DISORDERS 303accelerated psychomotor activity. Psychotherapy combinedwith medication can reduce the risk for suicide andinjury, provide support to the client and family, and helpthe client to accept the diagnosis and treatment plan.APPLICATION OF THE NURSING PROCESS:BIPOLAR DISORDERThe focus of this discussion is on the client experiencing amanic episode of bipolar disorder. The reader shouldreview the Application of the Nursing Process: Depressionsection to examine nursing care of the client experiencinga depressed phase of bipolar disorder.AssessmentHistoryTaking a history with a client in the manic phase oftenproves difficult. The client may jump from subject to subject,which makes it difficult for the nurse to follow.Obtaining data in several short sessions, as well as talkingto family members, may be necessary. The nurse can obtainmuch information, however, by watching and listening.General Appearance and Motor BehaviorClients with mania experience psychomotor agitation andseem to be in perpetual motion; sitting still is difficult.This continual movement has many ramifications: clientscan become exhausted or injure themselves.In the manic phase, the client may wear clothes thatreflect the elevated mood: brightly colored, flamboyant,attention-getting, and perhaps sexually suggestive. Forexample, a woman in the manic phase may wear a lot ofjewelry and hair ornaments, or her makeup may be garishand heavy, whereas a male client may wear a tight andrevealing muscle shirt or go bare-chested.Clients experiencing a manic episode think, move, andtalk fast. Pressured speech, one of the hallmark symptoms, isevidenced by unrelentingly rapid and often loud speech withoutpauses. Those with pressured speech interrupt and cannotlisten to others. They ignore verbal and nonverbal cues indicatingthat others wish to speak, and they continue with constantintelligible or unintelligible speech, turning from onelistener to another or speaking to no one at all. If interrupted,clients with mania often start over from the beginning.Mood and AffectMania is reflected in periods of euphoria, exuberant activity,grandiosity, and false sense of well-being. Projection ofan all-knowing and all-powerful image may be an unconsciousdefense against underlying low self-esteem. Someclients manifest mania with an angry, verbally aggressivetone and are sarcastic and irritable, especially when othersset limits on their behavior. Clients’ mood is quite labile,and they may alternate between periods of loud laughterand episodes of tears.Thought Process and ContentCognitive ability or thinking is confused and jumbled withthoughts racing one after another, which is often referredto as flight of ideas. Clients cannot connect concepts, andthey jump from one subject to another. Circumstantialityand tangentiality also characterize thinking. At times, clientsmay be unable to communicate thoughts or needs inways that others understand.These clients start many projects at one time but cannotcarry any to completion. There is little true planning, butclients talk nonstop about plans and projects to anyone andeveryone, insisting on the importance of accomplishingthese activities. Sometimes they try to enlist help from othersin one or more activities. They do not consider risks orpersonal experience, abilities, or resources. Clients startthese activities as they occur in their thought processes.Examples of these multiple activities are going on shoppingsprees, using credit cards excessively while unemployedand broke, starting several business ventures at once, havingpromiscuous sex, gambling, taking impulsive trips,embarking on illegal endeavors, making risky investments,talking with multiple people, and speeding (APA, 2000).Some clients experience psychotic features during mania;they express grandiose delusions involving importance,fame, privilege, and wealth. Some may claim to be the president,a famous movie star, or even God or a prophet.Sensorium and Intellectual ProcessesClients may be oriented to person and place but rarely totime. Intellectual functioning, such as fund of knowledge,is difficult to assess during the manic phase. Clients mayclaim to have many abilities they do not possess. The abilityto concentrate or to pay attention is grossly impaired.Again, if a client is psychotic, he or she may experiencehallucinations.Judgment and InsightPeople in the manic phase are easily angered and irritatedand strike back at what they perceive as censorship by othersbecause they impose no restrictions on themselves.They are impulsive and rarely think before acting or speaking,which makes their judgment poor. Insight is limitedbecause they believe they are “fine” and have no problems.They blame any difficulties on others.Self-ConceptClients with mania often have exaggerated self-esteem;they believe they can accomplish anything. They rarelydiscuss their self-concept realistically. Nevertheless, a falsesense of well-being masks difficulties with chronic lowself-esteem.Roles and RelationshipsClients in the manic phase rarely can fulfill role responsibilities.They have trouble at work or school (if they areeven attending) and are too distracted and hyperactive to

304UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSpay attention to children or activities of daily living.Although they may begin many tasks or projects, theycomplete few.These clients have a great need to socialize but littleunderstanding of their excessive, overpowering, andconfrontational social interactions. Their need for socializationoften leads to promiscuity. Clients invade theintimate space and personal business of others. Argumentsresult when others feel threatened by such boundaryinvasions. Although the usual mood of manic peopleis elation, emotions are unstable and can fluctuate (labileemotions) readily between euphoria and hostility. Clientswith mania can become hostile to others whom theyperceive as standing in way of desired goals. They cannotpostpone or delay gratification. For example, a manicclient tells his wife, “You are the most wonderful womanin the world. Give me $50 so I can buy you a ticket tothe opera.” When she refuses, he snarls and accuses herof being cheap and selfish and may even strike her.Physiologic and Self-Care ConsiderationsClients with mania can go days without sleep or food andnot even realize they are hungry or tired. They may be onthe brink of physical exhaustion but are unwilling orunable to stop, rest, or sleep. They often ignore personalhygiene as “boring” when they have “more importantthings” to do. Clients may throw away possessions ordestroy valued items. They may even physically injurethemselves and tend to ignore or be unaware of healthneeds that can worsen.Data AnalysisThe nurse analyzes assessment data to determine prioritiesand to establish a plan of care. Nursing diagnoses commonlyestablished for clients in the manic phase are asfollows:• Risk for Other-Directed Violence• Risk for Injury• Imbalanced Nutrition: Less Than Body Requirements• Ineffective Coping• Noncompliance• Ineffective Role Performance• Self-Care Deficit• Chronic Low Self-Esteem• Disturbed Sleep PatternOutcome IdentificationExamples of outcomes appropriate to mania are as follows:• The client will not injure self or others.• The client will establish a balance of rest, sleep, andactivity.• The client will establish adequate nutrition, hydration,and elimination.• The client will participate in self-care activities.• The client will evaluate personal qualities realistically.• The client will engage in socially appropriate, realitybasedinteraction.• The client will verbalize knowledge of his or her illnessand treatment.InterventionProviding for SafetyBecause of the safety risks that clients in the manic phasetake, safety plays a primary role in care, followed by issuesrelated to self-esteem and socialization. A primary nursingresponsibility is to provide a safe environment for clientsand others. The nurse assesses clients directly for suicidalideation and plans or thoughts of hurting others. In addition,clients in the manic phase have little insight intotheir anger and agitation and how their behaviors affectothers. They often intrude into others’ space, take others’belongings without permission, or appear aggressive inapproaching others. This behavior can threaten or angerpeople who then retaliate. It is important to monitor theclients’ whereabouts and behaviors frequently.The nurse also should tell clients that staff members willhelp them control their behavior if clients cannot do soalone. For clients who feel out of control, the nurse mustestablish external controls empathetically and nonjudgmentally.These external controls provide long-term comfortto clients, although their initial response may beaggression. People in the manic phase have labile emotions;it is not unusual for them to strike staff members who haveset limits in a way clients dislike.These clients physically and psychologically invadeboundaries. It is necessary to set limits when they cannot setlimits on themselves. For example, the nurse might say,for ManiaNURSING INTERVENTIONS• Provide for client’s physical safety and those around.• Set limits on client’s behavior when needed.• Remind the client to respect distances between self andothers.• Use short, simple sentences to communicate.• Clarify the meaning of client’s communication.• Frequently provide finger foods that are high in caloriesand protein.• Promote rest and sleep.• Protect the client’s dignity when inappropriate behavioroccurs.• Channel client’s need for movement into sociallyacceptable motor activities.

CHAPTER 15 • MOOD DISORDERS 305or“John, you are too close to my face. Please standback 2 feet.”“It is unacceptable to hug other clients. You maytalk to others, but do not touch them.”When setting limits, it is important to clearly identifythe unacceptable behavior and the expected, appropriatebehavior. All staff must consistently set and enforce limitsfor those limits to be effective.Meeting Physiologic NeedsClients with mania may get very little rest or sleep, even ifthey are on the brink of physical exhaustion. Medicationmay be helpful, though clients may resist taking it. Decreasingenvironmental stimulation may assist clients to relax.The nurse provides a quiet environment without noise,television, or other distractions. Establishing a bedtimeroutine, such as a tepid bath, may help clients to calmdown enough to rest.Nutrition is another area of concern. Manic clients maybe too “busy” to sit down and eat, or they may have suchpoor concentration that they fail to stay interested in foodfor very long. “Finger foods” or things clients can eat whilemoving around are the best options to improve nutrition.Such foods also should be as high in calories and proteinas possible. For example, celery and carrots are fingerfoods, but they supply little nutrition. Sandwiches, proteinbars, and fortified shakes are better choices. Clients withmania also benefit from food that is easy to eat withoutmuch preparation. Meat that must be cut into bite sizes orplates of spaghetti are not likely to be successful options.Having snacks available between meals, so clients can eatwhenever possible, is also useful.The nurse needs to monitor food and fluid intake andhours of sleep until clients routinely meet these needswithout difficulty. Observing and supervising clients atmeal times are also important to prevent clients from takingfood from others.Providing Therapeutic CommunicationClients with mania have short attention spans, so the nurseuses clear, simple sentences when communicating. Theymay not be able to handle a lot of information at once, sothe nurse breaks information into many small segments. Ithelps to ask clients to repeat brief messages to ensure theyhave heard and incorporated them.Clients may need to undergo baseline and follow-uplaboratory tests. A brief explanation of the purpose of eachtest allays anxiety. The nurse gives printed information toreinforce verbal messages, especially those related to rules, schedules,civil rights, treatment, staff names, and client education.The speech of manic clients may be pressured: rapid,circumstantial, rhyming, noisy, or intrusive with flightsof ideas. Such disordered speech indicates thought processesthat are flooded with thoughts, ideas, andimpulses. The nurse must keep channels of communicationopen with clients, regardless of speech patterns.The nurse can say,“Please speak more slowly. I’m having troublefollowing you.”This puts the responsibility for the communication difficultyon the nurse rather than on the client. This nursepatiently and frequently repeats this request during conversationbecause clients will return to rapid speech.Clients in the manic phase often use pronouns whenreferring to people, making it difficult for listeners tounderstand who is being discussed and when the conversationhas moved to a new subject. While clients are agitatedlytalking, they usually are thinking and moving justas quickly, so it is a challenge for the nurse to follow acoherent story. The nurse can ask clients to identify eachperson, place, or thing being discussed.When speech includes flight of ideas, the nurse can askclients to explain the relationship between topics—forexample,or“What happened then?”“Was that before or after you got married?”The nurse also assesses and documents the coherenceof messages.Clients with pressured speech rarely let others speak.Instead, they talk nonstop until they run out of steam orjust stand there looking at the other person before movingaway. Those with pressured speech do not respond to others’verbal or nonverbal signals that indicate a desire tospeak. The nurse avoids becoming involved in powerstruggles over who will dominate the conversation. Instead,the nurse may talk to clients away from others so there isno “competition” for the nurse’s attention. The nurse alsosets limits regarding taking turns speaking and listening aswell as giving attention to others when they need it. Clientswith mania cannot have all requests granted immediatelyeven though that may be their desire.

306UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSPromoting Appropriate BehaviorsThese clients need to be protected from their pursuit of sociallyunacceptable and risky behaviors. The nurse can direct theirneed for movement into socially acceptable, large motor activitiessuch as arranging chairs for a community meeting or walking.In acute mania, clients lose the ability to control theirbehavior and engage in risky activities. Because acutely manicclients feel extraordinarily powerful, they place few restrictionson themselves. They act out impulsive thoughts, have inflatedand grandiose perceptions of their abilities, are demanding,and need immediate gratification. This can affect their physical,social, occupational, or financial safety as well as that ofothers. Clients may make purchases that exceed their ability topay. They may give away money or jewelry or other possessions.The nurse may need to monitor a client’s access to suchitems until his or her behavior is less impulsive.In an acute manic episode, clients also may lose sexualinhibitions, resulting in provocative and risky behaviors.Clothing may be flashy or revealing, or clients may undress inpublic areas. They may engage in unprotected sex with virtualstrangers. Clients may ask staff members or other clients (ofthe same or opposite sex) for sex, graphically describe sexualacts, or display their genitals. The nurse handles such behaviorin a matter-of-fact, nonjudgmental manner. For example,“Mary, let’s go to your room and find a sweater.”It is important to treat clients with dignity and respectdespite their inappropriate behavior. It is not helpful to“scold” or chastise them; they are not children engaging inwillful misbehavior.In the manic phase, clients cannot understand personalboundaries, so it is the staff’s role to keep clients in viewfor intervention as necessary. For example, a staff memberwho sees a client invading the intimate space of others cansay,“Jeffrey, I’d appreciate your help in setting up acircle of chairs in the group therapy room.”This large motor activity distracts Jeffrey from his inappropriatebehavior, appeals to his need for heightenedphysical activity, is noncompetitive, and is socially acceptable.The staff’s vigilant redirection to a more sociallyappropriate activity protects clients from the hazards ofunprotected sex and reduces embarrassment over suchbehaviors when they return to normal behavior.Managing MedicationsLithium is not metabolized; rather, it is reabsorbed by theproximal tubule and excreted in the urine. Periodic serumlithium levels are used to monitor the client’s safety and toensure that the dose given has increased the serum lithiumlevel to a treatment level or reduced it to a maintenance level.There is a narrow range of safety among maintenance levels(0.5 to 1 mEq/L), treatment levels (0.8 to 1.5 mEq/L), andtoxic levels (1.5 mEq/L and above). It is important to assessfor signs of toxicity and to ensure that clients and their familieshave this information before discharge (Table 15.8).Table 15.8SYMPTOMS AND INTERVENTIONS OF LITHIUM TOXICITYSerum Lithium Level Symptoms of Lithium Toxicity Interventions1.5–2 mEq/L Nausea and vomiting, diarrhea, reducedcoordination, drowsiness, slurredspeech, and muscle weakness2–3 mEq/L Ataxia, agitation, blurred vision, tinnitus,giddiness, choreoathetoid movements,confusion, muscle fasciculation,hyperreflexia, hypertonic muscles, myoclonictwitches, pruritus, maculopapularrash, movement of limbs, slurred speech,large output of dilute urine, incontinenceof bladder or bowel, and vertigo3.0 mEq/L and above Cardiac arrhythmia, hypotension, peripheralvascular collapse, focal or generalizedseizures, reduced levels ofconsciousness from stupor to coma,myoclonic jerks of muscle groups, andspasticity of musclesWithhold next dose; call physician. Serum lithiumlevels are ordered and doses of lithium are usuallysuspended for a few days or the dose isreduced.Withhold future doses, call physician, stat serumlithium level. Gastric lavage may be used toremove oral lithium; IV containing saline andelectrolytes used to ensure fluid and electrolytefunction and maintain renal function.All preceding interventions plus lithium ion excretionis augmented with use of aminophylline,mannitol, or urea. Hemodialysis may also beused to remove lithium from the body. Respiratory,circulatory, thyroid, and immune systemsare monitored and assisted as needed.

CHAPTER 15 • MOOD DISORDERS 307Older adults can have symptoms of toxicity at lower serumlevels. Lithium is potentially fatal in overdose.Clients should drink adequate water (approximately2 L/day) and continue with the usual amount of dietarytable salt. Having too much salt in the diet because ofunusually salty foods or the ingestion of salt-containingantacids can reduce receptor availability for lithium andincrease lithium excretion, so the lithium level will betoo low. If there is too much water, lithium is diluted andthe lithium level will be too low to be therapeutic. Drinkingtoo little water or losing fluid through excessivesweating, vomiting, or diarrhea increases the lithiumlevel, which may result in toxicity. Monitoring dailyweights and the balance between intake and output andchecking for dependent edema can be helpful in monitoringfluid balance. The physician should be contactedif the client has diarrhea, fever, flu, or any condition thatleads to dehydration.Thyroid function tests usually are ordered as a baselineand every 6 months during treatment with lithium.In 6 to 18 months, one third of clients taking lithiumhave an increased level of thyroid-stimulating hormone,which can cause anxiety, labile emotions, and sleepingdifficulties. Decreased levels are implicated in fatigue anddepression.Because most lithium is excreted in the urine, baselineand periodic assessments of renal status are necessary toassess renal function. The reduced renal function in olderadults necessitates lower doses. Lithium is contraindicatedin people with compromised renal function or urinaryretention and those taking low-salt diets or diuretics. Lithiumalso is contraindicated in people with brain or cardiovasculardamage.Providing Client and Family TeachingEducating clients about the dangers of risky behavior isnecessary; however, clients with acute mania largely fail toheed such teaching because they have little patience orcapacity to listen, understand, and see the relevance of thisinformation. Clients with euphoria may not see why thebehavior is a problem because they believe they can doanything without impunity. As they begin to cycle towardnormalcy, however, risky behavior lessens, and they becomeready and able for teaching.Manic clients start many tasks, create many goals, andtry to carry them out all at once. The result is that theycannot complete any. They move readily between thesegoals while sometimes obsessing about the importance ofone over another, but the goals can quickly change. Clientsmay invest in a business in which they have noknowledge or experience, go on spending sprees, impulsivelytravel, speed, make new “best friends,” and takethe center of attention in any group. They are egocentricand have little concern for others except as listeners, sexualpartners, or the means to achieve one of their poorlyconceived goals.CLIENT FAMILY EDUCATIONfor Mania• Teach about bipolar illness and ways to manage thedisorder.• Teach about medication management, including theneed for periodic blood work and management of sideeffects.• For clients taking lithium, teach about the need foradequate salt and fluid intake.• Teach the client and family about signs of toxicity andthe need to seek medical attention immediately.• Educate the client and family about risk-taking behaviorand how to avoid it.• Teach about behavioral signs of relapse and how toseek treatment in early stages.Education about the cause of bipolar disorder, medicationmanagement, ways to deal with behaviors, andpotential problems that manic people can encounter isimportant for family members. Education reduces theguilt, blame, and shame that accompany mental illness;increases client safety; enlarges the support system forclients and the family members; and promotes compliance.Education takes the “mystery” out of treatment formental illness by providing a proactive view: this is whatwe know, this is what can be done, and this is what youcan do to help.Family members often say they know clients havestopped taking their medication when, for example, clientsbecome more argumentative, talk about buyingexpensive items that they cannot afford, hotly deny anythingis wrong, or demonstrate any other signs of escalatingmania. People sometimes need permission to act ontheir observations, so a family education session is anappropriate place to give this permission and to set upinterventions for various behaviors.Clients should learn to adhere to the established dosageof lithium and not to omit doses or change dosageintervals; unprescribed dosage alterations interfere withmaintenance of serum lithium levels. Clients shouldknow about the many drugs that interact with lithiumand should tell each physician they consult that theyare taking lithium. When a client taking lithium seemsto have increased manic behavior, lithium levels shouldbe checked to determine whether there is lithium toxicity.Periodic monitoring of serum lithium levels is necessaryto ensure the safety and adequacy of the treatmentregimen. Persistent thirst and diluted urine canindicate the need to call a physician and have the serumlithium level checked to see if the dosage needs to bereduced.

308UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSClients and family members should know the symptomsof lithium toxicity and interventions to take, includingbackup plans if the physician is not immediately available.The nurse should give these in writing and explain them toclients and family.EvaluationEvaluation of the treatment of bipolar disorder includesbut is not limited to the following:• Safety issues• Comparison of mood and affect between start of treatmentand present• Adherence to treatment regimen of medication andpsychotherapy• Changes in client’s perception of quality of life• Achievement of specific goals of treatment includingnew coping methodsSUICIDESuicide is the intentional act of killing oneself. Suicidalthoughts are common in people with mood disorders,especially depression. Each year, more than 30,000 suicidesare reported in the United States; suicide attempts are estimatedto be 8 to 10 times higher. In the United States, mencommit approximately 72% of suicides, which is roughlythree times the rate of women, although women are fourtimes more likely than men to attempt suicide. The highersuicide rates for men are partly the result of the methodchosen (e.g., shooting, hanging, jumping from a highplace). Women are more likely to overdose on medication.Men, young women, whites, and separated and divorcedpeople are at increased risk for suicide. Adults older thanage 65 years compose 10% of the population but accountfor 25% of suicides. Suicide is the second leading cause ofdeath (after accidents) among people 15 to 24 years ofage, and the rate of suicide is increasing most rapidly in thisage group (Andreasen & Black, 2006).Clients with psychiatric disorders, especially depression,bipolar disorder, schizophrenia, substance abuse,posttraumatic stress disorder, and borderline personalitydisorder, are at increased risk for suicide (Rihmer, 2007).Chronic medical illnesses associated with increased risk forsuicide include cancer, HIV or AIDS, diabetes, cerebrovascularaccidents, and head and spinal cord injury. Environmentalfactors that increase suicide risk include isolation,recent loss, lack of social support, unemployment, criticallife events, and family history of depression or suicide.Behavioral factors that increase risk include impulsivity,erratic or unexplained changes from usual behavior, andunstable lifestyle (Smith et. al., 2008).Suicidal ideation means thinking about killing oneself.Active suicidal ideation is when a person thinks about andseeks ways to commit suicide. Passive suicidal ideation iswhen a person thinks about wanting to die or wishes he orshe were dead but has no plans to cause his or her death.People with active suicidal ideation are considered morepotentially lethal.Attempted suicide is a suicidal act that either failed orwas incomplete. In an incomplete suicide attempt, the persondid not finish the act because (1) someone recognizedthe suicide attempt as a cry for help and responded or (2)the person was discovered and rescued (Sudak, 2005).Suicide involves ambivalence. Many fatal accidentsmay be impulsive suicides. It is impossible to know, forexample, whether the person who drove into a telephonepole did this intentionally. Hence, keeping accurate statisticson suicide is difficult. There are also many mythsand misconceptions about suicide of which the nurseshould be aware. The nurse must know the facts andwarning signs for those at risk for suicide as described inBox 15.2.AssessmentA history of previous suicide attempts increases risk forsuicide. The first 2 years after an attempt represent thehighest risk period, especially the first 3 months. Thosewith a relative who committed suicide are at increased riskfor suicide: the closer the relationship, the greater the risk.One possible explanation is that the relative’s suicide offersa sense of “permission” or acceptance of suicide as a methodof escaping a difficult situation. This familiarity and acceptancealso is believed to contribute to “copycat suicides” byteenagers, who are greatly influenced by their peers’ actions(Sudak, 2005).Many people with depression who have suicidal ideationlack the energy to implement suicide plans. Thenatural energy that accompanies increased sunlight inspring is believed to explain why most suicides occur inApril. Most suicides happen on Monday mornings, whenmost people return to work (another energy spurt).Research has shown that antidepressant treatment actuallycan give clients with depression the energy to act on suicidalideation (Sudak, 2005).Warnings of Suicidal IntentMost people with suicidal ideation send either direct orindirect signals to others about their intent to harm themselves.The nurse never ignores any hint of suicidal ideationregardless of how trivial or subtle it seems and theclient’s intent or emotional status. Often, people contemplatingsuicide have ambivalent and conflicting feelingsabout their desire to die; they frequently reach out to othersfor help. For example, a client might say,“I keep thinking about taking my entire supplyof medications to end it all” (direct) or “I justcan’t take it anymore” (indirect).

CHAPTER 15 • MOOD DISORDERS 309BOX 15.2 MYTHS AND FACTS ABOUT SUICIDEMythsPeople who talk about suicide never commitsuicide.Suicidal people only want to hurt themselves,not others.There is no way to help someone who wants tokill himself or herself.Do not mention the word suicide to a personyou suspect to be suicidal, because this couldgive him or her the idea to commit suicide.Ignoring verbal threats of suicide or challenginga person to carry out his or her suicide plans willreduce the individual’s use of these behaviors.Once a suicide risk, always a suicide risk.FactsSuicidal people often send out subtle or not-so-subtle messages thatconvey their inner thoughts of hopelessness and self-destruction.Both subtle and direct messages of suicide should be taken seriouslywith appropriate assessments and interventions.Although the self-violence of suicide demonstrates anger turnedinward, the anger can be directed toward others in a planned orimpulsive action.Physical harm: Psychotic people may be responding to innervoices that command the individual to kill others before killingthe self. A depressed person who has decided to commit suicidewith a gun may impulsively shoot the person who tries to grabthe gun in an effort to thwart the suicide.Emotional harm: Often, family members, friends, health care professionals,and even police involved in trying to avert a suicide orthose who did not realize the person’s depression and plans tocommit suicide feel intense guilt and shame because of their failureto help and are “stuck” in a never-ending cycle of despair andgrief. Some people, depressed after the suicide of a loved one,will rationalize that suicide was a “good way out of the pain” andplan their own suicide to escape pain. Some suicides are plannedto engender guilt and pain in survivors, e.g., as someone whowants to punish another for rejecting or not returning love.Suicidal people have mixed feelings (ambivalence) about their wishto die, wish to kill others, or to be killed. This ambivalence oftenprompts the cries for help evident in overt or covert cues. Interventioncan help the suicidal individual get help from situational supports,choose to live, learn new ways to cope, and move forward inlife.Suicidal people have already thought of the idea of suicide and mayhave begun plans. Asking about suicide does not cause a nonsuicidalperson to become suicidal.Suicidal gestures are a potentially lethal way to act out. Threatsshould not be ignored or dismissed, nor should a person be challengedto carry out suicidal threats. All plans, threats, gestures,or cues should be taken seriously and immediate help given thatfocuses on the problem about which the person is suicidal.When asked about suicide, it is often a relief for the client toknow that his or her cries for help have been heard and that help ison the way.Although it is true that most people who successfully commit suicidehave made attempts at least once before, most people withsuicidal ideation can have positive resolution to the suicidal crisis.With proper support, finding new ways to resolve the problem helpsthese individuals become emotionally secure and have no furtherneed for suicide as a way to resolve a problem.

310UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 15.3 SUICIDAL IDEATION: CLIENT STATEMENTS AND NURSE RESPONSESClient StatementNurse Responses“I just want to go to sleep and not think anymore.” “Specifically just how are you planning to sleep and notthink anymore?”“By ‘sleep,’ do you mean ‘die’?”“What is it you do not want to think of anymore?”“I want it to be all over.” “I wonder if you are thinking of suicide.”“What is it you specifically want to be over?”“It will just be the end of the story.”“Are you planning to end your life?”“How do you plan to end your story?”“You have been a good friend.”“You sound as if you are saying good-bye. Are you?”“Remember me.”“Are you planning to commit suicide?”“What is it you really want me to remember about you?”“Here is my chess set that you have always admired.” “What is going on that you are giving away things toremember you by?”“If there is ever any need for anyone to know this, mywill and insurance papers are in the top drawer of mydresser.”“I appreciate your trust. However, I think there is an importantmessage you are giving me. Are you thinking of endingyour life?”“I can’t stand the pain anymore.” “How do you plan to end the pain?”“Tell me about the pain.”“Sounds like you are planning to harm yourself.”“Everyone will feel bad soon.”“Who is the person you want to feel bad by killingyourself?”“I just can’t bear it anymore.” “What is it you cannot bear?”“How do you see an end to this?”“Everyone would be better off without me.”“Who is one person you believe would be better off withoutyou?”“How do you plan to eliminate yourself, if you think everyonewould be better off without you?”“What is one way you perceive others would be better offwithout you?”Nonverbal change in behavior from agitated to calm,anxious to relaxed, depressed to smiling, hostile tobenign, from being without direction to appearing tobe goal directed“You seem different today. What is this about?”“I sense you have reached a decision. Share it with me.”Box 15.3 provides more examples of client statementsabout suicide and effective responses from the nurse.Asking clients directly about thoughts of suicide is important.Psychiatric admission assessment interview formsroutinely include such questions. It is also standard practiceto inquire about suicide or self-harm thoughts in any settingwhere people seek treatment for emotional problems.Risky BehaviorsA few people who commit suicide give no warning signs.Some artfully hide their distress and suicide plans. Others actimpulsively by taking advantage of a situation to carry outthe desire to die. Some suicidal people in treatment describeplacing themselves in risky or dangerous situations such asspeeding in a blinding rainstorm or when intoxicated. This“Russian roulette” approach carries a high risk for harm toclients and innocent bystanders alike. It allows clients to feelbrave by repeatedly confronting death and surviving.Lethality AssessmentWhen a client admits to having a “death wish” or suicidalthoughts, the next step is to determine potential

CHAPTER 15 • MOOD DISORDERS 311lethality. This assessment involves asking the followingquestions:• Does the client have a plan? If so, what is it? Is the planspecific?• Are the means available to carry out this plan? (For example,if the person plans to shoot himself, does hehave access to a gun and ammunition?)• If the client carries out the plan, is it likely to be lethal?(For example, a plan to take 10 aspirin is not lethal,while a plan to take a 2-week supply of a tricyclicantidepressant is.)• Has the client made preparations for death, such as givingaway prized possessions, writing a suicide note, ortalking to friends one last time?• Where and when does the client intend to carry out theplan?• Is the intended time a special date or anniversary thathas meaning for the client?Specific and positive answers to these questions all increasethe client’s likelihood of committing suicide. It is importantto consider whether or not the client believes her orhis method is lethal even if it is not. Believing a method tobe lethal poses a significant risk.Outcome IdentificationSuicide prevention usually involves treating the underlyingdisorder, such as mood disorder or psychosis, withpsychoactive agents. The overall goals are first to keep theclient safe and later to help him or her to develop new copingskills that do not involve self-harm. Other outcomesmay relate to activities of daily living, sleep and nourishmentneeds, and problems specific to the crisis such asstabilization of psychiatric illness/symptoms.Examples of outcomes for a suicidal person include thefollowing:• The client will be safe from harming self or others.• The client will engage in a therapeutic relationship.• The client will establish a no-suicide contract.• The client will create a list of positive attributes.• The client will generate, test, and evaluate realistic plansto address underlying issues.InterventionUsing an Authoritative RoleIntervention for suicide or suicidal ideation becomes the firstpriority of nursing care. The nurse assumes an authoritativerole to help clients stay safe. In this crisis situation, clients seefew or no alternatives to resolve their problems. The nurselets clients know their safety is the primary concern and takesprecedence over other needs or wishes. For example, a clientmay want to be alone in her room to think privately. This isnot allowed while she is at increased risk for suicide.Providing a Safe EnvironmentInpatient hospital units have policies for general environmentalsafety. Some policies are more liberal than others,but all usually deny clients access to materials on cleaningcarts, their own medications, sharp scissors, and penknives.For suicidal clients, staff members remove anyitem they can use to commit suicide, such as sharp objects,shoelaces, belts, lighters, matches, pencils, pens, and evenclothing with drawstrings.Again, institutional policies for suicide precautionsvary, but usually staff members observe clients every10 minutes if lethality is low. For clients with high potentiallethality, one-to-one supervision by a staff person isinitiated. This means that clients are in direct sight of andno more than 2 to 3 feet away from a staff member for allactivities, including going to the bathroom. Clients areunder constant staff observation with no exceptions. Thismay be frustrating or upsetting to clients, so staff membersusually need to explain the purpose of such supervisionmore than once.No-suicide or no-self-harm contracts have been usedwith suicidal clients. In such contracts, clients agree tokeep themselves safe and to notify staff at the first impulseto harm themselves (at home, clients agree to notify theircaregivers; the contract must identify backup people incase caregivers are unavailable). These contracts, however,are not a guarantee of safety, and their use has been sharplycriticized (McMyler & Pryjmachuk, 2008). At no timeshould a nurse assume that a client is safe based on a singlestatement by the client. Rather a complete assessment anda thorough discussion with the client are more reliable.Creating a Support System ListSuicidal clients often lack social support systems such asrelatives and friends or religious, occupational, and communitysupport groups. This lack may result from socialwithdrawal, behavior associated with a psychiatric or medicaldisorder, or movement of the person to a new areabecause of school, work, or change in family structure orfinancial status. The nurse assesses support systems and thetype of help each person or group can give a client. Mentalhealth clinics, hotlines, psychiatric emergency evaluationservices, student health services, church groups, and selfhelpgroups are part of the community support system.The nurse makes a list of specific names and agenciesthat clients can call for support; he or she obtains clientconsent to avoid breach of confidentiality. Many suicidalpeople do not have to be admitted to a hospital and can betreated successfully in the community with the help ofthese support people and agencies.Family ResponseSuicide is the ultimate rejection of family and friends.Implicit in the act of suicide is the message to others thattheir help was incompetent, irrelevant, or unwelcome.

312UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSSome suicides are done to place blame on a certainperson—even to the point of planning how that personwill be the one to discover the body. Most suicides areefforts to escape untenable situations. Even if a personbelieves love for family members prompted his or her suicide—asin the case of someone who commits suicide toavoid lengthy legal battles or to save the family the financialand emotional cost of a lingering death—relatives stillgrieve and may feel guilt, shame, and anger.Significant others may feel guilty for not knowing howdesperate the suicidal person was, angry because the persondid not seek their help or trust them, ashamed thattheir loved one ended his or her life with a socially unacceptableact, and sad about being rejected. Suicide is newsworthy,and there may be whispered gossip and even newscoverage. Life insurance companies may not pay survivors’benefits to families of those who kill themselves. Also, theone death may spark “copycat suicides” among familymembers or others, who may believe they have been givenpermission to do the same. Families can disintegrate aftera suicide.Nurse’s ResponseWhen dealing with a client who has suicidal ideation orattempts, the nurse’s attitude must indicate unconditionalpositive regard not for the act but for the person and his orher desperation. The ideas or attempts are serious signalsof a desperate emotional state. The nurse must convey thebelief that the person can be helped and can grow andchange.Trying to make clients feel guilty for thinking of orattempting suicide is not helpful; they already feel incompetent,hopeless, and helpless. The nurse does not blameclients or act judgmentally when asking about the detailsof a planned suicide. Rather, the nurse uses a nonjudgmentaltone of voice and monitors his or her body languageand facial expressions to make sure not to conveydisgust or blame.Nurses believe that one person can make a difference inanother’s life. They must convey this belief when caringfor suicidal people. Nevertheless, nurses also must realizethat no matter how competent and caring interventionsare, a few clients will still commit suicide. A client’s suicidecan be devastating to the staff members who treatedhim or her, especially if they have gotten to know the personand his or her family well over time. Even with therapy,staff members may end up leaving the health carefacility or the profession as a result.Legal and Ethical ConsiderationsAssisted suicide is a topic of national legal and ethicaldebate, with much attention focusing on the court decisionsrelated to the actions of Dr. Jack Kevorkian, a physicianwho has participated in numerous assisted suicides.Oregon was the first state to adopt assisted suicide into lawand has set up safeguards to prevent indiscriminate assistedsuicide. Many people believe it should be legal in any statefor health care professionals or family to assist those whoare terminally ill and want to die. Others view suicide asagainst the laws of humanity and religion and believe thathealth care professionals should be prosecuted if theyassist those trying to die. Groups, such as the HemlockSociety, and people, such as Dr. Kevorkian, are lobbyingfor changes in laws that would allow health care professionalsand family members to assist with suicide attemptsfor the terminally ill. Controversy and emotion continueto surround the issue.Often, nurses must care for terminally or chronically illpeople with a poor quality of life, such as those with theintractable pain of terminal cancer or severe disability orthose kept alive by life-support systems. It is not the nurse’srole to decide how long these clients must suffer. It is thenurse’s role to provide supportive care for clients and familyas they work through the difficult emotional decisionsabout if and when these clients should be allowed to die;people who have been declared legally dead can be disconnectedfrom life support. Each state has defined legal deathand the ways to determine it.Elder ConsiderationsSakauye (2008) reports that depression is common amongthe elderly and is markedly increased when elders aremedically ill. Elders tend to have psychotic features, particularlydelusions, more frequently than younger peoplewith depression. Suicide among persons older than age 65is doubled compared with suicide rates of persons youngerthan 65. Late-onset bipolar disorder is rare.Elders are treated for depression with ECT more frequentlythan younger persons. Elder persons haveincreased intolerance of side effects of antidepressantmedications and may not be able to tolerate doses highenough to effectively treat the depression. Also, ECT producesa more rapid response than medications, which maybe desirable if the depression is compromising the medicalhealth of the elder person. Because suicide among theelderly is increased, the most rapid response to treatmentbecomes even more important (Sakauye, 2008).COMMUNITY-BASED CARENurses in any area of practice in the community frequentlyare the first health care professionals to recognize behaviorsconsistent with mood disorders. In some cases, a familymember may mention distress about a client’s withdrawalfrom activities; difficulty thinking, eating, and sleeping;complaints of being tired all the time; sadness; and agitation(all symptoms of depression). They might also mentioncycles of euphoria, spending binges, loss of inhibitions,changes in sleep and eating patterns, and loud clothingstyles and colors (all symptoms of the manic phase

CHAPTER 15 • MOOD DISORDERS 313Antidepressants and Suicide RiskDepressed clients who begin taking an antidepressant mayhave a continued or increased risk for suicide in the first fewweeks of therapy. They may experience an increase in energyfrom the antidepressant but remain depressed. Thisincrease in energy may make clients more likely to act onsuicidal ideas and able to carry them out. Also, because antidepressantstake several weeks to reach their peak effect,clients may become discouraged and act on suicidal ideasbecause they believe the medication is not helping them.For these reasons, it is extremely important to monitor thesuicidal ideation of depressed clients until the risk hassubsided.of bipolar disorder). Documenting and reporting suchbehaviors can help these people to receive treatment. Estimatesare that nearly 40% of people who have been diagnosedwith a mood disorder do not receive treatment(Akiskal, 2005). Contributing factors may include thestigma still associated with mental disorders, the lack ofunderstanding about the disruption to life that mood disorderscan cause, confusion about treatment choices, or amore compelling medical diagnosis; these combine with thereality of limited time that health care professionals devoteto any one client.People with depression can be treated successfully inthe community by psychiatrists, psychiatric advancedpractice nurses, and primary care physicians. People withbipolar disorder, however, should be referred to a psychiatristor psychiatric advanced practice nurse for treatment.The physician or nurse who treats a person with bipolardisorder must understand the drug treatment, dosages,desired effects, therapeutic levels, and potential side effectsso that he or she can answer questions and promote compliancewith treatment.MENTAL HEALTH PROMOTIONMany studies have been conducted to determine how toprevent mood disorders and suicide, but prediction of suiciderisk in clinical practice remains difficult. Programsthat use an educational approach designed to address theunique stressors that contribute to the increased incidenceof depressive illness in women have had some success.These programs focus on increasing self-esteem and reducingloneliness and hopelessness, which in turn decreasethe likelihood of depression.Efforts to improve primary care treatment of depressionhave built upon a chronic illness care model that includespatient self-management, or helping people be better preparedto deal with life issues and changes. This includeshaving a partnership with their provider, having a crisis orrelapse prevention plan, creating a social support network,and making needed behavioral changes to promote health(Bachman, Swensen, Reardon, & Miller, 2006).Because suicide is a leading cause of death among adolescents,prevention, early detection, and treatment arevery important. Strengthening protective factors (thosefactors associated with a reduction in suicide risk) wouldimprove the mental health of adolescents. Protective factorsinclude close parent–child relationships, academicachievement, family-life stability, and connectedness withpeers and others outside the family. School-based programscan be universal (general information for allstudents) or indicated (targeting young people at risk).Indicated or selective programs have been more successfulthan universal programs (Horowitz & Garber, 2006; Rapeeet al., 2006). Likewise, screening for early detection of riskfactors such as family strife, parental alcoholism or mentalillness, history of fighting, and access to weapons in thehome can lead to referral and early intervention.SELF-AWARENESS ISSUESNurses working with clients who aredepressed often empathize with them andalso begin to feel sad or agitated. They mayunconsciously start to avoid contact withthese clients to escape such feelings. The nurse mustmonitor his or her feelings and reactions closely whendealing with clients with depression to be sure he or shefulfills the responsibility to establish a therapeutic nurse–client relationship.People with depression are usually negative, pessimistic,and unable to generate new ideas easily. They feelhopeless and incompetent. The nurse easily can becomeconsumed with suggesting ways to fix the problems. Mostclients find some reason why the nurse’s solutions will notwork: “I have tried that,” “It would never work,” “I don’thave the time to do that,” or “You just don’t understand.”Rejection of suggestions can make the nurse feel incompetentand question his or her professional skill. Unless aclient is suicidal or is experiencing a crisis, the nurse doesnot try to solve the client’s problems. Instead, the nurseuses therapeutic techniques to encourage clients to generatetheir own solutions. Studies have shown that clientstend to act on plans or solutions they generate rather thanthose that others offer (Schultz & Videbeck, 2009). Findingand acting on their own solutions gives clients renewedcompetence and self-worth.Working with clients who are manic can be exhausting.They are so hyperactive that the nurse may feel spent ortired after caring for them. The nurse may feel frustratedbecause these clients engage in the same behaviors repeatedly,such as being intrusive with others, undressing,

314UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSsinging, rhyming, and dancing. It takes hard work toremain patient and calm with the manic client, but it isessential for the nurse to provide limits and redirection ina calm manner until the client can control his or her ownbehavior independently.Some health care professionals consider suicidal peopleto be failures, immoral, or unworthy of care. These negativeattitudes may result from several factors. They may reflectsociety’s negative view of suicide: many states still have lawsagainst suicide, although they rarely enforce these laws.Health care professionals may feel inadequate and anxiousdealing with suicidal clients, or they may be uncomfortableabout their own mortality. Many people have had thoughtsabout “ending it all,” even if for a fleeting moment when lifeis not going well. The scariness of remembering such flirtationswith suicide causes anxiety. If this anxiety is notresolved, the staff person can demonstrate avoidance,demeaning behavior, and superiority to suicidal clients.Therefore, to be effective, the nurse must be aware of his orher own feelings and beliefs about suicide.Points to Consider When Working withClients with Mood Disorders• Remember that clients with mania may seem happy, butthey are suffering inside.• For clients with mania, delay client teaching until theacute manic phase is resolving.• Schedule specific, short periods with depressed or agitatedclients to eliminate unconscious avoidance ofthem.• Do not try to fix a client’s problems. Use therapeutictechniques to help him or her find solutions.• Use a journal to deal with frustration, anger, or personalneeds.• If a particular client’s care is troubling, talk with anotherprofessional about the plan of care, how it is beingcarried out, and how it is working.Critical Thinking Questions1. Is it possible for someone to make a “rational” decisionto commit suicide? Under what circumstances?2. Are laws ethical that permit physician-assisted suicide?Why or why not?3. A person with bipolar disorder frequently discontinuestaking medication when out of the hospital, becomesmanic, and engages in risky behavior such as speeding,drinking and driving, and incurring large debts. Howdo you reconcile the client’s right to refuse medicationwith public or personal safety? Who should makesuch a decision? How could it be enforced?KEY POINTS• Studies have found a genetic component tomood disorders. The incidence of depressionis up to three times greater in first-degree relativesof people with diagnosed depression.People with bipolar disorder usually have a blood relativewith bipolar disorder.• Only 9% of people with mood disorders exhibit psychosis.• Major depression is a mood disorder that robs the personof joy, self-esteem, and energy. It interferes withrelationships and occupational productivity.• Symptoms of depression include sadness, disinterest inpreviously pleasurable activities, crying, lack of motivation,asocial behavior, and psychomotor retardation(slowed thinking, talking, and movement). Sleep disturbances,somatic complaints, loss of energy, change inweight, and a sense of worthlessness are other commonfeatures.• Several antidepressants are used to treat depression.SSRIs, the newest type, have the fewest side effects. Tricyclicantidepressants are older and have a longer lagperiod before reaching adequate serum levels; they arethe least expensive type. MAOIs are used least: Clientsare at risk for hypertensive crisis if they ingest tyraminerichfoods and fluids while taking these drugs. MAOIsalso have a lag period before reaching adequate serumlevels.• People with bipolar disorder cycle between mania, normalcy,and depression. They also may cycle only betweenmania and normalcy or between depression andnormalcy.• Clients with mania have a labile mood, are grandioseand manipulative, have high self-esteem, and believethey are capable of anything. They sleep little, are alwaysin frantic motion, invade others’ boundaries, cannotsit still, and start many tasks. Speech is rapid andpressured, reflects rapid thinking, and may be circumstantialand tangential with features of rhyming, punning,and flight of ideas. Clients show poor judgmentwith little sense of safety needs and take physical, financial,occupational, or interpersonal risks.• Lithium is used to treat bipolar disorder. It is helpful forbipolar mania and can partially or completely eradicatecycling toward bipolar depression. Lithium is effectivein 75% of clients but has a narrow range of safety; thus,ongoing monitoring of serum lithium levels is necessaryto establish efficacy while preventing toxicity. Clientstaking lithium must ingest adequate salt and water toavoid overdosing or underdosing because lithium saltuses the same postsynaptic receptor sites as sodiumchloride does. Other antimanic drugs include sodiumvalproate, carbamazepine, other anticonvulsants, andclonazepam, which is also a benzodiazepine.• For clients with mania, the nurse must monitor foodand fluid intake, rest and sleep, and behavior, with a

CHAPTER 15 • MOOD DISORDERS 315INTERNET RESOURCESRESOURCES• American Association of Suicidology• Suicide Prevention Resource Center• Depression Information and Support• Depression Issues• National Institute of Mental Health Suicide ResearchConsortium• Postpartum Depression Resources• SAD AssociationINTERNET ADDRESShttp://www.suicidology.org/web/guest/homehttp://www.sprc.orghttp://www.depression.about.comhttp://www.bipolardepressioninfo.comhttp://www.depressionissues.comhttp://www.squidoo.com/postpartumhttp://babyparenting.about.com/b/a/132722.htmhttp://www.sada.org.uk/focus on safety, until medications reduce the acute stageand clients resume responsibility for themselves.• Suicidal ideation means thinking of suicide.• People with increased rates of suicide include singleadults, divorced men, adolescents, older adults, the verypoor or very wealthy, urban dwellers, migrants, students,whites, people with mood disorders, substanceabusers, people with medical or personality disorders,and people with psychosis.• The nurse must be alert to clues to a client’s suicidalintent—both direct (making threats of suicide) and indirect(giving away prized possessions, putting his orher life in order, making vague good-byes).• Conducting a suicide lethality assessment involves determiningthe degree to which the person has plannedhis or her death, including time, method, tools, place,person to find the body, reason, and funeral plans.• Nursing interventions for a client at risk for suicide involvekeeping the person safe by instituting a no-suicidecontract, ensuring close supervision, and removing objectsthat the person could use to commit suicide.REFERENCESAkiskal, H. S. (2005). Mood disorders: Historical introduction and conceptualoverview. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensivetextbook of psychiatry (Vol. 1, 8th ed., pp. 1559–1575). Philadelphia:Lippincott Williams & Wilkins.American Psychiatric Association [APA]. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington,DC: Author.Andreasen, N. C., & Black, D. W. (2006). Introductory textbook of psychiatry(4th ed.). Washington, DC: American Psychiatric Publishing.Andrews, M. M., & Boyle, J. S. (2007). Transcultural concepts in nursingcare (5th ed.). Philadelphia: Lippincott Williams & Wilkins.Bachman, J., Swensen, S., Reardon, M. E., & Miller, D. (2006). Patientself-management in the primary care treatment of depression.Administration and Policy in Mental Health, 33(1), 76–85.Bowden, C. L. (2006). Valproate. In A. F Schatzberg & C. B. Nemeroff(Eds.), Essentials of clinical pharmacology (2nd ed., pp. 355–366).Washington, DC: American Psychiatric Publishing.Eitan, R., & Lerer, B. (2006). Nonpharmacological, somatic treatmentsof depression: Electroconvulsive therapy and novel brain stimulationmodalities. Dialogues in Clinical Neuroscience, 8(2), 241–258.Facts and Comparisons (2009). Drug facts and comparisons (63rd ed.).St. Louis: Facts and Comparisons: A Wolters Kluwer Company.Fenton, L., Fasula, M., Ostroff, R., & Sanacora, G. (2006). Can cognitivebehavioral therapy reduce relapse rates of depression after ECT? Apreliminary study. Journal of ECT, 22(3), 196–198.Frederikse, M., Petrides, G., & Kellner, C. (2006). Continuation andmaintenance electroconvulsive therapy for the treatment of depressiveillness: A response to the National Institute for ClinicalExcellence report. (2006). Journal of ECT, 22(1), 13–17.Freeman, M. P., Wiegand, C., & Gelenberg, A. J. (2006). Lithium. InA. F. Schatzberg & C. B. Nemeroff (Eds.), Essentials of clinical pharmacology(2nd ed., pp. 335–354). Washington, DC: AmericanPsychiatric Publishing.Horowitz, J. L., & Garber, J. (2006). The prevention of depressive symptomsin children and adolescents: A meta-analytic review. Journal ofConsulting and Clinical Psychology, 74(3), 401–415.Kelsoe, J. R. (2005). Mood disorders: Genetics. In B. J. Sadock & V.A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8thed., pp. 1582–1594). Philadelphia: Lippincott Williams & Wilkins.Ketter, T. A., Wang, P. W., & Post, R. M. (2006). Carbamazepine andoxcarbazepine. In A. F. Schatzberg & C. B. Nemeroff (Eds.). Essentialsof clinical pharmacology (2nd ed., pp. 367–393). Washington, DC:American Psychiatric Publishing.Markowitz, J. C., & Milrod, B. (2005). Mood disorders: Intrapsychic andinterpersonal aspects. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1603–1611).Philadelphia: Lippincott Williams & Wilkins.McMyler, C., & Pryjmachuk, S. (2008). Do “no-suicide” contractswork? Journal of Psychiatric and Mental Health Nursing, 15(6),512–522.Rapee, R. M., Wignall, A., Sheffield, J., et al. (2006). Adolescents’ reactionsto universal and indicated prevention programs for depression:Perceived stigma and consumer satisfaction. Prevention Science, 7(2),167–177.Rastad, C., Ulfberg, J., & Lindberg, P. (2008). Light room therapy effectivein mild forms of seasonal affective disorder—A randomizedcontrolled study. Journal of Affective Disorders, 108(3), 291–296.Rihmer, Z. (2007). Suicide risk in mood disorders. Current Opinion inPsychiatry, 20(1), 17–22.Rihmer, Z., & Angst, J. (2005). Mood disorders: Epidemiology. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1575–1582). Philadelphia: Lippincott Williams& Wilkins.Ross, C. A. (2006). The sham ECT literature: Implications for consent toECT. Ethical Human Psychology and Psychiatry, 8(1), 17–28.

316UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSRush, A. J. (2005). Mood disorders: Treatment of depression. In B. J. Sadock& V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8thed., pp. 1652–1661). Philadelphia: Lippincott Williams & Wilkins.Sakauye, K. (2008). Geriatric psychiatry basics. New York: W. W. Norton& Co.Schultz, J. M., & Videbeck, S. (2009). Lippincott’s manual of psychiatric nursingcare plans (8th ed.). Philadelphia: Lippincott Williams & Wilkins.Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A review of postpartumpsychosis. Journal of Women’s Health, 15(4), 352–368.Smith, A. R., Witte, T. K., Teale, N. E., King, S. L., Bender, T. W., &Joiner, T. E. (2008). Revisiting impulsivity in suicide: Implicationsfor civil liability of third parties. Behavioral Sciences & the Law, 26(6),779–797.Sudak, H. S. (2005). Suicide. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 2, 8th ed., pp. 2442–2453).Philadelphia: Lippincott Williams & Wilkins.Tecott, L. H., & Smart, S. L. (2005). Monoamine neurotransmitters. InB. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 49–60). Philadelphia: Lippincott Williams& Wilkins.Thase, M. E. (2005). Mood disorders: Neurobiology. In B. J. Sadock &V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8thed., pp. 1594–1603). Philadelphia: Lippincott Williams & Wilkins.ADDITIONAL READINGSCrocker, L., Clare, L., & Evans, K. (2006). Giving up or finding a solution?The experience of attempted suicide in later life. Aging &Mental Health, 10(6), 638–647.King, M., Semylen, J., Tai, J. J., Killaspy, H., Osborn, D., Popelyuk, D., et al.(2008). A systematic review of mental disorder, suicide, and deliberateself harm in lesbian, gay, and bisexual people. BMC Psychiatry, 8, 70.Lurie, S. J., Gawinski, B., Pierce, D., & Rousseau, S. J. (2006). Seasonalaffective disorder. American Family Physician, 74(9), 1521–1524.Ratnarajah, D., & Schofield, M. J. (2008). Survivors’ narratives of theimpact of parental suicide. Suicide & Life-threatening Behavior, 38(5),618–630.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The nurse observes that a client with bipolar disorder ispacing in the hall, talking loudly and rapidly, and usingelaborate hand gestures. The nurse concludes that theclient is demonstrating which of the following?a. Aggressionb. Angerc. Anxietyd. Psychomotor agitation2. A client with bipolar disorder begins taking lithiumcarbonate (lithium), 300 mg four times a day. After3 days of therapy, the client says, “My hands are shaking.”The best response by the nurse isa. “Fine motor tremors are an early effect of lithiumtherapy that usually subsides in a few weeks.”b. “It is nothing to worry about unless it continues forthe next month.”c. “Tremors can be an early sign of toxicity, but we’llkeep monitoring your lithium level to make sureyou’re okay.”d. “You can expect tremors with lithium. You seem veryconcerned about such a small tremor.”3. What are the most common types of side effects fromSSRIs?a. Dizziness, drowsiness, and dry mouthb. Convulsions and respiratory difficultiesc. Diarrhea and weight gaind. Jaundice and agranulocytosis4. The nurse observes that a client with depression sat at atable with two other clients during lunch. The bestfeedback the nurse could give the client is:a. “Do you feel better after talking with others duringlunch?”b. “I’m so happy to see you interacting with otherclients.”c. “I see you were sitting with others at lunch today.”d. “You must feel much better than you were a few daysago.”5. Which of the following typifies the speech of a personin the acute phase of mania?a. Flight of ideasb. Psychomotor retardationc. Hesitantd. Mutism6. What is the rationale for a person taking lithium tohave enough water and salt in his or her diet?a. Salt and water are necessary to dilute lithium toavoid toxicity.b. Water and salt convert lithium into a usable solute.c. Lithium is metabolized in the liver, necessitatingincreased water and salt.d. Lithium is a salt that has greater affinity for receptorsites than sodium chloride.7. Identify the serum lithium level for maintenance andsafety.a. 0.1 to 1.0 mEq/Lb. 0.5 to 1.5 mEq/Lc. 10 to 50 mEq/Ld. 50 to 100 mEq/L8. A client says to the nurse, “You are the best nurse I’veever met. I want you to remember me.” What is anappropriate response by the nurse?a. “Thank you. I think you are special too.”b. “I suspect you want something from me. What isit?”c. “You probably say that to all your nurses.”d. “Are you thinking of suicide?”9. A client with mania begins dancing around the dayroom. When she twirled her skirt in front of the maleclients, it was obvious she had no underpants on. Thenurse distracts her and takes her to her room to put onunderpants. The nurse acted as she did to:a. Minimize the client’s embarrassment about her presentbehavior.b. Keep her from dancing with other clients.c. Avoid embarrassing the male clients who arewatching.d. Teach her about proper attire and hygiene.317

318 UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Which of the following would indicate an increasedsuicidal risk?a. An abrupt improvement in mood.b. Calling family members to make amends.c. Crying when discussing sadness.d. Feeling overwhelmed by simple daily tasks.e. Statements such as “I’m such a burden for everyone.”f. Statements such as “Everything will be better soon.”2. Which of the following activities would be appropriatefor a client with mania?a. Drawing a pictureb. Modeling clayc. Playing bingod. Playing table tennise. Stretching exercisesf. Stringing beadsCLINICAL EXAMPLEJune, 46 years old, is divorced with three children: 10, 13, and 16 years of age. She worksin the county clerk’s office and has called in sick four times in the past 2 weeks. June haslost 17 pounds in the past 2 months, is spending a lot of time in bed, but still feels exhausted“all the time.” During the admission interview, June looks overwhelmingly sad, is tearful,has her head down, and makes little eye contact. She answers the nurse’s questionswith one or two words. The nurse considers postponing the remainder of the interviewbecause June seems unable to provide much information.1. What assessment data are crucial for the nurse to obtain before ending the interview?2. Identify three nursing diagnoses on the basis of the available data.3. Identify a short-term outcome for each of the nursing diagnoses.4. Discuss nursing interventions that would be helpful for June.

16Personality DisordersLearning ObjectivesAfter reading this chapter, you should be able to:Key Terms• antisocial personality disorder• avoidant personality disorder• borderline personality disorder• character• cognitive restructuring• confrontation• decatastrophizing• dependent personality disorder• depressive personality disorder• dysphoric• histrionic personality disorder• limit setting• narcissistic personality disorder• no-self-harm contract• obsessive–compulsivepersonality disorder• paranoid personality disorder• passive-aggressive personalitydisorder• personality• personality disorders• positive self-talk• schizoid personality disorder• schizotypal personality disorder• temperament• thought stopping• time-out1. Describe personality disorders in terms of the client’s difficulty in perceiving,relating to, and thinking about self, others, and the environment.2. Discuss factors thought to influence the development of personalitydisorders.3. Apply the nursing process to the care of clients with personality disorders.4. Provide education to clients, families, and community members to increasetheir knowledge and understanding of personality disorders.5. Evaluate personal feelings, attitudes, and responses to clients with personalitydisorders.PERSONALITY CAN BE DEFINED as an ingrained enduring pattern of behavingand relating to self, others, and the environment; it includes perceptions,attitudes, and emotions. These behaviors and characteristics areconsistent across a broad range of situations and do not change easily. Aperson usually is not consciously aware of her or his personality. Manyfactors influence personality: some stem from biologic and geneticmakeup, whereas some are acquired as a person develops and interactswith the environment and other people.Personality disorders are diagnosed when personality traits becomeinflexible and maladaptive and significantly interfere with how a personfunctions in society or cause the person emotional distress. They usually arenot diagnosed until adulthood, when personality is more completely formed.Nevertheless, maladaptive behavioral patterns often can be traced to earlychildhood or adolescence. Although there can be great variance among clientswith personality disorders, many experience significant impairment infulfilling family, academic, employment, and other functional roles.Diagnosis is made when the person exhibits enduring behavioral patternsthat deviate from cultural expectations in two or more of the following areas:• Ways of perceiving and interpreting self, other people, and events(cognition)• Range, intensity, lability, and appropriateness of emotional response (affect)Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!319

320UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS• Interpersonal functioning• Ability to control impulses or express behavior at theappropriate time and place (impulse control)Personality disorders are longstanding because personalitycharacteristics do not change easily. Thus, clientswith personality disorders continue to behave in theirsame familiar ways even when these behaviors cause themdifficulties or distress. No specific medication alters personality,and therapy designed to help clients make changesis often long term with very slow progress. Some peoplewith personality disorders believe their problems stemfrom others or the world in general; they do not recognizetheir own behavior as the source of difficulty. For thesereasons, people with personality disorders are difficult totreat, which may be frustrating for the nurse and othercaregivers as well as for family and friends. There are alsodifficulties in diagnosing and treating clients with personalitydisorders because of similarities and subtle differencesbetween categories or types. Types often overlap,and many people with personality disorders also havecoexisting mental illnesses.CATEGORIES OF PERSONALITY DISORDERSThe Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision (DSM-IV-TR; American PsychiatricAssociation [APA], 2000) lists personality disorders asa separate and distinct category from other major mentalillnesses. They are on axis II of the multiaxial classificationsystem (see Chapter 1). The DSM-IV-TR classifies personalitydisorders into “clusters,” or categories, based on thepredominant or identifying features (Box 16.1):• Cluster A includes people whose behavior appears oddor eccentric and includes paranoid, schizoid, andschizotypal personality disorders.Box 16.1DSM-IV-TR PERSONALITYDISORDER CATEGORIESCluster A: Individuals whose behavior appears odd oreccentric (paranoid, schizoid, and schizotypal personalitydisorders)Cluster B: Individuals who appear dramatic, emotional,or erratic (antisocial, borderline, histrionic, and narcissisticpersonality disorders)Cluster C: Individuals who appear anxious or fearful(avoidant, dependent, and obsessive–compulsive personalitydisorders)Proposed personality disorder categories: depressive andpassive-aggressive personality disordersAdapted from American Psychiatric Association. (2000). DSM-IV-TR:Diagnostic and statistical manual of mental disorders (4th ed., textrevision). Washington, DC: APA.• Cluster B includes people who appear dramatic, emotional,or erratic and includes antisocial, borderline,histrionic, and narcissistic personality disorders.• Cluster C includes people who appear anxious or fearfuland includes avoidant, dependent, and obsessive–compulsive personality disorders.In psychiatric settings, nurses most often encounter clientswith antisocial and borderline personality disorders.Thus, these two disorders are the primary focus of thischapter. Clients with antisocial personality disorder mayenter a psychiatric setting as part of a court-ordered evaluationor as an alternative to jail. Clients with borderlinepersonality disorder often are hospitalized because theiremotional instability may lead to self-inflicted injuries.This chapter discusses the other personality disordersbriefly. Most clients with these disorders are not treated inacute care settings for these personality disorders. Nursesmay encounter these clients in any health-care setting orin the psychiatric setting when a client is already hospitalizedfor another major mental illness.Two disorders currently being studied for inclusion aspersonality disorders are depressive and passive-aggressivepersonality disorders, both of which are included in theDSM-IV-TR. This chapter discusses them briefly as well.ONSET AND CLINICAL COURSEPersonality disorders are relatively common, occurring in10% to 13% of the general population. Incidence is evenhigher for people in lower socioeconomic groups and unstableor disadvantaged populations. Fifteen percent of all psychiatricinpatients have a primary diagnosis of a personalitydisorder. Forty percent to 45% of those with a primary diagnosisof major mental illness also have a coexisting personalitydisorder that significantly complicates treatment. Inmental health outpatient settings, the incidence of personalitydisorder is 30% to 50% (Svrakic & Cloninger, 2005).Clients with personality disorders have a higher death rate,especially as a result of suicide; they also have higher ratesof suicide attempts, accidents, and emergency departmentvisits and increased rates of separation, divorce, and involvementin legal proceedings regarding child custody (Svrakic& Cloninger, 2005). Personality disorders have been correlatedhighly with criminal behavior (70% to 85% of criminalshave personality disorders), alcoholism (60% to 70% ofalcoholics have personality disorders), and drug abuse (70%to 90% of those who abuse drugs have personality disorders;Svrakic & Cloninger, 2005).People with personality disorders often are described as“treatment resistant.” This is not surprising, consideringthat personality characteristics and behavioral patterns aredeeply ingrained. It is difficult to change one’s personality;if such changes occur, they evolve slowly. The slow courseof treatment can be very frustrating for family, friends, andhealth-care providers.

CHAPTER 16 • PERSONALITY DISORDERS 321Another barrier to treatment is that many clients withpersonality disorders do not perceive their dysfunctional ormaladaptive behaviors as a problem; indeed, sometimesthese behaviors are a source of pride. For example, a belligerentor aggressive person may perceive himself or herself ashaving a strong personality and being someone who can’t betaken advantage of or pushed around. Clients with personalitydisorders frequently fail to understand the need tochange their behavior and may view changes as a threat.The difficulties associated with personality disorderspersist throughout young and middle adulthood but tendto diminish in the 40s and 50s. Those with antisocial personalitydisorder are less likely to engage in criminalbehavior, although problems with substance abuse anddisregard for the feelings of others persist. Clients withborderline personality disorder tend to demonstratedecreased impulsive behavior, increased adaptive behavior,and more stable relationships by 50 years of age. Thisincreased stability and improved behavior can occur evenwithout treatment. Some personality disorders, such asschizoid, schizotypal, paranoid, avoidant, and obsessive–compulsive, tend to remain consistent throughout life.ETIOLOGYBiologic TheoriesPersonality develops through the interaction of hereditarydispositions and environmental influences. Temperamentrefers to the biologic processes of sensation, association,and motivation that underlie the integration of skills andhabits based on emotion. Genetic differences account forabout 50% of the variances in temperament traits.The four temperament traits are harm avoidance, noveltyseeking, reward dependence, and persistence. Each ofthese four genetically influenced traits affects a person’sautomatic responses to certain situations. These responsepatterns are ingrained by 2 to 3 years of age (Svrakic &Cloninger, 2005).People with high harm avoidance exhibit fear of uncertainty,social inhibition, shyness with strangers, rapid fatigability,and pessimistic worry in anticipation of problems.Those with low harm avoidance are carefree, energetic,outgoing, and optimistic. High harm-avoidance behaviorsmay result in maladaptive inhibition and excessive anxiety.Low harm-avoidance behaviors may result in unwarrantedoptimism and unresponsiveness to potential harmor danger.A high novelty-seeking temperament results in someonewho is quick tempered, curious, easily bored, impulsive,extravagant, and disorderly. He or she may be easilybored and distracted with daily life, prone to angry outbursts,and fickle in relationships. The person low in noveltyseeking is slow tempered, stoic, reflective, frugal,reserved, orderly, and tolerant of monotony; he or she mayadhere to a routine of activities.Reward dependence defines how a person responds tosocial cues. People high in reward dependence are tenderhearted,sensitive, sociable, and socially dependent. Theymay become overly dependent on approval from othersand readily assume the ideas or wishes of others withoutregard for their own beliefs or desires. People with lowreward dependence are practical, tough minded, cold,socially insensitive, irresolute, and indifferent to beingalone. Social withdrawal, detachment, aloofness, and disinterestin others can result.Highly persistent people are hardworking and ambitiousoverachievers who respond to fatigue or frustrationas a personal challenge. They may persevere even when asituation dictates they should change or stop. People withlow persistence are inactive, indolent, unstable, and erratic.They tend to give up easily when frustrated and rarelystrive for higher accomplishments.These four genetically independent temperament traitsoccur in all possible combinations. Some of the previousdescriptions of high and low levels of traits correspondclosely with the descriptions of the various personalitydisorders. For example, people with antisocial personalitydisorder are low in harm-avoidance traits and high innovelty-seeking traits, whereas people with dependentpersonality disorder are high in reward-dependence traitsand harm-avoidance traits.Psychodynamic TheoriesAlthough temperament is largely inherited, social learning,culture, and random life events unique to each personinfluence character. Character consists of concepts aboutthe self and the external world. It develops over time as aperson comes into contact with people and situations andconfronts challenges. Three major character traits havebeen distinguished: self-directedness, cooperativeness,and self-transcendence. When fully developed, thesecharacter traits define a mature personality (Svrakic &Cloninger, 2005).Self-directedness is the extent to which a person isresponsible, reliable, resourceful, goal oriented, and selfconfident.Self-directed people are realistic and effective andcan adapt their behavior to achieve goals. People low in selfdirectednessare blaming, helpless, irresponsible, and unreliable.They cannot set and pursue meaningful goals.Cooperativeness refers to the extent to which a personsees himself or herself as an integral part of human society.Highly cooperative people are described as empathic, tolerant,compassionate, supportive, and principled. Peoplewith low cooperativeness are self-absorbed, intolerant,critical, unhelpful, revengeful, and opportunistic; that is,they look out for themselves without regard for the rightsand feelings of others.Self-transcendence describes the extent to which a personconsiders himself or herself to be an integral part of the universe.Self-transcendent people are spiritual, unpretentious,

322UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERShumble, and fulfilled. These traits are helpful when dealingwith suffering, illness, or death. People low in selftranscendenceare practical, self-conscious, materialistic,and controlling. They may have difficulty accepting suffering,loss of control, personal and material losses, and death.Character matures in stepwise stages from infancythrough late adulthood. Chapter 3 discusses psychologicaldevelopment according to Freud, Erikson, and others.Each stage has an associated developmental task that theperson must perform for mature personality development.Failure to complete a developmental task jeopardizes theperson’s ability to achieve future developmental tasks. Forexample, if the task of basic trust is not achieved in infancy,mistrust results and subsequently interferes with achievementof all future tasks.Experiences with family, peers, and others can significantlyinfluence psychosocial development. Social educationin the family creates an environment that can supportor oppress specific character development. For example, afamily environment that does not value and demonstratecooperation with others (compassion or tolerance) fails tosupport the development of that trait in its children. Likewise,the person with nonsupportive or difficult peer relationshipsgrowing up may have lifelong difficulty relatingto others and forming satisfactory relationships.In summary, personality develops in response to inheriteddispositions (temperament) and environmental influences(character), which are experiences unique to eachperson. Personality disorders result when the combinationof temperament and character development produces maladaptive,inflexible ways of viewing self, coping with theworld, and relating to others.CULTURAL CONSIDERATIONSJudgments about personality functioning must involve aconsideration of the person’s ethnic, cultural, and socialbackground (APA, 2000). Members of minority groups,immigrants, political refugees, and people from differentethnic backgrounds may display guarded or defensivebehavior as a result of language barriers or previous negativeexperiences; this should not be confused with paranoidpersonality disorder. People with religious or spiritualbeliefs, such as clairvoyance, speaking in tongues, or evilspirits as a cause of disease, could be misinterpreted ashaving schizotypal personality disorder.There is also a difference in how some cultural groupsview avoidance or dependent behavior, particularly forwomen. An emphasis on deference, passivity, and politenessshould not be confused with a dependent personalitydisorder. Cultures that value work and productivity mayproduce citizens with a strong emphasis in these areas;this should not be confused with obsessive–compulsivepersonality disorder.Certain personality disorders—for example, antisocialand schizoid personality disorders—are diagnosed moreoften in men. Borderline and histrionic personalitydisorders are diagnosed more often in women. Socialstereotypes about typical gender roles and behaviorscan influence diagnostic decisions if clinicians areunaware of such biases.TREATMENTSeveral treatment strategies are used with clients with personalitydisorders; these strategies are based on the disorder’stype and severity or the amount of distress or functionalimpairment the client experiences. Combinations of medicationand group and individual therapies are more likely to beeffective than is any single treatment (Svrakic & Cloninger,2005). Not all people with personality disorders seek treatment,however, even when significant others urge them todo so. Typically, people with paranoid, schizoid, schizotypal,narcissistic, and passive-aggressive personality disorders areleast likely to engage or remain in any treatment. They seeother people, rather than their own behavior, as the cause oftheir problems.PsychopharmacologyPharmacologic treatment of clients with personality disordersfocuses on the client’s symptoms rather than the particularsubtype. The four symptom categories that underliepersonality disorders are cognitive–perceptual distortions,including psychotic symptoms; affective symptoms andmood dysregulation; aggression and behavioral dysfunction;and anxiety. These four symptom categories relate tothe underlying temperaments that distinguish the DSM-IV-TR clusters of personality disorders:• Low reward dependence and cluster A disorders correspondto the categories of affective dysregulation, detachment,and cognitive disturbances.• High novelty seeking and cluster B disorders correspondto the target symptoms of impulsiveness andaggression.• High harm avoidance and cluster C disorders correspondto the categories of anxiety and depressionsymptoms.Cognitive–perceptual disturbances include magical thinking,odd beliefs, illusions, suspiciousness, ideas of reference,and low-grade psychotic symptoms. These chronicsymptoms usually respond to low-dose antipsychoticmedications (Simeon & Hollander, 2006).Several types of aggression have been described in peoplewith personality disorders. Aggression may occur inimpulsive people (some with a normal electroencephalogramand some with an abnormal one); people who exhibitpredatory or cruel behavior; or people with organic-likeimpulsivity, poor social judgment, and emotional lability.Lithium, anticonvulsant mood stabilizers, and benzodiazepinesare used most often to treat aggression. Low-dose

CHAPTER 16 • PERSONALITY DISORDERS 323neuroleptics may be useful in modifying predatory aggression(Simeon & Hollander, 2006).Mood dysregulation symptoms include emotionalinstability, emotional detachment, depression, and dysphoria.Emotional instability and mood swings respondfavorably to lithium, carbamazepine (Tegretol), valproate(Depakote), or low-dose neuroleptics such ashaloperidol (Haldol). Emotional detachment, cold andaloof emotions, and disinterest in social relations oftenrespond to selective serotonin reuptake inhibitors oratypical antipsychotics such as risperidone (Risperdal),olanzapine (Zyprexa), and quetiapine (Seroquel). Atypicaldepression is often treated with selective serotoninreuptake inhibitors, monoamine oxidase inhibitor antidepressants,or low-dose antipsychotic medications(Simeon & Hollander, 2006).Anxiety seen with personality disorders may be chroniccognitive anxiety, chronic somatic anxiety, or severe acuteanxiety. Chronic cognitive anxiety responds to selectiveserotonin reuptake inhibitors and monoamine oxidaseinhibitors, as does chronic somatic anxiety or anxietymanifested as multiple physical complaints. Episodes ofsevere acute anxiety are best treated with monoamine oxidaseinhibitors or low-dose antipsychotic medications.Table 16.1 summarizes drug choices for various targetsymptoms of personality disorders. These drugs, includingside effects and nursing considerations, are discussedin detail in Chapter 2.Individual and Group PsychotherapyTherapy helpful to clients with personality disorders variesaccording to the type and severity of symptoms and the particulardisorder. Inpatient hospitalization usually is indicatedwhen safety is a concern, for example, when a person withborderline personality disorder has suicidal ideas or engagesin self-injury. Otherwise, hospitalization is not useful andmay even result in dependence on the hospital and staff.Individual and group psychotherapy goals for clientswith personality disorders focus on building trust, teachingbasic living skills, providing support, decreasing distressingsymptoms such as anxiety, and improving interpersonalrelationships. Relaxation or meditation techniques can helpmanage anxiety for clients with cluster C personality disorders.Improvement in basic living skills through the relationshipwith a case manager or therapist can improve thefunctional skills of people with schizotypal and schizoidpersonality disorders. Assertiveness training groups canassist people with dependent and passive-aggressive personalitydisorders to have more satisfying relationships withothers and to build self-esteem.Cognitive–behavioral therapy has been particularlyhelpful for clients with personality disorders (Lynch, Trost,Salsman, & Linehan, 2007). Several cognitive restructuringtechniques are used to change the way the client thinksabout self and others: thought stopping, in which theTable 16.1Target SymptomAggression/impulsivityAffective aggression(normal)Predatory (hostility/cruelty)Organic-like aggressionIctal aggression (abnormal)Mood dysregulationEmotional labilityAtypical depression/dysphoriaEmotional detachmentAnxietyChronic cognitiveChronic somaticSevere anxietyPsychotic symptomsAcute and psychosisChronic and low-levelpsychotic-like symptomsDRUG CHOICESFOR SYMPTOMS OFPERSONALITY DISORDERSDrug of ChoiceLithiumAnticonvulsantsLow-dose antipsychoticsAntipsychoticsLithiumCholinergic agonists(donepezil)Imipramine (Tofranil)Carbamazepine (Tegretol)Diphenylhydantoin (Dilantin)BenzodiazepinesLithiumCarbamazepine (Tegretol)AntipsychoticsMAOIsSSRIsAntipsychoticsSSRIsAtypical antipsychoticsSSRIsMAOIsBenzodiazepinesMAOIsSSRIsMAOIsLow-dose antipsychoticsAntipsychoticsLow-dose antipsychoticsMAOIs, monoamine oxidase inhibitors; SSRIs, selective serotonin reuptake inhibitors.Adapted from Svrakic, D. M., & Cloninger, C. R. (2005). Personality disorders.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry,(Vol. 2, 8th ed., pp. 2063–2104). Philadelphia: Lippincott Williams & Wilkins.client stops negative thought patterns; positive self-talk,designed to change negative self-messages; and decatastrophizing,which teaches the client to view life events morerealistically and not as catastrophes. Examples of thesetechniques are presented later in this chapter.Dialectical behavior therapy was designed for clientswith borderline personality disorder (Linehan, 1993). Itfocuses on distorted thinking and behavior based on theassumption that poorly regulated emotions are the underlyingproblem. Table 16.2 summarizes the symptoms ofand nursing interventions for personality disorders.

324UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 16.2SUMMARY OF SYMPTOMS AND NURSING INTERVENTIONS FORPERSONALITY DISORDERSPersonality Disorder Symptoms/Characteristics Nursing InterventionsParanoidMistrust and suspicions of others; guarded,restricted affectSerious, straightforward approach; teachclient to validate ideas before takingaction; involve client in treatment planningImprove client’s functioning in the commu-SchizoidDetached from social relationships; restrictedaffect; involved with things more than people nity; assist client to find case managerSchizotypalAcute discomfort in relationships; cognitive Develop self-care skills; improve communityor perceptual distortions; eccentric behavior functioning; social skills trainingAntisocial Disregard for rights of others, rules, and laws Limit setting; confrontation; teach client tosolve problems effectively and manageemotions of anger or frustrationBorderlineUnstable relationships, self-image, and affect;impulsivity; self-mutilationPromote safety; help client to cope and controlemotions; cognitive restructuring techniques;structure time; teach social skillsHistrionic Excessive emotionality and attention seeking Teach social skills; provide factual feedbackNarcissisticAvoidantDependentObsessive –compulsiveDepressivePassive-aggressiveGrandiose; lack of empathy; need foradmirationSocial inhibitions; feelings of inadequacy;hypersensitive to negative evaluationSubmissive and clinging behavior; excessiveneed to be taken care ofPreoccupation with orderliness, perfectionism,and controlPattern of depressive cognitions and behaviorsin a variety of contextsPattern of negative attitudes and passiveresistance to demands for adequate performancein social and occupational situationsabout behaviorMatter-of-fact approach; gain cooperationwith needed treatment; teach client anyneeded self-care skillsSupport and reassurance; cognitive restructuringtechniques; promote self-esteemFoster client’s self-reliance and autonomy;teach problem-solving and decision-makingskills; cognitive restructuring techniquesEncourage negotiation with others; assist clientto make timely decisions and completework; cognitive restructuring techniquesAssess self-harm risk; provide factual feedback;promote self-esteem; increaseinvolvement in activitiesHelp client to identify feelings and expressthem directly; assist client to examine ownfeelings and behavior realisticallyCLUSTER A: PERSONALITY DISORDERSPARANOID PERSONALITY DISORDERClinical PictureParanoid personality disorder is characterized by pervasivemistrust and suspiciousness of others. Clientswith this disorder interpret others’ actions as potentiallyharmful. During periods of stress, they maydevelop transient psychotic symptoms. Incidence isestimated to be 0.5% to 2.5% of the general population;the disorder is more common in men than in women.Data about prognosis and long-term outcomes are limitedbecause most people with paranoid personalitydisorder do not readily seek or remain in treatment(APA, 2000).Clients appear aloof and withdrawn and may remain aconsiderable physical distance from the nurse; they viewthis as necessary for their protection. Clients also mayappear guarded or hypervigilant; they may survey theroom and its contents, look behind furniture or doors, andgenerally appear alert to any impending danger. They maychoose to sit near the door to have ready access to an exitor with their backs against the wall to prevent anyone fromsneaking up behind them. They may have a restrictedaffect and may be unable to demonstrate warm or empathicemotional responses such as “You look nice today” or “I’msorry you’re having a bad day.” Mood may be labile, quicklychanging from quietly suspicious to angry or hostile.Responses may become sarcastic for no apparent reason.The constant mistrust and suspicion that clients feeltoward others and the environment distorts thoughts,thought processing, and content. Clients frequently see

CHAPTER 16 • PERSONALITY DISORDERS 325malevolence in the actions of others when none exists.They may spend disproportionate time examining andanalyzing the behavior and motives of others to discoverhidden and threatening meanings. Clients often feelattacked by others and may devise elaborate plans or fantasiesfor protection.These clients use the defense mechanism of projection,which is blaming other people, institutions, orevents for their own difficulties. It is common for suchclients to blame the government for personal problems.For example, a client who gets a parking ticket may sayit is part of a plot by the police to drive him out of theneighborhood. He may engage in fantasies of retributionor devise elaborate and sometimes violent plans to geteven. Although most clients do not carry out such plans,there is a potential danger.Conflict with authority figures on the job is common;clients may even resent being given directions from asupervisor. Paranoia may extend to feelings of being singledout for menial tasks, treated as stupid, or more closelymonitored than other employees.Nursing InterventionsForming an effective working relationship with paranoidor suspicious clients is difficult. The nurse must rememberthat these clients take everything seriously and are particularlysensitive to the reactions and motivations of others.Therefore, the nurse must approach these clients in a formal,business-like manner and refrain from social chitchator jokes. Being on time, keeping commitments, and beingparticularly straightforward are essential to the success ofthe nurse–client relationship.Because these clients need to feel in control, it is importantto involve them in formulating their plans of care. Thenurse asks what the client would like to accomplish inconcrete terms, such as minimizing problems at work orgetting along with others. Clients are more likely to engagein the therapeutic process if they believe they have somethingto gain. One of the most effective interventions ishelping clients to learn to validate ideas before takingaction; however, this requires the ability to trust and tolisten to one person. The rationale for this intervention isthat clients can avoid problems if they can refrain fromtaking action until they have validated their ideas withanother person. This helps prevent clients from acting onparanoid ideas or beliefs. It also assists them to start basingdecisions and actions on reality.SCHIZOID PERSONALITY DISORDERClinical PictureSchizoid personality disorder is characterized by apervasive pattern of detachment from social relationshipsand a restricted range of emotional expression ininterpersonal settings. It occurs in approximately 0.5%to 7% of the general population and is more common inmen than in women. People with schizoid personalitydisorder avoid treatment as much as they avoid otherrelationships, unless their life circumstances changesignificantly (APA, 2000).Clients with schizoid personality disorder display aconstricted affect and little, if any, emotion. They are aloofand indifferent, appearing emotionally cold, uncaring, orunfeeling. They report no leisure or pleasurable activitiesbecause they rarely experience enjoyment. Even understress or adverse circumstances, their response appearspassive and disinterested. There is marked difficulty experiencingand expressing emotions, particularly anger oraggression. Oddly, clients do not report feeling distressedabout this lack of emotion; it is more distressing to familymembers. Clients usually have a rich and extensive fantasylife, although they may be reluctant to reveal thatinformation to the nurse or anyone else. The ideal relationshipsthat occur in the client’s fantasies are rewardingand gratifying; these fantasies, though, are in stark contrastto real-life experiences. The fantasy relationshipoften includes someone the client has met only briefly.Nevertheless, these clients can distinguish fantasies fromreality, and no disordered or delusional thought processesare evident.Clients generally are accomplished intellectually andoften involved with computers or electronics in hobbies orwork. They may spend long hours solving puzzles ormathematical problems, although they see these pursuitsas useful or productive rather than fun.Clients may be indecisive and lack future goals or direction.They see no need for planning and really have noaspirations. They have little opportunity to exercise judgmentor decision-making because they rarely engage inthese activities. Insight might be described as impaired, atleast by the social standards of others: these clients do notsee their situation as a problem and fail to understand whytheir lack of emotion or social involvement troubles others.They are self-absorbed and loners in almost all aspectsof daily life. Given an opportunity to engage with otherpeople, these clients decline. They also are indifferent topraise or criticism and are relatively unaffected by theemotions or opinions of others. They also experience dissociationfrom or no bodily or sensory pleasures. Forexample, the client has little reaction to beautiful scenery,a sunset, or a walk on the beach.Clients have a pervasive lack of desire for involvementwith others in all aspects of life. They do not have or desirefriends, rarely date or marry, and have little or no sexualcontact. They may have some connection with a firstdegreerelative, often a parent. Clients may remain in theparental home well into adulthood if they can maintainadequate separation and distance from other family members.They have few social skills, are oblivious to the socialcues or overtures of others, and do not engage in social

326UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSconversation. They may succeed in vocational areas, providedthey value their jobs and have little contact withothers in work, which typically involves computers orelectronics.Nursing InterventionsNursing interventions focus on improved functioning inthe community. If a client needs housing or a change inliving circumstances, the nurse can make referrals to socialservices or appropriate local agencies for assistance. Thenurse can help agency personnel find suitable housingthat accommodates the client’s desire and need for solitude.For example, the client with a schizoid personalitydisorder would function best in a board and care facility,which provides meals and laundry service but requireslittle social interaction. Facilities designed to promotesocialization through group activities would be lessdesirable.If the client has an identified family member as his orher primary relationship, the nurse must ascertain whetherthat person can continue in that role. If that person cannot,the client may need to establish at least a workingrelationship with a case manager in the community. Thecase manager then can help the client to obtain servicesand health care, manage finances, and so on. The clienthas a greater chance of success if he or she can relate his orher needs to one person (as opposed to neglecting importantareas of daily life).SCHIZOTYPAL PERSONALITY DISORDERClinical PictureSchizotypal personality disorder is characterized by apervasive pattern of social and interpersonal deficitsmarked by acute discomfort with and reduced capacityfor close relationships as well as by cognitive or perceptualdistortions and behavioral eccentricities. Incidence isabout 3% to 5% of the population; the disorder is slightlymore common in men than in women. Clients may experiencetransient psychotic episodes in response to extremestress. An estimated 10% to 20% of people with schizotypalpersonality disorder eventually develop schizophrenia(APA, 2000).Clients often have an odd appearance that causes othersto notice them. They may be unkempt and disheveled,and their clothes are often ill-fitting, do not match, andmay be stained or dirty. They may wander aimlessly and, attimes, become preoccupied with some environmentaldetail. Speech is coherent but may be loose, digressive, orvague. Clients often provide unsatisfactory answers toquestions and may be unable to specify or to describeinformation clearly. They frequently use words incorrectly,which makes their speech sound bizarre. For example, inresponse to a question about sleeping habits, the clientmight respond, “Sleep is slow, the REMs don’t flow.” Theseclients have a restricted range of emotions; that is, theylack the ability to experience and to express a full range ofemotions such as anger, happiness, and pleasure. Affect isoften flat and sometimes is silly or inappropriate.Cognitive distortions include ideas of reference, magicalthinking, odd or unfounded beliefs, and a preoccupationwith parapsychology, including extrasensory perceptionand clairvoyance. Ideas of reference usually involve theclient’s belief that events have special meaning for him orher; however, these ideas are not firmly fixed and delusional,as may be seen in clients with schizophrenia. Inmagical thinking, which is normal in small children, aclient believes he or she has special powers—that by thinkingabout something, he or she can make it happen. Inaddition, clients may express ideas that indicate paranoidthinking and suspiciousness, usually about the motives ofother people.Clients experience great anxiety around other people,especially those who are unfamiliar. This does not improvewith time or repeated exposures; rather, the anxiety mayintensify. This results from the belief that strangers cannotbe trusted. Clients do not view their anxiety as a problemthat arises from a threatened sense of self. Interpersonalrelationships are troublesome; therefore, clients may haveonly one significant relationship, usually with a firstdegreerelative. They may remain in their parents’ homewell into the adult years. They have a limited capacity forclose relationships, even though they may be unhappybeing alone.Clients cannot respond to normal social cues and hencecannot engage in superficial conversation. They may haveskills that could be useful in a vocational setting, but theyare not often successful in employment without supportor assistance. Mistrust of others, bizarre thinking andideas, and unkempt appearance can make it difficult forthese clients to get and to keep jobs.Nursing InterventionsThe focus of nursing care for clients with schizotypal personalitydisorder is development of self-care and socialskills and improved functioning in the community. Thenurse encourages clients to establish a daily routine forhygiene and grooming. Such a routine is important becauseit does not depend on the client to decide when hygieneand grooming tasks are necessary. It is useful for clients tohave an appearance that is not bizarre or disheveledbecause stares or comments from others can increase discomfort.Because these clients are uncomfortable aroundothers and this is not likely to change, the nurse must helpthem function in the community with minimal discomfort.It may help to ask clients to prepare a list of people inthe community with whom they must have contact, suchas a landlord, store clerk, or pharmacist. The nurse can

CHAPTER 16 • PERSONALITY DISORDERS 327then role-play interactions that clients would have witheach of these people; this allows clients to practice clearand logical requests to obtain services or to conduct personalbusiness. Because face-to-face contact is moreuncomfortable, clients may be able to make writtenrequests or to use the telephone for business. Social skillstraining may help clients to talk clearly with others and toreduce bizarre conversations. It helps to identify one personwith whom clients can discuss unusual or bizarrebeliefs, such as a social worker or a family member. Givenan acceptable outlet for these topics, clients may be able torefrain from these conversations with people who mightreact negatively.CLUSTER B: PERSONALITY DISORDERSANTISOCIAL PERSONALITY DISORDERAntisocial personality disorder is characterized by a pervasivepattern of disregard for and violation of the rights ofothers—and with the central characteristics of deceit andmanipulation. This pattern also has been referred to as psychopathy,sociopathy, or dyssocial personality disorder. Itoccurs in about 3% of the general population and is threeto four times more common in men than in women. Inprison populations, about 50% are diagnosed with antisocialpersonality disorder. Antisocial behaviors tend to peakin the 20s and diminish significantly after 45 years of age(APA, 2000).APPLICATION OF THE NURSING PROCESS:ANTISOCIAL PERSONALITY DISORDERAssessmentClients are skillful at deceiving others, so during assessment,it helps to check and to validate information fromother sources.HistoryOnset is in childhood or adolescence, although formaldiagnosis is not made until the client is 18 years of age.Childhood histories of enuresis, sleepwalking, and syntonicacts of cruelty are characteristic predictors. In adolescence,clients may have engaged in lying, truancy, sexualpromiscuity, cigarette smoking, substance use, and illegalactivities that brought them into contact with police.Families have high rates of depression, substance abuse,antisocial personality disorder, poverty, and divorce. Erratic,neglectful, harsh, or even abusive parenting frequentlymarks the childhoods of these clients (Bongers, Koot, vander Ende, & Verhulst, 2007).General Appearance and Motor BehaviorAppearance usually is normal; these clients may be quiteengaging and even charming. Depending on theDSM-IV-TR DIAGNOSTIC CRITERIA:Antisocial Personality Disorder• Violation of the rights of others• Lack of remorse for behavior• Shallow emotions• Lying• Rationalization of own behavior• Poor judgment• Impulsivity• Irritability and aggressiveness• Lack of insight• Thrill-seeking behaviors• Exploitation of people in relationships• Poor work history• Consistent irresponsibilityAdapted from DSM-IV-TR (2000).CLINICAL VIGNETTE: ANTISOCIAL PERSONALITY DISORDERSteve found himself in the local jail again after beingarrested for burglary. Steve had told the police it wasn’tbreaking and entering; he had his friend’s permission touse his parents’ home, but they’d just forgotten to leavethe key. Steve has a long juvenile record of truancy, fighting,and marijuana use, which he blames on “having thewrong friends.” This is his third arrest, and Steve claimsthe police are picking on him ever since an elderly lady inthe community gave him $5,000 when he was out ofwork. He intends to pay her back when his ship comes in.Steve’s wife of 3 years left him recently, claiming hecouldn’t hold a decent job and was running up bills theycouldn’t pay. Steve was tired of her nagging and wasready for a new relationship anyway. He wishes he couldwin the lottery and find a beautiful girl to love him. He’stired of people demanding that he grow up, get a job, andsettle down. They just don’t understand that he’s got moreexciting things to do.

328UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERScircumstances of the interview, they may exhibit signs ofmild or moderate anxiety, especially if another person oragency arranged the assessment.Mood and AffectClients often display false emotions chosen to suit theoccasion or to work to their advantage. For example, a clientwho is forced to seek treatment instead of going to jailmay appear engaging or try to evoke sympathy by sadlyrelating a story of his or her “terrible childhood.” The client’sactual emotions are quite shallow.These clients cannot empathize with the feelings ofothers, which enables them to exploit others without guilt.Usually, they feel remorse only if they are caught breakingthe law or exploiting someone.Thought Process and ContentClients do not experience disordered thoughts, but theirview of the world is narrow and distorted. Because coercionand personal profit motivate them, they tend tobelieve that others are similarly governed. They view theworld as cold and hostile and therefore rationalize theirbehavior. Clichés such as “It’s a dog-eat-dog world” representtheir viewpoint. Clients believe they are only takingcare of themselves because no one else will.Sensorium and Intellectual ProcessesClients are oriented, have no sensory–perceptual alterations,and have average or above-average IQs.Judgment and InsightThese clients generally exercise poor judgment for variousreasons. They pay no attention to the legality of theiractions and do not consider morals or ethics when makingdecisions. Their behavior is determined primarily by whatthey want, and they perceive their needs as immediate. Inaddition to seeking immediate gratification, these clientsalso are impulsive. Such impulsivity ranges from simplefailure to use normal caution (waiting for a green light tocross a busy street) to extreme thrill-seeking behaviorssuch as driving recklessly.Clients lack insight and almost never see their actionsas the cause of their problems. It is always someone else’sfault: some external source is responsible for their situationor behavior.Self-ConceptSuperficially, clients appear confident, self-assured, andaccomplished, perhaps even flip or arrogant. They feelfearless, disregard their own vulnerability, and usuallybelieve they cannot be caught in lies, deceit, or illegalactions. They may be described as egocentric (believingthe world revolves around them), but actually the self isquite shallow and empty; these clients are devoid of personalemotions. They realistically appraise their ownstrengths and weaknesses.Roles and RelationshipsClients manipulate and exploit those around them. Theyview relationships as serving their needs and pursue othersonly for personal gain. They never think about therepercussions of their actions to others. For example, a clientis caught scamming an older person out of her entirelife savings. The client’s only comment when caught is“Can you believe that’s all the money I got? I was cheated!There should have been more.”These clients often are involved in many relationships,sometimes simultaneously. They may marry and have children,but they cannot sustain long-term commitments.They usually are unsuccessful as spouses and parents andleave others abandoned and disappointed. They mayobtain employment readily with their adept use of superficialsocial skills, but over time their work history is poor.Problems may result from absenteeism, theft, or embezzlement,or they may simply quit out of boredom.Data AnalysisPeople with antisocial personality disorder generally donot seek treatment voluntarily unless they perceive somepersonal gain from doing so. For example, a client maychoose a treatment setting as an alternative to jail or togain sympathy from an employer; they may cite stress as areason for absenteeism or poor performance. Inpatienttreatment settings are not necessarily effective for theseclients and may, in fact, bring out their worst qualities.Nursing diagnoses commonly used when working withthese clients include the following:• Ineffective Coping• Ineffective Role Performance• Risk for Other-Directed ViolenceOutcome IdentificationThe treatment focus often is behavioral change. Althoughtreatment is unlikely to affect the client’s insight or viewof the world and others, it is possible to make changesin behavior. Treatment outcomes may include thefollowing:• The client will demonstrate nondestructive ways to expressfeelings and frustration.• The client will identify ways to meet his or her ownneeds that do not infringe on the rights of others.• The client will achieve or maintain satisfactory role performance(e.g., at work or as a parent).InterventionForming a Therapeutic Relationship and PromotingResponsible BehaviorThe nurse must provide structure in the therapeutic relationship,identify acceptable and expected behaviors, and

CHAPTER 16 • PERSONALITY DISORDERS 329Nursing Care Plan | Antisocial Personality DisorderNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inabilityto use available resources.ASSESSMENT DATA• Low frustration tolerance• Impulsive behavior• Inability to delay gratification• Poor judgment• Conflict with authority• Difficulty following rules and obeying laws• Lack of feelings of remorse• Socially unacceptable behavior• Dishonesty• Ineffective interpersonal relationships• Manipulative behavior• Failure to learn or change behavior based on pastexperience or punishment• Failure to accept or handle responsibilityEXPECTED OUTCOMESImmediateThe client will• Not harm self or others• Identify behaviors leading to hospitalization• Function within limits of therapeutic milieu, e.g.,follow no-smoking rules, participate in groupactivitiesStabilizationThe client will• Demonstrate nondestructive ways to deal withstress and frustration• Identify ways to meet own needs that do notinfringe on the rights of othersCommunityThe client will• Achieve or maintain satisfactory work performance• Meet own needs without exploiting or infringing onthe rights of othersIMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Encourage the client to identify the actions that precipitatedhospitalization (e.g., debts, marital problems,law violation).Give positive feedback for honesty. The client maytry to avoid responsibility by acting as though heor she is “sick” or helpless.Identify unacceptable behaviors, either general(stealing others’ possessions) or specific(embarrassing Ms. X by telling lewd jokes).Develop specific consequences for unacceptable behaviors(e.g., the client may not watch television).Avoid any discussion about why requirements exist.State the requirement in a matter-of-fact manner.Avoid arguing with the client.Inform the client of unacceptable behaviors andthe resulting consequences in advance of theiroccurrence.RationaleThese clients frequently deny responsibility for consequencesof their own actions.Honest identification of the consequences of theclient’s behavior is necessary for future behaviorchange.You must supply clear, concrete limits when the clientis unable or unwilling to do so.Unpleasant consequences may help decrease oreliminate unacceptable behaviors. The consequencesmust be related to something the clientenjoys to be effective.The client may attempt to bend the rules “just thisonce” with numerous excuses and justifications.Your refusal to be manipulated or charmed willhelp decrease manipulative behavior.The client must be aware of expectations andconsequences.(continued)

330UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSIMPLEMENTATIONNursing Care Plan | Antisocial Personality Disorder, cont.Nursing Interventions (* denotes collaborativeinterventions)*Communicate and document in the client’s careplan all behaviors and consequences in specificterms.Avoid discussing another staff member’s actionsor statements unless the other staff memberis present.*Be consistent and firm with the care plan. Do not makeindependent changes in rules or consequences. Anychange should be made by the staff as a group and conveyedto all staff members working with this client. (Youmay designate a primary staff person to be responsible forminor decisions and refer all questions to this person.)Avoid trying to coax or convince the client to do the“right thing.”When the client exceeds a limit, provide consequencesimmediately after the behavior in amatter-of-fact manner.Point out the client’s responsibility for his or herbehavior in a nonjudgmental manner.Provide immediate positive feedback or reward foracceptable behavior.Gradually, require longer periods of acceptable behaviorand greater rewards, and inform the client of changesas decisions are made. For example, at first the clientmust demonstrate acceptable behavior for 2 hours toearn 1 hour of television time. Gradually, the clientcould progress to 5 days of acceptable behavior andearn a 2-day weekend pass.Encourage the client to identify sources of frustration,how he or she dealt with it previously, andany unpleasant consequences that resulted.Explore alternative, socially and legally acceptablemethods of dealing with identified frustrations.Help the client to try alternatives as situations arise.Give positive feedback when the client usesalternatives successfully.*Discuss job seeking, work attendance, courtappearances, and so forth when working withthe client in anticipation of discharge.RationaleThe client may attempt to gain favor with individualstaff members or play one staff member againstanother. (“Last night the nurse told me I could dothat.”) If all team members follow the written plan,the client will not be able to manipulate changes.The client may try to manipulate staff members orfocus attention on others to decrease attention tohimself or herself.Consistency is essential. If the client can find just oneperson to make independent changes, any planwill become ineffective.The client must decide to accept responsibility for hisor her behavior and its consequences.Consequences are most effective when they closelyfollow the unacceptable behavior. Do not react tothe client in an angry or punitive manner. If youshow anger toward the client, the client may takeadvantage of it. It is better to get out of the situationif possible and let someone else handle it.The client needs to learn the connection betweenbehavior and the consequences, but blame andjudgment are not appropriate.Immediate positive feedback will help to increase acceptablebehavior. The client must receive attention forpositive behaviors, not just unacceptable ones.This gradual progression will help to develop the client’sability to delay gratification. This is necessaryif the client is to function effectively in society.This may facilitate the client’s ability to acceptresponsibility for his or her own behavior.The client has the opportunity to learn to make alternativechoices.The client can role-play alternatives in a nonthreateningenvironment.Dealing with consequences and working are responsiblebehaviors. The client may have had little orno successful experience in these areas and maybenefit from assistance.Adapted from Schultz J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: Lippincott Williams & Wilkins.

CHAPTER 16 • PERSONALITY DISORDERS 331NURSING INTERVENTIONSfor Antisocial Personality DisorderPromoting responsible behavior• Limit settingState the limit.Identify consequences of exceeding the limit.Identify expected or acceptable behavior.• Consistent adherence to rules and treatment plan• ConfrontationPoint out problem behavior.Keep client focused on self.Helping clients solve problems and control emotions• Effective problem-solving skills• Decreased impulsivity• Expressing negative emotions such as anger orfrustration• Taking a time-out from stressful situationsEnhancing role performance• Identifying barriers to role fulfillment• Decreasing or eliminating use of drugs and alcoholbe consistent in those expectations. He or she must minimizeattempts by these clients to manipulate and to controlthe relationship.Limit setting is an effective technique that involvesthree steps:1. Stating the behavioral limit (describing the unacceptablebehavior)2. Identifying the consequences if the limit is exceeded3. Identifying the expected or desired behaviorConsistent limit setting in a matter-of-fact nonjudgmentalmanner is crucial to success. For example, a clientmay approach the nurse flirtatiously and attempt to gainpersonal information. The nurse would use limit settingby saying,“It is not acceptable for you to ask personalquestions. If you continue, I will terminate ourinteraction. We need to use this time to work onsolving your job-related problems.”The nurse should not become angry or respond to theclient harshly or punitively.Confrontation is another technique designed to managemanipulative or deceptive behavior. The nurse pointsout a client’s problematic behavior while remaining neutraland matter-of-fact; he or she avoids accusing the client.The nurse also can use confrontation to keep clientsfocused on the topic and in the present. The nurse canfocus on the behavior itself rather than on attempts byclients to justify it. For example:Nurse: “You’ve said you’re interested in learningto manage angry outbursts, but you’ve missedthe last three group meetings.”Client: “Well, I can tell no one in the grouplikes me. Why should I bother?”Nurse: “The group meetings are designed to help youand the others, but you can’t work on issues if you’re notthere.”Helping Clients Solve Problemsand Control EmotionsClients with antisocial personality disorder have anestablished pattern of reacting impulsively when confrontedwith problems. The nurse can teach problemsolvingskills and help clients to practice them.Problem-solving skills include identifying the problem,exploring alternative solutions and related consequences,choosing and implementing an alternative,and evaluating the results. Although these clients havethe cognitive ability to solve problems, they need tolearn a step-by-step approach to deal with them. Forexample, a client’s car isn’t running, so he stops going towork. The problem is transportation to work; alternativesolutions might be taking the bus, asking a coworkerProblem-solving skills

332UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLIENT / FAMILY EDUCATIONfor Antisocial Personality Disorder• Avoiding use of alcohol and other drugs• Appropriate social skills• Effective problem-solving skills• Managing emotions such as anger and frustration• Taking a time-out to avoid stressful situationsfor a ride, and getting the car fixed. The nurse can helpthe client to discuss the various options and choose oneso that he can go back to work.Managing emotions, especially anger and frustration,can be a major problem. When clients are calm and notupset, the nurse can encourage them to identify sources offrustration, how they respond to it, and the consequences.In this way, the nurse assists clients to anticipate stressfulsituations and to learn ways to avoid negative future consequences.Taking a time-out or leaving the area and goingto a neutral place to regain internal control is often a helpfulstrategy. Time-outs help clients to avoid impulsivereactions and angry outbursts in emotionally charged situations,regain control of emotions, and engage in constructiveproblem-solving.Enhancing Role PerformanceThe nurse helps clients to identify specific problems at workor home that are barriers to success in fulfilling roles. Assessinguse of alcohol and other drugs is essential when examiningrole performance because many clients use or abusethese substances. These clients tend to blame others for theirfailures and difficulties, and the nurse must redirect them toexamine the source of their problems realistically. Referralsto vocational or job programs may be indicated.EvaluationThe nurse evaluates the effectiveness of treatment basedon attainment of or progress toward outcomes. If a clientcan maintain a job with acceptable performance, meetbasic family responsibilities, and avoid committing illegalor immoral acts, then treatment has been successful.BORDERLINE PERSONALITY DISORDERBorderline personality disorder is characterized by apervasive pattern of unstable interpersonal relationships,self-image, and affect as well as marked impulsivity.About 2% to 3% of the general population hasborderline personality disorder; it is five times morecommon in those with a first-degree relative with thediagnosis. Borderline personality disorder is the mostDSM-IV-TR DIAGNOSTIC CRITERIA:Borderline Personality Disorder• Fear of abandonment, real or perceived• Unstable and intense relationships• Unstable self-image• Impulsivity or recklessness• Recurrent self-mutilating behavior or suicidal threatsor gestures• Chronic feelings of emptiness and boredom• Labile mood• Irritability• Polarized thinking about self and others (“splitting”)• Impaired judgment• Lack of insight• Transient psychotic symptoms such as hallucinationsdemanding self-harmAdapted from DSM-IV-TR (2000).common personality disorder found in clinical settings.It is three times more common in women than in men.Under stress, transient psychotic symptoms are common.Between 8% and 10% of people with this diagnosiscommit suicide, and many more suffer permanent damagefrom self-mutilation injuries, such as cutting orburning (APA, 2000). Typically, recurrent self- mutilationis a cry for help, an expression of intense anger or helplessness,or a form of self-punishment. The resultingphysical pain is also a means to block emotional pain.Clients who engage in self-mutilation do so to reinforcethat they are still alive; they seek to experience physicalpain in the face of emotional numbing (Mangnall &Yurkovich, 2008).Working with clients who have borderline personalitydisorder can be frustrating. They may cling and ask for helpone minute and then become angry, act out, and reject alloffers of help in the next minute. They may attempt tomanipulate staff to gain immediate gratification of needs andat times sabotage their own treatment plans by purposelyfailing to do what they have agreed. Their labile mood,unpredictability, and diverse behaviors can make it seem asif the staff is always “back to square one” with them.APPLICATION OF THE NURSING PROCESS:BORDERLINE PERSONALITY DISORDERAssessmentHistoryMany of these clients report disturbed early relationshipswith their parents that often begin at 18 to 30 months ofage. Commonly, early attempts by these clients to achieve

CHAPTER 16 • PERSONALITY DISORDERS 333developmental independence were met with punitiveresponses from parents or threats of withdrawal of parentalsupport and approval. Fifty percent of these clientshave experienced childhood sexual abuse; others haveexperienced physical and verbal abuse and parental alcoholism(Meissner, 2005). Clients tend to use transitionalobjects (e.g., teddy bears, pillows, blankets, and dolls)extensively; this may continue into adulthood. Transitionalobjects are often similar to favorite items from childhoodthat the client used for comfort or security.General Appearance and Motor BehaviorClients experience a wide range of dysfunction—fromsevere to mild. Initial behavior and presentation may varywidely depending on a client’s present status. When dysfunctionis severe, clients may appear disheveled and maybe unable to sit still, or they may display very labile emotions.In other cases, initial appearance and motor behaviormay seem normal. The client seen in the emergencyroom threatening suicide or self-harm may seem out ofcontrol, whereas a client seen in an outpatient clinic mayappear fairly calm and rational.Mood and AffectThe pervasive mood is dysphoric, involving unhappiness,restlessness, and malaise. Clients often report intenseloneliness, boredom, frustration, and feeling “empty.”They rarely experience periods of satisfaction or wellbeing.Although there is a pervasive depressed affect, it isunstable and erratic. Clients may become irritable, evenhostile or sarcastic, and complain of episodes of panic anxiety.They experience intense emotions such as anger andrage but rarely express them productively or usefully. Theyusually are hypersensitive to others’ emotions, which caneasily trigger reactions. Minor changes may precipitate asevere emotional crisis, for example, when an appointmentmust be changed from one day to the next. Commonly,these clients experience major emotional traumawhen their therapists take vacations.Thought Process and ContentThinking about self and others is often polarized andextreme, which is sometime referred to as splitting. Clientstend to adore and idealize other people even after a briefacquaintance but then quickly devalue them if theseothers do not meet their expectations in some way. Clientshave excessive and chronic fears of abandonment even innormal situations; this reflects their intolerance of beingalone. They also may engage in obsessive ruminationabout almost anything, regardless of the issue’s relativeimportance.Clients may experience dissociative episodes (periodsof wakefulness when they are unaware of their actions).Self-harm behaviors often occur during these dissociativeepisodes, although other times clients may be fully awareof injuring themselves. As stated earlier, under extremestress, clients may develop transient psychotic symptomssuch as delusions or hallucinations.Sensorium and Intellectual ProcessesIntellectual capacities are intact, and clients are fully orientedto reality. The exception is transient psychotic symptoms;during such episodes, reports of auditory hallucinationsencouraging or demanding self-harm are most common.These symptoms usually abate when the stress is relieved.Many clients also report flashbacks of previous abuse ortrauma. These experiences are consistent with posttraumaticstress disorder, which is common in clients with borderlinepersonality disorder (see Chapter 11).Judgment and InsightClients frequently report behaviors consistent with impairedjudgment and lack of care and concern for safety, such asgambling, shoplifting, and reckless driving. They makedecisions impulsively based on emotions rather than facts.Clients have difficulty accepting responsibility formeeting needs outside a relationship. They see life’s problemsand failures as a result of others’ shortcomings.Because others are always to blame, insight is limited. Atypical reaction to a problem is “I wouldn’t have gotteninto this mess if so-and-so had been there.”Unstable, unhappy affect of borderline personality disorderSelf-ConceptClients have an unstable view of themselves that shiftsdramatically and suddenly. They may appear needy and

334UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLINICAL VIGNETTE: BORDERLINE PERSONALITY DISORDERSally had been calling her therapist all day, ever sincetheir session this morning. But the therapist hadn’t calledher back, even though all her messages said this was anemergency. She was sure her therapist was angry at herand was probably going to drop her as a client. Then she’dhave no one; she’d be abandoned by the only person inthe world she could talk to. Sally was upset and crying asshe began to run the razor blade across her arm. As theblood trickled out, she began to calm down. Then hertherapist called and asked what the problem was. Sallywas sobbing as she told her therapist that she was cuttingher arm because the therapist didn’t care anymore, thatshe was abandoning Sally just like everyone else in herlife—her parents, her best friend, every man she had arelationship with. No one was ever there for her when sheneeded them.dependent one moment and angry, hostile, and rejectingthe next. Sudden changes in opinions and plans aboutcareer, sexual identity, values, and types of friends arecommon. Clients view themselves as inherently bad or eviland often report feeling as if they don’t really exist at all.Suicidal threats, gestures, and attempts are common.Self-harm and mutilation, such as cutting, punching, orburning, are common. These behaviors must be taken veryseriously because these clients are at increased risk forcompleted suicide, even if numerous previous attemptshave not been life threatening. These self-inflicted injuriescause much pain and often require extensive treatment;some result in massive scarring or permanent disabilitysuch as paralysis or loss of mobility from injury to nerves,tendons, and other essential structures.Roles and RelationshipsClients hate being alone, but their erratic, labile, andsometimes dangerous behaviors often isolate them. Relationshipsare unstable, stormy, and intense; the cyclerepeats itself continually. These clients have extremefears of abandonment and difficulty believing a relationshipstill exists once the person is away from them. Theyengage in many desperate behaviors, even suicideattempts, to gain or to maintain relationships. Feelingsfor others are often distorted, erratic, and inappropriate.For example, they may view someone they have metonly once or twice as their best and only friend or the“love of my life.” If another person does not immediatelyreciprocate their feelings, they may feel rejected, becomehostile, and declare him or her to be their enemy. Theseerratic emotional changes can occur in the space of1 hour. Often, these situations precipitate self-mutilatingbehavior; occasionally, clients may attempt to harmothers physically.Clients usually have a history of poor school and workperformance because of constantly changing career goalsand shifts in identity or aspirations, preoccupation withmaintaining relationships, and fear of real or perceivedabandonment. Clients lack the concentration and selfdisciplineto follow through on sometimes mundane tasksassociated with work or school.Physiologic and Self-Care ConsiderationsIn addition to suicidal and self-harm behavior, clients alsomay engage in binging (excessive overeating) and purging(self-induced vomiting), substance abuse, unprotectedsex, or reckless behavior such as driving while intoxicated.They usually have difficulty sleeping.Data AnalysisNursing diagnoses for clients with borderline personalitydisorder may include the following:• Risk for Suicide• Risk for Self-Mutilation• Risk for Other-Directed Violence• Ineffective Coping• Social IsolationOutcome IdentificationTreatment outcomes may include the following:• The client will be safe and free of significant injury.• The client will not harm others or destroy property.• The client will demonstrate increased control of impulsivebehavior.• The client will take appropriate steps to meet his or herown needs.• The client will demonstrate problem-solving skills.• The client will verbalize greater satisfaction withrelationships.InterventionsClients with borderline personality disorder often areinvolved in long-term psychotherapy to address issues offamily dysfunction and abuse. The nurse is most likely tohave contact with these clients during crises, when they

CHAPTER 16 • PERSONALITY DISORDERS 335NURSING INTERVENTIONSfor Borderline Personality DisorderPromoting client’s safety• No-self-harm contract• Safe expression of feelings and emotionsHelping client to cope and control emotions• Identifying feelings• Journal entries• Moderating emotional responses• Decreasing impulsivity• Delaying gratificationCognitive restructuring techniques• Thought stopping• DecatastrophizingStructuring timeTeaching social skillsTeaching effective communication skillsEntering therapeutic relationship• Limit setting• Confrontationare exhibiting self-harm behaviors or transient psychoticsymptoms. Brief hospitalizations often are used to managethese difficulties and to stabilize the client’s condition.Promoting Clients’ SafetyClients’ physical safety is always a priority. The nursemust always seriously consider suicidal ideation with thepresence of a plan, access to means for enacting the plan,and self-harm behaviors and institute appropriate interventions(see Chapter 15). Clients often experience chronicsuicidality or ongoing intermittent ideas of suicide overmonths or years. The challenge for the nurse, in concertwith clients, is to determine when suicidal ideas are likelyto be translated into action.Clients may enact self-harm urges by cutting, burning,or punching themselves, which sometimes causes permanentphysical damage. Self-injury can occur when a clientis enraged or experiencing dissociative episodes or psychoticsymptoms, or it may occur for no readily apparentreason. Helping clients to avoid self-injury can be difficultwhen antecedent conditions vary greatly. Sometimes, clientsmay discuss self-harm urges with the nurse if they feelcomfortable doing so. The nurse must remain nonjudgmentalwhen discussing this topic.It has been common practice in many settings toencourage clients to enter a no-self-harm contract, inwhich a client promises to not engage in self-harm and toreport to the nurse when he or she is losing control. Theno-self-harm contract is not a promise to the nurse but isthe client’s promise to himself or herself to be safe. Thoughnot legally binding, such a contract is thought to bebeneficial to the client’s treatment by promoting selfresponsibilityand encouraging dialogue between clientand nurse. However, over time, there is no evidence tosupport the effectiveness of these contracts, and in fact,some believe they may interfere with the therapeutic relationship(McMyler & Pryjmachuk, 2008).When clients are relatively calm and thinking clearly, itis helpful for the nurse to explore self-harm behavior. Thenurse avoids sensational aspects of the injury; the focus ison identifying mood and affect, level of agitation and distress,and circumstances surrounding the incident. In thisway, clients can begin to identify trigger situations, moods,or emotions that precede self-harm and to use more effectivecoping skills to deal with the trigger issues.If clients do injure themselves, the nurse assesses theinjury and need for treatment in a calm, matter-of-factmanner. Lecturing or chastising clients is punitive andhas no positive effect on self-harm behaviors. Deflectingattention from the actual physical act is usuallydesirable.Promoting the Therapeutic RelationshipRegardless of the clinical setting, the nurse must providestructure and limit setting in the therapeutic relationship.In a clinic setting, this may mean seeing the clientfor scheduled appointments of a predetermined lengthrather than whenever the client appears and demandsthe nurse’s immediate attention. In the hospital setting,the nurse would plan to spend a specific amount of timewith the client working on issues or coping strategiesrather than giving the client exclusive access when heor she has had an outburst. Limit-setting and confrontationtechniques, which are described earlier, are alsohelpful.Establishing Boundaries in RelationshipsClients have difficulty maintaining satisfying interpersonalrelationships. Personal boundaries are unclear, and clientsoften have unrealistic expectations. Erratic patterns ofthinking and behaving often alienate them from others.This may be true for both professional and personal relationships.Clients easily can misinterpret the nurse’s genuineinterest and caring as a personal friendship, and thenurse may feel flattered by a client’s compliments. Thenurse must be quite clear about establishing the boundariesof the therapeutic relationship to ensure that neitherthe client’s nor the nurse’s boundaries are violated. Forexample:Client: “You’re better than my family and thedoctors. You understand me more than anyoneelse.”Nurse: “I’m interested in helping you getbetter, just as the other staff members are.”(establishing boundaries)

336UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLIENT/FAMILY EDUCATIONfor Borderline Personality DisorderTeaching social skills• Maintaining personal boundaries• Realistic expectations of relationshipsTeaching time structuring• Making a written schedule of activities• Making a list of solitary activities to combat boredomTeaching self-management through cognitive restructuring• Decatastrophizing situation• Thought stopping• Positive self-talkUsing assertiveness techniques such as “I” statementsUsing distraction, such as walking or listening to musicTeaching Effective Communication SkillsIt is important to teach basic communication skills such aseye contact, active listening, taking turns talking, validatingthe meaning of another’s communication, and using“I” statements (“I think …,” “I feel …,” “I need …”). Thenurse can model these techniques and engage in roleplayingwith clients. The nurse asks how clients feel wheninteracting and gives feedback about nonverbal behavior,such as “I noticed you were looking at the floor whendiscussing your feelings.”Helping Clients to Cope and to Control EmotionsClients often react to situations with extreme emotionalresponses without actually recognizing their feelings. Thenurse can help clients to identify their feelings and learn totolerate them without exaggerated responses such asdestruction of property or self-harm. Keeping a journaloften helps clients gain awareness of feelings. The nursecan review journal entries as a basis for discussion.Another aspect of emotional regulation is decreasingimpulsivity and learning to delay gratification. When clientshave an immediate desire or request, they must learnthat it is unreasonable to expect it to be granted withoutdelay. Clients can use distraction such as taking a walk orlistening to music to deal with the delay, or they can thinkabout ways to meet needs themselves. Clients can write intheir journals about their feelings when gratification isdelayed.Reshaping Thinking PatternsThese clients view everything, people and situations, inextremes—totally good or totally bad. Cognitive restructuringis a technique useful in changing patterns ofthinking by helping clients to recognize negative thoughtsand feelings and to replace them with positive patterns ofthinking. Thought stopping is a technique to alter theprocess of negative or self-critical thought patterns suchas “I’m dumb, I’m stupid, I can’t do anything right.”When the thoughts begin, the client may actually say“Stop!” in a loud voice to stop the negative thoughts.Later, more subtle means such as forming a visual imageof a stop sign will be a cue to interrupt the negativethoughts. The client then learns to replace recurrent negativethoughts of worthlessness with more positive thinking.In positive self-talk, the client reframes negativethoughts into positive ones: “I made a mistake, but it’snot the end of the world. Next time, I’ll know what to do”(Andreasen & Black, 2006).Decatastrophizing is a technique that involves learningto assess situations realistically rather than always assuminga catastrophe will happen. The nurse asks, “So what is theworst thing that could happen?” or “How likely do youthink that is?” or “How do you suppose other people mightdeal with that?” or “Can you think of any exceptions tothat?” In this way, the client must consider other points ofview and actually think about the situation; in time, his orher thinking may become less rigid and inflexible ( Andreasen& Black, 2006).Structuring the Clients’ Daily ActivitiesFeelings of chronic boredom and emptiness, fear of abandonment,and intolerance of being alone are commonproblems. Clients often are at a loss about how to manageunstructured time, become unhappy and ruminative, andmay engage in frantic and desperate behaviors (e.g., selfharm)to change the situation. Minimizing unstructuredtime by planning activities can help clients to managetime alone. Clients can make a written schedule thatincludes appointments, shopping, reading the paper, andgoing for a walk. They are more likely to follow the planif it is in written form. This also can help clients to planahead to spend time with others instead of franticallycalling others when in distress. The written schedule alsoallows the nurse to help clients to engage in more healthfulbehaviors such as exercising, planning meals, andcooking nutritious food.EvaluationAs with any personality disorder, changes may be smalland slow. The degree of functional impairment of clientswith borderline personality disorder may vary widely. Clientswith severe impairment may be evaluated in terms oftheir ability to be safe and to refrain from self-injury. Otherclients may be employed and have fairly stable interpersonalrelationships. Generally, when clients experiencefewer crises less frequently over time, treatment iseffective.

CHAPTER 16 • PERSONALITY DISORDERS 337HISTRIONIC PERSONALITY DISORDERClinical PictureHistrionic personality disorder is characterized by a pervasivepattern of excessive emotionality and attentionseeking. It occurs in 2% to 3% of the general populationand in 10% to 15% of the clinical population. It is seenmore often in women than in men. Clients usually seektreatment for depression, unexplained physical problems,and difficulties in relationships (APA, 2000).The tendency of these clients to exaggerate the closenessof relationships or to dramatize relatively minoroccurrences can result in unreliable data. Speech is usuallycolorful and theatrical, full of superlative adjectives.It becomes apparent, however, that although colorful andentertaining, descriptions are vague and lack detail.Overall appearance is normal, although clients may overdress(e.g., wear an evening dress and high heels for aclinical interview). Clients are overly concerned withimpressing others with their appearance and spend inordinatetime, energy, and money to this end. Dress andflirtatious behavior are not limited to social situations orrelationships but also occur in occupational and professionalsettings. The nurse may feel these clients arecharming or even seductive.Clients are emotionally expressive, gregarious, and effusive.They often exaggerate emotions inappropriately. Forexample, a client says, “He is the most wonderful doctor! Heis so fantastic! He has changed my life!” to describe a physicianshe has seen once or twice. In such a case, the clientcannot specify why she views the doctor so highly. Expressedemotions, although colorful, are insincere and shallow; thisis readily apparent to others but not to clients. They experiencerapid shifts in moods and emotions and may be laughinguproariously one moment and sobbing the next. Thus,their displays of emotion may seem phony or forced toobservers. Clients are self-absorbed and focus most of theirthinking on themselves, with little or no thought about theneeds of others. They are highly suggestible and will agreewith almost anyone to gain attention. They express strongopinions very firmly, but because they base them on littleevidence or facts, the opinions often shift under the influenceof someone they are trying to impress.Clients are uncomfortable when they are not the centerof attention and go to great lengths to gain that status.They use their physical appearance and dress to gain attention.At times, they may fish for compliments in unsubtleways, fabricate unbelievable stories, or create public scenesto attract attention. They may even faint, become ill, or fallto the floor. They brighten considerably when given attentionafter some of these behaviors; this leaves others feelingthat they have been used. Any comment or statementthat could be interpreted as uncomplimentary or unflatteringmay produce a strong response such as a tempertantrum or crying outburst.Clients tend to exaggerate the intimacy of relationships.They refer to almost all acquaintances as “dear,dear friends.” They may embarrass family members orfriends by flamboyant and inappropriate public behaviorsuch as hugging and kissing someone who has just beenintroduced or sobbing uncontrollably over a minor incident.Clients may ignore old friends if someone new andinteresting has been introduced. People with whom theseclients have relationships often describe being used,manipulated, or exploited shamelessly.Clients may have a wide variety of vague physical complaintsor relate exaggerated versions of physical illness.These episodes usually involve the attention clientsreceived (or failed to receive) rather than any particularphysiologic concern.Nursing InterventionsThe nurse gives clients feedback about their social interactionswith others, including manner of dress and nonverbalbehavior. Feedback should focus on appropriatealternatives, not merely criticism. For example, the nursemight say,“When you embrace and kiss other people onfirst meeting them, they may interpret your behaviorin a sexual manner. It would be moreacceptable to stand at least 2 feet away fromthem and to shake hands.”It also may help to discuss social situations to exploreclients’ perceptions of others’ reactions and behavior.Teaching social skills and role-playing those skills in asafe, nonthreatening environment can help clients to gainconfidence in their ability to interact socially. The nursemust be specific in describing and modeling social skills,including establishing eye contact, engaging in activelistening, and respecting personal space. It also helps tooutline topics of discussion appropriate for casual acquaintances,closer friends or family, and the nurse only.Clients may be quite sensitive to discussing self-esteemand may respond with exaggerated emotions. It is importantto explore personal strengths and assets and to givespecific feedback about positive characteristics. Encouragingclients to use assertive communication, such as “I”statements, may promote self-esteem and help them to gettheir needs met more appropriately. The nurse must conveygenuine confidence in the client’s abilities.NARCISSISTIC PERSONALITY DISORDERClinical PictureNarcissistic personality disorder is characterized by a pervasivepattern of grandiosity (in fantasy or behavior), needfor admiration, and lack of empathy. It occurs in 1% to 2%

338UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSUnderlying self-esteem is almost always fragile andvulnerable. These clients are hypersensitive to criticismand need constant attention and admiration. They oftendisplay a sense of entitlement (unrealistic expectation ofspecial treatment or automatic compliance with wishes).They may believe that only special or privileged peoplecan appreciate their unique qualities or are worthy oftheir friendship. They expect special treatment fromothers and often are puzzled or even angry when they donot receive it. They often form and exploit relationshipsto elevate their own status. Clients assume total concernfrom others about their welfare. They discuss their ownconcerns in lengthy detail with no regard for the needsand feelings of others and often become impatient orcontemptuous of those who discuss their own needs andconcerns.At work, these clients may experience some successbecause they are ambitious and confident. Difficulties arecommon, however, because they have trouble workingwith others (whom they consider to be inferior) and havelimited ability to accept criticism or feedback. They alsoare likely to believe they are underpaid and underappreciatedor should have a higher position of authority eventhough they are not qualified.Narcissistic personalityof the general population and in 2% to 16% of the clinicalpopulation. Fifty percent to 75% of people with this diagnosisare men. Narcissistic traits are common in adolescenceand do not necessarily indicate that a personalitydisorder will develop in adulthood. Individual psychotherapyis the most effective treatment, and hospitalization israre unless comorbid conditions exist for which the clientrequires inpatient treatment (APA, 2000).Clients may display an arrogant or haughty attitude.They lack the ability to recognize or to empathize withthe feelings of others. They may express envy andbegrudge others any recognition or material successbecause they believe it rightfully should be theirs. Clientstend to disparage, belittle, or discount the feelings of others.They may express their grandiosity overtly, or theyquietly may expect to be recognized for their perceivedgreatness. They often are preoccupied with fantasies ofunlimited success, power, brilliance, beauty, or ideal love.These fantasies reinforce their sense of superiority.Clients may ruminate about long-overdue admirationand privilege and compare themselves favorably withfamous or privileged people.Thought processing is intact, but insight is limited orpoor. Clients believe themselves to be superior and specialand are unlikely to consider that their behavior has anyrelation to their problems: they view their problems as thefault of others.Nursing InterventionsClients with narcissistic personality disorder can presentone of the greatest challenges to the nurse. The nurse mustuse self-awareness skills to avoid the anger and frustrationthat these clients’ behavior and attitude can engender. Clientsmay be rude and arrogant, unwilling to wait, andharsh and critical of the nurse. The nurse must not internalizesuch criticism or take it personally. The goal is togain cooperation of these clients with other treatment asindicated. The nurse teaches about comorbid medical orpsychiatric conditions, medication regimen, and anyneeded self-care skills in a matter-of-fact manner. He orshe sets limits on rude or verbally abusive behavior andexplains his or her expectations of the client.CLUSTER C: PERSONALITY DISORDERSAVOIDANT PERSONALITY DISORDERClinical PictureAvoidant personality disorder is characterized by a pervasivepattern of social discomfort and reticence, lowself-esteem, and hypersensitivity to negative evaluation.It occurs in 0.5% to 1% of the general population and in10% of the clinical population. It is equally common inmen and women. Clients are good candidates for individualpsychotherapy (APA, 2000).These clients are likely to report being overly inhibitedas children and that they often avoid unfamiliar

CHAPTER 16 • PERSONALITY DISORDERS 339situations and people with an intensity beyond thatexpected for their developmental stage. This inhibition,which may have continued throughout upbringing,contributes to low self-esteem and social alienation.Clients are apt to be anxious and may fidget inchairs and make poor eye contact with the nurse. Theymay be reluctant to ask questions or to make requests.They may appear sad as well as anxious. They describebeing shy, fearful, socially awkward, and easily devastatedby real or perceived criticism. Their usualresponse to these feelings is to become more reticentand withdrawn.Clients have very low self-esteem. They are hypersensitiveto negative evaluation from others and readilybelieve themselves to be inferior. Clients are reluctant todo anything perceived as risky, which, for them, is almostanything. They are fearful and convinced they will makea mistake, be humiliated, or embarrass themselves andothers. Because they are unusually fearful of rejection,criticism, shame, or disapproval, they tend to avoid situationsor relationships that may result in these feelings.They usually strongly desire social acceptance andhuman companionship: they wish for closeness and intimacybut fear possible rejection and humiliation. Thesefears hinder socialization, which makes clients seemawkward and socially inept and reinforces their beliefsabout themselves. They may need excessive reassuranceof guaranteed acceptance before they are willing to riskforming a relationship.Clients may report some success in occupational rolesbecause they are so eager to please or to win a supervisor’sapproval. Shyness, awkwardness, or fear of failure, however,may prevent them from seeking jobs that might bemore suitable, challenging, or rewarding. For example, aclient may reject a promotion and continue to remain inan entry-level position for years even though he or she iswell qualified to advance.Nursing InterventionsThese clients require much support and reassurancefrom the nurse. In the nonthreatening context of therelationship, the nurse can help them to explore positiveself-aspects, positive responses from others, andpossible reasons for self-criticism. Helping clients topractice self-affirmations and positive self-talk may beuseful in promoting self-esteem. Other cognitive restructuringtechniques such as reframing and decatastrophizing(described previously) can enhance self-worth. Thenurse can teach social skills and help clients to practicethem in the safety of the nurse–client relationship.Although these clients have many social fears, those areoften counterbalanced by their desire for meaningfulsocial contact and relationships. The nurse must becareful and patient with clients and not expect them toimplement social skills too rapidly.DEPENDENT PERSONALITY DISORDERClinical PictureDependent personality disorder is characterized by a pervasiveand excessive need to be taken care of, which leadsto submissive and clinging behavior and fears of separation.These behaviors are designed to elicit caretaking fromothers. The disorder occurs in as much as 15% of the populationand is seen three times more often in women thanin men. It runs in families and is most common in theyoungest child. People with dependent personality disorderoften seek treatment for anxious, depressed, or somaticsymptoms (APA, 2000).Clients are frequently anxious and may be mildlyuncomfortable. They are often pessimistic and selfcritical;other people hurt their feelings easily. Theycommonly report feeling unhappy or depressed; this isassociated most likely with the actual or threatened lossof support from another. They are preoccupied excessivelywith unrealistic fears of being left alone to carefor themselves. They believe they would fail on theirown, so keeping or finding a relationship occupies muchof their time. They have tremendous difficulty makingdecisions, no matter how minor. They seek advice andrepeated reassurances about all types of decisions, fromwhat to wear to what type of job to pursue. Althoughthey can make judgments and decisions, they lack theconfidence to do so.Clients perceive themselves as unable to functionoutside a relationship with someone who can tell themwhat to do. They are very uncomfortable and feel helplesswhen alone, even if the current relationship isintact. They have difficulty initiating projects or completingsimple daily tasks independently. They believethey need someone else to assume responsibility forthem, a belief that far exceeds what is age or situationappropriate. They may even fear gaining competencebecause doing so would mean an eventual loss of supportfrom the person on whom they depend. They maydo almost anything to sustain a relationship, even oneof poor quality. This includes doing unpleasant tasks,going places they dislike, or, in extreme cases, toleratingabuse. Clients are reluctant to express disagreementfor fear of losing the other person’s support or approval;they may even consent to activities that are wrong orillegal to avoid that loss.When these clients do experience the end of a relationship,they urgently and desperately seek another. Theunspoken motto seems to be “Any relationship is betterthan none at all.”Nursing InterventionsThe nurse must help clients to express feelings of grief andloss over the end of a relationship while fostering autonomyand self-reliance. Helping clients to identify their

340UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSstrengths and needs is more helpful than encouraging theoverwhelming belief that “I can’t do anything alone!” Cognitiverestructuring techniques such as reframing anddecatastrophizing may be beneficial.Clients may need assistance in daily functioning if theyhave little or no past success in this area. Included are suchthings as planning menus, doing the weekly shopping,budgeting money, balancing a checkbook, and paying bills.Careful assessment to determine areas of need is essential.Depending on the client’s abilities and limitations, referralto agencies for services or assistance may be indicated.The nurse also may need to teach problem-solving anddecision-making and help clients apply them to daily life.He or she must refrain from giving advice about problemsor making decisions for clients even though clients mayask the nurse to do so. The nurse can help the client toexplore problems, serve as a sounding board for discussionof alternatives, and provide support and positive feedbackfor the client’s efforts in these areas.OBSESSIVE–COMPULSIVE PERSONALITYDISORDERClinical PictureObsessive–compulsive personality disorder is characterizedby a pervasive pattern of preoccupation with perfectionism,mental and interpersonal control, and orderlinessat the expense of flexibility, openness, and efficiency. Itoccurs in about 1% to 2% of the population, affecting twiceas many men as women. This increases to 3% to 10% inclients in mental health settings. Incidence is increased inoldest children and people in professions involving facts,figures, or methodical focus on detail. These people oftenseek treatment because they recognize that their life ispleasureless or they are experiencing problems with workor relationships. Clients frequently benefit from individualtherapy (APA, 2000).The demeanor of these clients is formal and serious,and they answer questions with precision and much detail.They often report feeling the need to be perfect beginningin childhood. They were expected to be good and to do theright thing to win parental approval. Expressing emotionsor asserting independence was probably met with harshdisapproval and emotional consequences. Emotional rangeis usually quite constricted. They have difficulty expressingemotions, and any emotions they do express are rigid,stiff, and formal, lacking spontaneity. Clients can be verystubborn and reluctant to relinquish control, which makesit difficult for them to be vulnerable to others by expressingfeelings. Affect is also restricted: they usually appearanxious and fretful or stiff and reluctant to reveal underlyingemotions.Clients are preoccupied with orderliness and try tomaintain it in all areas of life. They strive for perfection asthough it were attainable and are preoccupied with details,rules, lists, and schedules to the point of often missing“the big picture.” They become absorbed in their ownperspective, believe they are right, and do not listen carefullyto others because they have already dismissed whatis being said. Clients check and recheck the details of anyproject or activity; often, they never complete the projectbecause of “trying to get it right.” They have problemswith judgment and decision-making—specifically actuallyreaching a decision. They consider and reconsideralternatives, and the desire for perfection prevents reachinga decision. Clients interpret rules or guidelines literallyand cannot be flexible or modify decisions based oncircumstances. They prefer written rules for each andevery activity at work. Insight is limited, and they areoften oblivious that their behavior annoys or frustratesothers. If confronted with this annoyance, these clientsare stunned, unable to believe others “don’t want me to doa good job.”These clients have low self-esteem and are always harsh,critical, and judgmental of themselves; they believe thatthey “could have done better” regardless of how well thejob has been done. Praise and reassurance do not changethis belief. Clients are burdened by extremely high andunattainable standards and expectations. Although no onecould live up to these expectations, they feel guilty andworthless for being unable to achieve them. They tend toevaluate self and others solely on deeds or actions withoutregard for personal qualities.These clients have much difficulty in relationships, fewfriends, and little social life. They do not express warm ortender feelings to others; attempts to do so are very stiffand formal and may sound insincere. For example, if asignificant other expresses love and affection, a client’sresponse might be “The feeling is mutual.”Marital and parent–child relationships are often difficultbecause these clients can be harsh and unrelenting.For example, most clients are frugal, do not givegifts or want to discard old items, and insist that thosearound them do the same. Shopping for something newto wear may seem frivolous and wasteful. Clients cannottolerate lack of control and hence may organizefamily outings to the point that no one enjoys them.These behaviors can cause daily strife and discord infamily life.At work, clients may experience some success, particularlyin fields when precision and attention to detail aredesirable. They may miss deadlines, however, while tryingto achieve perfection or may fail to make needed decisionswhile searching for more data. They fail to make timelydecisions because of continually striving for perfection.They have difficulty working collaboratively, preferring to“do it myself” so it is done correctly. If clients do accepthelp from others, they may give such detailed instructionsand watch the other person so closely that coworkers are

CHAPTER 16 • PERSONALITY DISORDERS 341insulted, annoyed, and refuse to work with them. Giventhis excessive need for routine and control, new situationsand compromise are also difficult.Nursing InterventionsNurses may be able to help clients to view decisionmakingand completion of projects from a different perspective.Rather than striving for the goal of perfection,clients can set a goal of completing the project or makingthe decision by a specified deadline. Helping clients toaccept or to tolerate less-than-perfect work or decisionsmade on time may alleviate some difficulties at work orhome. Clients may benefit from cognitive restructuringtechniques. The nurse can ask, “What is the worst thatcould happen?” or “How might your boss (or your wife)see this situation?” These questions may challenge somerigid and inflexible thinking.Encouraging clients to take risks, such as letting someoneelse plan a family activity, may improve relationships.Practicing negotiation with family or friends also may helpclients to relinquish some of their need for control.OTHER RELATED DISORDERSResearchers are studying two disorders, depressive personalitydisorder and passive-aggressive disorder, forinclusion as personality disorders. The DSM-IV-TR currentlylists and describes these conditions.DEPRESSIVE PERSONALITY DISORDERClinical PictureDepressive personality disorder is characterized by a pervasivepattern of depressive cognitions and behaviors in variouscontexts. It occurs equally in men and women and moreoften in people with relatives who have major depressive disorders.People with depressive personality disorders oftenseek treatment for their distress and generally have a favorableresponse to antidepressant medications (APA, 2000).Although clients with depressive personality disordermay seem to have similar behavior characteristics as clientswith major depression (e.g., moodiness, brooding,joylessness, or pessimism), the personality disorder ismuch less severe. Clients with depressive personality disorderusually do not experience the severity and longduration of major depression or the hallmark symptoms ofsleep disturbances, loss of appetite, recurrent thoughts ofdeath, and total disinterest in all activities. Major depressiveepisode is discussed in Chapter 15.These clients have a sad, gloomy, or dejected affect.They express persistent unhappiness, cheerlessness, andhopelessness, regardless of the situation. They often reportthe inability to experience joy or pleasure in any activity;they cannot relax and do not display a sense of humor.Clients may repress or not express anger. They brood andworry over all aspects of daily life. Thinking is negativeand pessimistic; these clients rarely see any hope for futureimprovement. They view this pessimism as “being realistic.”Regardless of positive outcomes in a given situation,negative thinking continues. Judgment or decision- makingskills are usually intact but dominated by pessimisticthinking; clients often blame themselves or others unjustlyfor situations beyond anyone’s control.Self-esteem is quite low, with feelings of worthlessnessand inadequacy even when clients have been successful.Self-criticism often leads to punitive behavior and feelingsof guilt or remorse. Clients may appear overtly quiet andpassive; they prefer to follow others rather than be leadersin any work or social situation. Although clients feeldependent on approval from others, they tend to be overlycritical and quick to reject others first. These clients, whoneed and want the approval and attention of others, actuallydrive others away; this reinforces feelings of beingunworthy of anyone’s attention.Nursing InterventionsWhen working with clients who report depressed feelings,it is always important to assess whether there is risk forself-harm. If a client expresses suicidal ideation or hasurges for self-injury, the nurse must provide interventionsand plan care as indicated (see Chapter 15).The nurse explains that the client must take action,rather than wait, to feel better. Encouraging the client tobecome involved in activities or engaged with others providesopportunities to interrupt the cyclical, negativethought patterns.Giving factual feedback, rather than general praise,reinforces attempts to interact with others and gives specificpositive information about improved behaviors. Anexample of general praise is“Oh, you’re doing so well today.”This statement does not identify specific positive behaviors.Allowing the client to identify specific positive behaviorsoften helps to promote self-esteem. An example ofspecific praise is“You talked to Mrs. Jones for 10 minutes, eventhough it was difficult. I know that took a lot ofeffort.”This statement gives the client a clear message about whatspecific behavior was effective and positive—the client’sability to talk to someone else.

342UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCognitive restructuring techniques such as thoughtstopping or positive self-talk (discussed previously) alsocan enhance self-esteem. Clients learn to recognize negativethoughts and feelings and learn new positive patternsof thinking about themselves.It may be necessary to teach the client effective socialskills such as eye contact, attentive listening, and topicsappropriate for initial social conversation (e.g., the weather,current events, or local news). Even if the client knowsthese social skills, practicing them is important—first withthe nurse and then with others. Practicing with the nurseis initially less threatening. Another simple but effectivetechnique is to help the client practice giving others compliments.This requires the client to identify somethingpositive rather than negative in others. Giving complimentsalso promotes receiving compliments, which furtherenhances positive feelings.PASSIVE-AGGRESSIVE PERSONALITYDISORDERClinical PicturePassive-aggressive personality disorder is characterizedby a negative attitude and a pervasive pattern of passiveresistance to demands for adequate social and occupationalperformance. It occurs in 1% to 3% of the generalpopulation and in 2% to 8% of the clinical population. It isthought to be slightly more prevalent in women than inmen (APA, 2000).These clients may appear cooperative, even ingratiating,or sullen and withdrawn, depending on the circumstances.Their mood may fluctuate rapidly and erratically,and they may be easily upset or offended. They may alternatebetween hostile self-assertion such as stubbornnessor fault finding and excessive dependence, expressingcontrition and guilt. There is a pervasive attitude that isnegative, sullen, and defeatist. Affect may be sad or angry.The negative attitude influences thought content: Clientsperceive and anticipate difficulties and disappointmentswhere none exist. They view the future negatively, believingthat nothing good ever lasts. Their ability to makejudgments or decisions is often impaired. Clients are frequentlyambivalent and indecisive, preferring to allowothers to make decisions that these clients then criticize.Insight is also limited: Clients tend to blame others fortheir own feelings and misfortune. Rather than acceptingreasonable responsibility for the situation, these clientsmay alternate blaming behavior with exaggerated remorseand contrition.Clients experience intense conflict between dependenceon others and a desire for assertion. Self-confidenceis low despite the bravado shown. Clients may complainthey are misunderstood and unappreciated by others andmay report feeling cheated, victimized, and exploited.They habitually resent, oppose, and resist demands tofunction at a level expected by others. This oppositionoccurs most frequently in work situations but also can beevident in social functioning. They express such resistancethrough procrastination, forgetfulness, stubbornness, andintentional inefficiency, especially in response to tasksassigned by authority figures. They also may obstruct theefforts of coworkers by failing to do their share. In socialor family relationships, these clients may play the role ofthe martyr who “sacrifices everything for others” or whomay be aggrieved and misunderstood. These behaviorssometimes are effective in manipulating others to do asclients wish, without clients needing to make a directrequest.These clients often have various vague or generalizedsomatic complaints and may even adopt a sick role. Theythen can be angry or bitter, complaining, “No one can figureout what’s wrong with me. I just have to suffer. It’s mybad luck!”Nursing InterventionsThe nurse may encounter much resistance from the clientin identifying feelings and expressing them directly. Often,clients do not recognize that they feel angry and mayexpress it indirectly. The nurse can help them examine therelationship between feelings and subsequent actions. Forexample, a client may intend to complete a project at workbut then procrastinates, forgets, or becomes “ill” andmisses the deadline. Or the client may intend to participatein a family outing but becomes ill, forgets, or has “anemergency” when it is time. By focusing on the behavior,the nurse can help the client to see what is so annoying ortroubling to others. The nurse also can help the client tolearn appropriate ways to express feelings directly, especiallynegative feelings such as anger. Methods such ashaving the client write about the feelings or role-play areeffective. If the client is unwilling to engage in this process,however, the nurse cannot force him or her to do so.ELDER CONSIDERATIONSPersonality disorders are not first diagnosed in elder personsbut may persist from young adulthood into older age.Sakauye (2008) wrote that personality disorders fromclusters A and C are more prevalent in older age and areclosely correlated with depression. Some persons withpersonality disorders tend to stabilize and experiencefewer difficulties in later life. Others are described as“aging badly”; that is, they are unable or unwilling toacknowledge limitations that come with aging, they refuseto accept help when needed, and they do not make reasonabledecisions about their health care, finances, or livingsituation. These individuals seems chronically angry,unhappy, or dissatisfied, resulting in strained relationshipsand even alienation from family, friends, caregivers, andhealth-care providers.

CHAPTER 16 • PERSONALITY DISORDERS 343COMMUNITY-BASED CARECaring for clients with personality disorders occurs primarilyin community-based settings. Acute psychiatricsettings such as hospitals are useful for safety concerns forshort periods. The nurse uses skills to deal with clientswho have personality disorders in clinics, outpatient settings,doctors’ offices, and many medical settings. Often,the personality disorder is not the focus of attention;rather, the client may be seeking treatment for a physicalcondition.Most people with personality disorders are treated ingroup or individual therapy settings, community supportprograms, or self-help groups. Others will not seek treatmentfor their personality disorder but may be treated fora major mental illness. Wherever the nurse encounters clientswith personality disorders, including in his or herown life, the interventions discussed in this chapter canprove useful.MENTAL HEALTH PROMOTIONThe treatment of individuals with a personality disorderoften focuses on mood stabilization, decreasing impulsivity,and developing social and relationship skills. Hayward,Slade, and Moran (2006) studied clients with personalitydisorders in terms of clients’ perceptions of their unmetneeds. They found that clients perceived unmet needs infive areas: self-care (keeping clean and tidy); sexual expression(dissatisfaction with sex life); budgeting (managingdaily finances); psychotic symptoms; and psychological distress.Although psychotic symptoms and psychologicaldistress are usually addressed by health-care providers, theother three areas are not. This suggests that dealing withthose areas in the treatment of a client might result in agreater sense of well-being and improved health.Children who have a greater number of “protective factors”are less likely to develop antisocial behavior as adults.These protective factors include school commitment orimportance of school, parent or peer disapproval of antisocialbehavior, and being involved in a religious community.Interestingly, the study found that children at riskfor abuse and those not at risk were less likely to haveantisocial behavior as adults if these protective factorswere present in their environment. Children lacking theseprotective factors are much more likely to develop antisocialbehavior as adults (Cohen, Chen, Gordon, Johnson,Brook, & Kasen, 2008).SELF-AWARENESS ISSUESBecause clients with personality disorders takea long time to change their behaviors, attitudes,or coping skills, nurses working withthem easily can become frustrated or angry.These clients continually test the limits, or boundaries, ofthe nurse–client relationship with attempts at manipulation.Nurses must discuss feelings of anger or frustrationwith colleagues to help them recognize and cope withtheir own feelings.The overall appearance of clients with personality disorderscan be misleading. Unlike clients who are psychoticor severely depressed, clients with personality disorderslook as though they are capable of functioning more effectively.The nurse can easily but mistakenly believe the clientsimply lacks motivation or the willingness to makechanges and may feel frustrated or angry. It is easy for thenurse to think, “Why does the client continue to do that?Can’t he see it only gets him into difficulties?” This reactionis similar to reactions the client has probably receivedfrom others.Clients with personality disorders also challenge theability of therapeutic staff to work as a team. For example,clients with antisocial or borderline personalities oftenmanipulate staff members by splitting them—that is, causingstaff members to disagree or to contradict one anotherin terms of the limits of the treatment plan. This can bequite disruptive. In addition, team members may have differingopinions about individual clients. One staff membermay believe that a client needs assistance, whereas anothermay believe the client is overly dependent. Ongoing communicationis necessary to remain firm and consistentabout expectations for clients.Points to Consider When Workingwith Clients with Personality Disorders• Talking to colleagues about feelings of frustration willhelp you to deal with your emotional responses so youcan be more effective with clients.• Clear, frequent communication with other health-careproviders can help to diminish the client’s manipulation.• Do not take undue flattery or harsh criticism personally;it is a result of the client’s personality disorder.• Set realistic goals and remember that behavior changesin clients with personality disorders take a long time.Progress can be very slow.Critical Thinking Questions1. Where do you see yourself in relation to the fourtypes of temperament (harm avoidance, noveltyseeking, reward dependence, and persistence)?2. There is a significant correlation between the diagnosisof antisocial personality disorder and criminalbehavior. The DSM-IV-TR includes “violation of therights of others” in the definition of this disorder. Isthis personality disorder more a social than a mentalhealth problem? Why?

344UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSINTERNET RESOURCESRESOURCES• Avoidant Personality Disorder• Borderline Personality Disorder• Cognitive Behavioral Therapy• Dependent Personality Disorder• Dialectical Behavior Therapy• Histrionic Personality Disorder• Narcissistic Personality Disorder• Paranoid Personality Disorder• Schizoid Personality Disorder• Schizotypal Personality DisorderINTERNET ADDRESShttp://www.mentalhealth.com/dis/p20-pe08.htmlhttp://www.borderlinepersonalitytoday.com/mainhttp://www.nacbt.org/whatiscbt.htmhttp://www.mentalhealth.com/dis/p20-pe09.htmlhttp://www.dbtselfhelp.comhttp://www.mentalhealth.com/dis/p20-pe06.htmlhttp://www.narcissisticpersonalitydisorderhttp://www.mentalhealth.com/dis/p20-pe01.htmlhttp://www.mentalhealth.com/dis/p20-pe02.htmlhttp://www.mayoclinic.com/health/schizotypal-personalitydisorder/DS00830KEY POINTS• People with personality disorders havetraits that are inflexible and maladaptiveand cause either significant functional impairmentor subjective distress.• Personality disorders are relatively common and diagnosedin early adulthood, although some behaviors areevident in childhood or adolescence.• Rapid or substantial changes in personality are unlikely.This can be a primary source of frustration for familymembers, friends, and health-care professionals.• Schizotypal personality disorder is characterized by socialand interpersonal deficits, cognitive and perceptualdistortions, and eccentric behavior.• People with paranoid personality disorders are suspicious,mistrustful, and threatened by others.• People with depressive personality disorder are sad,gloomy, and negative; experience no pleasure; and tendto brood or ruminate about their lives.• Schizoid personality disorder includes marked detachmentfrom others, restricted emotions, indifference, andfantasy.• People with antisocial personality disorder often appearglib and charming, but they are suspicious, insensitive,and uncaring and often exploit others for their owngain.• People with borderline personality disorder have markedlyunstable mood, affect, self-image, interpersonalrelationships, and impulsivity; they often engage in selfharmbehavior.• People with obsessive–compulsive personality disorderare preoccupied with orderliness, perfection, and interpersonalcontrol at the expense of flexibility, openness,and efficiency.• Histrionic personality disorder is characterized by excessiveemotionality and dramatic, attention-seeking,and seductive or provocative behavior.• Narcissistic personality disorder is characterized bygrandiosity, need for admiration, lack of empathy forothers, and a sense of entitlement.• Avoidant personality disorder is characterized by socialdiscomfort and reticence in all situations, low selfesteem,and hypersensitivity to negative evaluation.• Dependent personality disorder is characterized by apervasive and excessive need to be taken care of, whichleads to submissive and clinging behaviors and fears ofseparation and abandonment.• People with passive-aggressive personality disorderdemonstrate passive resistance to demands for adequatesocial and occupational performance and negativity;they often play the role of a martyr.• The therapeutic relationship is crucial in caring for clientswith personality disorders. Nurses can help clientsto identify their feelings and dysfunctional behaviorsand to develop appropriate coping skills and positive behaviors.Therapeutic communication and role modelinghelp to promote appropriate social interactions, whichhelp to improve interpersonal relationships.• Several therapeutic strategies are effective when workingwith clients with personality disorders. Cognitiverestructuring techniques such as thought stopping,positive self-talk, and decatastrophizing are useful; selfhelpskills aid the client to function better in thecommunity.• Psychotropic medications are prescribed for clients withpersonality disorders based on the type and severity ofsymptoms the client experiences in aggression and impulsivity,mood dysregulation, anxiety, and psychoticsymptoms.

CHAPTER 16 • PERSONALITY DISORDERS 345• Clients with borderline personality disorder often haveself-harm urges that they enact by cutting, burning, orpunching themselves; this behavior sometimes causespermanent physical damage. The nurse can encouragethe client to enter into a no-self-harm contract in whichthe client promises to try to keep from harming himselfor herself and to report to the nurse when he or she ishaving self-harm urges.• Nurses must use self-awareness skills to minimize clientmanipulation and deal with feelings of frustration.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Andreasen, N. C., & Black, D. W. (2006). Introductory textbook of psychiatry(4th ed.). Washington DC: American Psychiatric Publishing.Bongers, I. L., Koot, H. M., van der Ende, J., & Verhulst, F. C. (2007).Predicting young adult social functioning from developmentaltrajectories of externalizing behaviour. Psychological Medicine, 38,989–999.Cohen, P., Chen, H., Gordon, K., Johnson, J., Brook, J., & Kasen, S.(2008). Socioeconomic background and the developmental course ofschizotypal and borderline personality disorder symptoms.Development and Psychopathology, 20(2), 633–650.Hayward, M., Slade, M., & Moran, P. A. (2006). Personality disordersand unmet needs among psychiatric inpatients. Psychiatric Services,57(4), 538–543.Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personalitydisorder. New York: Guilford Press.Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007).Dialectical behavior therapy for borderline personality disorder.Annual Review of Clinical Psychology, 3, 181–205.Mangnall, J., & Yurkovich, E. (2008). A literature review of deliberateself-harm. Perspectives in Psychiatric Care, 44(3), 175–184.McMyler, C., & Pryjmachuk, S. (2008). Do “no-suicide” contracts work?Journal of Psychiatric and Mental Health Nursing, 15(6), 512–522.Meissner, W. W. (2005). Classic Psychoanalysis. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed,pp. 701–746). Philadelphia: Lippincott Williams & Wilkins.Sakauye, K. (2008). Geriatric psychiatry basics. New York: W. W. Norton.Simeon, D., & Hollander, E. (2006). Treatment of personality disorders.In A. F. Schatzberg & C. B. Nereroff (Eds.), Essentials of clinical psychopharmacology(2nd ed., pp. 689–705). Washington, DC: AmericanPsychiatric Publishing.Svrakic, D. M., & Cloninger, C. R. (2005). Personality disorders. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 2, 8th ed., pp. 2063–2104). Philadelphia: Lippincott Williams& Wilkins.ADDITIONAL READINGSHart, B. G. (2007). Cutting: Unraveling the mystery behind the marks.Journal of the American Association of Occupational Health Nurses,55(4), 161–166.Lynch, T. R., & Cheavens, J. S. (2008). Dialectical behavior therapy forcomorbid personality disorders. Journal of Clinical Psychology, 64(2),154–167.McQuillan, A., Nicastro, R., Guenot, F., Girard, M., Lissner, C., &Ferrero, F. (2005). Intensive dialectic behavior therapy for outpatientswith borderline personality disorder who are in crisis.Psychiatric Services, 56(2), 193–197.Oldham, J. M. (2006). Borderline personality disorder and suicidality.American Journal of Psychiatry, 163(1), 20–26.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. When working with a client with a paranoid personalitydisorder, the nurse would use which of the followingapproaches?a. Cheerfulb. Friendlyc. Seriousd. Supportive2. Which of the following underlying emotions is commonlyseen in a passive-aggressive personality disorder?a. Angerb. Depressionc. Feard. Guilt3. Cognitive restructuring techniques include all the followingexcepta. Decatastrophizingb. Positive self-talkc. Reframingd. Relaxation4. Transient psychotic symptoms that occur with borderlinepersonality disorder are most likely treated withwhich of the following?a. Anticonvulsant mood stabilizersb. Antipsychoticsc. Benzodiazepinesd. Lithium5. Clients with a histrionic personality disorder are mostlikely to benefit from which of the following nursinginterventions?a. Cognitive restructuring techniquesb. Improving community functioningc. Providing emotional supportd. Teaching social skills6. When interviewing any client with a personality disorder,the nurse would assess for which of the following?a. Ability to charm and manipulate peopleb. Desire for interpersonal relationshipsc. Disruption in some aspects of his or her lifed. Increased need for approval from others7. The nurse would assess for which of the following characteristicsin a client with narcissistic personalitydisorder?a. Entitlementb. Fear of abandonmentc. Hypersensitivityd. Suspiciousness8. The most important short-term goal for the client whotries to manipulate others would be toa. Acknowledge own behaviorb. Express feelings verballyc. Stop initiating argumentsd. Sustain lasting relationshipsMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. When working with a client with a personality disorder,the nurse would expect to assess the following:a. High levels of self-awarenessb. Impaired interpersonal relationshipsc. Inability to empathize with othersd. Minimal insighte. Motivation to changef. Poor reality testing2. The nurse working with a client with antisocial personalitydisorder would expect which of the followingbehaviors?a. Compliance with expectations and rulesb. Exploitation of other clientsc. Seeking special privilegesd. Superficial friendliness toward otherse. Utilization of rituals to allay anxietyf. Withdrawal from social activities346

CHAPTER 16 • PERSONALITY DISORDERS347CLINICAL EXAMPLESusan Marks, 25 years old, is diagnosed with borderline personality disorder. She has beenattending college sporadically but has only 15 completed credits and no real career goal.She is angry because her parents have told her she must get a job to support herself. Lastweek, she met a man in the park and fell in love with him on the first date. She has beencalling him repeatedly, but he will not return her calls. Declaring that her parents havedeserted her and her boyfriend doesn’t love her anymore, she slashes her forearms with asharp knife. She then calls 911, stating, “I’m about to die! Please help me!” She is taken byambulance to the emergency room and is admitted to the inpatient psychiatry unit.1. Identify two priority nursing diagnoses that would be appropriate for Susan on her admission to the unit.2. Write an expected outcome for each of the identified nursing diagnoses.3. List three nursing interventions for each of the identified nursing diagnoses.4. What community resources or referrals would be beneficial for Susan?

17Substance AbuseLearning ObjectivesAfter reading this chapter, you should be able to:Key Terms• 12-step program• blackout• codependence• controlled substance• denial• detoxification• dual diagnosis• flushing• hallucinogen• inhalant• intoxication• opioid• polysubstance abuse• spontaneous remission• stimulants• substance abuse• substance dependence• tapering• tolerance• tolerance break• withdrawal syndrome1. Explain the trends in substance abuse and discuss the need for relatedprevention programs.2. Discuss the characteristics, risk factors, and family dynamics prevalent withsubstance abuse.3. Describe the principles of a 12-step treatment approach for substanceabuse.4. Apply the nursing process to the care of clients with substance abuseissues.5. Provide education to clients, families, and community members to increaseknowledge and understanding of substance use and abuse.6. Discuss the nurse’s role in dealing with the chemically impairedprofessional.7. Evaluate your feelings, attitudes, and responses to clients and families withsubstance use and abuse.SUBSTANCE USE/ABUSE AND RELATED disorders are a national health problem.More than 15 million Americans are dependent on alcohol, and 500,000are between the ages of 9 and 12 years. Almost 7 million persons are bingedrinkers between the ages of 12 and 20 years—under the legal age limit fordrinking in most states. Five thousand deaths occur each year—motorvehicle accidents, homicide, suicide, injuries—due to alcohol in personsunder age 21 (National Institute on Alcohol Abuse and Alcoholism, 2009).The actual prevalence of substance abuse is difficult to determine preciselybecause many people meeting the criteria for diagnosis do not seek treatmentand surveys conducted to estimate prevalence are based on selfreporteddata that may be inaccurate.Drug and alcohol abuse costs business and industry an estimated$100 billion annually. Alcoholism alone accounts for 500 million lostdays of work. Up to 40% of industrial fatalities and 47% of workplace348Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 17 • SUBSTANCE ABUSE 349Drugs and alcohol can lead to legal problemsinjuries are linked to alcoholism and alcohol consumption.Estimates of motor vehicle fatalities related to alcoholare 50% (Substance Abuse and Mental HealthServices Administration, 2007). In the United States,one person is killed every 30 minutes in an alcoholrelatedtraffic accident.The number of infants suffering the physiologic andemotional consequences of prenatal exposure to alcoholor drugs (e.g., fetal alcohol syndrome, “crack babies”) isincreasing at alarming rates. Chemical abuse also resultsin increased violence, including domestic abuse, homicide,and child abuse and neglect. These rising statisticsregarding substance abuse do not bode well for futuregenerations.Forty-three percent of all Americans have been exposedto alcoholism in their families. Children of alcoholics arefour times more likely than the general population todevelop problems with alcohol (National Institute on AlcoholAbuse and Alcoholism, 2007a). Many adult people intreatment programs as adults report having had their firstdrink of alcohol as a young child, when they were youngerthan age 10. This first drink was often a taste of the drinkof a parent or family member. With the increasing rates ofuse being reported among young people today, this problemcould spiral out of control unless great strides can bemade through programs for prevention, early detection,and effective treatment.TYPES OF SUBSTANCE ABUSEMany substances can be used and abused; some can beobtained legally, whereas others are illegal. This discussionincludes alcohol and prescription medications as substancesthat can be abused. Abuse of more than one substanceis termed polysubstance abuse.The Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision (DSM-IV-TR) lists 11 diagnosticclasses of substance abuse:1. Alcohol2. Amphetamines or Similarly Acting Sympathomimetics3. Caffeine4. Cannabis5. Cocaine6. Hallucinogens7. Inhalants8. Nicotine9. Opioids10. Phencyclidine (PCP) or Similarly Acting Drugs11. Sedatives, Hypnotics, or AnxiolyticsIt also categorizes substance-related disorders into twogroups: (1) those that include disorders of abuse anddependence and (2) substance-induced disorders such asintoxication, withdrawal, delirium, dementia, psychosis,mood disorder, anxiety, sexual dysfunction, and sleepdisorder.This chapter describes the specific symptoms of intoxication,overdose, withdrawal, and detoxification for eachsubstance with the exception of caffeine and nicotine.Although caffeine and nicotine abuse can cause significantphysiologic health problems and result in substanceinduceddisorders such as sleep disorders, anxiety, andwithdrawal; treatment of these two substances usually isnot viewed as falling into the mental health arena.Intoxication is use of a substance that results in maladaptivebehavior. Withdrawal syndrome refers to thenegative psychologic and physical reactions that occurwhen use of a substance ceases or dramatically decreases.Detoxification is the process of safely withdrawing from asubstance. The treatment of other substance-induced disorderssuch as psychosis and mood disorders is discussedin depth in separate chapters.Substance abuse can be defined as using a drug in away that is inconsistent with medical or social norms anddespite negative consequences. The DSM-IV-TR distinguishessubstance abuse from dependence for purposes ofmedical diagnosis. Substance abuse denotes problems insocial, vocational, or legal areas of the person’s life, whereassubstance dependence also includes problems associatedwith addiction such as tolerance, withdrawal, and unsuccessfulattempts to stop using the substance. This distinctionbetween abuse and dependence frequently is viewedas unclear and unnecessary (Jaffe & Anthony, 2005)because the distinction does not affect clinical decisions

350UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSonce withdrawal or detoxification has been completed.Hence, the terms substance abuse and substance dependenceor chemical dependence can be used interchangeably. In thischapter, the term substance use is used to include bothabuse and dependence; it is not meant to refer to the occasionalor one-time user.ONSET AND CLINICAL COURSEMuch research on substance use has focused on alcoholbecause it is legal and more widely used; thus, more isknown about alcohol’s effects. The prognosis for alcoholuse in general is unclear because usually only people seekingtreatment for problems with alcohol are studied.The early course of alcoholism typically begins with thefirst episode of intoxication between 15 and 17 years ofage (Schuckit, 2005); the first evidence of minor alcoholrelatedproblems is seen in the late teens. These events donot differ significantly from the experiences of people whodo not go on to develop alcoholism. A pattern of moresevere difficulties for people with alcoholism begins toemerge in the mid-twenties to the mid-thirties; these difficultiescan be the alcohol-related breakup of a significantrelationship, an arrest for public intoxication or drivingwhile intoxicated, evidence of alcohol withdrawal, earlyalcohol-related health problems, or significant interferencewith functioning at work or school. During this time, theperson experiences his or her first blackout, which is anepisode during which the person continues to functionbut has no conscious awareness of his or her behavior atthe time or any later memory of the behavior.As the person continues to drink, he or she often developsa tolerance for alcohol; that is, he or she needs morealcohol to produce the same effect. After continued heavydrinking, the person experiences a tolerance break, whichmeans that very small amounts of alcohol intoxicate theperson.The later course of alcoholism, when the person’s functioningdefinitely is affected, is often characterized by periodsof abstinence or temporarily controlled drinking.Abstinence may occur after some legal, social, or interpersonalcrisis, and the person may then set up rules aboutdrinking such as drinking only at certain times or drinkingonly beer. This period of temporarily controlled drinkingsoon leads to an escalation of alcohol intake, more problems,and a subsequent crisis. The cycle repeats continuously(Schuckit, 2005).For many people, substance use is a chronic illnesscharacterized by remissions and relapses to former levelsof use (Jaffe & Anthony, 2005). The highest rates for successfulrecovery are for people who abstain from substances,are highly motivated to quit, and have a pasthistory of life success (i.e., satisfactory experiences in coping,work, relationships, etc.). Although an estimated 60%to 70% of people in alcoholism treatment remain soberafter 1 year (Schuckit, 2005), this estimate may beoptimistic—and misleading—because most relapses occurduring the second year after treatment.Evidence shows that some people with alcohol-relatedproblems can modify or quit drinking on their own withouta treatment program; this is called spontaneous remissionor natural recovery (Bischof, Rumpf, Meyer, Hapke,& John, 2007). The abstinence was often in response to acrisis or a promise to a loved one and was accomplished byengaging in alternative activities, relying on relationshipswith family and friends, and avoiding alcohol, alcoholusers, and social cues associated with drinking. Spontaneousremission can occur in as many as 20% of alcoholics,although it is highly unlikely that people in the late stageof alcoholism can recover without treatment (Schuckit,2005).Poor outcomes have been associated with an earlier ageat onset, longer periods of substance use, and the coexistenceof a major psychiatric illness. With extended use, therisk for mental and physical deterioration and infectiousdisease such as HIV and AIDS, hepatitis, and tuberculosisincreases, especially for those with a history of intravenousdrug use. In addition, people addicted to alcohol and drugshave a rate of suicide 20% higher than that of the generalpopulation.RELATED DISORDERSSubstance-induced disorders such as anxiety, mood disorders,and dementia are discussed in other chapters. Forinstance Chapter 21 discusses delirium, which may beseen in severe alcohol withdrawal. A clinical care plan fora client receiving treatment for substance abuse is featurednear the end of this chapter. The effects on adults whogrew up in a home with an alcoholic parent are discussedlater, as are the special needs of clients with a dual diagnosisof substance use and a major psychiatric disorder.ETIOLOGYThe exact causes of drug use, dependence, and addictionare not known, but various factors are thought to contributeto the development of substance-related disorders(Jaffe & Anthony, 2005). Much of the research on biologicand genetic factors has been done on alcohol abuse, butpsychologic, social, and environmental studies have examinedother drugs as well.Biologic FactorsChildren of alcoholic parents are at higher risk for developingalcoholism and drug dependence than are childrenof nonalcoholic parents. This increased risk is partly theresult of environmental factors, but evidence points to theimportance of genetic factors as well. Several studies oftwins have shown a higher rate of concordance (when onetwin has it, the other twin gets it) among identical than

CHAPTER 17 • SUBSTANCE ABUSE 351fraternal twins. Adoption studies have shown higher ratesof alcoholism in sons of biologic fathers with alcoholismthan in those of nonalcoholic biologic fathers. These studiesled theorists to describe the genetic component of alcoholismas a genetic vulnerability that is then influenced byvarious social and environmental factors (Jaffe & Anthony,2005). Schuckit (2009) found that about 50% of the variationin causes of alcoholism was the result of genetics,with the remainder caused by environmental influences.Neurochemical influences on substance use patternshave been studied primarily in animal research (Jaffe &Anthony, 2005). The ingestion of mood-altering substancesstimulates dopamine pathways in the limbic system,which produces pleasant feelings or a “high” that is areinforcing, or positive, experience. Distribution of thesubstance throughout the brain alters the balance of neurotransmittersthat modulate pleasure, pain, and rewardresponses. Researchers have proposed that some peoplehave an internal alarm that limits the amount of alcoholconsumed to one or two drinks, so that they feel a pleasantsensation but go no further. People without this internalsignaling mechanism experience the high initially but continueto drink until central nervous system depression ismarked and they are intoxicated.Psychologic FactorsIn addition to the genetic links to alcoholism, familydynamics are thought to play a part. Children of alcoholicsare four times as likely to develop alcoholism (Schuckit,2005) compared with the general population. Some theoristsbelieve that inconsistency in the parent’s behavior,poor role modeling, and lack of nurturing pave the way forthe child to adopt a similar style of maladaptive coping,stormy relationships, and substance abuse. Others hypothesizethat even children who abhorred their family livesare likely to abuse substances as adults because they lackadaptive coping skills and cannot form successful relationships(NIAAA, 2007a).Some people use alcohol as a coping mechanism or torelieve stress and tension, increase feelings of power, anddecrease psychologic pain. High doses of alcohol, however,actually increase muscle tension and nervousness(Schuckit, 2005).Social and Environmental FactorsCultural factors, social attitudes, peer behaviors, laws,cost, and availability all influence initial and continueduse of substances (Jaffe & Anthony, 2005). In general,younger experimenters use substances that carry lesssocial disapproval such as alcohol and cannabis, whereasolder people use drugs such as cocaine and opioids thatare more costly and rate higher disapproval. Alcohol consumptionincreases in areas where availability increasesand decreases in areas where costs of alcohol are higherbecause of increased taxation. Many people view the socialuse of cannabis, although illegal, as not very harmful;some even advocate legalizing the use of marijuana forsocial purposes. Urban areas where cocaine and opioidsare readily available also have high crime rates, high unemployment,and substandard school systems that contributeto high rates of cocaine and opioid use and low rates ofrecovery. Thus, environment and social customs can influencea person’s use of substances.CULTURAL CONSIDERATIONSAttitudes toward substance use, patterns of use, and physiologicdifferences to substances vary in different cultures.Muslims do not drink alcohol, but wine is an integral partof Jewish religious rites. Some Native American tribes usepeyote, a hallucinogen, in religious ceremonies. It isimportant to be aware of such beliefs when assessing for asubstance abuse problem.Certain ethnic groups have genetic traits that eitherpredispose them to or protect them from developing alcoholism.For instance, flushing, a reddening of the face andneck as a result of increased blood flow, has been linked tovariants of genes for enzymes involved in alcohol metabolism.Even small amounts of alcohol can produce flushing,which may be accompanied by headaches and nausea. Theflushing reaction is highest among people of Asian ancestry(Wakabayashi & Masuda, 2006).Another genetic difference between ethnic groups isfound in other enzymes involved in metabolizing alcoholin the liver. Variations have been found in the structureand activity levels of the enzymes among Asians, AfricanAmericans, and whites. One enzyme found in people ofJapanese descent has been associated with faster eliminationof alcohol from the body. Other enzyme variations arebeing studied to determine their effects on the metabolismof alcohol among various ethnic groups (National Instituteon Alcohol Abuse and Alcoholism, 2007b).Statistics for individual tribes vary, but alcohol abuseoverall plays a part in the five leading causes of death forNative Americans and Alaska Natives (motor vehiclecrashes, alcoholism, cirrhosis, suicide, and homicide).Among tribes with high rates of alcoholism, an estimated75% of all accidents are alcohol-related (National Instituteon Alcohol Abuse and Alcoholism, 2007b). Alaska Nativesare seven times more likely than the general population todie of alcohol-related problems (Malcolm, Hesselbrock, &Segal, 2006).In Japan, alcohol consumption has quadrupled since1960. The Japanese do not regard alcohol as a drug, andthere are no religious prohibitions against drinking. Excessivealcohol consumption is widely condoned at parties,business functions, and at home, and very few Japanesepeople go to alcohol treatment. Japan is sixth on the list ofhighest beer consuming countries in the world—behindChina, the United States, Germany, Brazil, and Russia

352UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS(Kitanaka, 2007). In Russia, high rates of alcohol abuse,suicide, cigarette smoking, accidents, violence, and cardiovasculardisease are found in the male population. Lifeexpectancy for Russian males is 60.5 years, whereas it is74 years for females. This is a trend mirrored across theentire former Soviet Union (Grogan, 2006).TYPES OF SUBSTANCES AND TREATMENTThe classes of mood-altering substances have some similaritiesand differences in terms of intended effect, intoxicationeffects, and withdrawal symptoms. Treatment approachesafter detoxification, however, are quite similar. This sectionpresents a brief overview of seven classes of substances andthe effects of intoxication, overdose, withdrawal, and detoxification,and it highlights important elements of which thenurse should be aware.AlcoholIntoxication and OverdoseAlcohol is a central nervous system depressant that isabsorbed rapidly into the bloodstream. Initially, the effectsare relaxation and loss of inhibitions. With intoxication,there is slurred speech, unsteady gait, lack of coordination,and impaired attention, concentration, memory, and judgment.Some people become aggressive or display inappropriatesexual behavior when intoxicated. The person whois intoxicated may experience a blackout.DSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Substance Abuse• Denial of problems• Minimizes use of substance• Rationalization• Blaming others for problems• Anxiety• Irritability• Impulsivity• Feelings of guilt and sadness or anger and resentment• Poor judgment• Limited insight• Low self-esteem• Ineffective coping strategies• Difficulty expressing genuine feelings• Impaired role performance• Strained interpersonal relationships• Physical problems such as sleep disturbances andinadequate nutritionAdapted from DSM-IV-TR (2000).Box 17.1• Cardiac myopathy• Wernicke’s encephalopathy• Korsakoff’s psychosis• Pancreatitis• Esophagitis• Hepatitis• Cirrhosis• Leukopenia• Thrombocytopenia• AscitesPHYSIOLOGIC EFFECTS OFLONG-TERM ALCOHOL USEAn overdose, or excessive alcohol intake in a shortperiod, can result in vomiting, unconsciousness, andrespiratory depression. This combination can cause aspirationpneumonia or pulmonary obstruction. Alcoholinducedhypotension can lead to cardiovascular shockand death. Treatment of an alcohol overdose is similar tothat for any central nervous system depressant: gastriclavage or dialysis to remove the drug and support of respiratoryand cardiovascular functioning in an intensive careunit. The administration of central nervous system stimulantsis contraindicated (Lehne, 2006). The physiologiceffects of repeated intoxication and long-term use arelisted in Box 17.1.Withdrawal and DetoxificationSymptoms of withdrawal usually begin 4 to 12 hours aftercessation or marked reduction of alcohol intake. Symptomsinclude coarse hand tremors, sweating, elevatedpulse and blood pressure, insomnia, anxiety, and nausea orvomiting. Severe or untreated withdrawal may progress totransient hallucinations, seizures, or delirium—calleddelirium tremens (DTs). Alcohol withdrawal usually peakson the second day and is over in about 5 days (AmericanPsychiatric Association [APA], 2000). This can vary, however,and withdrawal may take 1 to 2 weeks.Because alcohol withdrawal can be life-threatening,detoxification needs to be accomplished under medicalsupervision. If the client’s withdrawal symptoms are mildand he or she can abstain from alcohol, he or she can betreated safely at home. For more severe withdrawal or forclients who cannot abstain during detoxification, a shortadmission of 3 to 5 days is the most common setting. Somepsychiatric units also admit clients for detoxification, butthis is less common.Safe withdrawal is usually accomplished with theadministration of benzodiazepines such as lorazepam(Ativan), chlordiazepoxide (Librium), or diazepam (Valium)to suppress the withdrawal symptoms. Withdrawal can beaccomplished by fixed-schedule dosing known as tapering

CHAPTER 17 • SUBSTANCE ABUSE 353CLINICAL VIGNETTE: DETOXIFICATIONJohn, 62 years old, was admitted at 5 AM this morning for anelective knee replacement surgery. The surgical procedure,including the anesthetic, went smoothly. John was stabilizedin the recovery room in about 3 hours. His blood pressure was124/82, temperature 98.8ºF, pulse 76, and respirations 16.John was alert, oriented, and verbally responsive, so he wastransferred to a room on the orthopedic unit.By 10 PM, John is agitated, sweating, and saying, “I haveto get out of here!” His blood pressure is 164/98, pulse 98,and respirations 28. His surgical dressing is dry and intact,and he has no complaints of pain. The nurse talks withJohn’s wife and asks about his usual habits of alcohol consumption.John’s wife says he consumes three or four drinkseach evening after work and has beer or wine with dinner.John did not report his alcohol consumption to his doctorbefore surgery. John’s wife says, “No one ever asked meabout how much he drank, so I didn’t think it wasimportant.”or symptom-triggered dosing in which the presence andseverity of withdrawal symptoms determine the amount ofmedication needed and the frequency of administration.Often, the protocol used is based on an assessment toolsuch as the Clinical Institute Withdrawal Assessment ofAlcohol Scale, Revised, shown in Box 17.2. Total scoresless than 8 indicate mild withdrawal; scores from 8 to 15indicate moderate withdrawal (marked arousal); andscores greater than 15 indicate severe withdrawal. Clientson symptom-triggered dosing receive medication based onscores of this scale alone, whereas clients on fixed-dosetapers also can receive additional doses depending on thelevel of scores from this scale. Both methods of medicatingclients are safe and effective.Box 17.2ADDICTION RESEARCH FOUNDATION CLINICAL INSTITUTE WITHDRAWALASSESSMENT FOR ALCOHOL, REVISED (CIWA-AR)NAUSEA AND VOMITING—Ask “Do you feel sick to yourstomach? Have you vomited?” Observation.0 no nausea and no vomiting1 mild nausea with no vomiting234 intermittent nausea with dry heaves567 constant nausea, frequent dry heaves, and vomitingTREMOR—Arms extended and fingers spread apart.Observation.0 no tremor1 not visible, but can be felt fingertip to fingertip234 moderate, with patient’s arms extended567 severe, flapping tremorsPAROXYSMAL SWEATS—Observation.0 no sweat visible1 barely perceptible sweating, palms moist234 beads of sweat obvious on forehead567 drenching sweatsANXIETY—Ask, “Do you feel nervous?” Observation.0 no anxiety, at ease1 mildly anxious234 moderately anxious, or guarded, so anxiety is inferred567 equivalent to acute panic states as seen in severe deliriumor acute psychotic reactionsAGITATION—Observation.0 normal activity1 somewhat more than normal activity234 moderately fidgety and restless56continued on page 354

354UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 17.2ADDICTION RESEARCH FOUNDATION CLINICAL INSTITUTE WITHDRAWALASSESSMENT FOR ALCOHOL, REVISED (CIWA-AR) Continued7 paces back and forth during most of the interview, orconstantly thrashes aboutTACTILE DISTURBANCES—Ask, “Have you any itching, pinsand needles sensations, any burning, any numbness or doyou feel bugs crawling on or under your skin?”Observation.0 none1 very mild itching, pins and needles, burning ornumbness2 mild itching, pins and needles, burning or numbness3 moderate itching, pins and needles, burning ornumbness4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinationsAUDITORY DISTURBANCES—Ask, “Are you more aware ofsounds around you? Are they harsh? Do they frighten you?Are you hearing anything that is disturbing to you? Are youhearing things you know are not there?” Observation.0 not present1 very mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinationsVISUAL DISTURBANCES—Ask, “Does the light appear toobright? Is its color different? Does it hurt your eyes? Are youseeing anything that is disturbing to you? Are you seeingthings you know are not there?” Observation.0 not present1 very mild sensitivity2 mild sensitivity3 moderate sensitivity4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinationsHEADACHE, FULLNESS IN HEAD—Ask, “Does your headfeel different? Does it feel like there is a band around yourhead?” Do not rate for dizziness or lightheadedness. Otherwise,rate severity. Observation.0 not present1 very mild2 mild3 moderate4 moderately severe5 severe6 very severe7 extremely severeORIENTATION AND CLOUDING OF SENSORIUM—Ask,“What day is this? Where are you? Who am I?”Observation.0 oriented and can do serial additions1 cannot do serial additions or is uncertain about date2 disoriented for date by no more than 2 calendar days3 disoriented for date by more than 2 calendar days4 disoriented for place and/or personMaximum Possible Score 67A score of less than 10 usually indicates no need foradditional withdrawal medication.Sedatives, Hypnotics, and AnxiolyticsIntoxication and OverdoseThis class of drugs includes all central nervous systemdepressants: barbiturates, nonbarbiturate hypnotics, andanxiolytics, particularly benzodiazepines. Benzodiazepinesand barbiturates are the most frequently abused drugs inthis category (Ciraulo & Sarid-Segal, 2005). The intensityof the effect depends on the particular drug. The effects ofthe drugs, symptoms of intoxication, and withdrawalsymptoms are similar to those of alcohol. In the usual prescribeddoses, these drugs cause drowsiness and reduceanxiety, which is the intended purpose. Intoxication symptomsinclude slurred speech, lack of coordination, unsteadygait, labile mood, impaired attention or memory, and evenstupor and coma.Benzodiazepines alone, when taken orally in overdose,are rarely fatal, but the person is lethargic and confused.Treatment includes gastric lavage followed by ingestion ofactivated charcoal and a saline cathartic; dialysis can beused if symptoms are severe (Lehne, 2006). The client’sconfusion and lethargy improve as the drug is excreted.Barbiturates, in contrast, can be lethal when taken inoverdose. They can cause coma, respiratory arrest, cardiacfailure, and death. Treatment in an intensive care unit isrequired using lavage or dialysis to remove the drug fromthe system and to support respiratory and cardiovascularfunction.

CHAPTER 17 • SUBSTANCE ABUSE 355Withdrawal and DetoxificationThe onset of withdrawal symptoms depends on the halflifeof the drug (see Chapter 2). Medications such as lorazepam,whose actions typically last about 10 hours, producewithdrawal symptoms in 6 to 8 hours; longer-actingmedications such as diazepam may not produce withdrawalsymptoms for 1 week (APA, 2000). The withdrawalsyndrome is characterized by symptoms that are the oppositeof the acute effects of the drug: that is, autonomichyperactivity (increased pulse, blood pressure, respirations,and temperature), hand tremor, insomnia, anxiety,nausea, and psychomotor agitation. Seizures and hallucinationsoccur only rarely in severe benzodiazepine withdrawal(Ciraulo & Sarid-Segal, 2005).Detoxification from sedatives, hypnotics, and anxiolyticsis often managed medically by tapering the amount ofthe drug the client receives over a period of days or weeks,depending on the drug and the amount the client had beenusing. Tapering, or administering decreasing doses of amedication, is essential with barbiturates to prevent comaand death that occur if the drug is stopped abruptly. Forexample, when tapering the dosage of a benzodiazepine,the client may be given Valium, 10 mg four times a day;the dose is decreased every 3 days, and the number oftimes a day the dose is given also is decreased until the clientsafely withdraws from the drug.Stimulants (Amphetamines, Cocaine)Stimulants are drugs that stimulate or excite the centralnervous system. Although the DSM-IV-TR categorizesamphetamines, cocaine, and central nervous system stimulantsseparately, the effects, intoxication, and withdrawalsymptoms of these drugs are virtually identical. They aregrouped together here for this reason.Stimulants have limited clinical use (with the exceptionof stimulants used to treat attention deficit hyperactivitydisorder; see Chapter 20) and a high potential for abuse.Amphetamines (uppers) were popular in the past; theywere used by people who wanted to lose weight or to stayawake. Cocaine, an illegal drug with virtually no clinicaluse in medicine, is highly addictive and a popular recreationaldrug because of the intense and immediate feelingof euphoria it produces.Methamphetamine is particularly dangerous. It ishighly addictive and causes psychotic behavior. Braindamage related to its use is frequent, primarily as a resultof the substances used to make it—that is, liquid agriculturalfertilizer. The percentage of people admitted toinpatient settings for methamphetamine abuse hadincreased in 49 of the 50 states in the United States from2000 to 2005. Use of methamphetamine, however, seemsto have peaked and actually declined in the past few years(Substance Abuse and Mental Health Services Administration,2009).Intoxication and OverdoseIntoxication from stimulants develops rapidly; effectsinclude the high or euphoric feeling, hyperactivity, hypervigilance,talkativeness, anxiety, grandiosity, hallucinations,stereotypic or repetitive behavior, anger, fighting,and impaired judgment. Physiologic effects include tachycardia,elevated blood pressure, dilated pupils, perspirationor chills, nausea, chest pain, confusion, and cardiacdysrhythmias. Overdoses of stimulants can result in seizuresand coma; deaths are rare (Jaffe, Ling, & Rawson,2005). Treatment with chlorpromazine (Thorazine), anantipsychotic, controls hallucinations, lowers blood pressure,and relieves nausea (Lehne, 2006).Withdrawal and DetoxificationWithdrawal from stimulants occurs within a few hours toseveral days after cessation of the drug and is not lifethreatening.Marked dysphoria is the primary symptomand is accompanied by fatigue, vivid and unpleasantdreams, insomnia or hypersomnia, increased appetite, andpsychomotor retardation or agitation. Marked withdrawalsymptoms are referred to as “crashing”; the person mayexperience depressive symptoms, including suicidal ideation,for several days. Stimulant withdrawal is not treatedpharmacologically.Cannabis (Marijuana)Cannabis sativa is the hemp plant that is widely cultivatedfor its fiber used to make rope and cloth and for oil fromits seeds. It has become widely known for its psychoactiveresin (Hall & Degenhardt, 2005). This resin contains morethan 60 substances, called cannabinoids, of which -9-tetrahydrocannabinol is thought to be responsible for mostof the psychoactive effects. Marijuana refers to the upperleaves, flowering tops, and stems of the plant; hashish isthe dried resinous exudate from the leaves of the femaleplant. Cannabis is most often smoked in cigarettes (joints),but it can be eaten.Cannabis is the most widely used illicit substance in theUnited States. Research has shown that cannabis has shorttermeffects of lowering intraocular pressure, but it is notapproved for the treatment of glaucoma. It also has beenstudied for its effectiveness in relieving the nausea andvomiting associated with cancer chemotherapy and theanorexia and weight loss of AIDS. Currently, two cannabinoids,dronabinol (Marinol) and nabilone (Cesamet), havebeen approved for treating nausea and vomiting from cancerchemotherapy.Intoxication and OverdoseCannabis begins to act less than 1 minute after inhalation.Peak effects usually occur in 20 to 30 minutes andlast at least 2 to 3 hours. Users report a high feeling similarto that with alcohol, lowered inhibitions, relaxation,

356UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSeuphoria, and increased appetite. Symptoms of intoxicationinclude impaired motor coordination, inappropriatelaughter, impaired judgment and short-term memory,and distortions of time and perception. Anxiety, dysphoria,and social withdrawal may occur in some users.Physiologic effects, in addition to increased appetite,include conjunctival injection (bloodshot eyes), drymouth, hypotension, and tachycardia. Excessive use ofcannabis may produce delirium or, rarely, cannabis-inducedpsychotic disorder, both of which are treatedsymptomatically. Overdoses of cannabis do not occur(Hall & Degenhardt, 2005).Withdrawal and DetoxificationAlthough some people have reported withdrawal symptomsof muscle aches, sweating, anxiety, and tremors, noclinically significant withdrawal syndrome is identified(Lehne, 2006).OpioidsOpioids are popular drugs of abuse because they desensitizethe user to both physiologic and psychologic pain andinduce a sense of euphoria and well-being. Opioid compoundsinclude both potent prescription analgesics suchas morphine, meperidine (Demerol), codeine, hydromorphone,oxycodone, methadone, oxymorphone, hydrocodone,and propoxyphene as well as illegal substancessuch as heroin and normethadone. People who abuse opioidsspend a great deal of their time obtaining the drugs;they often engage in illegal activity to get them. Healthcare professionals who abuse opioids often write prescriptionsfor themselves or divert prescribed pain medicationfor clients to themselves (APA, 2000).and insomnia. Symptoms of opioid withdrawal cause significantdistress but do not require pharmacologic interventionto support life or bodily functions. Short-acting drugssuch as heroin produce withdrawal symptoms in 6 to 24hours; the symptoms peak in 2 to 3 days and gradually subsidein 5 to 7 days. Longer-acting substances such as methadonemay not produce significant withdrawal symptoms for2 to 4 days, and the symptoms may take 2 weeks to subside.Methadone can be used as a replacement for the opioid, andthe dosage is then decreased over 2 weeks. Substitution ofmethadone during detoxification reduces symptoms to noworse than a mild case of flu (Lehne, 2006). Withdrawalsymptoms such as anxiety, insomnia, dysphoria, anhedonia,and drug craving may persist for weeks or months.HallucinogensHallucinogens are substances that distort the user’s perceptionof reality and produce symptoms similar to psychosis,including hallucinations (usually visual) and depersonalization.Hallucinogens also cause increased pulse, bloodpressure, and temperature; dilated pupils; and hyperreflexia.Examples of hallucinogens are mescaline, psilocybin, lysergicacid diethylamide, and “designer drugs” such as Ecstasy.PCP, developed as an anesthetic, is included in this sectionbecause it acts similarly to hallucinogens.Intoxication and OverdoseHallucinogen intoxication is marked by several maladaptivebehavioral or psychologic changes: anxiety, depression,paranoid ideation, ideas of reference, fear of losing one’smind, and potentially dangerous behavior such as jumpingIntoxication and OverdoseOpioid intoxication develops soon after the initial euphoricfeeling; symptoms include apathy, lethargy, listlessness,impaired judgment, psychomotor retardation or agitation,constricted pupils, drowsiness, slurred speech, and impairedattention and memory. Severe intoxication or opioid overdosecan lead to coma, respiratory depression, pupillary constriction,unconsciousness, and death. Administration ofnaloxone (Narcan), an opioid antagonist, is the treatment ofchoice because it reverses all signs of opioid toxicity. Naloxoneis given every few hours until the opioid level drops tonontoxic; this process may take days (Lehne, 2006).Withdrawal and DetoxificationOpioid withdrawal develops when drug intake ceases ordecreases markedly, or it can be precipitated by the administrationof an opioid antagonist. Initial symptoms are anxiety,restlessness, aching back and legs, and cravings for moreopioids (Jaffe & Strain, 2005). Symptoms that develop aswithdrawal progresses include nausea, vomiting, dysphoria,lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever,Hallucinogens distort reality

CHAPTER 17 • SUBSTANCE ABUSE 357out a window in the belief that one can fly (Jones, 2005).Physiologic symptoms include sweating, tachycardia, palpitations,blurred vision, tremors, and lack of coordination.PCP intoxication often involves belligerence, aggression,impulsivity, and unpredictable behavior.Toxic reactions to hallucinogens (except PCP) are primarilypsychologic; overdoses as such do not occur. These drugsare not a direct cause of death, although fatalities have occurredfrom related accidents, aggression, and suicide. Treatment oftoxic reactions is supportive. Psychotic reactions are managedbest by isolation from external stimuli; physical restraints maybe necessary for the safety of the client and others. PCP toxicitycan include seizures, hypertension, hyperthermia, andrespiratory depression. Medications are used to control seizuresand blood pressure. Cooling devices such as hyperthermiablankets are used, and mechanical ventilation is usedto support respirations (Lehne, 2006).Withdrawal and DetoxificationNo withdrawal syndrome has been identified for hallucinogens,although some people have reported a craving forthe drug. Hallucinogens can produce flashbacks, whichare transient recurrences of perceptual disturbances likethose experienced with hallucinogen use. These episodesoccur even after all traces of the hallucinogen are gone andmay persist for a few months up to 5 years.InhalantsInhalants are a diverse group of drugs that include anesthetics,nitrates, and organic solvents that are inhaled fortheir effects. The most common substances in this categoryare aliphatic and aromatic hydrocarbons found in gasoline,glue, paint thinner, and spray paint. Less frequently usedhalogenated hydrocarbons include cleaners, correctionfluid, spray can propellants, and other compounds containingesters, ketones, and glycols (APA, 2000). Most of thevapors are inhaled from a rag soaked with the compound,from a paper or plastic bag, or directly from the container.Inhalants can cause significant brain damage, peripheralnervous system damage, and liver disease.Intoxication and OverdoseInhalant intoxication involves dizziness, nystagmus, lackof coordination, slurred speech, unsteady gait, tremor,muscle weakness, and blurred vision. Stupor and comacan occur. Significant behavioral symptoms are belligerence,aggression, apathy, impaired judgment, and inabilityto function. Acute toxicity causes anoxia, respiratorydepression, vagal stimulation, and dysrhythmias. Deathmay occur from bronchospasm, cardiac arrest, suffocation,or aspiration of the compound or vomitus (Crowley &Sakai, 2005). Treatment consists of supporting respiratoryand cardiac functioning until the substance is removedfrom the body. There are no antidotes or specific medicationsto treat inhalant toxicity.Withdrawal and DetoxificationThere are no withdrawal symptoms or detoxification proceduresfor inhalants as such, although frequent usersreport psychologic cravings. People who abuse inhalantsmay suffer from persistent dementia or inhalant-induceddisorders such as psychosis, anxiety, or mood disorderseven if the inhalant abuse ceases. These disorders are alltreated symptomatically (Crowley & Sakai, 2005).TREATMENT AND PROGNOSISCurrent treatment modalities are based on the concept ofalcoholism (and other addictions) as a medical illness thatis progressive, chronic, and characterized by remissionsand relapses (Jaffe & Anthony, 2005). Until the 1970s,organized treatment programs and clinics for substanceabuse were scarce. Before the illness of addiction was fullyunderstood, most of the society and even the medical communityviewed chemical dependency as a personal problem;the user was advised to “pull yourself together” and“get control of your problem.” Founded in 1949, theHazelden Clinic in Minnesota is the noted exception;because of its success, many programs are based on theHazelden model of treatment.Today, treatment for substance use is available in a varietyof community settings, not all of which involve healthprofessionals. Alcoholics Anonymous (AA) was foundedin the 1930s by alcoholics. This self-help group developedthe 12-step program model for recovery (Box 17.3), whichis based on the philosophy that total abstinence is essentialand that alcoholics need the help and support of others tomaintain sobriety. Key slogans reflect the ideas in the 12steps, such as “one day at a time” (approach sobriety oneday at a time), “easy does it” (don’t get frenzied about dailylife and problems), and “let go and let God” (turn your lifeover to a higher power). People who are early in recoveryare encouraged to have a sponsor to help them progressthrough the 12 steps of AA. Once sober, a member can bea sponsor for another person.Regular attendance at meetings is emphasized. Meetingsare available daily in large cities and at least weekly insmaller towns or rural areas. AA meetings may be “closed”(only those who are pursuing recovery can attend) or“open” (anyone can attend). Meetings may be educationalwith a featured speaker; other meetings focus on a reading,daily meditation, or a theme, and then offer the opportunityfor members to relate their battles with alcohol and toask the others for help staying sober.Many treatment programs, regardless of setting, use the12-step approach and emphasize participation in AA. Theyalso include individual counseling and a wide variety ofgroups. Group experiences involve education about substancesand their use, problem-solving techniques, andcognitive techniques to identify and to modify faulty waysof thinking. An overall theme is coping with life, stress,and other people without the use of substances.

358UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 17.3 TWELVE STEPS OF ALCOHOLICS ANONYMOUS1. We admitted we were powerless over alcohol, that ourlives had become unmanageable.2. Came to believe that a Power greater than ourselvescould restore us to sanity.3. Made a decision to turn our wills and lives over to thecare of God as we understood Him.4. Made a searching and fearless moral inventory ofourselves.5. Admitted to God, to ourselves, and to another humanbeing the exact nature of our wrongs.6. Were entirely ready to have God remove all thesedefects of character.7. Humbly asked Him to remove our shortcomings.8. Made a list of all persons we had harmed, and becamewilling to make amends to them all.9. Made direct amends to such people whenever possible,except when to do so would injure them or others.10. Continued to take personal inventory and when wewere wrong promptly admitted it.11. Sought through prayer and meditation to improve ourconscious contact with God as we understood Him,praying only for knowledge of His will for us and thepower to carry that out.12. Having had a spiritual awakening as a result of thesesteps, we tried to carry this message to alcoholics andto practice these principles in all our affairs.CLINICAL VIGNETTE: ALCOHOLISMSam, age 38, is married with two children. Sam’s father wasan alcoholic, and his childhood was chaotic. His father wasseldom around for Sam’s school activities or family events,and when he was present, his drunken behavior spoiled theoccasion. When Sam graduated from high school and lefthome, he vowed he would never be like his father.Initially, Sam had many hopes and dreams about becomingan architect and raising a family with love and affection,and he pictured himself as a devoted and loving spouse. Buthe’d had some bad luck. He got into trouble for underagedrinking in college, and his grades slipped because he missedclasses after celebrating with his friends. Sam believes lifehas treated him unfairly—after all, he only has a few beerswith friends to relax. Sometimes he overdoes it and he drinksmore than he intended—but doesn’t everybody? Sam’s bigplans for the future are on hold.Today, Sam’s boss told him he would be fired if he waslate or absent from work in the next 30 days. Sam tells himselfthat the boss is being unreasonable; after all, Sam is anexcellent worker, when he’s there. The last straw was whenSam’s wife told him she was tired of his drinking and irresponsiblebehavior. She threatened to leave if Sam did notstop drinking. Her parting words were, “You’re just like yourfather!”Although traditional treatment programs and AA havebeen successful for many people, they are not effective foreveryone. Some object to the emphasis on God and spirituality;others do not respond well to the confrontationalapproach sometimes used in treatment or to identifyinghimself or herself as an alcoholic or an addict. Women andminorities have reported feeling overlooked or ignored byan essentially “white, male, middle-class” organization.Treatment programs have been developed to meet theseneeds, such as Women for Sobriety (exclusively forwomen) and Rainbow Recovery (for gay and lesbian individuals).AA groups may also be designated for women orgay and lesbian people.The 12-step concept of recovery has been used for otherdrugs as well. Such groups include Narcotics Anonymous;Al-Anon, a support group for spouses, partners, andfriends of alcoholics; and AlaTeen, a group for children ofparents with substance problems. This same model hasbeen used in self-help groups for people with gamblingproblems and eating disorders. National addresses forthese groups are listed in Box 17.4.Treatment Settings and ProgramsClients being treated for intoxication and withdrawal ordetoxification are encountered in a wide variety of medicalsettings from emergency departments to outpatient clinics.Clients needing medically supervised detoxificationoften are treated on medical units in the hospital settingand then referred to an appropriate outpatient treatmentsetting when they are medically stable.Health professionals provide extended or outpatienttreatment in various settings, including clinics or centersoffering day and evening programs, halfway houses, residentialsettings, or special chemical dependency units inhospitals. Generally, the type of treatment setting selected

CHAPTER 17 • SUBSTANCE ABUSE 359Box 17.4NATIONAL ADDRESSES FOR SELF-HELP GROUPSAND TREATMENT PROGRAMSAlcoholics AnonymousPO Box 459, Grand Central StationNew York, NY 10163Phone: 1-212-870-3400Al-Anon Family Group Headquarters, Inc.1600 Corporate Landing ParkwayVirginia Beach, VA 23454-5617Phone: 1-757-563-1600Women for SobrietyPO Box 618Quakertown, PA 18951Phone: 1-215-536-8026Rainbow Recovery Inc.10833 US Highway 41 SouthGibsonton, FL 33534Phone: 1-800-281-5919is based on the client’s needs as well as on his or her insurancecoverage. For example, for someone who has limitedinsurance coverage, is working, and has a supportive family,the outpatient setting may be chosen first because it isless expensive, the client can continue to work, and thefamily can provide support. If the client cannot remainsober during outpatient treatment, then inpatient treatmentmay be required. Clients with repeated treatmentexperiences may need the structure of a halfway housewith a gradual transition into the community.Pharmacologic TreatmentPharmacologic treatment in substance abuse has two mainpurposes: (1) to permit safe withdrawal from alcohol,sedative-hypnotics, and benzodiazepines and (2) to preventrelapse. Table 17.1 summarizes drugs used in substanceabuse treatment. For clients whose primary substance isalcohol, vitamin B 1 (thiamine) often is prescribed to preventor to treat Wernicke–Korsakoff syndrome, which areneurologic conditions that can result from heavy alcoholuse. Cyanocobalamin (vitamin B 12 ) and folic acid often areprescribed for clients with nutritional deficiencies.Alcohol withdrawal usually is managed with a benzodiazepineanxiolytic agent, which is used to suppress thesymptoms of abstinence. The most commonly used benzodiazepinesare lorazepam, chlordiazepoxide, and diazepam.These medications can be administered on a fixed schedulearound the clock during withdrawal. Giving thesemedications on an as-needed basis according to symptomparameters, however, is just as effective and results in aspeedier withdrawal (Lehne, 2006).Disulfiram (Antabuse) may be prescribed to help deterclients from drinking. If a client taking disulfiram drinksalcohol, a severe adverse reaction occurs with flushing, athrobbing headache, sweating, nausea, and vomiting. Insevere cases, severe hypotension, confusion, coma, andeven death may result (see Chapter 2). The client also mustavoid a wide variety of products that contain alcohol suchas cough syrup, lotions, mouthwash, perfume, aftershave,vinegar, and vanilla and other extracts. The client mustread product labels carefully because any product containingalcohol can produce symptoms. Ingestion of alcoholmay cause unpleasant symptoms for 1 to 2 weeks after thelast dose of disulfiram.Acamprosate (Campral) may be prescribed for clientsrecovering from alcohol abuse or dependence to helpreduce cravings for alcohol and decrease the physical andemotional discomfort that occurs especially in the first fewmonths of recovery. These include sweating, anxiety, andsleep disturbances. The dosage is two tablets (333 mgeach) or 666 mg, three times a day. Persons with renalimpairment cannot take this drug. Side effects are reportedas mild and include diarrhea, nausea, flatulence, and pruritis.In one study, acamprosate was found to be moreeffective with “relief cravers,” while naltrexone (discussedlater in this section) was more effective with “rewardcravers” (Mann, Kiefer, Spanagel, & Littleton, 2008).Methadone, a potent synthetic opiate, is used as a substitutefor heroin in some maintenance programs. The clienttakes one daily dose of methadone, which meets thephysical need for opiates but does not produce cravingsfor more. Methadone does not produce the high associatedwith heroin. The client has essentially substituted his orher addiction to heroin for an addiction to methadone;however, methadone is safer because it is legal, controlledby a physician, and available in tablet form. The clientavoids the risks of intravenous drug use, the high cost ofheroin (which often leads to criminal acts), and the questionablecontent of street drugs.Levomethadyl is a narcotic analgesic whose only purposeis the treatment of opiate dependence. It is used inthe same manner as methadone.Naltrexone (ReVia) is an opioid antagonist often usedto treat overdose. It blocks the effects of any opioids thatmight be ingested, thereby negating the effects of usingmore opioids. It also has been found to reduce the cravingsfor alcohol in abstinent clients (Richardson et al., 2008).There are four medications that are sometimes prescribedfor the off-label use of decreasing craving for cocaine. They

360UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 17.1DRUGS USED FOR SUBSTANCE ABUSE TREATMENTDrug Use Dosage Nursing ConsiderationsLorazepam (Ativan) Alcohol withdrawal 2–4 mg every 2–4 hours PRN Monitor vital signs and globalassessments for effectiveness;may cause dizziness ordrowsinessChlordiazepoxide(Librium)Disulfiram (Antabuse)Methadone (Dolophine)Levomethadyl (Orlaam)Naltrexone (ReVia,Trexan)Clonidine (Catapres)Acamprosate (Campral)Thiamine (vitamin B 1 )Folic acid (folate)Cyanocobalamin(vitamin B 12 )Alcohol withdrawalMaintains abstinence fromalcoholMaintains abstinencefrom heroinMaintains abstinencefrom opiatesBlocks the effects ofopiates; reducesalcohol cravingsSuppresses opiate withdrawalsymptomsSuppresses alcoholcravingsPrevents or treatsWernicke–Korsakoffsyndrome in alcoholismTreats nutritionaldeficienciesTreats nutritionaldeficiencies50–100 mg, repeat in2–4 hours if necessary;not to exceed 300 mg/day500 mg/day for 1–2 weeks,then 250 mg/dayUp to 120 mg/day formaintenance60–90 mg three times a weekfor maintenance350 mg/week, divided intothree doses for opiateblockingeffect; 50 mg/dayfor up to 12 weeks foralcohol cravingsMonitor vital signs and globalassessments for effectiveness;may cause dizziness ordrowsinessTeach client to read labels toavoid products with alcoholMay cause nausea andvomitingDo not take drug on consecutivedays; take-home dosesare not permittedClient may not respond tonarcotics used to treatcough, diarrhea, or pain; takewith food or milk; may causeheadache, restlessness, orirritability0.1 mg every 6 hours PRN Take blood pressure beforeeach dose; withhold if clientis hypotensive666 mg three times daily Monitor for diarrhea, vomiting,flatulence, and pruritis100 mg/day Teach client about propernutrition1–2 mg/day Teach client about propernutrition; urine may be darkyellow25–250 mcg/day Teach client about propernutritionare disulfiram (discussed earlier); modafinil (Provigil), anantinarcoleptic; propranolol (Inderal), a -blocker; andtopiramate (Topamax), an anticonvulsant also used to stabilizemoods and treat migraines.Clonidine (Catapres) is an alpha-2-adrenergic ( 2 -adrenergic) agonist used to treat hypertension. It is given toclients with opiate dependence to suppress some effects ofwithdrawal or abstinence. It is most effective against nausea,vomiting, and diarrhea but produces modest relief frommuscle aches, anxiety, and restlessness (Lehne, 2006).Ondansetron (Zofran), a 5-HT 3 antagonist that blocksthe vagal stimulation effects of serotonin in the small intestine,is used as an antiemetic. It has been used in youngmales at high risk for alcohol dependence or with earlyonsetalcohol dependence. It is being studied for treatmentof methamphetamine addiction.Dual DiagnosisThe client with both substance abuse and another psychiatricillness is said to have a dual diagnosis. Dual diagnosisclients who have schizophrenia, schizoaffective disorder, orbipolar disorder present the greatest challenge to healthcare professionals. It is estimated that 50% of people with asubstance abuse disorder also have a mental health diagnosis(Jaffe & Anthony, 2005). Traditional methods for treatmentof major psychiatric illness or primary substance abuseoften have little success in these clients for the followingreasons:• Clients with a major psychiatric illness may have impairedabilities to process abstract concepts; this is amajor barrier in substance abuse programs.

CHAPTER 17 • SUBSTANCE ABUSE 361• Substance use treatment emphasizes avoidance of allpsychoactive drugs. This may not be possible for theclient who needs psychotropic drugs to treat his or hermental illness.• The concept of “limited recovery” is more acceptable inthe treatment of psychiatric illnesses, but substanceabuse has no limited recovery concept.• The notion of lifelong abstinence, which is central tosubstance use treatment, may seem overwhelming andimpossible to the client who lives “day to day” with achronic mental illness.• The use of alcohol and other drugs can precipitate psychoticbehavior; this makes it difficult for professionalsto identify whether symptoms are the result of activemental illness or substance abuse.Clients with a dual diagnosis (substance use andmental illness) present challenges that traditionalsettings cannot meet. Studies of successful treatmentand relapse prevention strategies for this populationfound several key elements that need to be addressed.These include healthy, nurturing, supportive living environments;assistance with fundamental life changes,such as finding a job and abstinent friends; connectionswith other recovering people; and treatment of theircomorbid conditions. Clients identified the need for stablehousing, positive social support, using prayer orrelying on a higher power, participation in meaningfulactivity, eating regularly, getting sufficient sleep, andlooking presentable as important components of relapseprevention. Quetiapine (Seroquel) was used in one studyto control alcohol cravings as well as moderating theirpsychiatric symptoms (Martinotti et al., 2008). For moreinformation, see the Nursing Care Plan: Dual Diagnosisin this chapter.Nursing Care Plan | Dual DiagnosisNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses,and/or inability to use available resources.ASSESSMENT DATA• Poor impulse control• Low self-esteem• Lack of social skills• Dissatisfaction with life circumstances• Lack of purposeful daily activityEXPECTED OUTCOMESImmediateThe client will• Take only prescribed medication• Interact appropriately with staff and other clients• Express feelings openly• Develop plans to manage unstructured time; e.g.,walking, doing errandsStabilizationThe client will• Demonstrate appropriate or adequate social skills;e.g., initiate interactions with others• Identify social activities in drug- and alcohol-freeenvironments• Assess own strengths and weaknesses realisticallyCommunityThe client will• Maintain contact or relationship with a professionalin the community• Verbalize plans to join a community support groupthat meets the needs of clients with a dualdiagnosis, if available• Participate in drug- and alcohol-free programs andactivities(continued)

362UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Dual Diagnosis, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Encourage open expression of feelings.Validate the client’s frustration or anger in dealingwith dual problems (e.g., “I know this must bevery difficult.”).Consider alcohol or substance use as a factor thatinfluences the client’s ability to live in the community,similar to such factors as taking medications,keeping appointments, and so forth.Maintain frequent contact with the client, even if it isonly brief telephone calls.Give positive feedback for abstinence on aday-by-day basis.If drinking or substance use occurs, discuss theevents that led to the incident with the client in anonjudgmental manner.Discuss ways to avoid similar circumstances in thefuture.Assess the amount of unstructured time with whichthe client must cope.Assist the client to plan daily or weekly schedules ofpurposeful activities: errands, appointments, takingwalks, and so forth.Writing the schedule on a calendar may be beneficial.Encourage the client to record activities, feelings, andthoughts in a journal.Teach the client social skills. Describe and demonstratespecific skills, such as eye contact, attentive listening,nodding, and so forth. Discuss the kind of topics thatare appropriate for social conversation, such as theweather, news, local events, and so forth.Give positive support to the client for appropriate useof social skills.*Refer the client to volunteer or vocational services ifindicated.*Refer the client to community support services thataddress mental health and substance dependencerelatedneeds.RationaleVerbalizing feelings is an initial step toward dealingconstructively with those feelings.Expressing feelings outwardly, especially negativeones, may relieve some of the client’s stress andanxiety.Substance use is not necessarily the major problemthe client with a dual diagnosis experiences, onlyone of several problems. Overemphasis on anysingle factor does not guarantee success.Frequent contact decreases the length of time the clientfeels “stranded” or left alone to deal with problems.Positive feedback reinforces abstinent behavior.The client may be able to see the relatedness of theevents or a pattern of behavior while discussing thesituation.Anticipatory planning may prepare the client to avoidsimilar circumstances in the future.The client is more likely to experience frustration or dissatisfaction,which can lead to substance use, when heor she has excessive amounts of unstructured time.Scheduled events provide the client with somethingto anticipate or look forward to doing.Visualization of the schedule provides a concretereference for the client.A journal can provide a focus for the client and yieldinformation that is useful in future planning butmay otherwise be forgotten or overlooked.The client may have little or no knowledge of socialinteraction skills. Modeling the skills provides aconcrete example of the desired skills.Positive feedback will encourage the client to continuesocialization attempts and enhance selfesteem.Purposeful activity makes better use of the client’sunstructured time and can enhance the client’sfeelings of worth and self-esteem.Clients with dual diagnosis have complicated andlong-term problems that require ongoing, extendedassistance.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.

CHAPTER 17 • SUBSTANCE ABUSE 363APPLICATION OF THE NURSING PROCESSIdentifying people with substance use problems can be difficult.Substance use typically includes the use of defensemechanisms, especially denial. Clients may deny directlyhaving any problems or may minimize the extent of problemsor actual substance use. In addition, the nurse mayencounter clients with substance problems in various settingsunrelated to mental health. A client may come to aclinic for treatment of medical problems related to alcoholuse, or a client may develop withdrawal symptoms whilein the hospital for surgery or an unrelated condition. Thenurse must be alert to the possibility of substance use inthese situations and be prepared to recognize their existenceand to make appropriate referrals.The Alcohol Use Disorders Identification Test (AUDIT)is a useful screening device to detect hazardous drinkingpatterns that may be precursors to full-blown substanceuse disorders (Bohn, Babor, & Kranzler, 1995). This tool(Box 17.5) promotes recognition of problem drinking inthe early stage, when resolution without formal treatmentis more likely. Early detection and treatment are associatedwith more positive outcomes.Detoxification is the initial priority. A nursing care planfor the client in alcohol withdrawal is included at the endof this chapter. Priorities for individual clients are basedon their physical needs and may include safety, nutrition,fluids, elimination, and sleep. The remainder of this sectionfocuses on care of the client being treated for substanceabuse after detoxification.AssessmentHistoryClients with a parent or other family members with substanceabuse problems may report a chaotic family life,although this is not always the case. They generallydescribe some crisis that precipitated entry into treatment,such as physical problems or development of withdrawalsymptoms while being treated for another condition. Usually,other people such as an employer threatening loss ofa job or a spouse or partner threatening loss of a relationshipare involved in a client’s decision to seek treatment.Rarely do clients decide to seek treatment independentlywith no outside influence.Box 17.5 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)The following questionnaire will give you an indication ofthe level of risk associated with your current drinking pattern.To accurately assess your situation, you will need to behonest in your answers. This questionnaire was developedby the World Health Organization and is used in many countriesto assist people to better understand their current levelof risk in relation to alcohol consumption.1. How often do you have a drink containing alcohol?(0) Never, (1) Monthly or less, (2) 2 to 4 times a month,(3) 2 to 3 times a week, (4) 4 or more times a week.2. How many standard drinks do you have on a typical daywhen you are drinking? (0) 1 or 2, (1) 3 or 4, (2) 5 or 6,(3) 7 to 9, (4) 10 or more.3. How often do you have six or more drinks on one occasion?(0) Never, (1) Less than monthly, (2) Monthly,(3) Weekly, (4) Daily or almost daily.4. How often during the last year have you found that youwere not able to stop drinking once you had started?(0) Never, (1) Less than monthly, (2) Monthly, (3) Weekly,(4) Daily or almost daily.5. How often during the past year have you failed to dowhat was normally expected of you because ofdrinking? (0) Never, (1) Less than monthly, (2) Monthly,(3) Weekly, (4) Daily or almost daily.6. How often during the last year have you needed a drinkin the morning to get yourself going after a heavydrinking session? (0) Never, (1) Less than monthly, (2)Monthly, (3) Weekly, (4) Daily or almost daily.7. How often during the last year have you had a feelingof guilt or remorse after drinking? (0) Never, (1) Lessthan monthly, (2) Monthly, (3) Weekly, (4) Daily oralmost daily.8. How often during the last year have you been unable toremember what happened the night before becauseyou had been drinking? (0) Never, (1) Less than monthly,(2) Monthly, (3) Weekly, (4) Daily or almost daily.9. Have you or someone else been injured as a result ofyour drinking? (0) Never, (1) Less than monthly,(2) Monthly, (3) Weekly, (4) Daily or almost daily.10. Has a relative, a doctor, or other health worker beenconcerned about your drinking or suggested that youcut down? (0) No, (2) Yes, but not in the last year,(4) Yes, during the last year.Adapted from Babor, T., de la Fuente, J. R., Saunders, J., et al. (1992). Alcohol Use Disorders Identification Test (AUDIT): Guidelines for use in primary health care.World Health Organization, Geneva. Used with permission; Bohn, Babor, & Kranzler (1995).

364UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSGeneral Appearance and Motor BehaviorAssessment of general appearance and behavior usuallyreveals appearance and speech to be normal. Clients mayappear anxious, tired, and disheveled if they have justcompleted a difficult course of detoxification. Dependingon their overall health status and any health problemsresulting from substance use, clients may appear physicallyill. Most clients are somewhat apprehensive abouttreatment, resent being in treatment, or feel pressured byothers to be there. This may be the first time in a long timethat clients have had to deal with any difficulty withoutthe help of a psychoactive substance.Mood and AffectWide ranges of mood and affect are possible. Some clientsare sad and tearful, expressing guilt and remorse for theirbehavior and circumstances. Others may be angry and sarcasticor quiet and sullen, unwilling to talk to the nurse.Irritability is common because clients are newly free ofsubstances. Clients may be pleasant and seemingly happy,appearing unaffected by the situation, especially if they arestill in denial about the substance use.Thought Process and ContentDuring assessment of thought process and content, clientsare likely to minimize their substance use, blame othersfor their problems, and rationalize their behavior. Theymay believe they cannot survive without the substance ormay express no desire to do so. They may focus their attentionon finances, legal issues, or employment problems asthe main source of difficulty rather than their substanceuse. They may believe that they could quit “on their own”if they wanted to, and they continue to deny or minimizethe extent of the problem.Sensorium and Intellectual ProcessesClients generally are oriented and alert unless they areexperiencing lingering effects of withdrawal. Intellectualabilities are intact unless clients have experienced neurologicdeficits from long-term alcohol use or inhalant use.Judgment and InsightClients are likely to have exercised poor judgment, especiallywhile under the influence of the substance. Judgmentmay still be affected: clients may behave impulsivelysuch as leaving treatment to obtain the substance of choice.Insight usually is limited regarding substance use. Clientsmay have difficulty acknowledging their behavior whileusing or may not see loss of jobs or relationships as connectedto the substance use. They may still believe theycan control the substance use.Self-ConceptClients generally have low self-esteem, which they mayexpress directly or cover with grandiose behavior. They donot feel adequate to cope with life and stress without thesubstance and often are uncomfortable around otherswhen not using. They often have difficulty identifying andexpressing true feelings; in the past, they have preferred toescape feelings and to avoid any personal pain or difficultywith the help of the substance.Roles and RelationshipsClients usually have experienced many difficulties withsocial, family, and occupational roles. Absenteeism andpoor work performance are common. Often, family membershave told these clients that the substance use was aconcern, and it may have been the subject of family arguments.Relationships in the family often are strained. Clientsmay be angry with family members who were instrumentalin bringing them to treatment or who threatenedloss of a significant relationship.Physiologic ConsiderationsMany clients have a history of poor nutrition (using ratherthan eating) and sleep disturbances that persist beyonddetoxification. They may have liver damage from drinkingalcohol, hepatitis or HIV infection from intravenousdrug use, or lung or neurologic damage from usinginhalants.Data AnalysisEach client has nursing diagnoses specific to his or herphysical health status. These may include the following:• Imbalanced Nutrition: Less Than Body Requirements• Risk for Infection• Risk for Injury• Diarrhea• Excess Fluid Volume• Activity Intolerance• Self-Care DeficitsNursing diagnoses commonly used when working withclients with substance use include the following:• Ineffective Denial• Ineffective Role Performance• Dysfunctional Family Processes: Alcoholism• Ineffective CopingOutcome IdentificationTreatment outcomes for clients with substance use mayinclude the following:• The client will abstain from alcohol and drug use.• The client will express feelings openly and directly.• The client will verbalize acceptance of responsibility forhis or her own behavior.• The client will practice nonchemical alternatives to dealwith stress or difficult situations.• The client will establish an effective after-care plan.

CHAPTER 17 • SUBSTANCE ABUSE 365CLIENT/FAMILY EDUCATIONfor Substance Abuse• Substance abuse is an illness.• Dispel myths about substance abuse.• Abstinence from substances is not a matter ofwillpower.• Any alcohol, whether beer, wine, or liquor, can be anabused substance.• Prescribed medication can be an abused substance.• Feedback from family about relapse signs, e.g., a returnto previous maladaptive coping mechanisms, is vital.• Continued participation in an after-care program isimportant.InterventionProviding Health Teaching for Client and FamilyClients and family members need facts about the substance,its effects, and recovery. The nurse must dispel thefollowing myths and misconceptions:• “It’s a matter of will power.”• “I can’t be an alcoholic if I only drink beer or if I onlydrink on weekends.”• “I can learn to use drugs socially.”• “I’m okay now; I could handle using once in a while.”Education about relapse is important. Family membersand friends should be aware that clients who begin torevert to old behaviors, return to substance-using acquaintances,or believe they can “handle myself now” are at highrisk for relapse, and loved ones need to take action.Whether a client plans to attend a self-help group or hasother resources, a specific plan for continued support andinvolvement after treatment increases the client’s chancesfor recovery.Addressing Family IssuesAlcoholism (and other substance abuse) often is called afamily illness. All those who have a close relationship witha person who abuses substances suffer emotional, social,and sometimes physical anguish.Codependence is a maladaptive coping pattern on thepart of family members or others that results from a prolongedrelationship with the person who uses substances.Characteristics of codependence are poor relationshipskills, excessive anxiety and worry, compulsive behaviors,and resistance to change. Family members learn these dysfunctionalbehavior patterns as they try to adjust to thebehavior of the substance user. One type of codependentbehavior is called enabling, which is a behavior that seemshelpful on the surface but actually perpetuates the substanceuse. For example, a wife who continually calls in tofor Substance AbuseNURSING INTERVENTIONS• Health teaching for the client and family• Dispel myths surrounding substance abuse• Decrease codependent behaviors among familymembers• Make appropriate referrals for family members• Promote coping skills• Role-play potentially difficult situations• Focus on the here-and-now with clients• Set realistic goals such as staying sober todayreport that her husband is sick when he is really drunk orhungover prevents the husband from having to face thetrue implications and repercussions of his behavior. Whatappears to be a helpful action really just assists the husbandto avoid the consequences of his behavior and tocontinue abusing the substance.Roles may shift dramatically, such as when a child actuallylooks out for or takes care of a parent. Codependentbehaviors also have been identified in health care professionalswhen they make excuses for a client’s behavior ordo things for clients that clients can do for themselves.An adult child of an alcoholic is someone who wasraised in a family in which one or both parents wereaddicted to alcohol and who has been subjected to themany dysfunctional aspects associated with parental alcoholism.In addition to being at high risk for alcoholism andeating disorders, children of alcoholics often develop aninability to trust, an extreme need to control, an excessivesense of responsibility, and denial of feelings; these characteristicspersist into adulthood. Many people growing up inhomes with parental alcoholism believe their problems willbe solved when they are old enough to leave and escape thesituation. They may begin to have problems in relationships,low self-esteem, and excessive fears of abandonmentor insecurity as adults. Never having experienced normalfamily life, they may find that they do not know what “normal”is (Kearns-Bodkin & Leonard, 2008).Without support and help to understand and cope,many family members may develop substance abuse problemsof their own, thus perpetuating the dysfunctionalcycle. Treatment and support groups are available toaddress the issues of family members. Clients and familyalso need information about support groups, their purpose,and their locations in the community.Promoting Coping SkillsNurses can encourage clients to identify problem areas intheir lives and to explore the ways that substance use mayhave intensified those problems. Clients should not believethat all life’s problems will disappear with sobriety; rather,

366UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSsobriety will assist them to think about the problemsclearly. The nurse may need to redirect a client’s attentionto his or her behavior and how it influenced his or herproblems. The nurse should not allow clients to focus onexternal events or other people without discussing theirrole in the problem.Nurse: “Can you describe some problems you’vebeen having?”Client: “My wife is always nagging—nothingis ever good enough—so we don’t get alongvery well.”Nurse: “How do you communicate with your wife?”Client: “I can’t talk to her about anything; she won’tlisten.”Nurse: “Are you saying that you don’t talk to her verymuch?”It may be helpful to role-play situations that clientshave found difficult. This is also an opportunity to helpclients learn to solve problems or to discuss situationswith others calmly and more effectively. In the group settingin treatment, it is helpful to encourage clients to giveand to receive feedback about how others perceive theirinteraction or ability to listen.The nurse also can help clients to find ways to relievestress or anxiety that do not involve substance use. Relaxing,exercising, listening to music, or engaging in activitiesmay be effective. Clients also may need to develop newsocial activities or leisure pursuits if most of their friendsor habits of socializing involved the use of substances.The nurse can help clients to focus on the present, notthe past. It is not helpful for clients to dwell on past problemsand regrets. Rather, they must focus on what they cando now regarding their behavior or relationships. Clientsmay need support from the nurse to view life and sobrietyin feasible terms—taking it one day at a time. The nursecan encourage clients to set attainable goals such as, “Whatcan I do today to stay sober?” instead of feeling overwhelmedby thinking “How can I avoid substances for therest of my life?” Clients need to believe that they cansucceed.EvaluationThe effectiveness of substance abuse treatment is basedheavily on the client’s abstinence from substances. In addition,successful treatment should result in more stable roleperformance, improved interpersonal relationships, andincreased satisfaction with quality of life.ELDER CONSIDERATIONSOnset of initial drinking problems after the age of 50 yearsis not uncommon. Some elders with alcohol use problemsare those who had a drinking problem early in life, had asignificant period of abstinence, and then resumeddrinking again in later life. Others may have been heavy orreactive consumers of alcohol early in life. However, estimatesare that 30% to 60% of elders in treatment programsbegan drinking abusively after age 60.Risk factors for late-onset substance abuse in eldersinclude chronic illness that causes pain, long-term use ofprescription medication (sedative-hypnotics, anxiolytics),life stress, loss, social isolation, grief, depression, and anabundance of discretionary time and money (Watts, 2007).Elders may experience physical problems associated withsubstance abuse rather quickly, especially if their overallmedical health is compromised by other illnesses.COMMUNITY-BASED CAREMany people receiving treatment for substance abuse doso in community-based settings such as outpatient treatment,freestanding substance abuse treatment facilities,and recovery programs such as AA and Rational Recovery.Follow-up or after-care for clients in the community isbased on the client’s preferences or the programs available.Some clients remain active in self-help groups. Othersattend after-care program sessions sponsored by the agencywhere they completed treatment. Still others seek individualor family counseling. In addition to formal after-care,the nurse may also encounter recovering clients in clinicsor physicians’ offices.MENTAL HEALTH PROMOTIONA person only has to watch television or read a magazineto see many advertisements targeted at the promotion ofresponsible drinking or encouraging parents to be an“antidrug” for their children. Increasing public awarenessand educational advertising have not made any significantchange in the rates of substance abuse in the United States(NIAAA, 2007c). Two populations currently identified forprevention programs are older adults and college-agedadults.Late-onset alcoholism in older adults is usually milderand more amenable to treatment, yet health care professionalsoverlook it more frequently. Culbertson (2006)suggested use of a screening tool, such as the AUDIT, in allprimary care settings to promote early identification ofolder adults with alcoholism. Brief interventions have beeneffective in producing sustained abstinence or reduced levelsof alcohol consumption, thereby decreasing hazardousand harmful drinking in this population.The College Drinking Prevention Program, which isgovernment sponsored, is a response to some of the followingstatistics about college students between ages18 and 24 (National Institute on Alcohol Abuse andAlcoholism, 2007).• 1,700 students die annually from alcohol-related unintentionalinjuries.

CHAPTER 17 • SUBSTANCE ABUSE 367• 599,000 students are unintentionally injured whileunder the influence of alcohol.• 606,000 students are assaulted by another studentunder the influence of alcohol.• 97,000 students are victims of alcohol-related assault ordate rape.• One-third of first-year students fail to enroll for theirsecond year.This prevention program was designed to help collegestudents avoid the “predictable” or expected binge drinkingcommon at U.S. colleges and universities. Some campusesoffer alcohol and drug-free dormitories for students,and some college-wide activities no longer allow alcoholto be served. Educational programs (about the previousstatistics) are designed to raise student awareness aboutexcessive drinking. Students who wish to abstain fromalcohol are encouraged to socialize together and providesupport to one another for this lifestyle choice.SUBSTANCE ABUSE IN HEALTHPROFESSIONALSPhysicians, dentists, and nurses have far higher rates ofdependence on controlled substances, such as opioids, stimulants,and sedatives, than other professionals of comparableeducational achievement, such as lawyers. One reason isthought to be the ease of obtaining controlled substances(Jaffe & Anthony, 2005). Health care professionals also havehigher rates of alcoholism than the general population.The issue of reporting colleagues with suspected substanceabuse is an important and extremely sensitive one.It is difficult for colleagues and supervisors to report theirpeers for suspected abuse. Nurses may hesitate to reportsuspected behaviors for several reasons: They have difficultybelieving that a trained health care professionalwould engage in abuse; they may feel guilty or fear falselyaccusing someone; or they may simply want to avoid conflict.Substance abuse by health professionals is very serious,however, because it can endanger clients. Nurses havean ethical responsibility to report suspicious behavior to asupervisor and, in some states, a legal obligation as definedin the state’s nurse practice act. Nurses should not try tohandle such situations alone by warning the coworker;this often just allows the coworker to continue to abusethe substance without suffering any repercussions.General warning signs of abuse include poor work performance,frequent absenteeism, unusual behavior, slurredspeech, and isolation from peers. More specific behaviorsand signs that might indicate substance abuse include thefollowing:• Incorrect drug counts• Excessive controlled substances listed as wasted orcontaminated• Reports by clients of ineffective pain relief from medications,especially if relief had been adequate previously• Damaged or torn packaging on controlled substances• Increased reports of “pharmacy error”• Consistent offers to obtain controlled substances frompharmacy• Unexplained absences from the unit• Trips to the bathroom after contact with controlledsubstances• Consistent early arrivals at or late departures from workfor no apparent reasonNurses can become involved in substance abuse just asany other person might. Nurses with abuse problemsdeserve the opportunity for treatment and recovery as well.Reporting suspected substance abuse could be the crucialfirst step toward a nurse getting the help he or she needs.SELF-AWARENESS ISSUESThe nurse must examine his or her beliefs andattitudes about substance abuse. A history ofsubstance use in the nurse’s family can influencestrongly his or her interaction with clients.The nurse may be overly harsh and critical, tellingthe client that he or she should “realize how you’re hurtingyour family.” Conversely, the nurse may unknowingly actout old family roles and engage in enabling behavior suchas sympathizing with the client’s reasons for using substances.Examining one’s own substance use or the use byclose friends and family may be difficult and unpleasantbut is necessary if the nurse is to have therapeutic relationshipswith clients.The nurse also might have different attitudes about varioussubstances of abuse. For example, a nurse may haveempathy for clients who are addicted to prescription medication,but disgusted by clients who use heroin or otherillegal substances. It is important to remember that thetreatment process and underlying issues of substanceabuse, remission, and relapse are quite similar regardlessof the substance.Many clients experience periodic relapses. For some,being sober is a lifelong struggle. The nurse may becomecynical or pessimistic when clients return for multipleattempts at substance use treatment. Such thoughts as “hedeserves health problems if he keeps drinking” or “sheshould expect to get hepatitis or HIV infection if she keepsdoing intravenous drugs” are signs that the nurse has someself-awareness problems that prevent him or her fromworking effectively with clients and their families.Points to Consider When Working withClients and Families with SubstanceAbuse Problems• Remember that substance abuse is a chronic, recurringdisease for many people, just like diabetes or heart disease.Even though clients look like they should be able

368UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSINTERNET RESOURCESRESOURCES• Al-Anon/Alateen• Alcoholics Anonymous• Alcoholics Anonymous Meetings Database• Center for Substance Abuse Treatment• Narcotics Anonymous• National Council on Alcoholism and Drug Dependence• National Institute of Mental Health• National Institute on Alcohol Abuse and Alcoholism• Online AA Recovery Resources• Women for SobrietyINTERNET ADDRESShttp://www.al-anon.orghttp://www.aa.orghttp://www.meetingfinder.orghttp://www.csat.samhsa.gov/http://www.na.orghttp://www.ncadd.orghttp://nimh.nih.govhttp://www.niaaa.nih.govhttp://www.recovery.org/aahttp://www.womenforsobriety.orgto control their substance abuse easily, they cannotwithout assistance and understanding.• Examine substance abuse problems in your own familyand friends even though it may be painful. Recognizingyour own background, beliefs, and attitudes is the firststep toward managing those feelings effectively so thatthey do not interfere with the care of clients andfamilies.• Approach each treatment experience with an open andobjective attitude. The client may be successful in maintainingabstinence after his or her second or third (ormore) treatment experience.KEY POINTS• Substance use and substance-related disorderscan involve alcohol, stimulants, cannabis,opioids, hallucinogens, inhalants,sedatives, hypnotics, anxiolytics, caffeine,and nicotine.Critical Thinking Questions1. You discover that another nurse on your hospitalunit has taken Valium from a client’s medicationsupply. You confront the nurse, and she replies, “I’munder a lot of stress at home. I’ve never done anythinglike this before, and I promise it will neverhappen again.” What should you do, and why?2. In England, medical clinics provide daily doses ofdrugs such as heroin at no charge to persons who areaddicted in efforts to decrease illegal drug traffic andlower crime rates. Is this an effective method? Wouldyou advocate trying this in the United States? Whyor why not?• Substance use and dependence include major impairmentin the user’s social and occupational functioningand behavioral and psychologic changes.• Alcohol is the substance abused most often in the UnitedStates; cannabis is second.• Intoxication is the use of a substance that results in maladaptivebehavior.• Withdrawal syndrome is defined as negative psychologicand physical reactions when use of a substance ceases ordramatically decreases.• Detoxification is the process of safely withdrawing froma substance. Detoxification from alcohol and barbituratescan be life-threatening and requires medicalsupervision.• The most significant risk factors for alcoholism arehaving an alcoholic parent, genetic vulnerability, andgrowing up in an alcoholic home.• Routine screening with tools such as the AUDIT in awide variety of settings (clinics, physicians’ offices,through emergency services) can be used to detect substanceuse problems.• After detoxification, treatment of substance use continuesin various outpatient and inpatient settings. Approachesoften are based on the 12-step philosophy ofabstinence, altered lifestyles, and peer support.• Substance abuse is a family illness, meaning that it affectsall members in some way. Family members andclose friends need education and support to cope withtheir feelings toward the abuser. Many support groupsare available to family members and close friends.• Clients who are dually diagnosed with substance useproblems and major psychiatric illness do poorly in traditionaltreatment settings and need specialized attention.• Nursing interventions for clients being treated for substanceabuse include teaching clients and families aboutsubstance abuse, dealing with family issues, and helpingclients to learn more effective coping skills.

CHAPTER 17 • SUBSTANCE ABUSE 369• Health care professionals have increased rates of substanceuse problems, particularly involving opioids,stimulants, and sedatives. Reporting suspected substanceabuse in colleagues is an ethical (and sometimeslegal) responsibility of all health care professionals.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Bischof, G., Rumpf, H. J., Meyer, C., Hapke, U., & John, U. (2007).Stability of sub-types of natural recovery from alcohol dependenceafter two years. Addiction, 102(6), 904–908.Bohn, M. J., Babor, T. F., & Kranzler, H. R. (1995). The Alcohol UseDisorders Identification Test (AUDIT): Validation of a screeninginstrument for use in medical settings. Journal of Studies on Alcohol,56(4), 423–432.Ciraulo, D. A., & Sarid-Segal, O. (2005). Sedative-, hypnotic- oranxiolytic-related abuse. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1300–1318).Philadelphia: Lippincott Williams & Wilkins.Crowley, T. J., & Sakai, J. (2005). Inhalant-related disorders. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1247–1257). Philadelphia: Lippincott Williams& Wilkins.Culbertson, J. W. (2006). Alcohol use in the elderly: Beyond the CAGE.Part 2: Screening instruments and treatment strategies. Geriatrics,61(11), 20–26.Grogan, L. (2006). Alcoholism, tobacco and drug use in the countries ofcentral and eastern Europe and the former Soviet Union. SubstanceUse & Misuse, 41(4), 567–571.Hall, W., & Degenhardt, L. (2005). Cannabis-related disorders. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1211–1220). Philadelphia: Lippincott Williams& Wilkins.Jaffe, J. H., & Anthony, J. C. (2005). Substance-related disorders:Introduction and overview. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp. 1137–1168).Philadelphia: Lippincott Williams & Wilkins.Jaffe, J. H., Ling, W., & Rawson, R. A. (2005). Amphetamine (oramphetamine-like) related disorders. In B. J. Sadock & V. A. Sadock(Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed., pp.1188–1201). Philadelphia: Lippincott Williams & Wilkins.Jaffe, J. H., & Strain, E. C. (2005). Opioid-related disorders. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1265–1291). Philadelphia: Lippincott Williams& Wilkins.Jones, R. T. (2005). Hallucinogen-related disorders. In B. J. Sadock & V.A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8thed., pp. 1238–1247). Philadelphia: Lippincott Williams & Wilkins.Kearns-Bodkin, J. N., & Leonard, K. E. (2008). Relationship functioningamong adult children of alcoholics. Journal of Studies on Alcohol andDrugs, 69(6), 941–950.Kitanaka, A. (2007). Alcoholism in Japan. Retrieved March 8, 2009, fromhttp://www.japaninc.com/jin439.Lehne, R. A. (2006). Pharmacology for nursing care (6th ed.). Philadelphia:W. B. Saunders.Malcolm, B. P., Hesselbrock, M. N., & Segal, B. (2006). Multiple substancedependence and course of alcoholism among Alaska nativemen and women. Substance Use & Misuse, 41(5), 729–741.Mann, K., Kiefer, F., Spanagel, R., & Littleton, J. (2008). Acamprosate:Recent findings and future research directions. Alcoholism, Clinicaland Experimental Research, 32(7), 1105–1110.Martinotti, G., Andreoli, S., Di Nicola, M., Di Giannantonio, M.,Sarchiapone, M., & Janiri, L. (2008). Quetiapine decreases alcoholconsumption, craving, and psychiatric symptoms in dually diagnosedalcoholics. Human Psychopharmacology, 23(5), 417–424.National Institute on Alcohol Abuse and Alcoholism. (2007a). A familyhistory of alcoholism. Retrieved from http://www.pubs.niaaa.nih.gov/publications/FamilyHistory/famhist.htm.National Institute on Alcohol Abuse and Alcoholism. (2007b). Alcoholand minorities. Retrieved from http://www.niaaa.nih.gov/.National Institute on Alcohol Abuse and Alcoholism. (2007c). Statisticalsnapshot of college drinking. Retrieved from http://www.collegedrinkingprevention.gov.NIAAA. (2009). Data/statistical tables. Retrieved October 20, 2009, fromhttp://www.niaaa.gov/.Richardson, K., Baillie, A., Reid, S., Morley, K., Teesson, M., Sannibale, C.,et al. (2008). Do acamprosate or naltrexone have an effect on dailydrinking by reducing craving for alcohol? Addiction, 103(6),953–959.SAMHSA. (2009). Motor vehicle fatalities. Retrieved October 20, 2009,from http://www.oas.samhsa.gov/2k9/204/204DUIFaclty2k9.htm.Schuckit, M. A. (2005). Alcohol-related disorders. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed.,pp. 1168–1188). Philadelphia: Lippincott Williams & Wilkins.Schuckit, M. A. (2009). An overview of genetic influences in alcoholism.Journal of Substance Abuse Treatment, 36(1), S5–S14.Substance Abuse and Mental Health Services Administration. (2007).Statistics for alcoholism and drug dependency. United StatesDepartment of Health and Human Services. Retrieved from http://www.oas.samhsa.gov.Wakabayashi, I., & Masuda, H. (2006). Influence of drinking alcohol onatherosclerotic risk in alcohol flushers and non-flushers of Orientalpatients with type 2 diabetes mellitus. Alcohol and Alcoholism, 41(6),672–677.Watts, M. (2007). Incidences of excess alcohol consumption in the olderperson. Nursing Older People, 18(12), 27–30.ADDITIONAL READINGSFein, G., & McGillivray, S. (2007). Cognitive performance in long-termabstinent elderly alcoholics. Alcoholism, Clinical and ExperimentalResearch, 31(11), 1788–1799.Misch, D. A. (2007). “Natural recovery” from alcohol abuse among collegestudents. Journal of American College Health, 55(4), 215–218.Rajemdram R., Lewison, G., & Preedy, V. R. (2006). Worldwide alcoholrelatedresearch and the disease burden. Alcohol and Alcoholism,41(1), 99–106.Stolberg, V. B. (2006). A review of perspectives on alcohol and alcoholismin the history of American health and medicine. Journal ofEthnicity in Substance Abuse, 5(4), 39–106.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Which of the following statements would indicate thatteaching about naltrexone (ReVia) has been effective?a. “I’ll get sick if I use heroin while taking thismedication.”b. “This medication will block the effects of any opioidsubstance I take.”c. “If I use opioids while taking naltrexone, I’ll becomeextremely ill.”d. “Using naltrexone may make me dizzy.”2. Clonidine (Catapres) is prescribed for symptoms ofopioid withdrawal. Which of the following nursing assessmentsis essential before giving a dose of thismedication?a. Assess the client’s blood pressure.b. Determine when the client last used an opiate.c. Monitor the client for tremors.d. Complete a thorough physical assessment.3. Which of the following behaviors would indicate stimulantintoxication?a. Slurred speech, unsteady gait, impaired concentrationb. Hyperactivity, talkativeness, euphoriac. Relaxed inhibitions, increased appetite, distortedperceptionsd. Depersonalization, dilated pupils, visual hallucinations4. The 12 steps of AA teach thata. Acceptance of being an alcoholic will prevent urgesto drink.b. A Higher Power will protect individuals if they feellike drinking.c. Once a person has learned to be sober, he or she cangraduate and leave AA.d. Once a person is sober, he or she remains at risk todrink.5. The nurse has provided an in-service program on impairedprofessionals. She knows that teaching has beeneffective when staff identify the following as the greatestrisk for substance abuse among professionals:a. Most nurses are codependent in their personal andprofessional relationships.b. Most nurses come from dysfunctional families andare at risk for developing addiction.c. Most nurses are exposed to various substances andbelieve they are not at risk to develop the disease.d. Most nurses have preconceived ideas about whatkind of people become addicted.6. A client comes to day treatment intoxicated, but says heis not. The nurse identifies that the client is exhibitingsymptoms ofa. Denialb. Reaction formationc. Projectiond. Transference7. The client tells the nurse that she takes a drink everymorning to calm her nerves and stop her tremors. Thenurse realizes the client is at risk fora. An anxiety disorderb. A neurologic disorderc. Physical dependenced. Psychologic addictionMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. Which of the following would the nurse recognize assigns of alcohol withdrawal?a. Blackoutsb. Diaphoresisc. Elevated blood pressured. Lethargye. Nauseaf. Tremulousness2. The nurse would recognize which of the followingdrugs as central nervous system depressants?a. Cannabisb. Diazepam (Valium)c. Heroind. Merperidine (Demerol)e. Phenobarbitalf. Whiskey370

CHAPTER 17 • SUBSTANCE ABUSE371CLINICAL EXAMPLESharon, 43 years of age, is attending an outpatient treatment program for alcohol abuse. Sheis divorced, and her two children live with their father. Sharon broke up with her boyfriend of3 years just last week. She recently was arrested for the second time for driving while intoxicated,which is why she is in this treatment program. Sharon tells anyone who will listen thatshe is “not an alcoholic” but is in this program only to avoid serving time in jail.1. Identify two nursing diagnoses for Sharon.2. Write an expected outcome for each identified diagnosis.3. List three interventions for each of the diagnoses.

18Eating DisordersLearning ObjectivesAfter reading this chapter, you should be able to:Key Terms• alexithymia• anorexia nervosa• binge eating• body image• body image disturbance• bulimia nervosa• enmeshment• purging• satiety• self-monitoring1. Compare and contrast the symptoms of anorexia nervosa and bulimianervosa.2. Discuss various etiologic theories of eating disorders.3. Identify effective treatment for clients with eating disorders.4. Apply the nursing process to the care of clients with eating disorders.5. Provide teaching to clients, families, and community members to increaseknowledge and understanding of eating disorders.6. Evaluate your feelings, beliefs, and attitudes about clients with eatingdisorders.EATING IS PART OF EVERYDAY life. It is necessary for survival, but it is also asocial activity and part of many happy occasions. People go out for dinner,invite friends and family for meals in their homes, and celebrate specialevents such as marriages, holidays, and birthdays with food. Yet for somepeople, eating is a source of worry and anxiety. Are they eating too much?Do they look fat? Is some new weight loss promotion going to be theanswer?Obesity has been identified as a major health problem in the UnitedStates; some call it an epidemic. The number of obesity-related illnessesamong children has increased dramatically. At the same time, millions ofwomen are either starving themselves or engaging in chaotic eating patternsthat can lead to death.This chapter focuses on anorexia nervosa and bulimia nervosa, the twomost common eating disorders found in the mental health setting. It discussesstrategies for early identification and prevention of these disorders.OVERVIEW OF EATING DISORDERSAlthough many believe that eating disorders are relatively new, documentationfrom the Middle Ages indicates willful dieting leading to self-starvationin female saints who fasted to achieve purity. In the late 1800s, doctors in372Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 18 • EATING DISORDERS 373England and France described young women who apparentlyused self-starvation to avoid obesity. It was not untilthe 1960s, however, that anorexia nervosa was establishedas a mental disorder. Bulimia nervosa was first described asa distinct syndrome in 1979 (Anderson & Yager, 2005).Eating disorders can be viewed on a continuum, withclients with anorexia eating too little or starving themselves,clients with bulimia eating chaotically, and clientswith obesity eating too much. There is much overlapamong the eating disorders: 30% to 35% of normal-weightpeople with bulimia have a history of anorexia nervosaand low body weight, and about 50% of people withanorexia nervosa exhibit bulimic behavior. The distinguishingfeatures of anorexia include an earlier age atonset and below-normal body weight; the person fails torecognize the eating behavior as a problem. Clients withbulimia have a later age at onset and near-normal bodyweight. They usually are ashamed and embarrassed by theeating behavior.More than 90% of cases of anorexia nervosa and bulimiaoccur in females (American Psychiatric Association[APA], 2000). Although fewer men than women sufferfrom eating disorders, the number of men with anorexiaor bulimia may be much higher than previously believed,many of whom are athletes (Glazer, 2008). Men, however,are less likely to seek treatment. The prevalence ofboth eating disorders is estimated to be 1% to 3% of thegeneral population in the United States (Anderson &Yager, 2005).CATEGORIES OF EATING DISORDERS ANDRELATED DISORDERSAnorexia nervosa is a life-threatening eating disordercharacterized by the client’s refusal or inability to maintaina minimally normal body weight, intense fear of gainingweight or becoming fat, significantly disturbed perceptionof the shape or size of the body, and steadfast inability orrefusal to acknowledge the seriousness of the problem oreven that one exists (APA, 2000). Clients with anorexiahave a body weight that is 85% or less of that expected fortheir age and height, have experienced amenorrhea for atleast three consecutive cycles, and have a preoccupationwith food and food-related activities.For Diagnostic and Statistical Manual of Mental Disorders,4th edition, Text Revision (DSM-IV-TR; APA, 2000)diagnostic criteria for anorexia nervosa, please refer to thebox titled “Symptoms of Anorexia Nervosa.”Clients with anorexia nervosa can be classified into twosubgroups depending on how they control their weight.Clients with the restricting subtype lose weight primarilythrough dieting, fasting, or excessive exercising. Thosewith the binge eating and purging subtype engage regularlyin binge eating followed by purging. Binge eatingmeans consuming a large amount of food (far greater thanmost people eat at one time) in a discrete period of usually2 hours or less. Purging involves compensatory behaviorsdesigned to eliminate food by means of self-induced vomitingor misuse of laxatives, enemas, and diuretics. Someclients with anorexia do not binge but still engage in purgingbehaviors after ingesting small amounts of food.Clients with anorexia become totally absorbed in theirquest for weight loss and thinness. The term anorexia isactually a misnomer: These clients do not lose their appetites.They still experience hunger but ignore it and signsof physical weakness and fatigue; they often believe that ifthey eat anything, they will not be able to stop eating andwill become fat. Clients with anorexia often are preoccupiedwith food-related activities such as grocery shopping,collecting recipes or cookbooks, counting calories, creatingfat-free meals, and cooking family meals. They alsomay engage in unusual or ritualistic food behaviors suchas refusing to eat around others, cutting food into minutepieces, or not allowing the food they eat to touch their lips.These behaviors increase their sense of control. Excessiveexercise is common; it may occupy several hours a day.CLINICAL VIGNETTE: ANOREXIA NERVOSAMaggie, 15 years old, is 5 feet, 7 inches tall and weighs92 pounds. Though it is August, she is wearing sweatpantsand three layers of shirts. Her hair is dry, brittle, and uncombed,and she wears no makeup. Maggie’s family physician hasreferred her to the eating disorders unit because she has lost20 pounds in the last 4 months and her menstrual periodshave ceased. She also is lethargic and weak yet has troublesleeping. Maggie is an avid ballet student and believes she stillneeds to lose more weight to achieve the figure she wants.Her ballet instructor has expressed concern to Maggie’sparents about her appearance and fatigue.Maggie’s family reports that she has gone from being anA and B student to barely passing in school. She spendsmuch of her time isolated in her room and is often exercisingfor long hours, even in the middle of the night. Maggieseldom goes out with friends, and they have stopped callingher. The nurse interviews Maggie but gains little information,as Maggie is reluctant to discuss her eating. Maggiedoes say she is too fat and has no interest in gaining weight.She does not understand why her parents are forcing her tocome to “this place where all they want to do is fatten youup and keep you ugly.”

374UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSDSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Anorexia NervosaFear of gaining weight or becoming fat even when severelyunderweightBody image disturbanceAmenorrheaDepressive symptoms such as depressed mood, socialwithdrawal, irritability, and insomniaPreoccupation with thoughts of foodFeelings of ineffectivenessInflexible thinkingStrong need to control environmentLimited spontaneity and overly restrained emotionalexpressionComplaints of constipation and abdominal painCold intoleranceLethargyEmaciationHypotension, hypothermia, and bradycardiaHypertrophy of salivary glandsElevated BUN (blood urea nitrogen)Electrolyte imbalancesLeukopenia and mild anemiaElevated liver function studiesAdapted from DSM-IV-TR, 2000.Bulimia nervosa, often simply called bulimia, is an eatingdisorder characterized by recurrent episodes (at leasttwice a week for 3 months) of binge eating followed byinappropriate compensatory behaviors to avoid weightgain, such as purging, fasting, or excessively exercising(APA, 2000). The amount of food consumed during abinge episode is much larger than a person wouldnormally eat. The client often engages in binge eatingsecretly. Between binges, the client may eat low-caloriefoods or fast. Binging or purging episodes are often precipitatedby strong emotions and followed by guilt,remorse, shame, or self-contempt.The weight of clients with bulimia usually is in the normalrange, although some clients are overweight or underweight.Recurrent vomiting destroys tooth enamel, andincidence of dental caries and ragged or chipped teethincreases in these clients. Dentists are often the first healthcare professionals to identify clients with bulimia.Related eating disorders usually first diagnosed ininfancy and childhood include rumination disorder, pica,and feeding disorder (see Chapter 20). Common elementsin clients with these disorders are family dysfunction andparent–child conflicts.Binge eating disorder is listed as a research category in theDSM-IV-TR (APA, 2000); it is being investigated to determineits classification as a mental disorder. The essentialfeatures are recurrent episodes of binge eating; no regularuse of inappropriate compensatory behaviors, such as purgingor excessive exercise or abuse of laxatives; guilt, shame,and disgust about eating behaviors; and marked psychologicdistress. Binge eating disorder frequently affects peopleover age 35, and it occurs often in men (Yager, 2008). Individualsare more likely to be overweight or obese, overweightas children, and teased about their weight at an earlyage. Thirty-five percent reported that binge eating precededdieting; 65% reported dieting before binge eating.Night eating syndrome is characterized by morninganorexia, evening hyperphagia (consuming 50% of dailycalories after the last evening meal), and nighttime awakenings(at least once a night) to consume snacks. It is associatedwith life stress, low self-esteem, anxiety, depression,and adverse reactions to weight loss. Most people withnight eating syndrome are obese (Stunkard, Allison, &Lundgren, 2008). Treatment with SSRI antidepressantshas shown positive effects.CLINICAL VIGNETTE: BULIMIA NERVOSASusan is driving home from the grocery store and eatingfrom the grocery bags as she drives. In the 15-minute trip,she has already consumed a package of cookies, a large bagof potato chips, and a pound of ham from the deli. Shethinks “I have to hurry, I’ll be home soon. No one can seeme like this!” She knew when she bought these food itemsthat she would never get home with them.Susan hurriedly drops the groceries on the kitchen counterand races for the bathroom. Tears are streaming downher face as she vomits to get rid of what she has just eaten.She feels guilty and ashamed and does not understand whyshe cannot stop her behavior. If only she did not eat thosethings. She thinks, “I’m 30 years old, married with two beautifuldaughters, and a successful interior design consultant.What would my clients say if they could see me now? If myhusband and daughters saw me, they would be disgusted.”As Susan leaves the bathroom to put away the remainder ofthe groceries, she promises herself to stay away from allthose bad foods. If she just does not eat them, this won’thappen. This is a promise she has made many times before.

CHAPTER 18 • EATING DISORDERS 375Comorbid psychiatric disorders are common in clientswith anorexia nervosa and bulimia nervosa. Mood disorders,anxiety disorders, and substance abuse/dependenceare frequently seen in clients with eating disorders.Of those, depression and obsessive–compulsive disorderare most common (Anderson & Yager, 2005). Anorexiaand bulimia are both characterized by perfectionism,obsessive–compulsiveness, neuroticism, negative emotionality,harm avoidance, low self-directedness, lowcooperativeness, and traits associated with avoidant personalitydisorder. In addition, clients with bulimia mayalso exhibit high impulsivity, sensation seeking, noveltyseeking, and traits associated with borderline personalitydisorder (Thompson, 2009). Eating disorders often arelinked to a history of sexual abuse, especially if the abuseoccurred before puberty (Pike et al., 2008). Such a historymay be a factor contributing to problems with intimacy,sexual attractiveness, and low interest in sexual activity.Clients with eating disorders and a history of sexualabuse also have higher levels of depression and anxiety,lower self-esteem, more interpersonal problems, andmore severe obsessive–compulsive symptoms (Carteret al., 2006). Whether sexual abuse has a cause-and- effectrelationship with the development of eating disorders,however, remains unclear.ETIOLOGYA specific cause for eating disorders is unknown. Initially,dieting may be the stimulus that leads to their development.Biologic vulnerability, developmental problems, and familyand social influences can turn dieting into an eating disorder(Table 18.1). Psychologic and physiologic reinforcementof maladaptive eating behavior sustains the cycle (Anderson& Yager, 2005).Biologic FactorsStudies of anorexia nervosa and bulimia nervosa haveshown that these disorders tend to run in families. Geneticvulnerability also might result from a particular personalitytype or a general susceptibility to psychiatric disorders.Or it may directly involve a dysfunction of the hypothalamus.A family history of mood or anxiety disorders (e.g.,obsessive–compulsive disorder) places a person at risk foran eating disorder (Anderson & Yager, 2005).Disruptions of the nuclei of the hypothalamus may producemany of the symptoms of eating disorders. Two setsof nuclei are particularly important in many aspects ofhunger and satiety (satisfaction of appetite): the lateralhypothalamus and the ventromedial hypothalamus. Deficitsin the lateral hypothalamus result in decreased eatingand decreased responses to sensory stimuli that are importantto eating. Disruption of the ventromedial hypothalamusleads to excessive eating, weight gain, and decreasedresponsiveness to the satiety effects of glucose, which arebehaviors seen in bulimia.Many neurochemical changes accompany eating disorders,but it is difficult to tell whether they cause orresult from eating disorders and the characteristic symptomsof starvation, binging, and purging. For example,norepinephrine levels rise normally in response to eating,allowing the body to metabolize and to use nutrients.Norepinephrine levels do not rise during starvation,however, because few nutrients are available to metabolize.Therefore, low norepinephrine levels are seen inTable 18.1 RISK FACTORS FOR EATING DISORDERSDisorderBiologic Risk FactorsDevelopmentalRisk FactorsFamily Risk FactorsSocioculturalRisk FactorsAnorexianervosaBulimia nervosaObesity; dieting at anearly ageObesity; early dieting;possible serotoninand norepinephrinedisturbances;chromosome 1susceptibilityIssues of developing autonomyand having controlover self and environment;developing aunique identity; dissatisfactionwith body imageSelf-perceptions ofbeing overweight, fat,unattractive, andundesirable; dissatisfactionwith body imageFamily lacks emotionalsupport;parental maltreatment;cannot dealwith conflictChaotic family withloose boundaries;parental maltreatmentincludingpossible physical orsexual abuseCultural ideal ofbeing thin; mediafocus on beauty,thinness, fitness;preoccupationwith achieving theideal bodySame as above;weight-relatedteasing

376UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSclients during periods of restricted food intake. Also, lowepinephrine levels are related to the decreased heart rateand blood pressure seen in clients with anorexia.Increased levels of the neurotransmitter serotonin andits precursor tryptophan have been linked with increasedsatiety. Low levels of serotonin as well as low platelet levelsof monoamine oxidase have been found in clients withbulimia and the binge and purge subtype of anorexia nervosa(Anderson & Yager, 2005); this may explain bingingbehavior. The positive response of some clients with bulimiato treatment with selective serotonin reuptake inhibitorantidepressants supports the idea that serotonin levelsat the synapse may be low in these clients.Developmental FactorsTwo essential tasks of adolescence are the struggle todevelop autonomy and the establishment of a unique identity.Autonomy, or exerting control over oneself and theenvironment, may be difficult in families that are overprotectiveor in which enmeshment (lack of clear role boundaries)exists. Such families do not support members’ effortsto gain independence, and teenagers may feel as thoughthey have little or no control over their lives. They begin tocontrol their eating through severe dieting and thus gaincontrol over their weight. Losing weight becomes reinforcing:by continuing to lose, these clients exert control overone aspect of their lives.It is important to identify potential risk factors fordeveloping eating disorders so that prevention programscan target those at greatest risk. Adolescent girls whoexpress body dissatisfaction are most likely to experienceadverse outcomes, such as emotional eating, binge eating,abnormal attitudes about eating and weight, low selfesteem,stress, and depression. Characteristics of thosewho developed an eating disorder included disturbed eatinghabits; disturbed attitudes toward food; eating insecret; preoccupation with food, eating, shape, or weight;fear of losing control over eating; and wanting to have acompletely empty stomach (Cave, 2009).The need to develop a unique identity, or a sense of whoone is as a person, is another essential task of adolescence.It coincides with the onset of puberty, which initiates manyemotional and physiologic changes. Self-doubt and confusioncan result if the adolescent does not measure up to theperson she or he wants to be.Advertisements, magazines, and movies that featurethin models reinforce the cultural belief that slimness isattractive. Excessive dieting and weight loss may be theway an adolescent chooses to achieve this ideal. Bodyimage is how a person perceives his or her body, that is, amental self-image. For most people, body image is consistentwith how others view them. For people with anorexianervosa, however, body image differs greatly from the perceptionof others. They perceive themselves as fat,Body image disturbanceunattractive, and undesirable even when they are severelyunderweight and malnourished. Body image disturbanceoccurs when there is an extreme discrepancy between one’sbody image and the perceptions of others and extremedissatisfaction with one’s body image.Self-perceptions of the body can influence the developmentof identity in adolescence greatly and often persistinto adulthood. Self-perceptions that include beingoverweight lead to the belief that dieting is necessarybefore one can be happy or satisfied. Clients with bulimianervosa report dissatisfaction with their bodies as well asthe belief that they are fat, unattractive, and undesirable.The binging and purging cycle of bulimia can begin atany time—after dieting has been unsuccessful, before thesevere dieting begins, or at the same time as part of a“weight loss plan.”Family InfluencesGirls growing up amid family problems and abuse are athigher risk for both anorexia and bulimia. Disordered eatingis a common response to family discord. Girls growing up infamilies without emotional support often try to escape their

CHAPTER 18 • EATING DISORDERS 377negative emotions. They place an intense focus outward onsomething concrete: physical appearance. Disordered eatingbecomes a distraction from emotions.Childhood adversity has been identified as a significantrisk factor in the development of problems with eating orweight in adolescence or early adulthood. Adversity isdefined as physical neglect, sexual abuse, or parental maltreatmentthat includes little care, affection, and empathyas well as excessive paternal control, unfriendliness, oroverprotectiveness.Sociocultural FactorsIn the United States and other Western countries, themedia fuels the image of the “ideal woman” as thin. Theculture equates beauty, desirability, and, ultimately, happinesswith being very thin, perfectly toned, and physicallyfit. Adolescents often idealize actresses and modelsas having the perfect “look” or body even though manyof these celebrities are underweight or use special effectsto appear thinner than they are. Books, magazines,dietary supplements, exercise equipment, plastic surgeryadvertisements, and weight loss programs abound; thedieting industry is a billion-dollar business. The cultureconsiders being overweight a sign of laziness, lack ofself-control, or indifference; it equates pursuit of the“perfect” body with beauty, desirability, success, and willpower. Thus, many women speak of being “good” whenthey stick to their diet and “bad” when they eat dessertsor snacks.Pressure from others also may contribute to eating disorders.Pressure from coaches, parents, and peers and theemphasis placed on body form in sports such as gymnastics,ballet, and wrestling can promote eating disorders inathletes. Parental concern over a girl’s weight and teasingfrom parents or peers reinforces a girl’s body dissatisfactionand her need to diet or control eating in some way.Studies in the United States and Europe conclude that bullyingand peer harassment are also related to an increase indisordered eating habits (Eisenberg & Neumark-Sztainer,2008; Sweetingham & Walter, 2008).CULTURAL CONSIDERATIONSBoth anorexia nervosa and bulimia nervosa are far moreprevalent in industrialized societies, where food is abundantand beauty is linked with thinness. In the UnitedStates, anorexia nervosa is less frequent among AfricanAmericans (Andreasen & Black, 2006). For example,before 1995, there was little television on the island of Fiji.Eating disorders were almost nonexistent, and being“plump” was considered the ideal shape for girls andwomen. In the 5 years following the widespread introductionof television, the number of eating disorders in Fijiskyrocketed.Eating disorders are most common in the United States,Canada, Europe, Australia, Japan, New Zealand, and SouthAfrica. Immigrants from cultures in which eating disordersare rare may develop eating disorders as they assimilatethe thin-body ideal (APA, 2000).A study conducted in Israel attempted to analyze socialand cultural influences of eating disorders. Israeli Jewishadolescents and women had incidences of disordered eatingsimilar to Westernized cultures. However, Israeli Arabshad little disordered eating among similar female and adolescentgroups—in keeping with their beliefs, which differsignificantly from Westernized ideas (Latzer, Witztum, &Stein, 2008).Eating disorders appear to be equally common amongHispanic and Caucasian women and less common amongAfrican American and Asian women (Anderson & Yager,2005). Minority women who are younger, better educated,and more closely identified with middle-class values are atincreased risk for developing an eating disorder.During the past several years, eating disorders haveincreased among all U.S. social classes and ethnic groups(Anderson & Yager, 2005). With today’s technology, theentire world is exposed to the Western ideal, which equatesthinness with beauty and desirability. As this ideal becomeswidespread to non-Western cultures, anorexia and bulimiawill likely increase there as well.ANOREXIA NERVOSAOnset and Clinical CourseAnorexia nervosa typically begins between 14 and 18 yearsof age. In the early stages, clients often deny they have a negativebody image or anxiety regarding their appearance. Theyare very pleased with their ability to control their weight andmay express this. When they initially come for treatment,they may be unable to identify or to explain their emotionsabout life events such as school or relationships with familyor friends. A profound sense of emptiness is common.As the illness progresses, depression and lability inmood become more apparent. As dieting and compulsivebehaviors increase, clients isolate themselves. This socialisolation can lead to a basic mistrust of others and evenparanoia. Clients may believe their peers are jealous oftheir weight loss and may believe that family and healthcare professionals are trying to make them “fat and ugly.”In long-term studies of clients with anorexia nervosa,Anderson and Yager (2005) reported that 30% were well,30% were partially improved, 30% were chronically ill,and 10% had died of anorexia-related causes. Clients withthe lowest body weights and longest durations of illnesstended to relapse most often and have the poorest outcomes.Clients who abuse laxatives are at a greater risk formedical complications. Table 18.2 lists common medicalcomplications of eating disorders.

378UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 18.2 MEDICAL COMPLICATIONS OF EATING DISORDERSBody SystemSymptomsRelated to weight lossMusculoskeletalLoss of muscle mass, loss of fat, osteoporosis, and pathologic fracturesMetabolicHypothyroidism (symptoms include lack of energy, weakness, intolerance to cold, andbradycardia), hypoglycemia, and decreased insulin sensitivityCardiacBradycardia, hypotension, loss of cardiac muscle, small heart, cardiac arrhythmias (includingatrial and ventricular premature contractions, prolonged QT interval, ventricular tachycardia),and sudden deathGastrointestinalDelayed gastric emptying, bloating, constipation, abdominal pain, gas, and diarrheaReproductiveAmenorrhea and low levels of luteinizing and follicle-stimulating hormonesDermatologicDry, cracking skin due to dehydration, lanugo (i.e., fine, baby-like hair over body), edema, andacrocyanosis (i.e., blue hands and feet)HematologicLeukopenia, anemia, thrombocytopenia, hypercholesterolemia, and hypercarotenemiaNeuropsychiatric Abnormal taste sensation, apathetic depression, mild organic mental symptoms, and sleepdisturbancesRelated to purging (vomiting and laxative abuse)MetabolicElectrolyte abnormalities, particularly hypokalemia, hypochloremic alkalosis, hypomagnesemia,and elevated blood urea nitrogenGastrointestinalSalivary gland and pancreas inflammation and enlargement with an increase in serum amylase,esophageal and gastric erosion or rupture, dysfunctional bowel, and superior mesentericartery syndromeDentalErosion of dental enamel (perimyolysis), particularly front teethNeuropsychiatric Seizures (related to large fluid shifts and electrolyte disturbances), mild neuropathies, fatigue,weakness, and mild organic mental symptomsAdapted from Anderson, A. E., & Yager, J. (2005). Eating disorders. In B. J. Sadock, & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 2, 8th ed.,pp. 2002–2021). Philadelphia: Lippincott Williams & Wilkins.Treatment and PrognosisClients with anorexia nervosa can be very difficult totreat because they are often resistant, appear uninterested,and deny their problems. Treatment settingsinclude inpatient specialty eating disorder units, partialhospitalization or day treatment programs, and outpatienttherapy. The choice of setting depends on the severityof the illness, such as weight loss, physical symptoms,duration of binging and purging, drive for thinness, bodydissatisfaction, and comorbid psychiatric conditions.Major life- threatening complications that indicate theneed for hospital admission include severe fluid, electrolyte,and metabolic imbalances; cardiovascular complications;severe weight loss and its consequences ( Andreasen& Black, 2006); and risk for suicide. Short hospital staysare most effective for clients who are amenable to weightgain, and gain weight rapidly while hospitalized. Longerinpatient stays are required for those who gain weightmore slowly and are more resistant to gaining additionalweight (Thiels, 2008). Outpatient therapy has the bestsuccess with clients who have been ill for fewer than6 months, are not binging and purging, and have parentslikely to participate effectively in family therapy. Cognitivebehavior therapy can also be effective in preventing relapseand improving overall outcomes.Medical ManagementMedical management focuses on weight restoration, nutritionalrehabilitation, rehydration, and correction of electrolyteimbalances. Clients receive nutritionally balancedmeals and snacks that gradually increase caloric intake toa normal level for size, age, and activity. Severely malnourishedclients may require total parenteral nutrition, tubefeedings, or hyperalimentation to receive adequate nutritionalintake. Generally, access to a bathroom is supervisedto prevent purging as clients begin to eat more food.Weight gain and adequate food intake are most often thecriteria for determining the effectiveness of treatment.PsychopharmacologySeveral classes of drugs have been studied, but few haveshown clinical success. Amitriptyline (Elavil) and the antihistaminecyproheptadine (Periactin) in high doses (up to28 mg/day) can promote weight gain in inpatients withanorexia nervosa. Olanzapine (Zyprexa) has been usedwith success because of its antipsychotic effect (on bizarre

CHAPTER 18 • EATING DISORDERS 379body image distortions) and associated weight gain.Fluoxetine (Prozac) has some effectiveness in preventingrelapse in clients whose weight has been partially or completelyrestored (Andreasen & Black, 2006); however,close monitoring is needed because weight loss can be aside effect.PsychotherapyFamily therapy may be beneficial for families of clientsyounger than 18 years. Families who demonstrate enmeshment,unclear boundaries among members, and difficultyhandling emotions and conflict can begin to resolve theseissues and improve communication. Family therapy alsois useful to help members to be effective participants inthe client’s treatment. However, in a dysfunctional family,significant improvements in family functioning may take2 years or more.Individual therapy for clients with anorexia nervosamay be indicated in some circumstances; for example, ifthe family cannot participate in family therapy, if the clientis older or separated from the nuclear family, or if the clienthas individual issues requiring psychotherapy. Therapythat focuses on the client’s particular issues and circumstances,such as coping skills, self-esteem, self-acceptance,interpersonal relationships, assertiveness, can improveoverall functioning and life satisfaction. Cognitive–behavioral therapy (CBT), long used with clients withbulimia, has been adapted for adolescents and usedsuccessfully (Schmidt, 2008).BULIMIAOnset and Clinical CourseBulimia nervosa usually begins in late adolescence or earlyadulthood; 18 or 19 years is the typical age of onset. Bingeeating frequently begins during or after dieting. Betweenbinging and purging episodes, clients may eat restrictively,choosing salads and other low-calorie foods. This restrictiveeating effectively sets them up for the next episode ofbinging and purging, and the cycle continues.Clients with bulimia are aware that their eating behavioris pathologic and go to great lengths to hide it fromothers. They may store food in their cars, desks, or secretlocations around the house. They may drive from one fastfoodrestaurant to another, ordering a normal amount offood at each but stopping at six places in 1 or 2 hours.Such patterns may exist for years until family or friendsdiscover the client’s behavior or until medical complicationsdevelop for which the client seeks treatment.Follow-up studies with clients with bulimia show that10 years after treatment, 30% continued to engage in recurrentbinge eating and purging behaviors, whereas 38% to 47% werefully recovered (Anderson & Yager, 2005). One third of fullyrecovered clients relapse. Clients with a comorbid personalitydisorder tend to have poorer outcomes than those without.DSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Bulimia NervosaRecurrent episodes of binge eatingCompensatory behavior such as self-induced vomiting,misuse of laxatives, diuretics, enema or other medications,or excessive exerciseSelf-evaluation overly influenced by body shape andweightUsually within normal weight range, possibly underweightor overweightRestriction of total calorie consumption between binges,selecting low-calorie foods while avoiding foods perceivedto be fattening or likely to trigger a bingeDepressive and anxiety symptomsPossible substance use involving alcohol or stimulantsLoss of dental enamelChipped, ragged, or moth-eaten appearance of teethIncreased dental cariesMenstrual irregularitiesDependence on laxativesEsophageal tearsFluid and electrolyte abnormalitiesMetabolic alkalosis (from vomiting) or metabolic acidosis(from diarrhea)Mildly elevated serum amylase levelsAdapted from DSM-IV-TR, 2000.The death rate from bulimia is estimated at 3% or less. (ForDSM-IV-TR diagnostic criteria for bulimia nervosa, please referto the box titled “Symptoms of Bulimia Nervosa.”)Most clients with bulimia are treated on an outpatientbasis. Hospital admission is indicated if binging and purgingbehaviors are out of control and the client’s medicalstatus is compromised. Most clients with bulimia havenear-normal weight, which reduces the concern aboutsevere malnutrition—a factor in clients with anorexianervosa.Treatment and PrognosisCognitive–Behavioral TherapyCBT has been found to be the most effective treatment forbulimia. This outpatient approach often requires a detailedmanual to guide treatment. Strategies designed to changethe client’s thinking (cognition) and actions (behavior)about food focus on interrupting the cycle of dieting, binging,and purging and altering dysfunctional thoughts andbeliefs about food, weight, body image, and overall selfconcept.CBT enhanced with assertiveness training andself-esteem enhancement has produced positive results(Schmidt et al., 2007).

380UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSPsychopharmacologySince the 1980s, several controlled studies have beenconducted to evaluate the effectiveness of antidepressantsto treat bulimia. Drugs, such as desipramine (Norpramin),imipramine (Tofranil), amitriptyline (Elavil),nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine(Prozac) were prescribed in the same dosages usedto treat depression (see Chapter 2). In all the studies, theantidepressants were more effective than were the placebosin reducing binge eating. They also improved moodand reduced preoccupation with shape and weight. Mostof the positive results, however, were short term, withabout one third of clients relapsing within a 2-year period(Agras, 2006).APPLICATION OF THE NURSING PROCESSAlthough anorexia and bulimia have several differences,many similarities are found in assessing, planning, implementing,and evaluating nursing care for clients with thesedisorders. Thus, this section addresses both eating disordersand highlights differences where they exist.Nursing Care Plan ❘ BulimiaNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices ofpracticed responses, and/or inability to use available resources.ASSESSMENT DATAEXPECTED OUTCOMES• Inability to meet basic needs• Inability to ask for help• Inability to solve problem• Inability to change behaviors• Self-destructive behavior• Suicidal thoughts or behavior• Inability to delay gratification• Poor impulse control• Stealing or shoplifting behavior• Desire for perfection• Feelings of worthlessness• Feelings of inadequacy or guilt• Unsatisfactory interpersonal relationships• Self-deprecatory verbalization• Denial of feelings, illness, or problems• Anxiety• Sleep disturbances• Low self-esteem• Excessive need to control• Feelings of being out of control• Preoccupation with weight, food, or diets• Distortions of body image• Overuse of laxatives, diet pills, or diuretics• Secrecy regarding eating habits or amounts eaten• Fear of being fat• Recurrent vomiting• Binge eating• Compulsive eating• Substance useImmediateThe client will• Be free from self-inflicted harm.• Identify methods not related to food of dealing withstress or crises, e.g., initiate interaction with othersor keep a journal/diary.• Verbalize feelings of guilt, anxiety, anger, or anexcessive need for control.StabilizationThe client will• Demonstrate more satisfying interpersonalrelationships.• Demonstrate alternative methods of dealing withstress or crises.• Eliminate shoplifting or stealing behaviors.• Express feelings in ways not related to food.• Verbalize understanding of disease process and safeuse of medications, if any.CommunityThe client will• Verbalize more realistic body image.• Follow through with discharge planning, includingsupport groups or therapy as indicated.• Verbalize increased self-esteem and self-confidence.(continued)

CHAPTER 18 • EATING DISORDERS 381Nursing Care Plan | Bulimia, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Ask the client directly about thoughts of suicide orself-harm.Set limits with the client about eating habits, e.g.,food will be eaten in a dining room setting, at atable, only at conventional mealtimes.Encourage the client to eat with other clients, whentolerated.Encourage the client to express feelings, such as anxietyand guilt about having eaten.Encourage the client to use a diary to write types andamounts of foods eaten and feelings that occurbefore, during, and after eating, especially related tourges to engage in binge or purge behavior.Discuss the types of foods that are soothing to theclient and that relieve anxiety.Encourage the client to describe and discuss feelingsverbally. Begin to separate dealing with feelingsfrom eating or purging behaviors. Maintain a nonjudgmentalapproach.Help the client explore ways to relieve anxiety,express feelings, and experience pleasure that arenot related to food or eating.Encourage the client to express his or her feelingsabout family members and significant others andtheir roles and relationships.Give positive feedback for the client’s efforts todiscuss feelings.*Teach the client and significant others about bulimicbehaviors, physical complications, nutrition, andso forth. Refer the client to a dietitian if indicated.*Teach the client and significant others about thepurpose, action, timing, and possible adverseeffects of medications, if any.Teach the client about the use of the problemsolvingprocess.Explore with the client his or her personal strengths.Making a written list is sometimes helpful.RationaleThe client’s safety is a priority. You will not give theclient ideas about suicide by addressing the issuedirectly.Limits will discourage binge behavior, such as hiding,sneaking, and gulping food, and help the clientreturn to normal eating patterns. Eating threemeals a day will prevent starvation and subsequentovereating in the evening.Eating with other people will discourage secrecyabout eating, though initially the client’s anxietymay be too high to join others at mealtime.Expressing feelings can help decrease the client’sanxiety and the urge to engage in purging behaviors.A diary can help the client explore food intake, feelings,and relationships among these feelings andbehaviors. Initially, the client may be able to writeabout these feelings and behaviors more easily thantalk about them.You may be able to help the client see how he or shehas used food to deal with feelings.Being nonjudgmental gives the client permission to discussfeelings that may be negative or unacceptable tohim or her without fear of rejection or reprisal.It is important to help the client separate emotionalissues from food and eating behaviors.Expressing feelings can help the client to identify,accept, and work through feelings in a direct manner.Your sincere praise can promote the client’s attemptsto deal openly and honestly with anxiety, anger, andother feelings.The client and significant others may have littleknowledge of the illness, food, and nutrition. Factualinformation can be useful in dispelling incorrectbeliefs and in separating food from emotional issues.Antidepressant and other medications may be prescribedfor bulimia. Remember, some antidepressant medicationsmay take several weeks to achieve a therapeuticeffect.Successful use of the problem-solving process can helpincrease the client’s self-esteem and confidence.You can help the client discover his or her strengths;he or she needs to identify them, so it will not beuseful for you to make a list for the client.(continued)

382UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Bulimia, cont.IMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)Discuss with the client the idea of accepting a lessthan “ideal” body weight.Encourage the client to incorporate fattening (or“bad”) foods into the diet as he or she tolerates.*Refer the client to assertiveness training books orclasses if indicated.*Refer the client to long-term therapy if indicated.Contracting with the client may be helpful to promotefollow through with continuing therapy.*Ongoing therapy may need to include significant othersto sustain the client’s non–food-related coping skills.*Refer the client and family and significant othersto support groups in the community or via theInternet (e.g., Anorexia Nervosa and AssociatedDisorders, Overeaters Anonymous).*Refer the client to a substance dependencetreatment program or substance dependencesupport group (e.g., Alcoholics Anonymous), ifappropriate.RationaleThe client’s previous expectations or perception of anideal weight may have been unrealistic, and evenunhealthy.This will enhance the client’s sense of control of overeating.Many bulimic clients are passive in interpersonalrelationships. Assertiveness training may foster asense of increased confidence and healthier relationshipdynamics.Treatment for eating disorders often is a long-termprocess. The client may be more likely to engage inongoing therapy if he or she has contracted to do this.Dysfunctional relationships with significant others oftenare a primary issue for clients with eating disorders.These groups can offer support, education, andresources to clients and their families or significantothers.Substance use is common among clients with bulimia.Adapted from Schultz, J. M., & Videbeck, S. L.(2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.AssessmentSeveral specialized tests have been developed for eatingdisorders. An assessment tool such as the Eating AttitudesTest often is used in studies of anorexia and bulimia. Thistest also can be used at the end of treatment to evaluateoutcomes because it is sensitive to clinical changes.HistoryFamily members often describe clients with anorexia nervosaas perfectionists with above-average intelligence, achievementoriented, dependable, eager to please, and seekingapproval before their condition began. Parents describe clientsas being “good, causing us no trouble” until the onset ofanorexia. Likewise, clients with bulimia often are focused onpleasing others and avoiding conflict. Clients with bulimia,however, often have a history of impulsive behavior such assubstance abuse and shoplifting as well as anxiety, depression,and personality disorders (Schultz & Videbeck, 2009).General Appearance and Motor BehaviorClients with anorexia appear slow, lethargic, and fatigued;they may be emaciated, depending on the amount of weightloss. They may be slow to respond to questions and havedifficulty deciding what to say. They are often reluctant toanswer questions fully because they do not want toacknowledge any problem. They often wear loose-fittingclothes in layers, regardless of the weather, both to hideweight loss and to keep warm (clients with anorexia aregenerally cold). Eye contact may be limited. Clients mayturn away from the nurse, indicating their unwillingness todiscuss problems or to enter treatment.Clients with bulimia may be underweight or overweightbut are generally close to expected body weight for ageand size. General appearance is not unusual, and theyappear open and willing to talk.Mood and AffectClients with eating disorders have labile moods that usuallycorrespond to their eating or dieting behaviors. Avoiding“bad” or fattening foods gives them a sense of powerand control over their bodies, whereas eating, binging, orpurging leads to anxiety, depression, and feeling out ofcontrol. Clients with eating disorders often seem sad, anxious,and worried. Those with anorexia seldom smile,laugh, or enjoy any attempts at humor; they are somber

CHAPTER 18 • EATING DISORDERS 383and serious most of the time. In contrast, clients with bulimiaare initially pleasant and cheerful as though nothing iswrong. The pleasant façade usually disappears when theybegin describing binge eating and purging; they mayexpress intense guilt, shame, and embarrassment.It is important to ask clients with eating disorders aboutthoughts of self-harm or suicide. It is not uncommon forthese clients to engage in self-mutilating behaviors, suchas cutting. Concern about self-harm and suicidal behaviorshould increase when clients have a history of sexual abuse(see Chapters 11 and 15).Thought Processes and ContentClients with eating disorders spend most of the time thinkingabout dieting, food, and food-related behavior. Theyare preoccupied with their attempts to avoid eating or eating“bad” or “wrong” foods. Clients cannot think aboutthemselves without thinking about weight and food. Thebody image disturbance can be almost delusional; even ifclients are severely underweight, they can point to areason their buttocks or thighs that are “still fat,” thereby fuelingtheir need to continue dieting. Clients with anorexiawho are severely underweight may have paranoid ideasabout their family and health care professionals, believingthey are their “enemies” who are trying to make them fatby forcing them to eat.Sensorium and Intellectual ProcessesGenerally, clients with eating disorders are alert and oriented;their intellectual functions are intact. The exceptionis clients with anorexia who are severely malnourished andshowing signs of starvation, such as mild confusion, slowedmental processes, and difficulty with concentration andattention.Judgment and InsightClients with anorexia have very limited insight and poorjudgment about their health status. They do not believethey have a problem; rather, they believe others are trying tointerfere with their ability to lose weight and to achieve thedesired body image. Facts about failing health status are notenough to convince these clients of their true problems.Clients with anorexia continue to restrict food intake orto engage in purging despite the negative effect on health.In contrast, clients with bulimia are ashamed of thebinge eating and purging. They recognize these behaviorsas abnormal and go to great lengths to hide them. Theyfeel out of control and unable to change even though theyrecognize their behaviors as pathologic. Box 18.1 showsan Eating Attitudes Test.Self-ConceptLow self-esteem is prominent in clients with eating disorders.They see themselves only in terms of their abilityto control their food intake and weight. They tend tojudge themselves harshly and see themselves as “bad” ifthey eat certain foods or fail to lose weight. They overlookor ignore other personal characteristics or achievementsas less important than thinness. Clients often perceivethemselves as helpless, powerless, and ineffective. Thisfeeling of lack of control over themselves and their environmentonly strengthens their desire to control theirweight.Roles and RelationshipsEating disorders interfere with the ability to fulfill rolesand to have satisfying relationships. Clients with anorexiamay begin to fail at school, which is in sharp contrast topreviously successful academic performance. They withdrawfrom peers and pay little attention to friendships.They believe that others will not understand or fear theywill begin out-of-control eating with others.Clients with bulimia feel great shame about their bingeeating and purging behaviors. As a result, they tend to leadsecret lives that include sneaking behind the backs offriends and family to binge and purge in privacy. The timespent buying and eating food and then purging can interferewith role performance both at home and at work.Physiologic and Self-Care ConsiderationsThe health status of clients with eating disorders relatesdirectly to the severity of self-starvation, purging behaviors,or both (see Table 18.2). In addition, clients mayexercise excessively, almost to the point of exhaustion, inan effort to control weight. Many clients have sleep disturbancessuch as insomnia, reduced sleep time, and earlymorningwakening. Those who frequently vomit havemany dental problems, such as loss of tooth enamel,chipped and ragged teeth, and dental caries. Frequentvomiting also may result in mouth sores. Complete medicaland dental examinations are essential.Data AnalysisNursing diagnoses for clients with eating disorders includethe following:• Imbalanced Nutrition: Less Than/More Than BodyRequirements• Ineffective Coping• Disturbed Body Image• Chronic Low Self-esteemOther nursing diagnoses may be pertinent, such as DeficientFluid Volume, Constipation, Fatigue, and ActivityIntolerance.Outcome IdentificationFor severely malnourished clients, their medical conditionmust be stabilized before psychiatric treatment can begin.Medical stabilization may include parenteral fluids, totalparenteral nutrition, and cardiac monitoring.

384UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 18.1 EATING ATTITUDES TESTPlease place an (X) under the column that applies best to each of the numbered statements. All the results will be strictlyconfidential. Most of the questions relate to food or eating, although other types of questions have been included. Pleaseanswer each question carefully. Thank you.AlwaysVeryOftenOftenSometimesRarely Never1. Like eating with other people. _____ _____ _____ _____ _____ __X__2. Prepare foods for others but do not eatwhat I cook. __X__ _____ _____ _____ _____ _____3. Become anxious prior to eating. __X__ _____ _____ _____ _____ _____4. Am terrified about being overweight. __X__ _____ _____ _____ _____ _____5. Avoid eating when I am hungry. __X__ _____ _____ _____ _____ _____6. Find myself preoccupied with food. __X__ _____ _____ _____ _____ _____7. Have gone on eating binges where I feel that Imay not be able to stop. __X__ _____ _____ _____ _____ _____8. Cut food into small pieces. __X__ _____ _____ _____ _____ _____9. Aware of the calorie content of foods that I eat. __X__ _____ _____ _____ _____ _____10. Particularly avoid foods with a high carbohydratecontent (e.g., bread, potatoes, rice, etc.). __X__ _____ _____ _____ _____ _____11. Feel bloated after meals. __X__ _____ _____ _____ _____ _____12. Feel that others would prefer I ate more. __X__ _____ _____ _____ _____ _____13. Vomit after I have eaten. __X__ _____ _____ _____ _____ _____14. Feel extremely guilty after eating. __X__ _____ _____ _____ _____ _____15. Am preoccupied with a desire to be thinner. __X__ _____ _____ _____ _____ _____16. Exercise strenuously to burn off calories. __X__ _____ _____ _____ _____ _____17. Weigh myself several times a day. __X__ _____ _____ _____ _____ _____18. Like my clothes to fit tightly. _____ _____ _____ _____ _____ __X__19. Enjoy eating meat. _____ _____ _____ _____ _____ __X__20. Wake up early in the morning. __X__ _____ _____ _____ _____ _____21. Eat the same foods day after day. __X__ _____ _____ _____ _____ _____22. Think about burning up calories when I exercise. __X__ _____ _____ _____ _____ _____23. Have regular menstrual periods. _____ _____ _____ _____ _____ __X__24. Other people think I am too thin. __X__ _____ _____ _____ _____ _____25. Am preoccupied with the thought of havingfat on my body. __X__ _____ _____ _____ _____ _____26. Take longer than others to eat. __X__ _____ _____ _____ _____ _____27. Enjoy eating at restaurants. _____ _____ _____ _____ _____ __X__28. Take laxatives. __X__ _____ _____ _____ _____ _____29. Avoid foods with sugar in them. __X__ _____ _____ _____ _____ _____30. Eat diet foods. __X__ _____ _____ _____ _____ _____31. Feel that food controls my life. __X__ _____ _____ _____ _____ _____32. Display self-control around food. __X__ _____ _____ _____ _____ _____33. Feel that others pressure me to eat. __X__ _____ _____ _____ _____ _____34. Give too much time and thought to food. __X__ _____ _____ _____ _____ _____35. Suffer from constipation. _____ __X__ _____ _____ _____ _____36. Feel uncomfortable after eating sweets. __X__ _____ _____ _____ _____ _____37. Engage in dieting behavior. __X__ _____ _____ _____ _____ _____38. Like my stomach to be empty. __X__ _____ _____ _____ _____ _____39. Enjoy trying new rich foods. _____ _____ _____ _____ _____ __X__40. Have impulse to vomit after meals. __X__ _____ _____ _____ _____ _____Scoring: The patient is given the questionnaire without the X’s, just blank. Three points are assigned to endorsements thatcoincide with the X’s; the adjacent alternatives are weighted as 2 points and 1 point, respectively. A total score of over30 indicates significant concerns with eating behavior.

CHAPTER 18 • EATING DISORDERS 385Examples of expected outcomes for clients with eatingdisorders include the following:• The client will establish adequate nutritional eatingpatterns.• The client will eliminate use of compensatory behaviorssuch as excessive exercise and use of laxatives anddiuretics.• The client will demonstrate coping mechanisms notrelated to food.• The client will verbalize feelings of guilt, anger, anxiety,or an excessive need for control.• The client will verbalize acceptance of body image withstable body weight.InterventionsEstablishing Nutritional Eating PatternsTypically, inpatient treatment is for clients with anorexia nervosawho are severely malnourished and clients with bulimiawhose binge eating and purging behaviors are out of control.Primary nursing roles are to implement and to supervise theregimen for nutritional rehabilitation. Total parenteral nutritionor enteral feedings may be prescribed initially when aclient’s health status is severely compromised.NURSING INTERVENTIONSfor Eating Disorders• Establishing nutritional eating patternsSit with the client during meals and snacks.Offer liquid protein supplement if client is unable tocomplete meal.Adhere to treatment program guidelines regardingrestrictions.Observe client following meals and snacks for1 to 2 hours.Weigh client daily in uniform clothing.Be alert for attempts to hide or discard food or inflateweight.• Helping the client identify emotions and developnon–food-related coping strategiesAsk the client to identify feelings.Self-monitoring using a journalRelaxation techniquesDistractionAssist client to change stereotypical beliefs.• Helping the client deal with body image issuesRecognize benefits of a more near-normal weight.Assist to view self in ways not related to body image.Identify personal strengths, interests, talents.• Providing client and family education (See Client/Family Education for Eating Disorders)When clients can eat, a diet of 1,200 to 1,500 caloriesper day is ordered, with gradual increases in calories untilclients are ingesting adequate amounts for height, activitylevel, and growth needs. Typically, allotted calories aredivided into three meals and three snacks. A liquid proteinsupplement is given to replace any food not eaten to ensureconsumption of the total number of prescribed calories.The nurse is responsible for monitoring meals and snacksand often initially will sit with a client during eating at atable away from other clients. Depending on the treatmentprogram, diet beverages and food substitutions may beprohibited, and a specified time may be set for consumingeach meal or snack. Clients also may be discouraged fromperforming food rituals such as cutting food into tinypieces or mixing food in unusual combinations. The nursemust be alert for any attempts by clients to hide or to discardfood.After each meal or snack, clients may be required toremain in view of staff for 1 to 2 hours to ensure they donot empty the stomach by vomiting. Some treatment programslimit client access to bathrooms without supervision,particularly after meals, to discourage vomiting. Asclients begin to gain weight and to become more independentin eating behavior, these restrictions are reducedgradually.In most treatment programs, clients are weighed onlyonce daily, usually on awakening and after they have emptiedthe bladder. Clients should wear minimal clothing,such as a hospital gown, each time they are weighed. Theymay attempt to place objects in their clothing to give theappearance of weight gain.Clients with bulimia often are treated on an outpatientbasis. The nurse must work closely with clients to establishnormal eating patterns and to interrupt the binge andpurge cycle. He or she encourages clients to eat meals withtheir families or, if they live alone, with friends. Clientsalways should sit at a table in a designated eating area suchas a kitchen or dining room. It is easier for clients to followa nutritious eating plan if it is written in advance and groceriesare purchased for the planned menus. Clients mustavoid buying foods frequently consumed during binges,such as cookies, candy bars, and potato chips. They shoulddiscard or move to the kitchen food that was kept at work,in the car, or in the bedroom.Identifying Emotions and DevelopingCoping StrategiesBecause clients with anorexia have problems with selfawareness,they often have difficulty identifying andexpressing feelings (alexithymia). Therefore, they oftenexpress these feelings in terms of somatic complaints suchas feeling fat or bloated. The nurse can help clients beginto recognize emotions such as anxiety or guilt by askingthem to describe how they are feeling and allowing adequatetime for response. The nurse should not ask, “Areyou sad?” or “Are you anxious?” because a client may

386UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSthan they would like, to be healthy, and to stay out of thehospital. When clients experience relief from emotionaldistress, have increased self-esteem, and can meet theiremotional needs in healthy ways, they are more likely toaccept their weight and body image.The nurse also can help clients to view themselves interms other than weight, size, shape, and satisfaction withbody image. Helping clients to identify areas of personalstrength that are not food related broadens clients’ perceptionsof themselves. This includes identifying talents,interests, and positive aspects of character unrelated tobody shape or size.Keeping a feelings diaryquickly agree rather than struggle for an answer. The nurseencourages the client to describe her or his feelings. Thisapproach can eventually help clients to recognize theiremotions and to connect them to their eating behaviors.Self-monitoring is a cognitive–behavioral techniquedesigned to help clients with bulimia. It may help clientsto identify behavior patterns and then implement techniquesto avoid or to replace them (Schmidt, 2008).Self-monitoring techniques raise client awareness aboutbehavior and help them to regain a sense of control. Thenurse encourages clients to keep a diary of all food eatenthroughout the day, including binges, and to record moods,emotions, thoughts, circumstances, and interactions surroundingeating and binging or purging episodes. In thisway, clients begin to see connections between emotionsand situations and eating behaviors. The nurse can thenhelp clients to develop ways to manage emotions such asanxiety by using relaxation techniques or distraction withmusic or another activity. This is an important step towardhelping clients find ways to cope with people, emotions,or situations that do not involve food.Dealing with Body Image IssuesThe nurse can help clients to accept a more normal bodyimage. This may involve clients agreeing to weigh moreProviding Client and Family EducationOne primary nursing role in caring for clients with eatingdisorders is providing education to help them take controlof nutritional requirements independently. This teachingcan be done in the inpatient setting during discharge planningor in the outpatient setting. The nurse providesextensive teaching about basic nutritional needs and theeffects of restrictive eating, dieting, and the binge andpurge cycle. Clients need encouragement to set realisticgoals for eating throughout the day (Sylvester & Forman,2008). Eating only salads and vegetables during the daymay set up clients for later binges as a result of too littledietary fat and carbohydrates.For clients who purge, the most important goal is tostop. Teaching should include information about theharmful effects of purging by vomiting and laxative abuse.The nurse explains that purging is an ineffective meansof weight control and only disrupts the neuroendocrinesystem. In addition, purging promotes binge eating bydecreasing the anxiety that follows the binge. The nurseCLIENT/FAMILY EDUCATIONfor Eating DisordersClient• Basic nutritional needs• Harmful effects of restrictive eating, dieting, and purging• Realistic goals for eating• Acceptance of healthy body imageFamily and Friends• Provide emotional support.• Express concern about client’s health.• Encourage client to seek professional help.• Avoid talking only about weight, food intake, and calories.• Become informed about eating disorders.• It is not possible for family and friends to force the clientto eat. The client needs professional help from a therapistor psychiatrist.

CHAPTER 18 • EATING DISORDERS 387explains that if clients can avoid purging, they may be lesslikely to engage in binge eating. The nurse also teaches thetechniques of distraction and delay because they are usefulagainst both binging and purging. The longer clients candelay either binging or purging, the less likely they are tocarry out the behavior.The nurse explains to family and friends that they canbe most helpful by providing emotional support, love, andattention. They can express concern about the client’shealth, but it is rarely helpful to focus on food intake, calories,and weight.EvaluationThe nurse can use assessment tools such as the EatingAttitudes Test to detect improvement for clients with eatingdisorders. Both anorexia and bulimia are chronic formany clients. Residual symptoms such as dieting, compulsiveexercising, and experiencing discomfort when eatingin a social setting are common. Treatment is consideredsuccessful if the client maintains a body weight within 5%to 10% of normal with no medical complications fromstarvation or purging.COMMUNITY-BASED CARETreatment for clients with eating disorders usually occursin community settings. Hospital admission is indicatedonly for medical necessity such as for clients with dangerouslylow weight, electrolyte imbalances, or renal, cardiac,or hepatic complications. Clients who cannot control thecycle of binge eating and purging may be treated briefly inan inpatient setting. Other treatment settings include partialhospitalization or day treatment programs, individualor group outpatient therapy, and self-help groups.MENTAL HEALTH PROMOTIONNurses can educate parents, children, and young peopleabout strategies to prevent eating disorders. Importantaspects include realizing that the “ideal” figures portrayedin advertisements and magazines are unrealistic, developingrealistic ideas about body size and shape, resisting peerpressure to diet, improving self-esteem, and learning copingstrategies for dealing with emotions and life issues.The Atlanta Center for Eating Disorders (2008) offersthe following advice:• Read the research about fad diets: They don’t work. Nofatdiets are unhealthy, and claims about diets that usespecial combinations of food are unfounded.• Send the right message to children about food and bodyimage issues. Parents who are constantly worryingabout or talking about weight or are always “on a diet”powerfully influence their children. Give up dietingand eat well-balanced meals.Box 18.2SAMPLE SCREENINGQUESTIONS• How often do you feel dissatisfied with your bodyshape or size?• Do you think you are fat or need to lose weight, evenwhen others say you are thin?• Do thoughts about food, weight, dieting, and eatingdominate your life?• Do you eat to make yourself feel better emotionally,and then feel guilty about it?• Listen to your conversations. Weight, dieting, andappearance are among the most common topics forwomen. Make a pact with friends to stop talking aboutyour bodies negatively.• Focus on the positive aspects of yourself and othersthat have nothing to do with physical appearance.• Encourage healthy expression of emotions. Learn positiveways to communicate.• Give up wanting to be thin before doing anything, andget on with enjoying your life.• Increase physical activity by focusing on the enjoymentof movement, not on how many calories you’ll burn.School nurses, student health nurses at colleges anduniversities, and nurses in clinics and doctors’ offices mayencounter clients in various settings who are at risk fordeveloping or who already have an eating disorder. In thesesettings, early identification and appropriate referral areprimary responsibilities of the nurse. Routine screening ofall young women in these settings would help identifythose at risk for an eating disorder. Box 18.2 contains asample of questions that can be used for such screening.Such early identification could result in early interventionand prevention of a full-blown eating disorder.SELF-AWARENESS ISSUESAn emaciated, starving client with anorexiacan be a shocking sight, and the nurse maywant to “take care of this child” and nurseher back to health. When the client rejectsthis help and resists the nurse’s caring actions, the nursecan become angry and frustrated and feel incompetent tohandle the situation.The client initially may view the nurse, who is responsiblefor making the client eat, as the enemy. The client mayhide or throw away food or become overtly hostile as anxietyabout eating increases. The nurse must remember thatthe client’s behavior is a symptom of anxiety and fear aboutgaining weight and not personally directed toward thenurse. Taking the client’s behavior personally may causethe nurse to feel angry and behave in a rejecting manner.

388UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSINTERNET RESOURCESRESOURCES• About Face (changing attitudes about body image)• Academy for Eating Disorders• Body Positive• Eating Disorder Referral and Information Center• National Association of Anorexia Nervosa & AssociatedEating Disorders• National Eating Disorders AssociationINTERNET ADDRESShttp://www.about-face.orghttp://www.aedweb.orghttp://www.bodypositive.comhttp://www.edreferral.comhttp://www.anad.orghttp://www.nationaleatingdisorders.org/Because eating is such a basic part of everyday life, thenurse may wonder why the client cannot just eat “likeeveryone else.” The nurse also may find it difficult tounderstand how a 75-pound client sees herself as fat whenshe looks in the mirror. Likewise, when working with aclient who binges and purges, the nurse may wonder whythe client cannot exert the willpower to stop. The nursemust remember that the client’s eating behavior has gottenout of control. Eating disorders are mental illnesses,just like schizophrenia and bipolar affective disorder.Points to Consider When Working withClients with Eating Disorders• Be empathetic and nonjudgmental, although this is noteasy. Remember the client’s perspective and fears aboutweight and eating.• Avoid sounding parental when teaching about nutritionor why laxative use is harmful. Presenting informationfactually without chiding the client will obtain morepositive results.• Do not label clients as “good” when they avoid purging oreat an entire meal. Otherwise, clients will believe they are“bad” on days when they purge or fail to eat enough food.Critical Thinking Questions1. You notice a friend or family member has been losingweight, has strange eating rituals, and constantlytalks about dieting. You suspect an eating disorder.How would you approach this person?2. Dieting behaviors and restriction of eating occurs inincreasingly younger children. At the same time,childhood obesity is increasing at an epidemic rate.How can this be explained? What needs to happento address both of these public health issues?KEY POINTS• Anorexia nervosa is a life-threatening eatingdisorder characterized by body weight lessthan 85% of normal, an intense fear of beingfat, a severely distorted body image, andrefusal to eat or binge eating and purging.• Bulimia nervosa is an eating disorder that involvesrecurrent episodes of binge eating and compensatorybehaviors such as purging, using laxatives and diuretics,or exercising excessively.• Ninety percent of clients with eating disorders arefemales. Anorexia begins between the ages of 14 and 18,and bulimia begins around age 18 or 19.• Many neurochemical changes are present in individualswith eating disorders, but it is uncertain whether thesechanges cause or are a result of the eating disorders.• Persons with eating disorders feel unattractive and ineffectiveand may be poorly equipped to deal with thechallenges of maturity.• Societal attitudes regarding thinness, beauty, desirability,and physical fitness may influence the developmentof eating disorders.• Severely malnourished clients with anorexia nervosamay require intensive medical treatment to restorehomeostasis before psychiatric treatment can begin.• Family therapy is effective for clients with anorexia;cognitive–behavioral therapy is most effective for clientswith bulimia.• Interventions for clients with eating disorders includeestablishing nutritional eating patterns, helping the clientto identify emotions and to develop coping strategiesnot related to food, helping the client to deal withbody image issues, and providing client and familyeducation.• Focus on healthy eating and pleasurable physical exercise;avoid fad or stringent dieting.• Parents must become aware of their own behavior andattitudes and the way they influence children.

CHAPTER 18 • EATING DISORDERS 389REFERENCESAgras, W. S. (2006). Treatment of eating disorders. In A. F. Schatzberg, &C. B. Nemeroff (Eds.), Essentials of clinical psychopharmacology(2nd ed., pp. 669–687). Washington, DC: American PsychiatricPublishing.American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Anderson, A. E., & Yager, J. (2005). Eating disorders. In B. J. Sadock, &V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed.,pp. 2002–2021). Philadelphia: Lippincott Williams & Wilkins.Andreasen, N. C., & Black, D. W. (2006). Introductory textbook ofpsychiatry (4th ed.). Washington, DC: American PsychiatricPublishing.Atlanta Center for Eating Disorders. (2008). How can you help preventeating disorders? Retrieved from http://www.eatingdisorders.cchelp.Carter, J. C., Bewell, C., Blackmore, E., & Woodside, D. B. (2006). Theimpact of childhood sexual abuse in anorexia nervosa. Child Abuse &Neglect, 30(3), 257–269.Cave, K. E. (2009). Influences of disordered eating in prepubescent children.Journal of Psychosocial Nursing, 47(2), 21–24.Eisenberg, M., & Neumark-Sztainer, D. (2008). Peer harassment anddisordered eating. International Journal of Adolescent Medicine andHealth, 20(2), 155–164.Glazer, J. L. (2008). Eating disorders among male athletes. Current SportsMedicine Reports, 7(6), 332–337.Latzer, Y., Witztum, E., & Stein, D. (2008). Eating disorders and disorderedeating in Israel: An updated review. European Eating DisordersReview, 16(5), 361–374.Pike, K. M., Hilbert, A., Wilfley, D. E., Fairburn, C. G., Dohm, F. A.,Walsh, B. T., et al. (2008). Toward an understanding of risk factorsfor anorexia nervosa: A case–control study. Psychological Medicine,38(10), 1443–1453.Schmidt, U. (2008). Cognitive behavioral approaches in adolescentanorexia and bulimia nervosa. Child & Adolescent Psychiatric Clinicsof North America, 18, 147–158.Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J., Yi, I., et al.(2007). A randomized controlled trial of family therapy and cognitivebehavior therapy guided self-care for adolescents with bulimia nervosaand related disorders. American Journal of Psychiatry, 164(4),591–598.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Stunkard, A., Allison, K., & Lundgren, J. (2008). Issues for DSM-IV:Night eating syndrome. American Journal of Psychiatry, 165(4), 424.Sweetingham, R., & Walter, G. (2008). Childhood experiences of beingbullied and teased in the eating disorders. European Eating DisordersReview, 16(5), 401–407.Sylvester, C. J., & Forman, S. F. (2008). Clinical practice guidelines fortreating restrictive eating disorder patients during medical hospitalization.Current Opinion in Pediatrics, 20(4), 390–397.Thiels, C. (2008). Forced treatment of patients with anorexia. CurrentOpinion in Psychiatry, 21(5), 495–498.Thompson, C. (2009). Men and eating disorders. Retrieved 3/1/09, fromhttp:www.raderprograms.com.Yager, J. (2008). Binge eating disorders: The search for better treatments.American Journal of Psychiatry, 165(1), 4–6.ADDITIONAL READINGSAllen, K. L., Byrne, S. M., McLean, N. J., & Davis, E. A. (2008).Overconcern with weight and shape is not the same as body dissatisfaction:Evidence from a prospective study of pre-adolescent boysand girls. Body Image, 5, 261–270.Couturier, J., & Lock, J. (2007). A review of medication use for childrenand adolescents with eating disorders. Journal of the CanadianAcademy of Child and Adolescent Psychiatry, 16(4), 173–176.Gluck, M. E., Venti, C. A., Salbe, A. D., & Krakoff, J. (2008). Nighttimeeating: Commonly observed and related to weight gain in an inpatientfood intake study. American Journal of Clinical Nutrition, 88(4),900–905.Pope, H. G., Jr., Lalonde, J. K., Pindyck, L. J., Walsh, T., Bulik, C. M.,Crow, S. J., et al. (2006). Binge eating disorder: A stable syndrome.American Journal of Psychiatry, 163(12), 2181–2183.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. Treating clients with anorexia nervosa with a selectiveserotonin reuptake inhibitor antidepressant such as fluoxetine(Prozac) may present which of the followingproblems?a. Clients object to the side effect of weight gain.b. Fluoxetine can cause appetite suppression andweight loss.c. Fluoxetine can cause clients to become giddy andsilly.d. Clients with anorexia get no benefit from fluoxetine.2. Which of the following is an example of a cognitive–behavioral technique?a. Distractionb. Relaxationc. Self-monitoringd. Verbalization of emotions3. The nurse is working with a client with anorexia nervosa.Even though the client has been eating all hermeals and snacks, her weight has remained unchangedfor 1 week. Which of the following interventions isindicated?a. Supervise the client closely for 2 hours after mealsand snacks.b. Increase the daily caloric intake from 1,500 to2,000 calories.c. Increase the client’s fluid intake.d. Request an order from the physician for fluoxetine.4. Which of the following statements is true?a. Anorexia nervosa was not recognized as an illnessuntil the 1960s.b. Cultures where beauty is linked to thinness have anincreased risk for eating disorders.c. Eating disorders are a major health problem only inthe United States and Europe.d. Persons with anorexia nervosa are popular with theirpeers as a result of their thinness.5. All but which of the following are initial goals for treatingthe severely malnourished client with anorexianervosa?a. Correction of body image disturbanceb. Correction of electrolyte imbalancesc. Nutritional rehabilitationd. Weight restoration6. The nurse is evaluating the progress of a client withbulimia. Which of the following behaviors would indicatethat the client is making positive progress?a. The client can identify calorie content for eachmeal.b. The client identifies healthy ways of coping withanxiety.c. The client spends time resting in her room aftermeals.d. The client verbalizes knowledge of former eatingpatterns as unhealthy.7. A teenaged girl is being evaluated for an eating disorder.Which of the following would suggest anorexia nervosa?a. Guilt and shame about eating patternsb. Lack of knowledge about food and nutritionc. Refusal to talk about food-related topicsd. Unrealistic perception of body size8. A client with bulimia is learning to use the techniqueof self-monitoring. Which of the following interventionsby the nurse would be most beneficial for thisclient?a. Ask the client to write about all feelings and experiencesrelated to food.b. Assist the client to make out daily meal plans for1 week.c. Encourage the client to ignore feelings and impulsesrelated to food.d. Teach the client about nutrition content and caloriesof various foods.390

CHAPTER 18 • EATING DISORDERS391MULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. A nurse doing an assessment with a client with anorexianervosa would expect to find which of the following?a. Belief that dieting behavior is not a problemb. Feelings of guilt and shame about eating behaviorc. History of dieting at a young aged. Performance of rituals or compulsive behaviore. Strong desire to get treatmentf. Views self as overweight or obese2. A nurse doing an assessment with a client with bulimiawould expect to find which of the following?a. Compensatory behaviors limited to purgingb. Dissatisfaction with body shape and sizec. Feelings of guilt and shame about eating behaviord. Near-normal body weight for height and agee. Performance of rituals or compulsive behaviorf. Strong desire to please others.CLINICAL EXAMPLEJudy is a 17-year-old high school junior who is active in gymnastics. She is 5 feet, 7 inchestall, weighs 85 pounds, and has not had a menstrual period for 5 months. The family physicianreferred her to the inpatient eating disorders unit with a diagnosis of anorexia nervosa.During the admission interview, Judy is defensive about her weight loss, stating she needsto be thin to be competitive in her sport. Judy points to areas on her buttocks and thighs,saying, “See this? I still have plenty of fat. Why can’t everyone just leave me alone?”1. Identify two nursing diagnoses that would be pertinent for Judy.2. Write an expected outcome for each identified nursing diagnosis.3. List three nursing interventions for each nursing diagnosis.

19Somatoform DisordersLearning ObjectivesAfter reading this chapter, you should be able to1. Explain what is meant by “psychosomatic illness.”Key Terms• body dysmorphic disorder• conversion disorder• disease conviction• disease phobia• emotion-focused copingstrategies• factitious disorder• hypochondriasis• hysteria• internalization• la belle indifférence• malingering• Munchausen syndrome• Munchausen syndromeby proxy• pain disorder• primary gain• problem-focused copingstrategies• psychosomatic• secondary gain• somatization• somatization disorder• somatoform disorders2. Describe somatoform disorders and identify their three central features.3. Discuss the etiologic theories related to somatoform disorders.4. Discuss the characteristics and dynamics of specific somatoform disorders.5. Distinguish somatoform disorders from factitious disorders andmalingering.6. Apply the nursing process to the care of clients with somatoform disorders.7. Provide education to clients, families, and the community to increaseknowledge and understanding of somatoform disorders.8. Evaluate your feelings, beliefs, and attitudes regarding clients with somatoformdisorders.IN THE EARLY 1800S, THE MEDICAL field began to consider the various socialand psychologic factors that influence illness. The term psychosomaticbegan to be used to convey the connection between the mind (psyche) andthe body (soma) in states of health and illness. Essentially, the mind cancause the body to create physical symptoms or to worsen physical illnesses.Real symptoms can begin, continue, or be worsened as a result of emotionalfactors. Examples include diabetes, hypertension, and colitis, all ofwhich are medical illnesses influenced by stress and emotions. When aperson is under a lot of stress or is not coping well with stress, symptomsof these medical illnesses worsen. In addition, stress can cause physicalsymptoms unrelated to a diagnosed medical illness. After a stressful day atwork, many people experience “tension headaches” that can be quite painful.The headaches are a manifestation of stress rather than a symptom ofan underlying medical problem.The term hysteria refers to multiple physical complaints with no organicbasis; the complaints are usually described dramatically. The concept of hysteriaprobably originated in Egypt and is about 4,000 years old. In the MiddleAges, hysteria was associated with witchcraft, demons, and sorcerers. People392Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journalarticles, and more!

CHAPTER 19 • SOMATOFORM DISORDERS 393with hysteria, usually women, were considered evil or possessedby evil spirits. Paul Briquet and Jean Martin Charcot,both French physicians, identified hysteria as a disorder ofthe nervous system.Sigmund Freud, working with Charcot, observed thatpeople with hysteria improved with hypnosis and experiencedrelief from their physical symptoms when theyrecalled memories and expressed emotions. This developmentled Freud to propose that people can convert unexpressedemotions into physical symptoms (Hollifield,2005), a process now referred to as somatization. Thischapter discusses somatoform disorders, which are basedon the concept of somatization.OVERVIEW OF SOMATOFORM DISORDERSSomatization is defined as the transference of mentalexperiences and states into bodily symptoms. Somatoformdisorders can be characterized as the presence of physicalsymptoms that suggest a medical condition without ademonstrable organic basis to account fully for them. Thethree central features of somatoform disorders are asfollows:• Physical complaints suggest major medical illness buthave no demonstrable organic basis.• Psychologic factors and conflicts seem important in initiating,exacerbating, and maintaining the symptoms.• Symptoms or magnified health concerns are not underthe client’s conscious control (Hollifield, 2005).Clients are convinced they harbor serious physicalproblems despite negative results during diagnostic testing.They actually experience these physical symptomsas well as the accompanying pain, distress, and functionallimitations such symptoms induce. Clients do notwillfully control the physical symptoms. Although theirillnesses are psychiatric in nature, many clients do notseek help from mental health professionals. Unfortunately,many health care professionals who do not understandthe nature of somatoform disorders are not sympatheticto these clients’ complaints (Andreasen & Black, 2006).Nurses must remember that these clients really experiencethe symptoms they describe and cannot voluntarilycontrol them.The five specific somatoform disorders are as follows(American Psychiatric Association [APA], 2000):• Somatization disorder is characterized by multiplephysical symptoms. It begins by 30 years of age, extendsover several years, and includes a combination ofpain and gastrointestinal, sexual, and pseudoneurologicsymptoms.• Conversion disorder, sometimes called conversion reaction,involves unexplained, usually sudden deficits insensory or motor function (e.g., blindness, paralysis).These deficits suggest a neurologic disorder but areDSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of SomatizationDisorderPain symptoms: complaints of headache; pain inthe abdomen, head, joints, back, chest, rectum;pain during urination, menstruation, or sexualintercourseGastrointestinal symptoms: nausea, bloating,vomiting (other than during pregnancy), diarrhea,or intolerance of several foodsSexual symptoms: sexual indifference, erectile orejaculatory dysfunction, irregular menses, excessivemenstrual bleeding, vomiting throughout pregnancyPseudoneurologic symptoms: conversion symptomssuch as impaired coordination or balance, paralysis orlocalized weakness, difficulty swallowing or lump inthroat, aphonia, urinary retention, hallucinations, lossof touch or pain sensation, double vision, blindness,deafness, seizures; dissociative symptoms such asamnesia; or loss of consciousness other than faintingSomatoform disordersAdapted from American Psychiatric Association. (2000). Diagnosticand statistical manual of mental disorders (4th ed., text revision).Washington, DC: American Psychiatric Association.

394UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCLINICAL VIGNETTE: CONVERSION DISORDERMatthew, 13, has just been transferred from a medical unitto the adolescent psychiatric unit. He had been on the medicalunit for 3 days, undergoing extensive tests to determinethe cause of a sudden onset of blindness. No organic pathologywas discovered, and Matthew was diagnosed witha conversion disorder.As the nurse interviews Matthew, she notices that he iscalm and speaks of his inability to see in a matter-of-factmanner, demonstrating no distress at his blindness. Matthewseems to have the usual interests of a 13-year-old, describinghis activities at school and with his friends. However, thenurse finds that Matthew has little to say about his parents,his younger brother, or activities at home.Later, the nurse has a chance to talk with Matthew’smother when she comes to the unit after work. Soon, Matthew’smother is crying, telling the nurse that her husband has adrinking problem and has been increasingly violent at home.She admitted that two days before Matthew’s symptomsdeveloped, Matthew witnessed one of his father’s rages,which included breaking furniture and hitting her. WhenMatthew tried to help his mother, his father called himspineless and worthless and told him to go to the basementand stay there. The nurse understands that the violenceMatthew has witnessed and his inability to change the situationmay be the triggering event for his conversiondisorder.associated with psychologic factors. An attitude of labelle indifférence, a seeming lack of concern or distress,is a key feature.• Pain disorder has the primary physical symptom ofpain, which generally is unrelieved by analgesics andgreatly affected by psychologic factors in terms of onset,severity, exacerbation, and maintenance.• Hypochondriasis is preoccupation with the fear thatone has a serious disease (disease conviction) or willget a serious disease (disease phobia). It is thought thatclients with this disorder misinterpret bodily sensationsor functions.• Body dysmorphic disorder is preoccupation with animagined or exaggerated defect in physical appearancesuch as thinking one’s nose is too large or teeth arecrooked and unattractive.Somatization disorder, conversion disorder, and pain disorderare more common in women than in men; hypochondriasisand body dysmorphic disorder are distributed equallyby gender. Somatization disorder occurs in 0.2% to 2% of thegeneral population. Conversion disorder occurs in less than1% of the population. Pain disorder is commonly seen inmedical practice, with 10% to 15% of people in the UnitedStates reporting work disability related to back pain alone(APA, 2000). Hypochondriasis is estimated to occur in 4% to9% of people seen in general medical practice. No statistics ofthe incidence of body dysmorphic disorder are available.ONSET AND CLINICAL COURSEClients with somatization disorder and body dysmorphicdisorder often experience symptoms in adolescence,although these diagnoses may not be made until early adulthood(about 25 years of age). Conversion disorder usuallyoccurs between 10 and 35 years of age. Pain disorder andhypochondriasis can occur at any age (APA, 2000).All the somatoform disorders are either chronic orrecurrent, lasting for decades for many people. Clientswith somatization disorder and conversion disordermost likely seek help from mental health professionalsafter they have exhausted efforts at finding a diagnosedmedical condition. Clients with hypochondriasis, paindisorder, and body dysmorphic disorder are unlikely toreceive treatment in mental health settings unless theyhave a comorbid condition. Clients with somatoformdisorders tend to go from one physician or clinic toanother, or they may see multiple providers at once inan effort to obtain relief of symptoms. They tend to bepessimistic about the medical establishment and oftenbelieve their disease could be diagnosed if providerswere more competent.RELATED DISORDERSSomatoform disorders need to be distinguished from otherbody-related mental disorders such as malingering andfactitious disorders in which people feign or intentionallyproduce symptoms for some purpose or gain. In malingeringand factitious disorders, people willfully control thesymptoms. In somatoform disorders, clients do not voluntarilycontrol their physical symptoms.Malingering is the intentional production of false orgrossly exaggerated physical or psychologic symptoms; itis motivated by external incentives such as avoiding work,evading criminal prosecution, obtaining financial compensation,or obtaining drugs. People who malinger haveno real physical symptoms or grossly exaggerate relativelyminor symptoms. Their purpose is some external incentiveor outcome that they view as important and resultsdirectly from the illness. People who malinger can stop thephysical symptoms as soon as they have gained what theywanted (Wang, Nadiga, & Jenson, 2005).

CHAPTER 19 • SOMATOFORM DISORDERS 395report feeling “natural, like they were intended to be” afteran amputation. From an ethical standpoint, few surgeonswill amputate a limb merely on a person’s request. Peoplewith BIID resort to actions such as packing the limb in dryice until the damage is so advanced that amputationbecomes a medical necessity, or in some cases, amputationis done with a power tool by nonmedical persons, leavinga physician to save the person’s life and deal with the damage(Mackenzie, 2008).Munchausen syndrome by proxyFactitious disorder occurs when a person intentionallyproduces or feigns physical or psychologic symptomssolely to gain attention. People with factitious disordermay even inflict injury on themselves to receive attention.The common term for factitious disorder is Munchausensyndrome. A variation of factitious disorder, Munchausensyndrome by proxy, occurs when a person inflicts illnessor injury on someone else to gain the attention of emergencymedical personnel or to be a “hero” for saving thevictim. An example would be a nurse who gives excessintravenous potassium to a client and then “saves his life”by performing cardiopulmonary resuscitation. Althoughfactitious disorders are uncommon, they occur most oftenin people who are in or familiar with medical professions,such as nurses, physicians, medical technicians, or hospitalvolunteers. People who injure clients or their childrenthrough Munchausen syndrome by proxy generally arearrested and prosecuted in the legal system (Stirling,2007).Body identity integrity disorder (BIID) is the term givento people who feel alienated from a part of their body anddesire amputation. This condition is also known as amputeeidentity disorder and apotemnophilia or “amputationlove.” This is not an officially accepted Diagnostic and StatisticalManual of Mental Disorders, fourth edition, textrevision (DSM-IV-TR) diagnosis, and there is disagreementabout the existence of the condition. People describe feelingsof anguish and distress with their intact bodies, andETIOLOGYPsychosocial TheoriesPsychosocial theorists believe that people with somatoformdisorders keep stress, anxiety, or frustration insiderather than expressing them outwardly. This is calledinternalization. Clients express these internalized feelingsand stress through physical symptoms (somatization).Both internalization and somatization are unconsciousdefense mechanisms. Clients are not consciouslyaware of the process, and they do not voluntarilycontrol it.People with somatoform disorders do not readily anddirectly express their feelings and emotions verbally. Theyhave tremendous difficulty dealing with interpersonalconflict. When placed in situations involving conflict oremotional stress, their physical symptoms appear toworsen. The worsening of physical symptoms helps themto meet psychologic needs for security, attention, andaffection through primary and secondary gain (Hollifield,2005). Primary gains are the direct external benefits thatbeing sick provides, such as relief of anxiety, conflict, ordistress. Secondary gains are the internal or personal benefitsreceived from others because one is sick, such asattention from family members and comfort measures(e.g., being brought tea, receiving a back rub). The personsoon learns that he or she “needs to be sick” to have theiremotional needs met.Somatization is associated most often with women, asevidenced by the old term hysteria (Greek for “wanderinguterus”). Ancient theorists believed that unexplainedfemale pains resulted from migration of the uterus throughoutthe woman’s body. Psychosocial theorists posit thatincreased incidence of somatization in women may berelated to various factors:• Boys in the United States are taught to be stoic and to“take it like a man,” causing them to offer fewer physicalcomplaints as adults.• Women seek medical treatment more often than men,and it is more socially acceptable for them to do so.• Childhood sexual abuse, which is related to somatization,happens more frequently to girls.• Women more often receive treatment for psychiatricdisorders with strong somatic components such asdepression.

396UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSTable 19.1CULTURE-BOUND SYNDROMESSyndrome Culture CharacteristicsDhat India Hypochondriacal concern about semen lossKoro Southeast Asia Belief that penis is shrinking and will disappear into abdomen,resulting in deathFalling-out episodes Southern United States, Sudden collapse; person cannot see or moveCaribbean islandsHwa-byung Korea Suppressed anger causes insomnia, fatigue, panic, indigestion,and generalized aches and painsPain, numbness, tremors, paralysis, seizures, blindness, heartattack, miscarriageSangue dormido(sleeping blood)Portuguese Cape VerdeIslandsShenjing shuariuo China Physical and mental fatigue, dizziness, headache, pain, sleepdisturbance, memory loss, GI problems, sexual dysfunctionAdapted from Mojtabai, R. (2005). Culture-bound syndromes with psychotic features. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1538–1542). Philadelphia: Lippincott Williams & Wilkins. © American Psychiatric Association. Reprinted with permission.Biologic TheoriesResearch has shown differences in the way that clientswith somatoform disorders regulate and interpret stimuli.These clients cannot sort relevant from irrelevant stimuliand respond equally to both types. In other words, theymay experience a normal body sensation such as peristalsisand attach a pathologic rather than a normal meaningto it (Hollifield, 2005). Too little inhibition of sensoryinput amplifies awareness of physical symptoms and exaggeratesresponse to bodily sensations. For example, minordiscomfort such as muscle tightness becomes amplifiedbecause of the client’s concern and attention to the tightness.This amplified sensory awareness causes the personto experience somatic sensations as more intense, noxious,and disturbing (Andreasen & Black, 2006).Somatization disorder is found in 10% to 20% of femalefirst-degree relatives of people with this disorder. Conversionsymptoms are found more often in relatives of peoplewith conversion disorder. First-degree relatives of thosewith pain disorder are more likely to have depressive disorders,alcohol dependence, and chronic pain (APA, 2000).Cultural ConsiderationsThe type and frequency of somatic symptoms and theirmeaning may vary across cultures. Pseudoneurologicsymptoms of somatization disorder in Africa and SouthAsia include burning hands and feet and the nondelusionalsensation of worms in the head or ants under theskin. Symptoms related to male reproduction are morecommon in some countries or cultures—for example,men in India often have dhat, which is a hypochondriacalconcern about loss of semen. Somatization disorder israre in men in the United States but more common inGreece and Puerto Rico.Many culture-bound syndromes have correspondingsomatic symptoms not explained by a medical condition(Table 19.1). Koro occurs in Southeast Asia and may berelated to body dysmorphic disorder. It is characterizedby the belief that the penis is shrinking and will disappearinto the abdomen, causing the man to die. Fallingoutepisodes, found in the southern United States and theCaribbean islands, are characterized by a sudden collapseduring which the person cannot see or move. Hwa-byungis a Korean folk syndrome attributed to the suppressionof anger and includes insomnia, fatigue, panic, indigestion,and generalized aches and pains. Sangue dormido(sleeping blood) occurs among Portuguese Cape VerdeIslanders who report pain, numbness, tremors, paralysis,seizures, blindness, heart attacks, and miscarriages.Shenjing shuariuo occurs in China and includes physicaland mental fatigue, dizziness, headache, pain, sleep disturbance,memory loss, gastrointestinal problems, andsexual dysfunction (Mojtabai, 2005).TreatmentTreatment focuses on managing symptoms and improvingquality of life. The health care provider must show empathyand sensitivity to the client’s physical complaints. A trustingrelationship helps to ensure that clients stay with and receivecare from one provider instead of “doctor shopping.”For many clients, depression may accompany or resultfrom somatoform disorders (Ferrari, Galeazzi, Mackinnon,& Rigatelli, 2008). Thus, antidepressants help in some cases.Selective serotonin reuptake inhibitors such as fluoxetine(Prozac), sertraline (Zoloft), and paroxetine (Paxil) areused most commonly (Table 19.2).For clients with pain disorder, referral to a chronicpain clinic may be useful. Clients learn methods of pain

CHAPTER 19 • SOMATOFORM DISORDERS 397Table 19.2ANTIDEPRESSANTS USED TO TREAT SOMATOFORM DISORDERSDrug Usual Dose (mg/day) Nursing ConsiderationsFluoxetine (Prozac) 20–60 Monitor for rash, hives, insomnia, headache, anxiety, drowsiness,nausea, loss of appetite; avoid alcoholParoxetine (Paxil) 20–60 Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolenceor insomnia, sweating, sexual dysfunction; avoid alcoholSertraline (Zoloft) 50–200 Monitor for nausea, loss of appetite, diarrhea, headache, insomnia,sexual dysfunction; avoid alcoholmanagement such as visual imaging and relaxation. Servicessuch as physical therapy to maintain and build muscletone help to improve functional abilities. Providersshould avoid prescribing and administering narcotic analgesicsto these clients because of the risk for dependenceor abuse. Clients can use nonsteroidal anti-inflammatoryagents to help reduce pain.Involvement in therapy groups is beneficial for somepeople with somatoform disorders. Studies of clients withsomatization disorder who participated in a structuredcognitive-behavioral group showed evidence of improvedphysical and emotional health 1 year later (Hollifield,2005). The overall goals of the group were offering peersupport, sharing methods of coping, and perceiving andexpressing emotions. Abramowitz and Braddock (2006)found that clients with hypochondriasis who were willingto participate in cognitive-behavioral therapy and takemedications were able to alter their erroneous perceptionsof threat (of illness) and improve. Cognitive-behavioraltherapy also produced significant improvement in clientswith somatization disorder (Allen, Woolfolk, Escobar,Gara, & Hamer, 2006).Nursing Care Plan | HypochondriasisNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inabilityto use available resources.ASSESSMENT DATA• Denial of emotional problems• Difficulty identifying and expressing feelings• Lack of insight• Self-preoccupation, especially with physicalfunctioning• Fears of or rumination on disease• Numerous somatic complaints (may involve manydifferent organs or systems)• Sensory complaints (pain, loss of taste sensation,olfactory complaints)• Reluctance or refusal to participate in psychiatrictreatment program or activities• Reliance on medications or physical treatments(such as laxative dependence)• Extensive use of over-the-counter medications,home remedies, enemas, and so forthEXPECTED OUTCOMESImmediateThe client will• Participate in the treatment program, e.g., talk withstaff for 15 minutes or participate in a groupactivity at least twice a day by a specified date.• Decrease the number and frequency of physicalcomplaints.• Demonstrate compliance with medical therapy andmedications.• Demonstrate adequate energy, food, and fluidintake, e.g., eat at least 50% of each meal by aspecified date.• Identify life stresses and anxieties.• Identify the relationship between stress andphysical symptoms.• Express feelings verbally.(continued)

398UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Hypochondriasis, cont.ASSESSMENT DATA• Ritualistic behaviors (such as exaggerated bowelroutines)• Tremors• Limited gratification from interpersonalrelationships• Lack of emotional support system• Anxiety• Secondary gains received for physical problems• History of repeated visits to physicians or hospitaladmissions• History of repeated medical evaluations with nofindings of abnormalitiesIMPLEMENTATIONNursing Interventions (* denotes collaborativeinterventions)The initial nursing assessment should include a completephysical assessment, a history of previouscomplaints and treatment, and a consideration ofeach current complaint.*The nursing staff should note the medical staff’sassessment of each complaint on the client’sadmission.*Each time the client voices a new complaint, theclient should be referred to the medical staff forassessment (and treatment if appropriate).*Work with the medical staff to limit the number, variety,strength, and frequency of medications, enemas,and so forth that are made available to the client.When the client requests a medication or treatment,encourage the client to identify what precipitatedhis or her complaint and to deal with it in otherways.Observe and record the circumstances related to complaints;talk about your observations with the client.Help the client identify and use nonchemical methodsof pain relief, such as relaxation.EXPECTED OUTCOMES• Identify alternative ways to deal with stress, anxiety,or other feelings, e.g., talking with others, physicalactivity, keeping a journal and so forth.StabilizationThe client will• Decrease ritualistic behaviors.• Decrease physical attention-seeking complaints.• Verbalize increased insight into the dynamics ofhypochondriacal behavior, including secondary gains.• Verbalize an understanding of therapeutic regimensand medications, if any.CommunityThe client will• Eliminate overuse of medications or physicaltreatments.• Demonstrate alternative ways to deal with stress,anxiety, or other feelings.RationaleThe nursing assessment provides a baseline fromwhich to begin planning care.Genuine physical problems must be noted and treated.It is unsafe to assume that all physical complaints arehypochondriacal—the client could really be ill orinjured. The client may attempt to establish thelegitimacy of complaints by being genuinely injuredor ill.A team effort helps to prevent the client’s manipulationof staff members to obtain additionalmedication.If the client can obtain stress relief in a nonchemical,nonmedical way, he or she is less likely to use themedication or treatment.Alerting the client to situations surrounding the complainthelps him or her see the relatedness of stressand physical symptoms.Using nonchemical pain relief shifts the focus of copingaway from medications and increases the client’ssense of control.

CHAPTER 19 • SOMATOFORM DISORDERS 399Nursing Care Plan | Hypochondriasis, cont.Nursing Interventions (* denotes collaborativeinterventions)*Minimize the amount of time and attention given tocomplaints. When the client makes a complaint,refer him or her to the medical staff (if it is a newcomplaint) or follow the team treatment plan; thentell the client you will discuss something else butnot bodily complaints. Tell the client that you areinterested in the client as a person, not just in hisor her physical complaints. If the complaint is notacute, ask the client to discuss the complaint duringa regular appointment with the medical staff.Withdraw your attention if the client insists on makingcomplaints the sole topic of conversation. Tell theclient your reason for withdrawal and that you willreturn later to discuss other topics.Allow the client a specific time limit (like 5 minutesper hour) to discuss physical complaints with oneperson. The remaining staff will discuss only otherissues with the client.Acknowledge the complaint as the client’s perceptionand then follow the previous approaches; do notargue about the somatic complaints.Use minimal objective reassurance in conjunction withquestions to explore the client’s feelings. (“Your testshave shown that you have no lesions. Do you still feelthat you do? What are your feelings about this?”)Initially, carefully assess the client’s self-image, socialpatterns, and ways of dealing with anger, stress, andso forth.Talk with the client about sources of satisfaction anddissatisfaction, relationships, employment, and soforth.After some discussion of the above and developing atrust relationship, talk more directly with the clientand encourage him or her to identify specificstresses, recent and ongoing.If the client is using denial as a defense mechanism,point out apparent or possible stresses (in a nonthreateningway) and ask the client for feedback.Gradually, help the client identify possible connectionsbetween anxiety and the occurrence of physicalsymptoms, such as: What makes the client moreor less comfortable? What is the client doing orwhat is going on around the client when he or sheexperiences symptoms?Encourage the client to discuss his or her feelingsabout the fears rather than the fears themselves.RationaleIf physical complaints are unsuccessful in gainingattention, they should decrease in frequency overtime.It is important to make clear to the client that attentionis withdrawn from physical complaints, not fromthe client as a person.Because physical complaints have been the client’sprimary coping strategy, it is less threatening to theclient if you limit this behavior initially rather thanforbid it. If the client is denied this coping mechanismbefore new skills can be developed, hypochondriacalbehavior may increase.Arguing gives the client’s complaints attention, albeitnegative, and the client is able to avoid discussingfeelings.This approach helps the client make the transition todiscussing feelings.This assessment provides a knowledge base regardinghypochondriacal behaviors.Open-ended discussion usually is nonthreatening andhelps the client begin self-assessment.The client’s perception of stressors forms the basis ofhis or her behavior and usually is more significantthan others’ perception of those stressors.If the client is in denial, more direct approaches mayproduce anger or hostility and threaten the trustrelationship.The client can begin to see the relatedness of stressand physical problems at his or her own pace. Selfrealizationwill be more acceptable to the client thanthe nurse telling the client the problem.The focus is on feelings of fear, not fear of physicalproblems.(continued)

400UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Hypochondriasis, cont.Nursing Interventions (* denotes collaborativeinterventions)Explore the client’s feelings of lack of control overstress and life events.Encourage the client to keep a diary of situations,stresses, and occurrence of symptoms and useit to identify relationships between stresses andsymptoms.Talk with the client at least once per shift, focusing onthe client’s identifying and expressing feelings.Encourage the client to ventilate feelings by talking orcrying, through physical activities, and so forth.Encourage the client to express feelings directly, especiallyfeelings with which the client is uncomfortable(such as anger or resentment).Notice the client’s interactions with others and givepositive feedback for self-assertion and expressingfeelings, especially anger, resentment, and other socallednegative emotions.*Teach the client and his or her family or significantothers about the dynamics of hypochondriacalbehavior and the treatment plan, including plansafter discharge.*Talk with the client and significant others aboutsecondary gains and together develop a plan toreduce those gains. Identify the needs the client isattempting to meet with secondary gains (such asattention or escape from responsibilities).Help the client plan to meet his or her needs in moredirect ways. Show the client that he or she can gainattention when he or she does not exhibit symptoms,deals with responsibilities directly, or assertshimself or herself in the face of stress.Reduce the benefits of illness as much as possible. Donot allow the client to avoid responsibilities or allowspecial privileges, such as staying in bed by voicingsomatic discomfort.Teach the client more healthful daily living habits,including diet, stress management techniques, dailyexercise, rest, possible connection between caffeineand anxiety symptoms, and so forth.RationaleThe client may have helpless feelings but may not recognizethis independently.Reflecting on written items may be more accurate andless threatening to the client.Demonstrating consistent interest in the client facilitatesthe relationship and can desensitize the discussionof emotional issues.The client may have difficulty expressing feelingsdirectly. Your support may help him or her developthese skills.Direct expression of feelings will minimize the need touse physical symptoms to express them.The client needs to know that appropriate expressionsof anger or other negative emotions are acceptableand that he or she can feel better physically as aresult of these expressions.The client and his or her family or significant othersmay have little or no knowledge of these areas.Knowledge of the treatment plan will promote longtermbehavior change.Maintaining limits to reduce secondary gain requireseveryone’s participation to be successful. The client’sfamily and significant others must be aware ofthe client’s needs if they want to be effective in helpingto meet those needs.Positive feedback and support for healthier behaviortend to make that behavior recur more frequently.The client’s family and significant others also mustuse positive reinforcement.If physical problems do not get the client what he orshe wants, the client is less likely to cope in thatmanner.Optimal physical wellness is especially importantwith clients using physical symptoms as a copingstrategy.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.

CHAPTER 19 • SOMATOFORM DISORDERS 401In terms of prognosis, somatoform disorders tend tobe chronic or recurrent. With treatment, conversion disorderoften remits in a few weeks but recurs in 25% ofclients. Somatization disorder, hypochondriasis, and paindisorder often last for many years, and clients report beingin poor health. People with body dysmorphic disordermay be preoccupied with the same or a different perceivedbody flaw throughout their lives (APA, 2000).APPLICATION OF THE NURSING PROCESSThe underlying mechanism of somatization is consistentfor clients with somatoform disorders of all types. Thissection discusses application of the nursing process for clientswith somatization; differences among the disordersare highlighted in the appropriate places.AssessmentThe nurse must investigate physical health statusthoroughly to ensure there is no underlying pathologyrequiring treatment. Box 19.1 contains a useful screeningtest for symptoms of somatization disorder. When a clienthas been diagnosed with a somatoform disorder, it isimportant not to dismiss all future complaints because atany time the client could develop a physical condition thatwould require medical attention.HistoryClients usually provide a lengthy and detailed account ofprevious physical problems, numerous diagnostic tests,and perhaps even a number of surgical procedures. It islikely that they have seen multiple health care providersover several years. Clients may express dismay or anger atthe medical community with comments such as “They justcan’t find out what’s wrong with me” or “They’re all incompetent,and they’re trying to tell me I’m crazy!” The exceptionmay be clients with conversion disorder, who showlittle emotion when describing physical limitations or lackof a medical diagnosis (la belle indifférence).General Appearance and Motor BehaviorOverall appearance usually is not remarkable. Often, clientswalk slowly or with an unusual gait because of thepain or disability caused by the symptoms. They mayexhibit a facial expression of discomfort or physical distress.In many cases, they brighten and look much betteras the assessment interview begins because they have thenurse’s undivided attention. Clients with somatization disorderusually describe their complaints in colorful, exaggeratedterms but often lack specific information.Mood and AffectMood is often labile, shifting from seeming depressed andsad when describing physical problems to looking brightand excited when talking about how they had to go to thehospital in the middle of the night by ambulance. Emotionsare often exaggerated, as are reports of physicalsymptoms. Clients describing a series of personal crisesrelated to their physical health may appear pleased ratherthan distressed about these situations. Clients with conversiondisorder display an unexpected lack of distress.Thought Process and ContentClients who somatize do not experience disorderedthought processes. The content of their thinking is primarilyabout often exaggerated physical concerns; forexample, when they have a simple cold, they may be convincedit is pneumonia. They may even talk about dyingand what music they want played at their funeral.Clients are unlikely to be able to think about or torespond to questions about emotional feelings. They willanswer questions about how they feel in terms of physicalhealth or sensations. For example, the nurse may ask,“How did you feel about having to quit your job?” The clientmight respond, “Well, I thought I’d feel better with theextra rest, but my back pain was just as bad as ever.”Clients with hypochondriasis focus on the fear of seriousillness rather than the existence of illness, as seen inclients with other somatoform disorders. However, theyare just as preoccupied with physical concerns as otherBox 19.1ASSESSMENT QUESTIONS FOR SYMPTOMS IN SCREENING TEST FORSOMATIZATION DISORDER1. Have you ever had trouble breathing?2. Have you ever had trouble with menstrual cramps?3. Have you ever had burning sensations in your sexualorgans, mouth, or rectum?4. Have you ever had difficulties swallowing or had an uncomfortablelump in your throat that stayed for at leastan hour?5. Have you ever found that you could not remember whatyou had been doing for hours or days at a time? If yes,did this happen even though you had not been drinkingor using drugs?6. Have you ever had trouble with frequent vomiting?7. Have you ever had frequent pain in your fingers ortoes?Adapted from Othmer, E., & DeSouza, C. (1983). A screening test for somatization disorder (hysteria). American Journal of Psychiatry, 142(10), 1146–1149.© American Psychiatric Association. Reprinted with permission.

402UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSsomatizing clients and are likewise very limited in theirabilities to identify emotional feelings or interpersonalissues. Clients with hypochondriasis are preoccupied withbodily functions, ruminate about illness, are fascinatedwith medical information, and have unrealistic fears aboutpotential infection and prescription medication.Sensorium and Intellectual ProcessesClients are alert and oriented. Intellectual functions areunimpaired.Judgment and InsightExaggerated responses to their physical health may affectclients’ judgment. They have little or no insight into theirbehavior. They are firmly convinced their problem isentirely physical and often believe that others don’tunderstand.Self-ConceptClients focus only on the physical part of themselves. Theyare unlikely to think about personal characteristics orstrengths and are uncomfortable when asked to do so. Clientswho somatize have low self-esteem and seem to dealwith it by totally focusing on physical concerns. They lackconfidence, have little success in work situations, and havedifficulty managing daily life issues, which they relatesolely to their physical status.Roles and RelationshipsClients are unlikely to be employed, although they mayhave a past work history. They often lose jobs because ofexcessive absenteeism or inability to perform work; clientsmay have quit working voluntarily because of poor physicalhealth. Consumed with seeking medical care, they havedifficulty fulfilling family roles. It is likely that these clientshave few friends and spend little time in social activities.They may decline to see friends or to go out sociallyfor fear that they would become desperately ill away fromhome. Most socialization takes place with members of thehealth care community.Clients may report a lack of family support and understanding.Family members may tire of the ceaseless complaintsand the client’s refusal to accept the absence of amedical diagnosis. The illnesses and physical conditionsoften interfere with planned family events such going onvacations or attending family gatherings. Home life is oftenchaotic and unpredictable.Physiologic and Self-Care ConcernsIn addition to the multitude of physical complaints, theseclients often have legitimate needs in terms of their healthpractices (Box 19.2). Clients who somatize often havesleep pattern disturbances, lack basic nutrition, and get noexercise. In addition, they may be taking multiple prescriptionsfor pain or other complaints. If a client has beenBox 19.2 CLINICAL NURSE ALERTJust because a client has been diagnosed with a somatoformdisorder, do not automatically dismiss all futurecomplaints. He or she should be completely assessed becausethe client could, at any time, develop a physicalcondition requiring medical attention.using anxiolytics or medications for pain, the nurse mustconsider the possibility of withdrawal (see Chapter 17).Data AnalysisNursing diagnoses commonly used when working withclients who somatize include the following:• Ineffective Coping• Ineffective Denial• Impaired Social Interaction• Anxiety• Disturbed Sleep Pattern• Fatigue• PainClients with conversion disorder may be at risk fordisuse syndrome from having pseudoneurologic paralysissymptoms. In other words, if clients do not use a limb fora long time, the muscles may weaken or atrophy from lackof use.Outcome IdentificationTreatment outcomes for clients with a somatoform disordermay include the following:• The client will identify the relationship between stressand physical symptoms.• The client will verbally express emotional feelings.• The client will follow an established daily routine.• The client will demonstrate alternative ways to dealwith stress, anxiety, and other feelings.• The client will demonstrate healthier behaviors regardingrest, activity, and nutritional intake.InterventionProviding Health TeachingThe nurse must help the client learn how to establish adaily routine that includes improved health behaviors.Adequate nutritional intake, improved sleep patterns, anda realistic balance of activity and rest are all areas withwhich the client may need assistance. The nurse should

CHAPTER 19 • SOMATOFORM DISORDERS 403CLIENT/FAMILY EDUCATIONfor Somatoform Disorders• Establish daily health routine, including adequate rest,exercise, and nutrition.• Teach about relationship of stress and physicalsymptoms and mind–body relationship.• Educate about proper nutrition, rest, and exercise.• Educate client in relaxation techniques: progressiverelaxation, deep breathing, guided imagery, anddistraction such as music or other activities.• Educate client by role-playing social situations andinteractions.• Encourage family to provide attention andencouragement when client has fewer complaints.• Encourage family to decrease special attention whenclient is in “sick” role.expect resistance, including protests from the client thatshe or he does not feel well enough to do these things. Thechallenge for the nurse is to validate the client’s feelingswhile encouraging her or him to participate in activities.Nurse: “Let’s take a walk outside for some freshair.” (encouraging collaboration)Client: “I wish I could, but I feel so terrible,I just can’t do it.”Nurse: “I know this is difficult, but some exerciseis essential. It will be a short walk.” (validation; encouragingcollaboration)The nurse can use a similar approach to gain clientparticipation in eating more nutritious foods, getting upand dressed at a certain time every morning, and setting aregular bedtime. The nurse also can explain that inactivityand poor eating habits perpetuate discomfort and thatoften it is necessary to engage in behaviors even when onedoesn’t feel like it.Client: “I just can’t eat anything. I have noappetite.”Nurse: “I know you don’t feel well, but it isimportant to begin eating.” (validation; encouragingcollaboration)Client: “I promise I’ll eat just as soon as I’m hungry.”Nurse: “Actually, if you begin to eat a few bites, you’ll beginto feel better, and your appetite may improve.” (encouragingcollaboration)The nurse should not strip clients of their somatizingdefenses until adequate assessment data are collected andother coping mechanisms are learned. The nurse shouldnot attempt to confront clients about somatic symptomsor attempt to tell them that these symptoms are not “real.”They are very real to clients, who actually experience thesymptoms and associated distress.Assisting the Client to Express EmotionsTeaching about the relationship between stress and physicalsymptoms is a useful way to help clients begin to seethe mind–body relationship. Clients may keep a detailedjournal of their physical symptoms. The nurse might askthem to describe the situation at the time such as whetherthey were alone or with others, whether any disagreementswere occurring, and so forth. The journal may help clientsto see when physical symptoms seemed worse or betterand what other factors may have affected that perception.Limiting the time that clients can focus on physicalcomplaints alone may be necessary. Encouraging them tofocus on emotional feelings is important, although this canbe difficult for clients. The nurse should provide attentionand positive feedback for efforts to identify and discussfeelings.It may help for the nurse to explain to the family aboutprimary and secondary gains. For example, if the family canprovide attention to clients when they are feeling better orfulfilling responsibilities, clients are more likely to continuedoing so. If family members have lavished attention onclients when they have physical complaints, the nurse canencourage the relatives to stop reinforcing the sick role.Teaching Coping StrategiesTwo categories of coping strategies are important for clientsto learn and to practice: emotion-focused copingstrategies, which help clients relax and reduce feelingsof stress, and problem-focused coping strategies, whichhelp to resolve or change a client’s behavior or situation ormanage life stressors. Emotion-focused strategies includeNURSING INTERVENTIONSfor Somatoform Disorders• Health teachingEstablish a daily routine.Promote adequate nutrition and sleep.• Expression of emotional feelingsRecognize relationship between stress/copingand physical symptoms.Keep a journal.Limit time spent on physical complaints.Limit primary and secondary gains.• Coping strategiesEmotion-focused coping strategies such as relaxationtechniques, deep breathing, guided imagery, anddistractionProblem-focused coping strategies such as problemsolvingstrategies and role-playing

404UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSprogressive relaxation, deep breathing, guided imagery,and distractions such as music or other activities. Manyapproaches to stress relief are available for clients to try.The nurse should help clients to learn and practice thesetechniques, emphasizing that their effectiveness usuallyimproves with routine use. Clients must not expect suchtechniques to eliminate their pain or physical symptoms;rather, the focus is helping them to manage or diminishthe intensity of the symptoms.Problem-focused coping strategies include learningproblem-solving methods, applying the process to identifiedproblems, and role-playing interactions with others.For example, a client may complain that no one comes tovisit or that she has no friends. The nurse can help the clientto plan social contact with others, can role-play what to talkabout (other than the client’s complaints), and can improvethe client’s confidence in making relationships. The nursealso can help clients to identify stressful life situations andplan strategies to deal with them. For example, if a clientfinds it difficult to accomplish daily household tasks, thenurse can help him to plan a schedule with difficult tasksfollowed by something the client may enjoy.EvaluationSomatoform disorders are chronic or recurrent, so changesare likely to occur slowly. If treatment is effective, the clientshould make fewer visits to physicians as a result of physicalcomplaints, use less medication and more positive copingtechniques, and increase functional abilities. Improved familyand social relationships are also a positive outcome thatmay follow improvements in the client’s coping abilities.COMMUNITY-BASED CAREHealth care professionals often encounter clients withsomatoform disorders in clinics, physicians’ offices, or settingsother than those related to mental health. Building atrusting relationship with the client, providing empathyand support, and being sensitive to rather than dismissiveof complaints are skills that the nurse can use in any settingwhere clients are seeking assistance. Making appropriatereferrals such as to a pain clinic for clients with paindisorder or providing information about support groups inthe community may be helpful. Encouraging clients tofind pleasurable activities or hobbies may help to meettheir needs for attention and security, thus diminishing thepsychologic needs for somatic symptoms.MENTAL HEALTH PROMOTIONA common theme in somatoform disorders is their occurrencein people who do not express conflicts, stress, andemotions verbally. They express themselves through physicalsymptoms; the resulting attention and focus on theirphysical ailments somewhat meet their needs. As theseclients are better able to express their emotions and needsdirectly, physical symptoms subside. Thus, assisting themto deal with emotional issues directly is a strategy for mentalhealth promotion.Somatoform disorders have declined over the past fewdecades, in part due to increased knowledge of the public,increasing self-awareness or self-knowledge, and scientificevidence of mind–body interaction. Some would credit theInternet with putting unlimited resources at people’s fingertips,and knowledge often precedes understanding andbehavior change. Interestingly, there are others that creditthe Internet accessibility with feeding some peoples’ fearsabout their health—called cyberchondria (Harding, Skritskaya,Doherty, & Fallon, 2008).SELF-AWARENESS ISSUESClients who cope through physical symptomscan be frustrating for the nurse. Initially, theyare unwilling to consider that anything otherthan major physical illness is the root of alltheir problems. When health professionals tell clientsthere is no physical illness and refer them to mental healthprofessionals, the response often is anger: Clients mayexpress anger directly or passively at the medical communityand be highly critical of the inadequate care theybelieve they have received. The nurse must not respondwith anger to such outbursts or criticism.The client’s progress is slow and painstaking, if anychange happens at all. Clients coping with somatizationhave been doing so for years. Changes are not rapid ordrastic. The nurse may feel frustrated because, after givingthe client his or her best efforts, the client returns timeafter time with the same focus on physical symptoms. Thenurse should be realistic about the small successes thatcan be achieved in any given period. To enhance the ongoingrelationship, the nurse must be able to accept the clientand his or her continued complaints and criticismswhile remaining nonjudgmental.Points to Consider When Working withClients with Somatoform Disorders• Carefully assess the client’s physical complaints. Evenwhen a client has a history of a somatoform disorder,the nurse must not dismiss physical complaints or assumethey are psychologic. The client actually mayhave a medical condition.• Validate the client’s feelings while trying to engage himor her in treatment; for example, use a reflective yetengaging comment such as “I know you’re not feelingwell, but it is important to get some exercise each day.”• Remember that the somatic complaints are not underthe client’s voluntary control. The client will have fewersomatic complaints when he or she improves copingskills and interpersonal relationships.

CHAPTER 19 • SOMATOFORM DISORDERS 405Critical Thinking Questions1. When a client has somatoform pain disorder, powerfulanalgesics such as narcotics are generally contraindicated,even though the client is sufferingunremitting pain. How might the nurse feel whenworking with this client? How does the nurse respondwhen the client says, “You know I’m in pain!Why won’t you do anything? Why do you let mesuffer?”2. Should a person who requests repeated cosmeticsurgical procedures continue to have surgery? Shouldthere be limits? What should those limits be? Whoshould decide?3. A mother is found to have caused a medical crisis bygiving her 6-year-old child a medication to whichthe child has a known severe allergy. The motheris diagnosed as having Munchausen syndrome byproxy. Should she be treated in the mental healthsetting? Charged with a criminal act? Why?KEY POINTS• Somatization means transforming mental experiencesand states into bodily symptoms.• The three central features of somatoformdisorders are physical complaints that suggestmajor medical illness but have no demonstrableorganic basis; psychologic factors and conflicts that seemimportant in initiating, exacerbating, and maintaining thesymptoms; and symptoms or magnified health concernsthat are not under the client’s conscious control.• Somatoform disorders include somatization disorder, conversiondisorder, hypochondriasis, pain disorder, and bodydysmorphic disorder.• Malingering means feigning physical symptoms forsome external gain such as avoiding work.• Factitious disorders are characterized by physical symptomsthat are feigned or inflicted for the sole purpose ofdrawing attention to oneself and gaining the emotionalbenefits of assuming the sick role.• Internalization and somatization are the chief defensemechanisms seen in somatoform disorders.• Clients with somatization disorder and conversion reactionseventually may be treated in mental health settings.Clients with other somatoform disorders typicallyare seen in medical settings.• Clients who cope with stress through somatizing are reluctantor unable to identify emotional feelings and interpersonalissues and have few coping abilities unrelatedto physical symptoms.• Nursing interventions that may be effective with clientswho somatize involve providing health teaching, identifyingemotional feelings and stress, and using alternativecoping strategies.• Coping strategies that are helpful to clients with somatoformdisorders include relaxation techniques such asguided imagery and deep breathing, distractions such asmusic, and problem-solving strategies such as identifyingstressful situations, learning new methods of managingthem, and role-playing social interactions.• Clients with somatization disorder actually experiencesymptoms and the associated discomfort and pain. Thenurse should never try to confront the client about theorigin of these symptoms until the client has learnedother coping strategies.• Somatoform disorders are chronic or recurrent, soprogress toward treatment outcomes can be slow anddifficult.• Nurses caring for clients with somatoform disordersmust show patience and understanding toward themas they struggle through years of recurrent somaticcomplaints and attempts to learn new emotion- andproblem-focused coping strategies.INTERNET RESOURCESRESOURCE• American Psychosomatic Society• Body Dysmorphic Disorder• Conversion Disorder• Munchausen Syndrome by Proxy Resources• HypochondriasisINTERNET ADDRESShttp://www.psychosomatic.orghttp://www.mayoclinic.com/health/body-dysmorphicdisorder/D500559http://www.mayoclinic.com/health/conversion-disorder/D500877http://www.vachss.com/help_text/msp.htmlhttp://my.clevelandclinic.org/disorders/Hypochondriasis/hic_Hypochondriasis.aspx

406UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSREFERENCESAbramowitz, J. S., & Braddock, A. E. (2006). Hypochondriasis:Conceptualization, treatment, and relationship to obsessive-compulsivedisorder. Psychiatric Clinics of North America, 29(2), 503–519.Allen, L. A., Woolfolk, R. L., Escobar, J. I., Gara, M. A., & Hamer, R. M.(2006). Cognitive-behavioral therapy for somatization disorder: Arandomized controlled trial. Archives of Internal Medicine, 166(14),1512–1518.American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Andreasen, N. C., & Black, D. W. (2006). Introductory textbook ofpsychiatry (2nd ed.). Washington, DC: American PsychiatricPublishing.Ferrari, S., Galeazzi, G. M., Mackinnon, A., & Rigatelli, M. (2008).Frequent attenders in primary care: Impact of medical, psychiatric,and psychosomatic disorders. Psychotherapy and Psychosomatics,77(5), 306–314.Harding, K. J., Skritskaya, N., Doherty, E., & Fallon, B. A. (2008).Advances in understanding illness anxiety. Current Psychiatry Reports,10(4), 311–317.Hollifield, M. A. (2005). Somatoform disorders. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1., 8th ed.,pp. 1800–1828). Philadelphia: Lippincott Williams & Wilkins.Mackenzie, R. (2008). Somatechnics of medico-legal taxonomies:Elective amputation and transableism. Medical Law Review, 16(3),390–412.Mojtabai, R. (2005). Culture-bound syndromes with psychotic features.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 1538–1541). Philadelphia: LippincottWilliams & Wilkins.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Stirling, J., Jr. (2007). Beyond Munchausen syndrome by proxy:Identification and treatment of child abuse in a medical setting.Pediatrics, 119(5), 1026–1030.Wang, D., Nadiga, D. N., & Jenson, J. J. (2005). Factitious disorders. InB. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1829–1843). Philadelphia: LippincottWilliams & Wilkins.Additional ReadingsMattila, A. K., Kronholm, E., Jula, A., Salminen, J. K., Koivisto, A. M., &Mielonen, R. L., et al. (2008). Alexithymia and somatization in generalpopulation. Psychosomatic Medicine, 70(6), 712–722.Noyes, R., Jr., Stuart, S. P., & Watson, D. B. (2008). A reconceptualizationof the somatoform disorders. Psychosomatics, 49(1), 14–22.Shaw, R. J., Dayal, S., Hartman, J. K., & DeMaso, D. R. (2008). Factitiousdisorder by proxy: Pediatric condition falsification. Harvard Review ofPsychiatry, 16(4), 215–224.Wick, J. Y., & Zanni, G. R. (2008). Hypochondria: The worried well. TheConsultant Pharmacist, 23(3), 192–194, 196–198, 207–208.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The nurse is caring for a client with a conversion disorder.Which of the following assessments will the nurseexpect to see?a. Extreme distress over the physical symptomb. Indifference about the physical symptomc. Labile moodd. Multiple physical complaints2. Which of the following statements would indicatethat teaching about somatization disorder has beeneffective?a. “The doctor believes I am faking my symptoms.”b. “If I try harder to control my symptoms, I will feelbetter.”c. “I will feel better when I begin handling stress moreeffectively.”d. “Nothing will help me feel better physically.”3. Paroxetine (Paxil) has been prescribed for a client witha somatoform disorder. The nurse instructs the client towatch for which of the following side effects?a. Constipationb. Increased appetitec. Increased flatulenced. Nausea4. Emotion-focused coping strategies are designed to accomplishwhich of the following outcomes?a. Helping the client manage difficult situations moreeffectivelyb. Helping the client manage the intensity ofsymptomsc. Teaching the client the relationship between stressand physical symptomsd. Relieving the client’s physical symptoms5. Which of the following is true about clients withhypochondriasis?a. They may interpret normal body sensations as signsof disease.b. They often exaggerate or fabricate physical symptomsfor attention.c. They do not show signs of distress about their physicalsymptoms.d. All the above are true statements.6. The client’s family asks the nurse, “What is hypochondriasis?”The best response by the nurse is, “Hypochondriasisisa. A persistent preoccupation with getting a seriousdisease.”b. An illness not fully explained by a diagnosed medicalcondition.”c. Characterized by a variety of symptoms over a numberof years.”d. The eventual result of excessive worrying aboutdiseases.”7. A client with somatization disorder has been attendinggroup therapy. Which of the following statements indicatesthat therapy is having a positive outcome for thisclient?a. “I feel better physically just from getting a chance totalk.”b. “I haven’t said much, but I get a lot from listening toothers.”c. “I shouldn’t complain too much; my problems aren’tas bad as others.”d. “The other people in this group have emotionalproblems.”8. A client who developed numbness in the right handcould not play the piano at a scheduled recital. Theconsequence of the symptom, not having to perform, isbest described asa. Emotion-focused copingb. Phobiac. Primary gaind. Secondary gain407

408 UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. When planning care for a client with somatization disorder,the nurse would include the following interventions:a. Confront the client with negative results from diagnostictesting.b. Encourage the client to participate in daily routineactivities.c. Help the client see the relationship between physicalsymptoms and life stress/events.d. Provide additional 1:1 attention when the client discussesphysical symptoms.e. Refuse to discuss or listen to any physical complaintsthe client may express.f. Validate the client’s physical and emotional distress.2. The nurse understands that secondary gain for the clientwith a somatoform disorder can include:a. Acceptable absence from workb. Freedom from daily choresc. Increased attention from familyd. Provision of care by otherse. Resolution of family conflictf. Temporary relief of anxietyCLINICAL EXAMPLEMary Jones, 34 years old, was referred to a chronic pain clinic with a diagnosis of pain disorder.She has been unable to work for 7 months because of back pain. Mary has seen severaldoctors, has had magnetic resonance imaging (MRI), and has tried various antiinflammatorymedications. She tells the nurse that she is at the clinic as a last resortbecause none of her doctors will “do anything” for her. Mary’s gait is slow, her posture isstiff, and she grimaces frequently while trying to sit in a chair. She reports being unable todrive a car, play with her children, do housework, or enjoy any of her previous leisureactivities.1. Identify three nursing diagnoses that would be pertinent for Mary’s plan of care.2. Identify two expected outcomes for Mary’s plan of care.3. Describe five interventions that the nurse might implement to achieve the outcomes.

CHAPTER 19 • SOMATOFORM DISORDERS4094. What other disciplines might make a contribution to Mary’s care at the clinic?5. Identify any community referrals the nurse might make for Mary.

20Child and AdolescentDisordersLearning ObjectivesAfter reading this chapter, you should be able toKey Terms• attention deficit hyperactivitydisorder (ADHD)• autistic disorder• conduct disorder• encopresis• enuresis• limit setting• pervasive developmentaldisorders• pica• stereotypic movements• therapeutic play• tic• time-out• Tourette’s disorder4101. Discuss the characteristics, risk factors, and family dynamics of psychiatricdisorders of childhood and adolescence.2. Apply the nursing process to the care of children and adolescents with psychiatricdisorders and their families.3. Provide education to clients, families, teachers, caregivers, and communitymembers for young clients with psychiatric disorders.4. Discuss the nurse’s role as an advocate for children and adolescents.5. Evaluate your feelings, beliefs, and attitudes about clients with psychiatricdisorders and their parents and caregivers.PSYCHIATRIC DISORDERS ARE not diagnosed as easily in children as they arein adults. Children usually lack the abstract cognitive abilities and verbalskills to describe what is happening. Because they are constantly changingand developing, children have limited sense of a stable, normal self toallow them to discriminate unusual or unwanted symptoms from normalfeelings and sensations. Additionally, behaviors that are normal in a childof one age may indicate problems in a child of another age. For example,an infant who cries and wails when separated from his or her mother isnormal. If the same child at 5 years of age cries and shows extreme anxietywhen separated only briefly from the mother, however, this behavior wouldwarrant investigation.Children and adolescents experience some of the same mental healthproblems as adults, such as mood and anxiety disorders, and are diagnosedwith these disorders using the same criteria as for adults. Eating disorders,especially anorexia, usually begin in adolescence and continue into adulthood.Mood, anxiety, and eating disorders are discussed in separate chaptersof this book.This chapter focuses on those psychiatric disorders usually first diagnosedin infancy, childhood, or adolescence (Box 20.1); many of these canpersist into adulthood. The childhood psychiatric disorders, most commonin mental health settings and specialized treatment units, include pervasivedevelopmental disorders, attention deficit hyperactivity disorderVisit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 411Box 20.1 DISORDERS FIRST DIAGNOSED IN INFANCY, CHILDHOOD, AND ADOLESCENCEMENTAL RETARDATION• Mild• Moderate• Severe• ProfoundATTENTION-DEFICIT AND DISRUPTIVE BEHAVIORDISORDERS• Attention deficit hyperactivity disorder• Conduct disorder• Oppositional defiant disorderLEARNING DISORDERS• Reading disorder• Mathematics disorder• Disorder of written expressionFEEDING AND EATING DISORDERS• Pica• Rumination disorder• Feeding disorder of infancy or early childhoodMOTOR SKILLS DISORDER• Developmental coordination disorderCOMMUNICATION DISORDERS• Expressive language disorder• Mixed receptive and expressive language disorder• Phonologic disorder• StutteringTIC DISORDERS• Tourette’s disorder• Chronic motor or tic disorder• Transient tic disorderELIMINATION DISORDERS• Encopresis• EnuresisPERVASIVE DEVELOPMENTAL DISORDERS• Autistic disorder• Rett’s disorder• Childhood disintegrative disorder• Asperger’s disorderOTHER DISORDERS OF INFANCY, CHILDHOOD,OR ADOLESCENCE• Separation anxiety disorder• Selective mutism• Reactive attachment disorder• Stereotypic movement disorderEach category except feeding and eating disorders has an additional diagnosis “Not Otherwise Specified” (NOS) for similar problems that do not meet the criteriafor other diagnoses in the category (DSM-IV-TR, 2000). Adapted from DSM-IV-TR (2000).(ADHD), and disruptive behavior disorders. For this reason,the chapter presents an in-depth discussion of ADHDand conduct disorder (the most prevalent disruptivebehavior disorder) with appropriate nursing diagnosesand interventions as well as sample nursing care plans. Itdiscusses less common disorders briefly; generally, most ofthese disorders are not treated in inpatient psychiatricunits unless they coexist with other disorders.MENTAL RETARDATIONThe essential feature of mental retardation is below-averageintellectual functioning (intelligence quotient [IQ] lessthan 70) accompanied by significant limitations in areas ofadaptive functioning such as communication skills,self-care, home living, social or interpersonal skills, use ofcommunity resources, self-direction, academic skills,work, leisure, and health and safety (King, Hodapp, &Dykens, 2005). The degree of retardation is based on IQand greatly affects the person’s ability to function:• Mild retardation: IQ 50 to 70• Moderate retardation: IQ 35 to 50• Severe retardation: IQ 20 to 35• Profound retardation: IQ less than 20Causes of mental retardation include hereditary conditionssuch as Tay–Sachs disease or fragile X chromosomesyndrome; early alterations in embryonic development,such as trisomy 21 or maternal alcohol intake, that cause

412UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSfetal alcohol syndrome; pregnancy or perinatal problemssuch as fetal malnutrition, hypoxia, infections, and trauma;medical conditions of infancy such as infection or leadpoisoning; and environmental influences such as deprivationof nurturing or stimulation.Some people with mental retardation are passive anddependent; others are aggressive and impulsive. Childrenwith mild-to-moderate mental retardation usually receivetreatment in their homes and communities and make periodicvisits to physicians. Those with severe or profoundmental retardation may require residential placement orday care services.LEARNING DISORDERSA learning disorder is diagnosed when a child’s achievementin reading, mathematics, or written expression isbelow that expected for age, formal education, and intelligence.Learning problems interfere with academicachievement and life activities requiring reading, math, orwriting (American Psychiatric Association [APA], 2000).Reading and written expression disorders usually are identifiedin the first grade; math disorder may go undetecteduntil the child reaches fifth grade. Approximately 5% ofchildren in U.S. public schools are diagnosed with a learningdisorder. The school dropout rate for students withlearning disorders is 1.5 times higher than the average ratefor all students (APA, 2000).Low self-esteem and poor social skills are common inchildren with learning disorders. As adults, some have problemswith employment or social adjustment; others haveminimal difficulties. Early identification of the learning disorder,effective intervention, and no coexisting problems isassociated with better outcomes. Children with learningdisorders are assisted with academic achievement throughspecial education classes in public schools.MOTOR SKILLS DISORDERThe essential feature of developmental coordination disorderis impaired coordination severe enough to interfere withacademic achievement or activities of daily living (APA,2000). This diagnosis is not made if the problem withmotor coordination is part of a general medical conditionsuch as cerebral palsy or muscular dystrophy. This disorderbecomes evident as a child attempts to crawl or walkor as an older child tries to dress independently or manipulatetoys such as building blocks. Developmental coordinationdisorder often coexists with a communicationdisorder. Its course is variable; sometimes lack of coordinationpersists into adulthood (APA, 2000). Schools provideadaptive physical education and sensory integrationprograms to treat motor skills disorder. Adaptive physicaleducation programs emphasize inclusion of movementgames such as kicking a football or soccer ball. Sensoryintegration programs are specific physical therapies prescribedto target improvement in areas where the child hasdifficulties. For example, a child with tactile defensiveness(discomfort at being touched by another person) might beinvolved in touching and rubbing skin surfaces (Pataki &Spence, 2005).COMMUNICATION DISORDERSA communication disorder is diagnosed when a communicationdeficit is severe enough to hinder development,academic achievement, or activities of daily living, includingsocialization. Expressive language disorder involves animpaired ability to communicate through verbal and signlanguages. The child has difficulty learning new wordsand speaking in complete and correct sentences; his or herspeech is limited. Mixed receptive-expressive language disorderincludes the problems of expressive language disorderalong with difficulty understanding (receiving) and determiningthe meaning of words and sentences. Both disorderscan be present at birth (developmental) or may beacquired as a result of neurologic injury or insult to thebrain. Phonologic disorder involves problems with articulation(forming sounds that are part of speech). Stuttering isa disturbance of the normal fluency and time patterning ofspeech. Phonologic disorder and stuttering run in familiesand occur more frequently in boys than in girls.Communication disorders may be mild to severe. Difficultiesthat persist into adulthood are related most closelyto the severity of the disorder. Speech and language therapistswork with children who have communication disordersto improve their communication skills and to teachparents to continue speech therapy activities at home( Johnson & Beitchman, 2005).PERVASIVE DEVELOPMENTALDISORDERSPervasive developmental disorders are characterized bypervasive and usually severe impairment of reciprocalsocial interaction skills, communication deviance, andrestricted stereotypical behavioral patterns (Volkmar, Klin,& Schultz, 2005). This category of disorders is also calledautism spectrum disorders and includes autistic disorder(classic autism), Rett’s disorder, childhood disintegrativedisorder, and Asperger’s disorder. Approximately 75% ofchildren with pervasive developmental disorders havemental retardation (APA, 2000).AUTISTIC DISORDERAutistic disorder, the best known of the pervasive developmentaldisorders, is more prevalent in boys than in girls,and it is identified usually by 18 months and no later than

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 4133 years of age. Children with autism display little eyecontact with and make few facial expressions toward others;they use limited gestures to communicate. They havelimited capacity to relate to peers or parents. They lackspontaneous enjoyment, express no moods or emotionalaffect, and cannot engage in play or make-believe withtoys. There is little intelligible speech. These childrenengage in stereotyped motor behaviors such as hand flapping,body twisting, or head banging.Eighty percent of cases of autism are early onset, withdevelopmental delays starting in infancy. The other 20%of children with autism have seemingly normal growthand development until 2 or 3 years of age, when developmentalregression or loss of abilities begins. Theystop talking and relating to parents and peers and beginto demonstrate the behaviors described earlier ( Volkmaret al., 2005).Autism was once thought to be rare and was estimatedto occur in 4 to 5 children per 10,000 in the 1960s. Currentestimates suggest that 1 in 1,000 to 1 in 500 U.S. childrenfrom 1 to 15 years of age have autism (National Institute ofChild Health and Human Development, 2006). Figures onthe prevalence of autism in adults are unreliable.Autism does have a genetic link; many children withautism have a relative with autism or autistic traits.Controversy continues about whether measles, mumps,and rubella (MMR) vaccinations contribute to the developmentof late-onset autism. The National Institute ofChild Health and Human Development, Centers forDisease control (CDC), and the Academy of Pediatricshave all conducted research studies for several yearsand have concluded that there is no relationship betweenvaccines and autism and that the MMR vaccine is safe.However, litigation and class action suits are still inprogress. The first decision from a panel of grand masterswas issued in February, 2009, regarding three testcases. The masters ruled that sufficient evidence hadnot been presented to prove vaccines had caused autism.National groups called for more investigation andresearch to find the cause(s) of autism (Cable NewsNetwork [CNN], 2009).Autism tends to improve, in some cases substantially,as children start to acquire and use language to communicatewith others. If behavior deteriorates in adolescence,it may reflect the effects of hormonal changes or the difficultymeeting increasingly complex social demands.Autistic traits persist into adulthood, and most peoplewith autism remain dependent to some degree on others.Manifestations vary from little speech and poor daily livingskills throughout life to adequate social skills thatallow relatively independent functioning. Social skillsrarely improve enough to permit marriage and child rearing.Adults with autism may be viewed as merely odd orreclusive, or they may be given a diagnosis of obsessive–compulsive disorder, schizoid personality disorder, ormental retardation.Until the mid-1970s, children with autism usually weretreated in segregated, specialty outpatient, or school programs.Those with more severe behaviors were referred toresidential programs. Since then, most residential programshave been closed; children with autism are being“mainstreamed” into local school programs whenever possible.Short-term inpatient treatment is used when behaviorssuch as head banging or tantrums are out of control.When the crisis is over, community agencies support thechild and family.The goals of treatment of children with autism are toreduce behavioral symptoms (e.g., stereotyped motor behaviors)and to promote learning and development, particularlythe acquisition of language skills. Comprehensive and individualizedtreatment, including special education and languagetherapy, is associated with more favorable outcomes(Myers & Johnson, 2007). Pharmacologic treatment withantipsychotics, such as haloperidol (Haldol) or risperidone(Risperdal), may be effective for specific target symptomssuch as temper tantrums, aggressiveness, self-injury, hyperactivity,and stereotyped behaviors. Other medications, suchas naltrexone (ReVia), clomipramine (Anafranil), clonidine(Catapres), and stimulants to diminish self-injury and hyperactiveand obsessive behaviors, have had varied but unremarkableresults (Volkmar et al., 2005).Rett’s DisorderRett’s disorder is a pervasive developmental disorder characterizedby the development of multiple deficits after aperiod of normal functioning. It occurs exclusively in girls,is rare, and persists throughout life. Rett’s disorder developsbetween birth and 5 months of age. The child losesmotor skills and begins showing stereotyped movementsinstead. She loses interest in the social environment, andsevere impairment of expressive and receptive languagebecomes evident as she grows older. Treatment is similarto that of autism.Childhood Disintegrative DisorderChildhood disintegrative disorder is characterized by markedregression in multiple areas of functioning after at least2 years of apparently normal growth and development(APA, 2000). Typical age at onset is between 3 and 4 years.Children with childhood disintegrative disorder have thesame social and communication deficits and behavioralpatterns seen with autistic disorder. This rare disorderoccurs slightly more often in boys than in girls.Asperger’s DisorderAsperger’s disorder is a pervasive developmental disordercharacterized by the same impairments of social interactionand restricted stereotyped behaviors seen in autisticdisorder, but there are no language or cognitive delays.This rare disorder occurs more often in boys than in girls,and the effects are generally lifelong.

414UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSATTENTION DEFICIT AND DISRUPTIVEBEHAVIOR DISORDERSATTENTION DEFICIT HYPERACTIVITYDISORDERAttention deficit hyperactivity disorder (ADHD) is characterizedby inattentiveness, overactivity, and impulsiveness.ADHD is a common disorder, especially in boys, andprobably accounts for more child mental health referralsthan any other single disorder (Hechtman, 2005). Theessential feature of ADHD is a persistent pattern of inattentionand/or hyperactivity and impulsivity more commonthan generally observed in children of the same age.ADHD affects an estimated 3% to 5% of all school-agedchildren. The ratio of boys to girls ranges from 3:1 in nonclinicalsettings to 9:1 in clinical settings (Hechtman,2005). To avoid overdiagnosis of ADHD, a qualified specialistsuch as a pediatric neurologist or a child psychiatristmust conduct the evaluation for ADHD. Childrenwho are very active or hard to handle in the classroom canbe diagnosed and treated mistakenly for ADHD. Some ofthese overly active children may suffer from psychosocialstressors at home, inadequate parenting, or other psychiatricAttention deficitCLINICAL VIGNETTE: ATTENTION DEFICIT HYPERACTIVITY DISORDERScott is 8 years old. At 7 AM, his mother looks into Scott’sbedroom and sees Scott playing. “Scott, you know the rules:no playing before you are ready for school. Get dressed andcome eat breakfast.” Although these rules for a school dayhave been set for the past 7 months, Scott always teststhem. In about 10 minutes, he is still not in the kitchen. Hismother checks his room and finds Scott on the floor, still inhis pajamas, playing with miniature cars. Once he getsstarted doing or talking about something, it is often difficultfor Scott to stop.“Scott, you need to get dressed first. Your jeans and shirtare over here on the chair.” “Mom, after school today, canwe go shopping? There is the coolest new car game thatanyone can play. I’d love to try it out.” As he is talking, Scottwalks over to the chair and begins to pull his shirt over hishead. “Scott, you’re putting your shirt over your pajamas.You need to take your pajamas off first,” his mother remindshim.Ten minutes later, Scott bounds into the kitchen, stillwithout socks and shoes, and hair tousled. “You forgot yoursocks, and your hair isn’t combed,” his mother reminds him.“Oh yeah. What’s for breakfast?” he says. “Scott, finishdressing first.” “Well, where are my shoes?” “By the backdoor where you left them.” This is the special designatedplace where Scott is supposed to leave his shoes so hedoesn’t forget.Scott starts toward his shoes but spots his younger sisterplaying with blocks on the floor. He hurries to her. “Wow,Amy, watch this—I can make these blocks into a huge tower,all the way to the ceiling.” He grabs the blocks and begins tostack them higher and higher. “Scott makes a better towerthan Amy,” he chants. Amy shrieks at this intrusion, but sheis used to Scott grabbing things from her. The shriek bringstheir mother into the room. She notices Scott’s feet still donot have socks and shoes.“Scott, get your socks and shoes on now and leave Amyalone!” “Where are my socks?” he asks. “Go to your roomand get a clean pair of socks and brush your teeth and hair.Then come eat your breakfast or you’ll miss the bus.”“I will in just a minute, Mom.” “No! Now! Go get yoursocks.” Scott continues stacking blocks.Wearily, his mother directs him toward his room. As he islooking for the socks, he is still chattering away. He finds a pairof socks and bolts in the direction of the kitchen, grabbingAmy and pinching her cheek as he swirls by her. Amy shrieksagain and he begins to chant, “Amy’s just a baby! Amy’s justa baby!” “Scott, stop it right now and come eat something!You’ve got just 10 minutes until the bus comes.”

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 415disorders. Distinguishing bipolar disorder from ADHD canbe difficult but is crucial in order to prescribe the mosteffective treatment (Hojman, 2008).Onset and Clinical CourseADHD usually is identified and diagnosed when the childbegins preschool or school, although many parents reportproblems from a much younger age. As infants, childrenwith ADHD are often fussy and temperamental and havepoor sleeping patterns. Toddlers may be described as“always on the go” and “into everything,” at times dismantlingtoys and cribs. They dart back and forth, jump andclimb on furniture, run through the house, and cannot toleratesedentary activities such as listening to stories. Atthis point in a child’s development, it can be difficult forparents to distinguish normal active behavior from excessivehyperactive behavior.By the time the child starts school, symptoms of ADHDbegin to interfere significantly with behavior and performance(Dang, Warrington, Tung, Baker, & Pan, 2007).The child fidgets constantly, is in and out of assigned seats,and makes excessive noise by tapping or playing with pencilsor other objects. Normal environmental noises, suchas someone coughing, distract the child. He or she cannotlisten to directions or complete tasks. The child interruptsand blurts out answers before questions are completed.DSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of ADHDInattentive BehaviorsMisses detailsMakes careless mistakesHas difficulty sustainingattentionDoesn’t seem to listenDoes not follow throughon chores or homeworkHas difficulty withorganizationAvoids tasks requiringmental effortOften loses necessarythingsIs easily distracted byother stimuliIs often forgetful in dailyactivitiesHyperactive/ImpulsiveBehaviorsFidgetsOften leaves seat (e.g.,during a meal)Runs or climbs excessivelyCan’t play quietlyIs always on the go; drivenTalks excessivelyBlurts out answersInterruptsCan’t wait for turnIs intrusive with siblings/playmatesAdapted from American Psychiatric Association. (2000). DSM-IV-TR.Academic performance suffers because the child makeshurried, careless mistakes in schoolwork, often loses orforgets homework assignments, and fails to followdirections.Socially, peers may ostracize or even ridicule the childfor his or her behavior. Forming positive peer relationshipsis difficult because the child cannot play cooperativelyor take turns and constantly interrupts others (APA,2000). Studies have shown that both teachers and peersperceive children with ADHD as more aggressive, morebossy, and less likable (Hechtman, 2005). This perceptionresults from the child’s impulsivity, inability to share ortake turns, tendency to interrupt, and failure to listen toand follow directions. Thus, peers and teachers mayexclude the child from activities and play, may refuse tosocialize with the child, or may respond to the child in aharsh, punitive, or rejecting manner.Approximately two thirds of children diagnosed withADHD continue to have problems in adolescence. Typicalimpulsive behaviors include cutting class, getting speedingtickets, failing to maintain interpersonal relationships,and adopting risk-taking behaviors, such as using drugs oralcohol, engaging in sexual promiscuity, fighting, and violatingcurfew. Many adolescents with ADHD have disciplineproblems serious enough to warrant suspension orexpulsion from high school (Hechtman, 2005). The secondarycomplications of ADHD, such as low self-esteemand peer rejection, continue to pose serious problems.Previously, it was believed that children outgrew ADHD,but it is now known that ADHD can persist into adulthood.Estimates are that 30% to 50% of children with ADHD havesymptoms that continue into adulthood. In one study,adults who had been treated for hyperactivity 25 years earlierwere three to four times more likely than their brothersto experience nervousness, restlessness, depression, lack offriends, and low frustration tolerance. Approximately 70%to 75% of adults with ADHD have at least one coexistingpsychiatric diagnosis, with social phobia, bipolar disorder,major depression, and alcohol dependence being the mostcommon (Antai-Otong, 2008). Box 20.2 contains a screeningquestionnaire for ADHD in adults.EtiologyAlthough much research has taken place, the definitivecauses of ADHD remain unknown. There may be corticalarousal,information-processing, or maturational abnormalitiesin the brain (Rowe & Hermens, 2006). Combinedfactors, such as environmental toxins, prenatal influences,heredity, and damage to brain structure and functions, arelikely responsible (Hechtman, 2005). Prenatal exposureto alcohol, tobacco, and lead and severe malnutrition inearly childhood increase the likelihood of ADHD.Although the relation between ADHD and dietary sugarand vitamins has been studied, results have been inconclusive( Hechtman, 2005).

416UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 20.2Brain images of people with ADHD suggest decreasedmetabolism in the frontal lobes, which are essential forattention, impulse control, organization, and sustainedgoal-directed activity. Studies also have shown decreasedblood perfusion of the frontal cortex in children withADHD and frontal cortical atrophy in young adults with ahistory of childhood ADHD. Another study showeddecreased glucose use in the frontal lobes of parentsof children with ADHD who had ADHD themselves( Hechtman, 2005). Evidence is not conclusive, butresearch in these areas seems promising.There seems to be a genetic link for ADHD that is mostlikely associated with abnormalities in catecholamine andpossibly serotonin metabolism. Having a first-degree relativewith ADHD increases the risk of the disorder by fourto five times more than that of the general population(Hechtman, 2005). Despite the strong evidence supportinga genetic contribution, there are also sporadic cases ofADHD with no family history of ADHD; this furthers thetheory of multiple contributing factors.Risk factors for ADHD include family history of ADHD;male relatives with antisocial personality disorder or alcoholism;female relatives with somatization disorder; lowersocioeconomic status; male gender; marital or family discord,including divorce, neglect, abuse, or parental deprivation;low birth weight; and various kinds of brain insult(Hechtman, 2005).Cultural ConsiderationsADULT ADHD SCREENINGQUESTIONS• How often do you have trouble wrapping up the finaldetails of a project once the challenging parts havebeen done?• How often do you have difficulty getting things inorder when you have to do a task that requiresorganization?• How often do you have problems rememberingappointments or obligations?• When you have a task that requires a lot of thought,how often do you avoid or delay getting started?• How often do you fidget or squirm with your handsor feet when you have to sit down for a long time?• How often do you feel overly active and compelled todo things, like you were driven by a motor?Adapted from World Health Organization. (2003). World HealthOrganization Composite Diagnostic Interview.ADHD is known to occur in various cultures. It is moreprevalent in Western cultures, but that may be the result ofdifferent diagnostic practices rather than the actual differencesin existence (APA, 2000).The Child Behavior Checklist, Teacher Report Form,and Youth Self Report (for ages 11 to 18 years) are ratingscales frequently used to determine problem areas andcompetencies. These scales are often part of a comprehensiveassessment of ADHD in children. They have beendetermined to be culturally competent and are widely usedin various countries (King et al., 2005).Pierce and Reid (2004) found that an increasingnumber of children from culturally diverse groups arediagnosed with ADHD. They believe this increase mayrepresent overidentification of ADHD in culturally diversechildren and urge practitioners to consider cultural contextbefore making the diagnosis.Yeh, Hough, McCabe, Lau, and Garland (2004) studiedparental beliefs about the causes of mental illness intheir children. They found that African-American, Asian/Pacific Islander American, and Latino parents were lesslikely to endorse biopsychosocial causes of mental illnessthan non-Hispanic white parents and were more likely tobelieve in sociologic causes. The authors believe this mayaffect participation in and compliance with prescribedtreatment.TreatmentNo one treatment has been found to be effective for ADHD;this gives rise to many different approaches such as sugarcontrolleddiets and megavitamin therapy. Parents need toknow that any treatment heralded as the cure for ADHD isprobably too good to be true (Hechtman, 2005). ADHD ischronic; goals of treatment involve managing symptoms,reducing hyperactivity and impulsivity, and increasing thechild’s attention so that he or she can grow and developnormally. The most effective treatment combines pharmacotherapywith behavioral, psychosocial, and educationalinterventions (Dang et al., 2007).PsychopharmacologyMedications often are effective in decreasing hyperactivityand impulsiveness and improving attention; this enablesthe child to participate in school and family life. The mostcommon medications are methylphenidate (Ritalin) andan amphetamine compound (Adderall) (Hechtman, 2005;Lehne, 2006). Methylphenidate is effective in 70% to 80%of children with ADHD; it reduces hyperactivity, impulsivity,and mood lability and helps the child to pay attentionmore appropriately. Dextroamphetamine (Dexedrine) andpemoline (Cylert) are other stimulants used to treat ADHD.The most common side effects of these drugs are insomnia,loss of appetite, and weight loss or failure to gain weight.Methylphenidate, dextroamphetamine, and amphetaminecompounds are also available in a sustained-release formtaken once daily; this eliminates the need for additionaldoses when the child is at school. Methylphenidate isalso available in a daily transdermal patch, marketed

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 417as Daytrana. Because pemoline can cause liver damage, itis the last of these drugs to be prescribed.Giving stimulants during daytime hours usually effectivelycombats insomnia. Eating a good breakfast withthe morning dose and substantial nutritious snacks latein the day and at bedtime helps the child to maintain anadequate dietary intake. When stimulant medicationsare not effective or their side effects are intolerable, antidepressantsare the second choice for treatment (seeChapter 2). Atomoxetine (Strattera) is the only nonstimulantdrug specifically developed and tested by the U.S.Food and Drug Administration for treatment of ADHD.It is an antidepressant, specifically a selective norepinephrinereuptake inhibitor. The most common sideeffects in children during clinical trials were decreasedappetite, nausea, vomiting, tiredness, and upset stomach.In adults, side effects were similar to those of otherantidepressants, including insomnia, dry mouth, urinaryretention, decreased appetite, nausea, vomiting, dizziness,and sexual side effects. In addition, atomoxetinecan cause liver damage, so individuals taking the drugneed to have liver function tests periodically (Cheng,Chen, Ko, & Ng, 2007). Table 20.1 lists drugs, dosages,and nursing considerations for clients with ADHD.Strategies for Home and SchoolMedications do not automatically improve the child’s academicperformance or ensure that he or she makes friends.Behavioral strategies are necessary to help the child tomaster appropriate behaviors. Environmental strategies atschool and home can help the child to succeed in thosesettings. Educating parents and helping them with parentingstrategies are crucial components of effective treatmentof ADHD. Effective approaches include providing consistentrewards and consequences for behavior, offering consistentpraise, using time-out, and giving verbal reprimands.Additional strategies are issuing daily report cards forbehavior and using point systems for positive and negativebehavior (Hechtman, 2005).In therapeutic play, play techniques are used to understandthe child’s thoughts and feelings and to promotecommunication. This should not be confused with playtherapy, a psychoanalytic technique used by psychiatrists.Dramatic play is acting out an anxiety-producing situationsuch as allowing the child to be a doctor or use a stethoscopeor other equipment to take care of a patient (a doll).Play techniques to release energy could include poundingpegs, running, or working with modeling clay. Creative playtechniques can help children to express themselves, forTable 20.1 DRUGS USED TO TREAT ADHDGeneric (Trade) Name Dosage (mg/day) Nursing ConsiderationsStimulantsMethylphenidate (Ritalin) 10–60 in 3–4 divided doses Monitor for appetite suppression or growthdelays.Sustained release (Ritalin-SR,Concerta, Metadate-CD)20–60 in the morning Give regular tablets after meals.Alert client that full drug effect takes 2 days.Transdermal patch (Daytrana) 15 Wear patch for 9 hours—drug effects last3 hours after removal.Dextroamphetamine (Dexedrine) 5–40 in 2–3 divided doses Monitor for insomnia.Sustained release (Dexedrine-SR) 10–30 in the morning Give last dose in early afternoon.Monitor for appetite suppression.Alert client that full drug effect takes 2 days.Amphetamine (Adderall) 5–40 in 2–3 divided doses Same as dextroamphetamineSustained release (Adderall-XR) 10–30 in the morningPemoline (Cylert) 37.5–112.5 in the morning Monitor for elevated liver function tests andappetite suppression.Alert client that drug may take 2 weeks forfull effect.Antidepressant (SNRI)Atomoxetine (Strattera)1.2 mg/kg/day in 1 or 2 divideddoses (children 70 kg and adults)Give with food.Monitor for appetite suppression.Use calorie-free beverages to relieve drymouth.Monitor for elevated liver function tests.Adapted from Drug Facts and Comparisons (2009). St. Louis: Wolters Kluwer.

418UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSexample, by drawing pictures of themselves, their family, andpeers. These techniques are especially useful when childrenare unable or unwilling to express themselves verbally.APPLICATION OF THE NURSING PROCESS:ATTENTION DEFICIT HYPERACTIVITYDISORDERAssessmentDuring assessment, the nurse gathers information throughdirect observation and from the child’s parents, day careproviders (if any), and teachers. Assessing the child in agroup of peers is likely to yield useful information becausethe child’s behavior may be subdued or different in afocused one-to-one interaction with the nurse. It is oftenhelpful to use a checklist when talking with parents tohelp focus their input on the target symptoms or behaviorstheir child exhibits.HistoryParents may report that the child was fussy and had problemsas an infant, or they may not have noticed the hyperactivebehavior until the child was a toddler or entered daycare or school. The child probably has difficulties in allmajor life areas such as school or play, and he or she likelydisplays overactive or even dangerous behavior at home.Often, parents say the child is “out of control,” and theyfeel unable to deal with the behavior. Parents may reportmany largely unsuccessful attempts to discipline the childor to change the behavior.for ADHDNURSING INTERVENTIONS• Ensuring the child’s safety and that of othersStop unsafe behavior.Provide close supervision.Give clear directions about acceptable and unacceptablebehavior.• Improved role performanceGive positive feedback for meeting expectations.Manage the environment (e.g., provide a quiet placefree of distractions for task completion).• Simplifying instructions/directionsGet child’s full attention.Break complex tasks into small steps.Allow breaks.• Structured daily routineEstablish a daily schedule.Minimize changes.• Client/family education and supportListen to parent’s feelings and frustrations.General Appearance and Motor BehaviorThe child cannot sit still in a chair and squirms and wiggleswhile trying to do so. He or she may dart around the roomwith little or no apparent purpose. Speech is unimpaired, butthe child cannot carry on a conversation: he or she interrupts,blurts out answers before the question is finished, andfails to pay attention to what has been said. Conversationtopics may jump abruptly. The child may appear immatureor lag behind in developmental milestones.Mood and AffectMood may be labile, even to the point of verbal outburstsor temper tantrums. Anxiety, frustration, and agitation arecommon. The child appears to be driven to keep moving ortalking and appears to have little control over movement orspeech. Attempts to focus the child’s attention or redirectthe child to a topic may evoke resistance and anger.Thought Process and ContentThere are generally no impairments in this area, althoughassessment can be difficult depending on the child’s activitylevel and age or developmental stage.Sensorium and Intellectual ProcessesThe child is alert and oriented with no sensory or perceptualalterations such as hallucinations. Ability to pay attentionor to concentrate is markedly impaired. The child’sattention span may be as little as 2 or 3 seconds with severeADHD or 2 or 3 minutes in milder forms of the disorder.Assessing the child’s memory may be difficult; he or shefrequently answers, “I don’t know,” because he or she cannotpay attention to the question or stop the mind fromracing. The child with ADHD is very distractible and rarelyable to complete tasks.Judgment and InsightChildren with ADHD usually exhibit poor judgment andoften do not think before acting. They may fail to perceiveharm or danger and engage in impulsive acts such as runninginto the street or jumping off high objects. Althoughassessing judgment and insight in young children is difficult,children with ADHD display more lack of judgmentwhen compared with others of the same age. Most youngchildren with ADHD are totally unaware that their behavioris different from that of others and cannot perceive howit harms others. Older children might report, “No one atschool likes me,” but they cannot relate the lack of friendsto their own behavior.Self-ConceptAgain, this may be difficult to assess in a very young child,but generally the self-esteem of children with ADHD is low.Because they are not successful at school, may not developmany friends, and have trouble getting along at home, theygenerally feel out of place and bad about themselves. The

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 419negative reactions their behavior evokes from others oftencause them to see themselves as bad or stupid.Roles and RelationshipsThe child is usually unsuccessful academically and sociallyat school. He or she frequently is disruptive and intrusiveat home, which causes friction with siblings and parents.Until the child is diagnosed and treated, parents oftenbelieve that the child is willful, stubborn, and purposefullymisbehaving. Generally, measures to discipline have limitedsuccess; in some cases, the child becomes physicallyout of control, even hitting parents or destroying familypossessions. Parents find themselves chronically exhaustedmentally and physically. Teachers often feel the same frustrationas parents, and day care providers or baby-sittersmay refuse to care for the child with ADHD, which adds tothe child’s rejection.Physiologic and Self-Care ConsiderationsChildren with ADHD may be thin if they do not take timeto eat properly or cannot sit through meals. Troublesettling down and difficulty sleeping are problems as well.If the child engages in reckless or risk-taking behaviors,there also may be a history of physical injuries.Data Analysis and PlanningNursing diagnoses commonly used when working withchildren with ADHD include the following:• Risk for Injury• Ineffective Role Performance• Impaired Social Interaction• Compromised Family CopingOutcome IdentificationTreatment outcomes for clients with ADHD may includethe following:• The client will be free of injury.• The client will not violate the boundaries of others.• The client will demonstrate age-appropriate social skills.• The client will complete tasks.• The client will follow directions.InterventionInterventions described in this section can be adapted tovarious settings and used by nurses and other health professionals,teachers, and parents or caregivers.Ensuring SafetySafety of the child and others is always a priority. If thechild is engaged in a potentially dangerous activity, thefirst step is to stop the behavior. This may require physicalintervention if the child is running into the street orattempting to jump from a high place. Attempting to talkto or reason with a child engaged in a dangerous activity isunlikely to succeed because his or her ability to pay attentionand to listen is limited. When the incident is over andthe child is safe, the adult should talk to the child directlyabout the expectations for safe behavior. Close supervisionmay be required for a time to ensure compliance andto avoid injury.Explanations should be short and clear, and the adultshould not use a punitive or belittling tone of voice. Theadult should not assume that the child knows acceptablebehavior but instead should state expectations clearly. Forexample, if the child was jumping down a flight of stairs,the adult might say,“It is unsafe to jump down stairs. From now on,you are to walk down the stairs, one at atime.”If the child crowded ahead of others, the adult would walkthe child back to the proper place in line and say,“It is not okay to crowd ahead of others. Takeyour place at the end of the line.”To prevent physically intrusive behavior, it also may benecessary to supervise the child closely while he or she isplaying. Again, it is often necessary to act first to stop theharmful behavior by separating the child from the friendsuch as stepping between them or physically removing thechild. Afterward, the adult should clearly explain expectedand unacceptable behaviors. For example, the adult mightsay,“It is not okay to grab other people. When youare playing with others, you must ask for thetoy.”Improving Role PerformanceIt is extremely important to give the child specific positivefeedback when he or she meets stated expectations. Doingso reinforces desired behaviors and gives the child a senseof accomplishment. For example, the adult might say,“You walked down the stairs safely” or “You dida good job of asking to play with the guitar andwaited until it was your turn.”Managing the environment helps the child to improvehis or her ability to listen, pay attention, and complete tasks.A quiet place with minimal noise and distraction is desirable.At school, this may be a seat directly facing the teacher

420UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Attention Deficit Hyperactivity DisorderNursing DiagnosisImpaired Social Interaction: Insufficient or excessive quantity or ineffective quality of social exchange.ASSESSMENT DATA• Short attention span• High level of distractibility• Labile moods• Low frustration tolerance• Inability to complete tasks• Inability to sit still or fidgeting• Excessive talking• Inability to follow directionsEXPECTED OUTCOMESImmediateThe client will• Successfully complete tasks or assignments withassistance• Demonstrate acceptable social skills whileinteracting with staff or family members, e.g.,listening while others talk rather than interruptingStabilizationThe client will• Participate successfully in the educational setting• Demonstrate the ability to complete tasks withreminders• Demonstrate successful interactions with familymembersCommunityThe client will• Verbalize positive statements about himself orherself• Complete tasks independentlyIMPLEMENTATIONNursing Interventions (*denotes collaborativeinterventions)Identify the factors that aggravate and alleviate theclient’s performance.Provide an environment as free from distractions aspossible. Institute interventions on a one-to-onebasis. Gradually increase the amount of environmentalstimuli.Engage the client’s attention before giving instructions(i.e., call the client’s name and establish eye contact).Give instructions slowly, using simple language andconcrete directions.Ask the client to repeat instructions before beginningtasks.Separate complex tasks into small steps.Provide positive feedback for completion of each step.RationaleThe external stimuli that exacerbate the client’s problemscan be identified and minimized. Likewise,ones that positively influence the client can be effectivelyused.The client’s ability to deal with external stimulation isimpaired.The client must hear instructions as a first step towardcompliance.The client’s ability to comprehend instructions (especiallyif they are complex or abstract) is impaired.Repetition demonstrates that the client has accuratelyreceived the information.The likelihood of success is enhanced with less complicatedcomponents of a task.The client’s opportunity for successful experiences isincreased by treating each step as an opportunity forsuccess.(continued)

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 421IMPLEMENTATIONNursing Care Plan | Attention Deficit Hyperactivity Disorder, cont.Nursing Interventions (*denotes collaborativeinterventions)Allow breaks, during which the client can movearound.State expectations for task completion clearly.Initially, assist the client to complete tasks.Progress to prompting or reminding the client toperform tasks or assignments.Give the client positive feedback for performing behaviorsthat come close to task achievement.Gradually decrease reminders.Assist the client to verbalize by asking sequencingquestions to keep on the topic (“Then what happens?”and “What happens next?”).*Teach the client’s family or caregivers to use the sameprocedures for the client’s tasks and interactions athome.*Explain and demonstrate “positive parenting” techniquesto family or caregivers such as time-in forgood behavior or being vigilant in identifying andresponding positively to the child’s first bid forattention; special time, or guaranteed time spentdaily with the child with no interruptions and nodiscussion of problem-related topics; ignoring minortransgressions by immediate withdrawal of eye contactor physical contact and cessation of discussionwith the child to avoid secondary gains.RationaleThe client’s restless energy can be given an acceptableoutlet, so he or she can attend to future tasks moreeffectively.The client must understand the request before he orshe can attempt task completion.If the client is unable to complete a task independently,having assistance will allow success and willdemonstrate how to complete the task.The amount of intervention gradually is decreased toincrease client independence as the client’s abilitiesincrease.This approach, called shaping, is a behavioral procedurein which successive approximations of adesired behavior are positively reinforced. It allowsrewards to occur as the client gradually masters theactual expectation.Client independence is promoted as staff participationis decreased.Sequencing questions provide a structure for discussionsto increase logical thought and decreasetangentiality.Successful interventions can be instituted by the client’sfamily or caregivers by using this process. Thiswill promote consistency and enhance the client’schances for success.It is important for parents or caregivers to engage intechniques that will maintain their loving relationshipwith the child while promoting, or at least notinterfering with, therapeutic goals. Children need tohave a sense of being lovable to their significant othersthat is not crucial to the nurse–client therapeuticrelationship.Adapted from Schultz, J. M., and Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia:Lippincott Williams & Wilkins.at the front of the room and away from the distraction of awindow or door. At home, the child should have a quietarea for homework away from the television or radio.Simplifying InstructionsBefore beginning any task, adults must gain the child’s fullattention. It is helpful to face the child on his or her level anduse good eye contact. The adult should tell the child whatneeds to be done and break the task into smaller steps if necessary.For example, if the child has 25 math problems, it mayhelp to give him or her 5 problems at a time, then 5 morewhen those are completed, and so on. This approach preventsoverwhelming the child and provides the opportunity forfeedback about each set of problems he or she completes.With sedentary tasks, it is also important to allow the child tohave breaks or opportunities to move around.

422UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSAdults can use the same approach for tasks such ascleaning or picking up toys. Initially, the child needs thesupervision or at least the presence of the adult. The adultcan direct the child to do one portion of the task at a time;when the child shows progress, the adult can give onlyoccasional reminders and then allow the child to completethe task independently. It helps to provide specific, stepby-stepdirections rather than give a general direction suchas “Please clean your room.” The adult could say,“Put your dirty clothes in the hamper.”After this step is completed, the adult gives anotherdirection:“Now make the bed.”CLIENT/FAMILY EDUCATIONfor ADHD• Include parents in planning and providing care• Refer parents to support groups• Focus on child’s strengths as well as problems• Teach accurate administration of medication andpossible side effects• Inform parents that child is eligible for special schoolservices• Assist parents to identify behavioral approaches to beused at home• Help parents achieve a balance of praising child andcorrecting child’s behavior• Emphasize the need for structure and consistency inchild’s daily routine and behavioral expectationsThe adult assigns specific tasks until the child has completedthe overall chore.Promoting a Structured Daily RoutineA structured daily routine is helpful. The child will accomplishgetting up, dressing, doing homework, playing, goingto bed, and so forth much more readily if there is a routinetime for these daily activities. Children with ADHD do notadjust to changes readily and are less likely to meet expectationsif times for activities are arbitrary or differ from dayto day.Providing Client and Family Educationand SupportIncluding parents in planning and providing care for thechild with ADHD is important. The nurse can teach parentsthe approaches described previously for use at home.Parents feel empowered and relieved to have specific strategiesthat can help both them and their child be moresuccessful.The nurse must listen to parents’ feelings. They mayfeel frustrated, angry, or guilty and blame themselves orthe school system for their child’s problems. Parents needto hear that neither they nor their child are at fault andthat techniques and school programs are available to help.Children with ADHD qualify for special school servicesunder the Individuals With Disabilities Education Act.Because raising a child with ADHD can be frustratingand exhausting, it often helps parents to attend supportgroups that can provide information and encouragementfrom other parents with the same problems. Parents mustlearn strategies to help their child improve his or her socialand academic abilities, but they also must understand howto help rebuild their child’s self-esteem. Most of thesechildren have low self-esteem because they have beenlabeled as having behavior problems and have been correctedcontinually by parents and teachers for not listening,not paying attention, and misbehaving. Parents shouldgive positive comments as much as possible to encouragethe child and acknowledge his or her strengths. One techniqueto help parents to achieve a good balance is to askthem to count the number of times they praise or criticizetheir child each day or for several days.Although medication can help reduce hyperactivity andinattention and allow the child to focus during school, it isby no means a cure-all. The child needs strategies andpractice to improve social skills and academic performance.Because these children are often not diagnoseduntil the second or third grade, they may have missedmuch basic learning for reading and math. Parents shouldknow that it takes time for them to catch up with otherchildren of the same age.EvaluationParents and teachers are likely to notice positive outcomesof treatment before the child does. Medications are ofteneffective in decreasing hyperactivity and impulsivity andimproving attention relatively quickly, if the child respondsto them. Improved sociability, peer relationships, and academicachievement happen more slowly and gradually butare possible with effective treatment.CONDUCT DISORDERConduct disorder is characterized by persistent antisocialbehavior in children and adolescents that significantlyimpairs their ability to function in social, academic, oroccupational areas. Symptoms are clustered in four areas:

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 423aggression to people and animals, destruction of property,deceitfulness and theft, and serious violation of rules(Thomas, 2005). People with conduct disorder have littleempathy for others; they have low self-esteem, poor frustrationtolerance, and temper outbursts. Conduct disorderfrequently is associated with early onset of sexual behavior,drinking, smoking, use of illegal substances, and otherreckless or risky behaviors. It occurs three times moreoften in boys than in girls. As many as 30% to 50% of thesechildren are diagnosed with antisocial personality disorderas adults.Onset and Clinical CourseTwo subtypes of conduct disorder are based on age atonset. The childhood-onset type involves symptoms before10 years of age, including physical aggression toward othersand disturbed peer relationships. These children aremore likely to have persistent conduct disorder and todevelop antisocial personality disorder as adults. Adolescent-onsettype is defined by no behaviors of conduct disorderuntil after 10 years of age. These adolescents are lesslikely to be aggressive, and they have more normal peerrelationships. They are less likely to have persistent conductdisorder or antisocial personality disorder as adults(APA, 2000).Conduct disorders can be classified as mild, moderate,or severe (APA, 2000):• Mild: The person has some conduct problems thatcause relatively minor harm to others. Examples includelying, truancy, and staying out late withoutpermission.• Moderate: The number of conduct problems increasesas does the amount of harm to others. Examples includevandalism and theft.DSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Conduct Disorder• Aggression to people and animals• Bullies, threatens, or intimidates others• Physical fights• Use of weapons• Forced sexual activity• Cruelty to people or animals• Destruction of property• Fire setting• Vandalism• Deliberate property destruction• Deceitfulness and theft• Lying• Shoplifting• Breaking into house, building, or car• Cons others to avoid responsibility• Serious violation of rules• Stays out overnight without parental consent• Runs away from home overnight• Truancy from schoolAdapted from American Psychiatric Association. (2000). DSM-IV-TR.• Severe: The person has many conduct problems thatcause considerable harm to others. Examples includeforced sex, cruelty to animals, use of a weapon, burglary,and robbery.The course of conduct disorder is variable. People withthe adolescent-onset type or mild problems can achieveadequate social relationships and academic or occupationalCLINICAL VIGNETTE: CONDUCT DISORDERTom, 14 years of age, leaves the principal’s office afterbeing involved in a physical fight in the hall. He knows hisparents will be furious because he is suspended for 1 week.“It wasn’t my fault,” he thinks to himself. “What am I supposedto do when someone calls me names?” Tom is angrythat he even came to school today; he’d much rather spendtime hanging out with his friends and having a few drinks orsmoking pot.On his way home, Tom sees a car parked next to thegrocery store, and it is unlocked and running. Tom jumps in,thinking, “This is my lucky day!” He speeds away, but soonhe can hear police sirens as a patrol car closes in on him. Heis eventually stopped and arrested. As he waits for hisparents at the station, he’s not sure what to do next. Hetells the police officer that the car belongs to a friend, andhe just borrowed it. He promises never to get into troubleagain if the officer will let him go. But the officer has Tom’srecord, which includes school truancy, underage drinking,suspicion in the disappearance of a neighbor’s pet cat, andshoplifting.When Tom’s father arrives, he smacks Tom across the faceand says, “You stupid kid! I told you the last time you’d betterstraighten up. And look at you now! What a sorry excusefor a son!” Tom slumps in his chair with a sullen, defiant lookon his face. “Go ahead and hit me! Who cares? I’m notgonna do what you say, so you might as well give up!”

424UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSConduct disordersuccess as adults. Those with the childhood-onset type ormore severe problem behaviors are more likely to developantisocial personality disorder as adults. Even those whodo not have antisocial personality disorder may lead troubledlives with difficult interpersonal relationships,unhealthy lifestyles, and an inability to support themselves(Thomas, 2005).EtiologyResearchers generally accept that genetic vulnerability,environmental adversity, and factors like poor copinginteract to cause the disorder. Risk factors include poorparenting, low academic achievement, poor peer relationships,and low self-esteem; protective factors include resilience,family support, positive peer relationships, andgood health (Thomas, 2005).There is a genetic risk for conduct disorder, althoughno specific gene marker has been identified (Thomas,2005). The disorder is more common in children whohave a sibling with conduct disorder or a parent with antisocialpersonality disorder, substance abuse, mood disorder,schizophrenia, or ADHD (APA, 2000).A lack of reactivity of the autonomic nervous systemhas been found in children with conduct disorder; thisnonresponsiveness is similar to adults with antisocial personalitydisorder. The abnormality may cause moreaggression in social relationships as a result of decreasednormal avoidance or social inhibitions. Research into therole of neurotransmitters is promising (Thomas, 2005).Poor family functioning, marital discord, poor parenting,and a family history of substance abuse and psychiatricproblems are all associated with the development ofconduct disorder. Prenatal exposure to alcohol causes anincreased risk for conduct disorder (Disney, Iacono,McGue, Tully, & Legrand, 2008). Child abuse is an especiallysignificant risk factor. The specific parenting patternsconsidered ineffective are inconsistent parentalresponses to the child’s demands and giving in to demandsas the child’s behavior escalates. Exposure to violence inthe media and community is a contributing factor for thechild at risk in other areas. Socioeconomic disadvantages,such as inadequate housing, crowded conditions, and poverty,also increase the likelihood of conduct disorder inat-risk children (McGuinness, 2006).Academic underachievement, learning disabilities, hyperactivity,and problems with attention span are all associatedwith conduct disorder. Children with conduct disorder havedifficulty functioning in social situations. They lack the abilitiesto respond appropriately to others and to negotiate conflict,and they lose the ability to restrain themselves whenemotionally stressed. They are often accepted only by peerswith similar problems (Thomas, 2005).Cultural ConsiderationsConcerns have been raised that “difficult” children may bemistakenly labeled as having conduct disorder. Knowingthe client’s history and circumstances is essential for accuratediagnosis. In high-crime areas, aggressive behaviormay be protective and not necessarily indicative of conductdisorder. In immigrants from war-ravaged countries,aggressive behavior may have been necessary for survival,so these individuals should not be diagnosed with conductdisorder (APA, 2000).TreatmentMany treatments have been used for conduct disorder withonly modest effectiveness. Early intervention is more effective,and prevention is more effective than treatment. Dramaticinterventions, such as “boot camp” or incarceration,have not proved effective and may even worsen the situation(Thomas, 2005). Treatment must be geared towardthe client’s developmental age; no one treatment is suitablefor all ages. Preschool programs, such as Head Start, resultin lower rates of delinquent behavior and conduct disorderthrough use of parental education about normal growthand development, stimulation for the child, and parentalsupport during crises.For school-aged children with conduct disorder, thechild, family, and school environment are the focus oftreatment. Techniques include parenting education, social

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 425skills training to improve peer relationships, and attemptsto improve academic performance and increase the child’sability to comply with demands from authority figures.Family therapy is considered to be essential for children inthis age group (Thomas, 2005).Adolescents rely less on their parents and more onpeers, so treatment for this age group includes individualtherapy. Many adolescent clients have some involvementwith the legal system as a result of criminal behavior, andconsequently they may have restrictions on their freedom.Use of alcohol and other drugs plays a more significantrole for this age group; any treatment plan must address thisissue. The most promising treatment approach includeskeeping the client in his or her environment with family andindividual therapies. The plan usually includes conflict resolution,anger management, and teaching social skills.Medications alone have little effect but may be used inconjunction with treatment for specific symptoms. Forexample, the client who presents a clear danger to othersmay be prescribed an antipsychotic medication, or a clientwith a labile mood may benefit from lithium or anothermood stabilizer such as carbamazepine (Tegretol) or valproicacid (Depakote) (Thomas, 2005).APPLICATION OF THE NURSING PROCESS:CONDUCT DISORDERAssessmentHistoryChildren with conduct disorder have a history of disturbedrelationships with peers, aggression toward people or animals,destruction of property, deceitfulness or theft, andserious violation of rules (e.g., truancy, running away fromhome, and staying out all night without permission). Thebehaviors and problems may be mild to severe.General Appearance and Motor BehaviorAppearance, speech, and motor behavior are typically normalfor the age group but may be somewhat extreme (e.g.,body piercings, tattoos, hairstyle, and clothing). Theseclients often slouch and are sullen and unwilling to beinterviewed. They may use profanity, call the nurse orphysician names, and make disparaging remarks aboutparents, teachers, police, and other authority figures.Mood and AffectClients may be quiet and reluctant to talk or openly hostileand angry. Their attitude is likely to be disrespectful towardparents, the nurse, or anyone in a position of authority.Irritability, frustration, and temper outbursts are common.Clients may be unwilling to answer questions or to cooperatewith the interview; they believe they do not needhelp or treatment. If a client has legal problems, he or shemay express superficial guilt or remorse, but it is unlikelythat these emotions are sincere.Thought Process and ContentThought processes are usually intact—that is, clients arecapable of logical rational thinking. Nevertheless, theyperceive the world to be aggressive and threatening, andthey respond in the same manner. Clients may be preoccupiedwith looking out for themselves and behave asthough everyone is “out to get me.” Thoughts or fantasiesabout death or violence are common.Sensorium and Intellectual ProcessesClients are alert and oriented with intact memory and nosensory-perceptual alterations. Intellectual capacity is notimpaired, but typically these clients have poor gradesbecause of academic underachievement, behavioral problemsin school, or failure to attend class and to completeassignments.Judgment and InsightJudgment and insight are limited for developmental stage.Clients consistently break rules with no regard for the consequences.Thrill-seeking or risky behavior is common, suchas use of drugs or alcohol, reckless driving, sexual activity,and illegal activities such as theft. Clients lack insight andusually blame others or society for their problems; theyrarely believe their behavior is the cause of difficulties.Self-ConceptAlthough these clients generally try to appear tough, theirself-esteem is low. They do not value themselves any morethan they value others. Their identity is related to theirbehaviors such as being cool if they have had many sexualencounters or feeling important if they have stolen expensivemerchandise or been expelled from school.Roles and RelationshipsRelationships with others, especially those in authority,are disruptive and may be violent. This includes parents,teachers, police, and most other adults. Verbal and physicalaggression is common. Siblings may be a target for ridiculeor aggression. Relationships with peers are limited toothers who display similar behaviors; these clients seepeers who follow rules as dumb or afraid. Clients usuallyhave poor grades, have been expelled, or have droppedout. It is unlikely that they have a job (if old enough)because they would prefer to steal. Their idea of fulfillingroles is being tough, breaking rules, and taking advantageof others.Physiologic and Self-Care ConsiderationsClients are often at risk for unplanned pregnancy andsexually transmitted diseases because of their early andfrequent sexual behavior. Use of drugs and alcohol is anadditional risk to health. Clients with conduct disordersare involved in physical aggression and violence includingweapons; this results in more injuries and deaths thancompared with others of the same age.

426UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Conduct DisorderNursing DiagnosisIneffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses,and/or inability to use available resources.ASSESSMENT DATA• Few or no meaningful peer relationships• Inability to empathize with others• Inability to give and receive affection• Low self-esteem, masked by “tough” actEXPECTED OUTCOMESImmediateThe client will• Engage in social interaction• Verbalize feelings• Learn problem-solving skillsStabilizationThe client will• Demonstrate effective problem-solving and copingskills• Assess own strengths and weaknesses realistically,e.g., make a list of strengths and weaknesses andreview with the nurseCommunityThe client will• Demonstrate development of relationships withpeers• Verbalize real feelings of self-worth that are ageappropriate• Perform at a satisfactory academic levelIMPLEMENTATIONNursing Interventions (*denotes collaborativeinterventions)Encourage the client to discuss his or her thoughts andfeelings.Give positive feedback for appropriate discussions.Tell the client that he or she is accepted as a person,although a particular behavior may not be acceptable.Give the client positive attention when behavior is notproblematic.Teach the client about limit setting and the need forlimits. Include time for discussion.RationaleVerbalizing feelings is an initial step toward dealingwith them in an appropriate manner.Positive feedback increases the likelihood of continuedperformance.Clients with conduct disorders frequently experiencerejection. The client needs support to increaseself-esteem, while understanding that behavioralchanges are necessary.The client may have been receiving the majority ofattention from others when he or she was engagedin problematic behavior, a pattern that needs tochange.This allows the client to hear about the relationshipbetween aberrant behavior and consequences whenbehavior is not problematic. The client may have noknowledge of the concept of limits and how limitscan be beneficial.(continued)

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 427Nursing Care Plan | Conduct Disorder, cont.IMPLEMENTATIONNursing Interventions (*denotes collaborativeinterventions)Teach the client the problem-solving process as an alternativeto acting out (identify the problem, consideralternatives, select and implement an alternative, andevaluate the effectiveness of the solution).Help the client practice the problem-solving processwith situations on the unit, then situations the clientmay face at home, school, and so forth.Role model appropriate conversation and social skillsfor the client.Specify and describe the skills you are demonstrating.Practice social skills with the client on a one-to-onebasis.Gradually introduce other clients into the interactionsand discussions.Assist the client to focus on age- and situationappropriatetopics.Encourage the client to give and receive feedback withothers in his or her age group.Facilitate expression of feelings among clients insupervised group situations.Teach the client about transmission of HIV infectionand other sexually transmitted diseases (STDs).*Assess the client’s use of alcohol or other substances,and provide referrals as indicated.RationaleThe client may not know how to solve problemsconstructively or may not have seen this behaviormodeled in the home.The client’s ability and skill will increase with practice.He or she will experience success with practice.This allows the client to see what is expected in a nonthreateningsituation.Clarification of expectations decreases the chance formisinterpretation.As the client gains comfort with the skills throughpractice, he or she will increase their use.Success with others is more likely to occur once theclient has been successful with the staff.Peer relationships are enhanced when the client is ableto interact as other adolescents do.Peer feedback can be influential in shaping the behaviorof an adolescent.Adolescents are reluctant to be vulnerable to peers andmay need encouragement to share feelings.Because these clients may act out sexually or use intravenousdrugs, it is especially important that they be educatedabout preventing transmission of HIV and STDs.Often adolescents with conduct disorders also havesubstance abuse issues.Adapted from Schultz, J. M., and Videbeck, S. L (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia:Lippincott Williams & Wilkins.Data Analysis and PlanningNursing diagnoses commonly used for clients with conductdisorders include the following:• Risk for Other-Directed Violence• Noncompliance• Ineffective Coping• Impaired Social Interaction• Chronic Low Self-EsteemOutcome IdentificationTreatment outcomes for clients with conduct disordersmay include the following:• The client will not hurt others or damage property.• The client will participate in treatment.• The client will learn effective problem-solving andcoping skills.• The client will use age-appropriate and acceptablebehaviors when interacting with others.• The client will verbalize positive, age-appropriate statementsabout self.InterventionDecreasing Violence and Increasing Compliancewith TreatmentThe nurse must protect others from the manipulativeor aggressive behaviors common with these clients. Heor she must set limits on unacceptable behavior at thebeginning of treatment. Limit setting involves threesteps:1. Inform clients of the rule or limit.2. Explain the consequences if clients exceed the limit.3. State expected behavior.

428UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNURSING INTERVENTIONSfor Conduct Disorder• Decreasing violence and increasing compliance withtreatmentProtect others from client’s aggression and manipulationSet limits for unacceptable behaviorProvide consistency with client’s treatment planUse behavioral contractsInstitute time-outProvide a routine schedule of daily activities• Improving coping skills and self-esteemShow acceptance of the person, not necessarily thebehaviorEncourage the client to keep a diaryTeach and practice problem-solving skills• Promoting social interactionTeach age-appropriate social skillsRole model and practice social skillsProvide positive feedback for acceptable behavior• Providing client and family educationProviding consistent limit enforcement with no exceptionsby all members of the health team, including parents,is essential. For example, the nurse might say,“It is unacceptable to hit another person. Ifyou are angry, tell a staff person about youranger. If you hit someone, you will be restrictedfrom recreation time for 24 hours.”For limit setting to be effective, the consequences musthave meaning for clients—that is, they must value ordesire recreation time (in this example). If a client wantedto be alone in his or her room, then this consequencewould not be effective.The nurse can negotiate with a client a behavioralcontract outlining expected behaviors, limits, and rewardsto increase treatment compliance. The client can refer tothe written agreement to remember expectations, andstaff can refer to the agreement if the client tries to changeany terms. A contract can help staff to avoid power strugglesover requests for special favors or attempts to altertreatment goals or behavioral expectations.Whether there is a written contract or treatment plan,staff must be consistent with these clients. They will attemptto bend or break rules, blame others for noncompliance, ormake excuses for behavior. Consistency in following thetreatment plan is essential to decrease manipulation.Time-out is retreat to a neutral place so clients canregain self-control. It is not a punishment. When a client’sbehavior begins to escalate, such as when he or sheyells at or threatens someone, a time-out may preventaggression or acting out. Staff may need to institute atime-out for clients if they are unwilling or unable to doso. Eventually, the goal is for clients to recognize signs ofincreasing agitation and take a self-instituted time-out tocontrol emotions and outbursts. After the time-out, thenurse should discuss the events with the client. Doing socan help clients to recognize situations that triggeremotional responses and to learn more effective ways ofdealing with similar situations in the future. Providingpositive feedback for successful efforts at avoiding aggressionhelps to reinforce new behaviors for clients.It helps for clients to have a schedule of daily activities,including hygiene, school, homework, and leisure time.Clients are more likely to establish positive habits if theyhave routine expectations about tasks and responsibilities.They are more likely to follow a daily routine if they haveinput concerning the schedule.Improving Coping Skills and Self-EsteemThe nurse must show acceptance of clients as worthwhilepersons even if their behavior is unacceptable. This meansthat the nurse must be matter-of-fact about setting limits andmust not make judgmental statements about clients. He orshe must focus only on the behavior. For example, if a clientbroke a chair during an angry outburst, the nurse would say,“John, breaking chairs is unacceptable behavior.You need to let staff know you’re upsetso you can talk about it instead of acting out.”The nurse must avoid saying things like,“What’s the matter with you? Don’t you knowany better?”Comments such as these are subjective and judgmentaland do not focus on the specific behavior; they reinforcethe client’s self-image as a “bad person.”Clients with a conduct disorder often have a toughexterior and are unable or reluctant to discuss feelings andemotions. Keeping a diary may help them to identify andexpress their feelings. The nurse can discuss these feelingswith clients and explore better, safer expressions thanthrough aggression or acting out.Clients also may need to learn how to solve problemseffectively. Problem solving involves identifying the problem,exploring all possible solutions, choosing and implementingone of the alternatives, and evaluating the results(see Chapter 16). The nurse can help clients to work onactual problems using this process. Problem-solving skillsare likely to improve with practice.Promoting Social InteractionClients with conduct disorder may not have age-appropriatesocial skills, so teaching social skills is important. The

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 429nurse can role model these skills and help clients to practiceappropriate social interaction. The nurse identifieswhat is not appropriate, such as profanity and name calling,and also what is appropriate. Clients may have littleexperience discussing the news, current events, sports, orother topics. As they begin to develop social skills, thenurse can include other peers in these discussions. Positivefeedback is essential to let clients know they are meetingexpectations.Providing Client and Family EducationParents may also need help in learning social skills, solvingproblems, and behaving appropriately. Often, parentshave their own problems, and they have had difficultieswith the client for a long time before treatment was instituted.Parents need to replace old patterns such as yelling,hitting, or simply ignoring behavior with more effectivestrategies. The nurse can teach parents age-appropriateactivities and expectations for clients such as reasonablecurfews, household responsibilities, and acceptable behaviorat home. The parents may need to learn effective limitsetting with appropriate consequences. Parents often needto learn to communicate their feelings and expectationsclearly and directly to these clients. Some parents mayneed to let clients experience the consequences of theirbehavior rather than rescuing them. For example, if a clientgets a speeding ticket, the parents should not pay thefine for him or her. If a client causes a disturbance inschool and receives detention, the parents can support theteacher’s actions instead of blaming the teacher or school.EvaluationTreatment is considered effective if the client stops behavingin an aggressive or illegal way, attends school, and followsreasonable rules and expectations at home. The clientwill not become a model child in a short period;instead, he or she may make modest progress with somesetbacks over time.CLIENT/ FAMILY EDUCATIONfor Conduct Disorder• Teach parents social and problem-solving skills whenneeded• Encourage parents to seek treatment for their ownproblems• Help parents to identify age-appropriate activities andexpectations• Assist parents with direct, clear communication• Help parents to avoid “rescuing” the client• Teach parents effective limit-setting techniques• Help parents identify appropriate discipline strategiesCOMMUNITY-BASED CAREClients with conduct disorder are seen in acute care settingsonly when their behavior is severe and only for short periodsof stabilization. Much long-term work takes place atschool and home or another community setting. Someclients are placed outside their parents’ home for short orlong periods. Group homes, halfway houses, and residentialtreatment settings are designed to provide safe, structuredenvironments and adequate supervision if that cannot beprovided at home. Clients with legal issues may be placedin detention facilities, jails, or jail-diversion programs.Chapter 4 discusses treatment settings and programs.MENTAL HEALTH PROMOTIONParental behavior profoundly influences children’s behavior.Parents who engage in risky behaviors such as smoking,drinking, and ignoring their health are more likely tohave children who also engage in risky behaviors, includingearly unprotected sex. Group-based parenting classesare effective to deal with problem behaviors in childrenand to prevent later development of conduct disorders(Turner & Sanders, 2006).Eisen, Raleigh, and Neuhoff (2008) reported that anearly intervention program for children at risk for anxietydisorders improved behavior. The program consisted ofparent sessions, child anxiety management, parent–childsessions that emphasized coping skills, and graduatedexposure to anxiety-provoking situations.The SNAP-IV teacher and parent rating scale (Swanson,2000) is an assessment tool that can be used for initialevaluation in many areas of concern such as ADHD, oppositionaldefiant disorder (ODD), conduct disorder, anddepression (Box 20.3). Such tools can identify problems orpotential problems that signal a need for further evaluationand follow-up. Early detection and successful interventionare often the key to mental health promotion.Oppositional Defiant DisorderODD consists of an enduring pattern of uncooperative,defiant, and hostile behavior toward authority figureswithout major antisocial violations. A certain level ofoppositional behavior is common in children and adolescents;indeed, it is almost expected at some phases such as2 to 3 years of age and in early adolescence. Table 20.2contrasts acceptable characteristics with abnormal behaviorin adolescents. ODD is diagnosed only when behaviorsare more frequent and intense than in unaffected peers andcause dysfunction in social, academic, or work situations.This disorder is diagnosed in about 5% of the populationand occurs equally among male and female adolescents.Most authorities believe that genes, temperament, andadverse social conditions interact to create ODD. Twentyfivepercent of people with this disorder develop conductdisorder; 10% are diagnosed with antisocial personality

430UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 20.3 THE SNAP-IV TEACHER AND PARENT RATING SCALEName: _______________________________________Gender: ____________ Age: ____________ Grade: ____________Ethnicity (circle one which best applies): African-American Asian Caucasian Hispanic Other ______________Completed by: ______________________________________Type of Class: ______________ Class size: ______________For each item, check the column which best describes this child: Not at Just a Quite VeryAll Little a Bit Much1. Often fails to give close attention to details or makes careless mistakes _____ _____ _____ _____in schoolwork or tasks2. Often has difficulty sustaining attention in tasks or play activities _____ _____ _____ _____3. Often does not seem to listen when spoken to directly _____ _____ _____ _____4. Often does not follow through on instructions and fails to finish schoolwork,_____ _____ _____ _____chores, or duties5. Often has difficulty organizing tasks and activities _____ _____ _____ _____6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained _____ _____ _____ _____mental effort7. Often loses things necessary for activities (e.g., toys, school assignments, _____ _____ _____ _____pencils, or books)8. Often is distracted by extraneous stimuli _____ _____ _____ _____9. Often is forgetful in daily activities _____ _____ _____ _____10. Often has difficulty maintaining alertness, orienting to requests, or _____ _____ _____ _____executing directions11. Often fidgets with hands or feet or squirms in seat _____ _____ _____ _____12. Often leaves seat in classroom or in other situations in which remaining _____ _____ _____ _____seated is expected13. Often runs about or climbs excessively in situations in which it is _____ _____ _____ _____inappropriate14. Often has difficulty playing or engaging in leisure activities quietly _____ _____ _____ _____15. Often is “on the go” or often acts as if “driven by a motor” _____ _____ _____ _____16. Often talks excessively _____ _____ _____ _____17. Often blurts out answers before questions have been completed _____ _____ _____ _____18. Often has difficulty awaiting turn _____ _____ _____ _____19. Often interrupts or intrudes on others (e.g., butts into conversations/ _____ _____ _____ _____games)20. Often has difficulty sitting still, being quiet, or inhibiting impulses in the _____ _____ _____ _____classroom or at home21. Often loses temper _____ _____ _____ _____22. Often argues with adults _____ _____ _____ _____23. Often actively defies or refuses adult requests or rules _____ _____ _____ _____24. Often deliberately does things that annoy other people _____ _____ _____ _____25. Often blames others for his or her mistakes or misbehavior _____ _____ _____ _____26. Often is touchy or easily annoyed by others _____ _____ _____ _____27. Often is angry and resentful _____ _____ _____ _____28. Often is spiteful or vindictive _____ _____ _____ _____29. Often is quarrelsome _____ _____ _____ _____30. Often is negative, defiant, disobedient, or hostile toward authorityfigures_____ _____ _____ _____continued on page 431

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 431Box 20.3 THE SNAP-IV TEACHER AND PARENT RATING SCALE ContinuedFor each item, check the column which best describes this child: Not at Just a Quite VeryAll Little a Bit Much31. Often makes noises (e.g., humming or odd sounds) _____ _____ _____ _____32. Often is excitable, impulsive _____ _____ _____ _____33. Often cries easily _____ _____ _____ _____34. Often is uncooperative _____ _____ _____ _____35. Often acts “smart” _____ _____ _____ _____36. Often is restless or overactive _____ _____ _____ _____37. Often disturbs other children _____ _____ _____ _____38. Often changes mood quickly and drastically _____ _____ _____ _____39. Often easily frustrated if demands are not met immediately _____ _____ _____ _____40. Often teases other children and interferes with their activities _____ _____ _____ _____41. Often is aggressive to other children (e.g., picks fights or bullies) _____ _____ _____ _____42. Often is destructive with property of others (e.g., vandalism) _____ _____ _____ _____43. Often is deceitful (e.g., steals, lies, forges, copies the work of others, or _____ _____ _____ _____“cons” others)44. Often and seriously violates rules (e.g., is truant, runs away, or completely_____ _____ _____ _____ignores class rules)45. Has persistent pattern of violating the basic rights of others or major _____ _____ _____ _____societal norms46. Has episodes of failure to resist aggressive impulses (to assault others or _____ _____ _____ _____to destroy property)47. Has motor or verbal tics (sudden, rapid, recurrent, and nonrhythmic _____ _____ _____ _____motor or verbal activity)48. Has repetitive motor behavior (e.g., hand waving, body rocking, or picking_____ _____ _____ _____at skin)49. Has obsessions (persistent and intrusive inappropriate ideas, thoughts, _____ _____ _____ _____or impulses)50. Has compulsions (repetitive behaviors or mental acts to reduce anxiety _____ _____ _____ _____or distress)51. Often is restless or seems keyed up or on edge _____ _____ _____ _____52. Often is easily fatigued _____ _____ _____ _____53. Often has difficulty concentrating (mind goes blank) _____ _____ _____ _____54. Often is irritable _____ _____ _____ _____55. Often has muscle tension _____ _____ _____ _____56. Often has excessive anxiety and worry (e.g., apprehensive expectation) _____ _____ _____ _____57. Often has daytime sleepiness (unintended sleeping in inappropriate _____ _____ _____ _____situations)58. Often has excessive emotionality and attention-seeking behavior _____ _____ _____ _____59. Often has need for undue admiration, grandiose behavior, or lack of _____ _____ _____ _____empathy60. Often has instability in relationships with others, reactive mood, and _____ _____ _____ _____impulsivity61. Sometimes for at least a week has inflated self-esteem or grandiosity _____ _____ _____ _____62. Sometimes for at least a week is more talkative than usual or seemspressured to keep talking_____ _____ _____ _____continued on page 432

432UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 20.3 THE SNAP-IV TEACHER AND PARENT RATING SCALE ContinuedFor each item, check the column which best describes this child: Not at Just a Quite VeryAll Little a Bit Much63. Sometimes for at least a week has flight of ideas or says that thoughts _____ _____ _____ _____are racing64. Sometimes for at least a week has elevated, expansive, or euphoric _____ _____ _____ _____mood65. Sometimes for at least a week is excessively involved in pleasurable but _____ _____ _____ _____risky activities66. Sometimes for at least 2 weeks has depressed mood (sad, hopeless, _____ _____ _____ _____discouraged)67. Sometimes for at least 2 weeks has irritable or cranky mood (not just _____ _____ _____ _____when frustrated)68. Sometimes for at least 2 weeks has markedly diminished interest or _____ _____ _____ _____pleasure in most activities69. Sometimes for at least 2 weeks has psychomotor agitation (even more _____ _____ _____ _____active than usual)70. Sometimes for at least 2 weeks has psychomotor retardation (slowed _____ _____ _____ _____down in most activities)71. Sometimes for at least 2 weeks is fatigued or has loss of energy _____ _____ _____ _____72. Sometimes for at least 2 weeks has feelings of worthlessness or excessive,_____ _____ _____ _____inappropriate guilt73. Sometimes for at least 2 weeks has diminished ability to think or _____ _____ _____ _____concentrate74. Chronic low self-esteem most of the time for at least a year _____ _____ _____ _____75. Chronic poor concentration or difficulty making decisions most of the _____ _____ _____ _____time for at least a year76. Chronic feelings of hopelessness most of the time for at least a year _____ _____ _____ _____77. Currently is hypervigilant (overly watchful or alert) or has exaggerated _____ _____ _____ _____startle response78. Currently is irritable, has anger outbursts, or has difficulty _____ _____ _____ _____concentrating79. Currently has an emotional (e.g., nervous, worried, hopeless, tearful) _____ _____ _____ _____response to stress80. Currently has a behavioral (e.g., fighting, vandalism, and truancy) _____ _____ _____ _____response to stress81. Has difficulty getting started on classroom assignments _____ _____ _____ _____82. Has difficulty staying on task for an entire classroom period _____ _____ _____ _____83. Has problems in completion of work on classroom assignments _____ _____ _____ _____84. Has problems in accuracy or neatness of written work in the classroom _____ _____ _____ _____85. Has difficulty attending to a group classroom activity or discussion _____ _____ _____ _____86. Has difficulty making transitions to the next topic or classroom period _____ _____ _____ _____87. Has problems in interactions with peers in the classroom _____ _____ _____ _____88. Has problems in interactions with staff (teacher or aide) _____ _____ _____ _____89. Has difficulty remaining quiet according to classroom rules _____ _____ _____ _____90. Has difficulty staying seated according to classroom rules _____ _____ _____ _____Developed by James M. Swanson, Ph.D., University of California, Irvine.

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 433Table 20.2AcceptableACCEPTABLE CHARACTERISTICS AND ABNORMAL BEHAVIORIN ADOLESCENCEAbnormalOccasional psychosomatic complaintsInconsistent and unpredictable behaviorEagerness for peer approvalCompetitive in playErratic work-leisure patternsCritical of self and othersHighly ambivalent toward parentsAnxiety about lost parental nurturingVerbal aggression to parentsStrong moral and ethical perceptionsFears, anxiety, and guilt about sex, health, and educationDefiant, negative, or depressed behaviorFrequent hypochondriacal complaintsLearning irregular or deficientPoor personal relationships with peersInability to postpone gratificationUnwillingness to assume greater autonomyActs of delinquency, ritualism, obsessionsSexual aberrationsInability to work or socializeAdapted from Pataki, C. (2005). Normal adolescence. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed., pp. 3035–3043).Philadelphia: Lippincott Williams & Wilkins.disorder as adults (Thomas, 2005). ODD is often comorbidwith other psychiatric disorders such as ADHD, anxiety,and affective disorders that need to be treated as well.Treatment approaches for ODD are similar to those usedfor conduct disorder.Feeding and Eating Disorders of Infancyand Early ChildhoodThe disorders of feeding and eating included in this categoryare persistent in nature and are not explained byunderlying medical conditions. They include pica, ruminationdisorder, and feeding disorder.PicaPica is persistent ingestion of nonnutritive substances suchas paint, hair, cloth, leaves, sand, clay, or soil. Pica is commonlyseen in children with mental retardation; it occasionallyoccurs in pregnant women. It comes to the clinician’sattention only if a medical complication develops such as abowel obstruction or an infection or if a toxic conditiondevelops such as lead poisoning. In most instances, thebehavior lasts for several months and then remits.Rumination DisorderRumination disorder is the repeated regurgitation and rechewingof food. The child brings partially digested food up intothe mouth and usually rechews and reswallows the food.The regurgitation does not involve nausea, vomiting, or anymedical condition (APA, 2000). This disorder is relativelyuncommon and occurs more often in boys than in girls; itresults in malnutrition, weight loss, and even death in about25% of affected infants. In infants, the disorder frequentlyremits spontaneously, but it may continue in severe cases.Oppositional defiant disorderFeeding DisorderFeeding disorder of infancy or early childhood is characterizedby persistent failure to eat adequately, which results insignificant weight loss or failure to gain weight. Feeding disorderis equally common in boys and girls and occurs mostoften during the first year of life. Estimates are that 5% of allpediatric hospital admissions are for failure to gain weight,and up to 50% of those admissions reflect a feeding disorder

434UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSwith no predisposing medical condition. In severe cases,malnutrition and death can result, but most children haveimproved growth after some time (APA, 2000).Tic DisordersA tic is a sudden, rapid, recurrent, nonrhythmic, stereotypedmotor movement or vocalization (APA, 2000). Ticscan be suppressed but not indefinitely. Stress exacerbatestics, which diminish during sleep and when the person isengaged in an absorbing activity. Common simple motortics include blinking, jerking the neck, shrugging theshoulders, grimacing, and coughing. Common simplevocal tics include clearing the throat, grunting, sniffing,snorting, and barking. Complex vocal tics include repeatingwords or phrases out of context, coprolalia (use ofsocially unacceptable words, frequently obscene), palilalia(repeating one’s own sounds or words), and echolalia(repeating the last-heard sound, word, or phrase; APA,2000). Complex motor tics include facial gestures, jumping,or touching or smelling an object.Tic disorders tend to run in families. Abnormal transmissionof the neurotransmitter dopamine is thought toplay a part in tic disorders (Scahill & Leckman, 2005). Ticdisorders usually are treated with risperidone (Risperdal)or olanzapine (Zyprexa), which are atypical antipsychotics.It is important for clients with tic disorders to getplenty of rest and to manage stress because fatigue andstress increase symptoms.Tourette’s DisorderTourette’s disorder involves multiple motor tics and oneor more vocal tics, which occur many times a day for morethan 1 year. The complexity and severity of the tics changeover time, and the person experiences almost all the possibletics described previously during his or her lifetime.The person has significant impairment in academic, social,or occupational areas and feels ashamed and self- conscious.This rare disorder (4 or 5 in 10,000) is more common inboys and is usually identified by 7 years of age. Somepeople have lifelong problems; others have no symptomsafter early adulthood (APA, 2000).Chronic Motor or Tic DisorderChronic motor or vocal tic differs from Tourette’s disorderin that either the motor or the vocal tic is seen, but notboth. Transient tic disorder may involve single or multiplevocal or motor tics, but the occurrences last no longerthan 12 months.Elimination DisordersEncopresis is the repeated passage of feces into inappropriateplaces such as clothing or the floor by a child who isat least 4 years of age either chronologically or developmentally.It is often involuntary, but it can be intentional.Involuntary encopresis usually is associated withconstipation that occurs for psychological, not medical,reasons. Intentional encopresis often is associated withODD or conduct disorder.Enuresis is the repeated voiding of urine during the dayor at night into clothing or bed by a child at least 5 yearsof age either chronologically or developmentally. Mostoften enuresis is involuntary; when intentional, it is associatedwith a disruptive behavior disorder. Seventy-fivepercent of children with enuresis have a first-degree relativewho had the disorder. Most children with enuresis donot have a coexisting mental disorder.Both encopresis and enuresis are more common in boysthan in girls; 1% of all 5 year olds have encopresis, and 5%of all 5 year olds have enuresis. Encopresis can persist withintermittent exacerbations for years; it is rarely chronic.Most children with enuresis are continent by adolescence;only 1% of all cases persist into adulthood.Impairment associated with elimination disordersdepends on the limitations on the child’s social activities,effects on self-esteem, degree of social ostracism by peers,and anger, punishment, and rejection on the part of parentsor caregivers (APA, 2000).Enuresis can be treated effectively with imipramine (Tofranil),an antidepressant with a side effect of urinary retention.Both elimination disorders respond to behavioralapproaches such as a pad with a warning bell and to positivereinforcement for continence. For children with a disruptivebehavior disorder, psychological treatment of that disordermay improve the elimination disorder (Mikkelsen, 2005).Other Disorders of Infancy, Childhood,or AdolescenceSeparation Anxiety DisorderSeparation anxiety disorder is characterized by anxietyexceeding that expected for developmental level related toseparation from the home or those to whom the child isattached (APA, 2000). When apart from attachment figures,the child insists on knowing their whereabouts andmay need frequent contact with them, such as phone calls.These children are miserable away from home and mayfear never seeing their homes or loved ones again. Theyoften follow parents like a shadow, cannot be in a roomalone, and have trouble going to bed at night unless someonestays with them. Fear of separation may lead to avoidancebehaviors such as refusal to attend school or go onerrands. Separation anxiety disorder often is accompaniedby nightmares and multiple physical complaints such asheadaches, nausea, vomiting, and dizziness.Separation anxiety disorders are thought to result froman interaction between temperament and parenting behaviors.Inherited temperament traits such as passivity, avoidance,fearfulness, or shyness in novel situations coupledwith parenting behaviors that encourage avoidance as a wayto deal with strange or unknown situations are thought tocause anxiety in the child (Bernstein & Layne, 2005).

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 435Depending on the severity of the disorder, children mayhave academic difficulties and social withdrawal if theiravoidance behavior keeps them from school or relationshipswith others. Children may be described as demanding,intrusive, and in need of constant attention, or theymay be compliant and eager to please. As adults, they maybe slow to leave the family home or overly concernedabout and protective of their own spouses and children.They may continue to have marked discomfort when separatedfrom home or family. Parent education and familytherapy are essential components of treatment; 80%of children experience remission at 4-year follow-up(Bernstein & Layne, 2005).Selective MutismSelective mutism is characterized by persistent failure tospeak in social situations where speaking is expected suchas school (APA, 2000). Children may communicate bygestures, nodding or shaking the head, or occasionallyone-syllable vocalizations in a voice different from theirnatural voice. These children are often excessively shy,socially withdrawn or isolated, and clinging; they mayhave temper tantrums. Selective mutism is rare and slightlymore common in girls than in boys. It usually lasts only afew months but may persist for years.Reactive Attachment DisorderReactive attachment disorder involves a markedly disturbedand developmentally inappropriate social relatednessin most situations. This disorder usually beginsbefore 5 years of age and is associated with grossly pathogeniccare such as parental neglect, abuse, or failure tomeet the child’s basic physical or emotional needs.Repeated changes in primary caregivers, such as multiplefoster care placements, also can prevent the formation ofstable attachments (APA, 2000). The disturbed socialrelatedness may be evidenced by the child’s failure to initiateor respond to social interaction (inhibited type) orindiscriminate sociability or lack of selectivity in choiceof attachment figures (disinhibited type). In the first type,the child will not cuddle or desire to be close to anyone.In the second type, the child’s response is the same to astranger or to a parent.Initially, treatment focuses on the child’s safety, includingremoval of the child from the home if neglect or abuseis found. Individual and family therapy (either with parentsor foster caregivers) is most effective. With earlyidentification and effective intervention, remission orconsiderable improvements can be attained. Otherwise,the disorder follows a continuous course, with relationshipproblems persisting into adulthood.Stereotypic Movement DisorderStereotypic movement disorder is associated with manygenetic, metabolic, and neurologic disorders and oftenaccompanies mental retardation. The precise cause isunknown. It involves repetitive motor behavior that isnonfunctional and either interferes with normal activitiesor results in self-injury requiring medical treatment (APA,2000). Stereotypic movements may include waving, rocking,twirling objects, biting fingernails, banging the head,biting or hitting oneself, or picking at the skin or bodyorifices. Generally speaking, the more severe the retardation,the higher the risk for self-injury behaviors. Stereotypicmovement behaviors are relatively stable over timebut may diminish with age (Shah, 2005).No specific treatment has been shown effective.Clomipramine (Anafranil) and desipramine (Norpramin)are effective in treating severe nail biting; haloperidol(Haldol) and chlorpromazine (Thorazine) have beeneffective for stereotypic movement disorder associatedwith mental retardation and autistic disorder.SELF-AWARENESS ISSUESWorking with children and adolescents can beboth rewarding and difficult. Many disordersof childhood such as severe developmentaldisorders severely limit the child’s abilities. Itmay be difficult for the nurse to remain positive with thechild and parents when the prognosis for improvement ispoor. Even in overwhelming and depressing situations,the nurse has an opportunity to positively influence childrenand adolescents, who are still in crucial phases ofdevelopment. The nurse often can help these clientsto develop coping mechanisms they will use throughoutadulthood.Working with parents is a crucial aspect of dealing withchildren with these disorders. Parents often have the mostinfluence on how these children learn to cope with theirdisorders. The nurse’s beliefs and values about raising childrenaffect how he or she deals with children and parents.The nurse must not be overly critical about how parentshandle their children’s problems until the situation is fullyunderstood: Caring for a child as a nurse is very differentfrom being responsible around the clock. Given their ownskills and problems, parents often give their best efforts.Given the opportunity, resources, support, and education,many parents can improve their parenting.Points to Consider When Workingwith Children and Adolescents andTheir Parents• Remember to focus on the client’s and parents’ strengthsand assets, not just their problems.• Support parents’ efforts to remain hopeful while dealingwith the reality of their child’s situation.• Ask parents how they are doing. Offer to answer questions,and provide support or make referrals to meettheir needs as well as those of the client.

436UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSCritical Thinking Questions1. There are numerous internet sites addressing autismspectrum disorders—some are legitimate sites with accurateinformation, others are sites that include inaccurateinformation, speculation and conjecturepresented as fact which can confuse and mislead parents.How can you help parents learn to evaluate internetsites and the information they present?2. What values or beliefs about child rearing and familiesdo you have as a result of your own experiences growingup? Have these values and beliefs changed overtime? If so, how?KEY POINTS• Psychiatric disorders are more difficult todiagnose in children than in adults becausetheir basic development is incomplete andchildren may lack the ability to recognizeor to describe what they are experiencing.• Children and adolescents can experience some of thesame mental health problems seen in adults such as depression,bipolar disorder, and anxiety.• The disorders of childhood and adolescence most oftenencountered in mental health settings include pervasivedevelopmental disorders, ADHD, and disruptive behaviordisorders.• Mental retardation involves below-average intellectualfunctioning (IQ below 70) and is accompanied by significantlimitations in adaptive functioning such ascommunication, self-care, self-direction, academicachievement, work, and health and safety. The degree ofimpairment is directly related to the IQ.• Learning disorders include categories for substandardachievement in reading, mathematics, and written expression.They are treated through special education inschools.• Communication disorders may be expressive or receptiveand expressive. They primarily involve articulationor stuttering and are treated by speech and languagetherapists.• Pervasive developmental disorders are characterized bysevere impairment of reciprocal social interaction skills,communication deviance, and restricted stereotypedbehavioral patterns.• Children with autism, the best known of the pervasivedevelopmental disorders, seem detached and make littleeye contact with, and few facial expressions towardothers. They do not relate to peers or parents, lackspontaneous enjoyment, and cannot engage in play ormake-believe with toys. Autism often is treated withbehavioral approaches. Months or years of treatmentmay be needed before positive outcomes appear.• The essential feature of ADHD is a persistent pattern ofinattention and/or hyperactivity and impulsivity. ADHD,the most common disorder of childhood, results in pooracademic performance, strained family relations, andrejection by peers.• Interventions for ADHD include a combination of medication,behavioral interventions, and parental education.Often, special educational assistance is needed tohelp with academic achievement.• Conduct disorder, the most common disruptive behaviordisorder, is characterized by aggression to peopleand animals, destruction of property, deceitfulness andtheft, and serious violation of rules.• Interventions for conduct disorder include decreasingviolent behavior, increasing compliance, improvingcoping skills and self-esteem, promoting social interaction,and educating and supporting parents.• Feeding and eating disorders of infancy and childhoodinclude pica, rumination, and feeding disorders. Picaand rumination often improve with time, and most casesof feeding disorders can be successfully treated.• Tic disorders involve various combinations of involuntaryvocal and/or motor tics. Tourette’s disorder is mostcommon. Tic disorders are usually treated successfullywith atypical antipsychotic medications.• Elimination disorders cause impairment for the childbased on the response of parents, the level of self-esteem,and the degree of ostracism by peers.REFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Antai-Otong, D. (2008). The art of prescribing pharmacological managementof adult ADHD: Implications for care. Perspectives in PsychiatricCare, 44(3), 196–201.Bernstein, G. A., & Layne, A. E. (2005). Separation anxiety disorder andother anxiety disorders. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (8th ed., pp. 3292–3302).Philadelphia: Lippincott Williams & Wilkins.Cheng, J. Y., Chen, R. Y., Ko, J. S., & Ng, E. M. (2007). Efficacy andsafety of atomoxetine for attention deficit/hyperactivity disorder inchildren and adolescents—a meta-analysis and meta-regressionanalysis. Psychopharmacology, 194(4), 197–209.Cable News Network (CNN). 2009. Vaccines didn’t cause autism, courtrules. Retrieved March 10, 2009 at http://www.cnn.com/2009/HEALTH/02/12/autism.vaccines.Dang, M. T., Warrington, D., Tung, T., Baker, D., & Pan, R. J. (2007). Aschool-based approach to early identification and management ofstudents with ADHD. Journal of School Nursing, 23(1), 2–12.Disney, E. R., Iacono, W., McGue, M., Tully, E., & Legrand, L. (2008).Strengthening the case: Prenatal alcohol exposure is associated withincreased risk for conduct disorder. Pediatrics, 122(6), e1225–e1230.Eisen, A. R., Raleigh, H., & Neuhoff, C. C. (2008). The unique mpact ofparent training for separation anxiety in children. Behavior Therapy,39(2), 195–206.Hechtman, L. (2005). Attention deficit disorders. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed.,pp. 3183–3198). Philadelphia: Lippincott Williams & Wilkins.Hojman, H. (2008). The danger of shortcuts in diagnosing children andadolescents. The Brown University Child and Adolescent BehaviorLetter, 24(7), 1–8.

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS 437INTERNET RESOURCESRESOURCES• Administration on Developmental Disabilities• American Academy of Child and Adolescent Psychiatry• Center for the Study of Autism• Children and Adults with Attention Deficit Disorders(CHADD)• Parent Support Groups• National Attention Deficit Disorder Association• National Center for Learning Disabilities• Tourette Syndrome Association, Inc.INTERNET ADDRESShttp://www.acf.dhhs.gov/programs/addhttp://www.aacap.org/http://www.autism.comhttp://www.chadd.org/http://www.conductdisorders.comhttp://www.add.orghttp://www.ncld.orghttp://www.tsa-usa.orgJohnson, C. J., & Beitchman, J. H. (2005). Communication disorders. InB. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(8th ed., pp. 3136–3154). Philadelphia: Lippincott Williams& Wilkins.King, B. H., Hodapp, R. M., & Dykens, E. M. (2005). Mental retardation.In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (8th ed., pp. 3076–3106). Philadelphia: LippincottWilliams & Wilkins.Lehne, R. A. (2006). Pharmacology for nursing care (6th ed.). Philadelphia:W. B. Saunders.McGuinness, T. M. (2006). Update on conduct disorder. Journal ofPsychosocial Nursing, 44(12), 21–25.Mikkelsen, E. J. (2005). Elimination disorders. In B. J. Sadock & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed.,pp. 3237–3246). Philadelphia: Lippincott Williams & Wilkins.Myers, S. M., & Johnson, C. P. (2007). Management of children withautism spectrum disorders. Pediatrics, 120(5), 1162–1182.National Institute of Child Health and Human Development. (2006).Available at http://www.nichd.nih.gov/publications/pubs/autismfacts.pdf.Pataki, C. S. (2005). Normal adolescence. In B. J. Sadock & V. A. Sadock(Eds.), Comprehensive textbook of psychiatry (8th ed., pp. 3035–3043).Philadelphia: Lippincott Williams & Wilkins.Pataki, C. S., & Spence, S. J. (2005). Motor skills disorder: Developmentalcoordination disorder. In B. J. Sadock & V. A. Sadock (Eds.),Comprehensive textbook of psychiatry (8th ed., pp. 3130–3135).Philadelphia: Lippincott Williams & Wilkins.Pierce, C. D., & Reid, R. (2004). Attention deficit hyperactivity disorder:Assessment and treatment of children from culturally different groups.Seminars in Speech and Language, 25(3), 233–240.Rowe, D. L., & Hermens, D. F. (2006). Attention-deficit/hyperactivitydisorder: Neurophysiology, information processing, arousal, and drugdevelopment. Expert Review of Neurotherapeutics, 6(11), 1721–1734.Scahill, L., & Leckman, J. F. (2005). Tic disorders. In B. J. Sadock & V.A. Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed.,pp. 3228–3236). Philadelphia: Lippincott Williams & Wilkins.Shah, B. G. (2005). Stereotypic movement disorder of infancy. In B. J. Sadock& V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(8th ed., pp. 3254–3257). Philadelphia: Lippincott Williams & Wilkins.Swanson, J. M. (2000). The SNAP-IV Teacher and Parent Rating Scale.Available at http://www.adhd.net/snap-iv-form.pdf.Thomas, C. R. (2005). Disruptive behavior disorders. In B. J. Sadock& V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed.,pp. 3205–3216). Philadelphia: Lippincott Williams & Wilkins.Turner, K. M., & Sanders, M. R. (2006). Help when it’s needed first: Acontrolled evaluations of brief, preventive behavioral family interventionin a primary care setting. Behavior Therapy, 37(2), 131–142.Volkmar, F. R., Klin, A., & Schultz, R. T. (2005). Pervasive developmentaldisorders. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensivetextbook of psychiatry (8th ed., pp. 3164–3182). Philadelphia:Lippincott Williams & Wilkins.Yeh, M., Hough, R. L., McCabe, K., Lau, A., & Garland, A. (2004).Parental beliefs about the causes of child problems: Exploring racial/ethnic patterns. Journal of the American Academy of Child andAdolescent Psychiatry, 43(5), 605–612.ADDITIONAL READINGSBoylen, K., Vaillancourt, T., Boyle, M., & Szatmari, P. (2007). Comorbidityof internalizing disorders in children with oppositional defiant disorder.European Child & Adolescent Psychiatry, 16(8), 484–494.Gordon, M. F. (2005). Normal child development. In B. J. Sadock & V.A. Sadock (Eds.), Comprehensive textbook of psychiatry (8th ed., pp.3018–3035). Philadelphia: Lippincott Williams & Wilkins.Kolar, K. R., & Davey, D. (2007). Silent victims: Children exposed tofamily violence. Journal of School Nursing, 23(2), 86–91.Pataki, C. S. (2005). Child psychiatry: Introduction and overview. In B. J.Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(8th ed., pp. 3015–3017). Philadelphia: Lippincott Williams & Wilkins.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. A child is taking pemoline (Cylert) for ADHD. Thenurse must be aware of which of the following sideeffects?a. Decreased thyroid-stimulating hormoneb. Decreased red blood cell countc. Elevated white blood cell countd. Elevated liver function tests2. Teaching for methylphenidate (Ritalin) should includewhich of the following?a. Give the medication after mealsb. Give the medication when the child becomesoveractivec. Increase the child’s fluid intake when he or she istaking the medicationd. Take the child’s temperature daily3. The nurse would expect to see all the following symptomsin a child with ADHD excepta. Easily distracted and forgetfulb. Excessive running, climbing, and fidgetingc. Moody, sullen, and pouting behaviord. Interrupts others and can’t take turns4. Which of the following is normal adolescent behavior?a. Critical of self and othersb. Defiant, negative, and depressed behaviorc. Frequent hypochondriacal complaintsd. Unwillingness to assume greater autonomy5. Which of the following is used to treat enuresis?a. Imipramine (Tofranil)b. Methylphenidate (Ritalin)c. Olanzapine (Zyprexa)d. Risperidone (Risperdal)6. An effective nursing intervention for the impulsive andaggressive behaviors that accompany conduct disorder isa. Assertiveness trainingb. Consistent limit settingc. Negotiation of rulesd. Open expression of feelings7. The nurse recognizes which of the following as a commonbehavioral sign of autism?a. Clinging behavior toward parentsb. Creative imaginative play with peersc. Early language developmentd. Indifference to being hugged or heldMULTIPLE-RESPONSE QUESTIONSSelect all that apply.1. The nurse understands that effective limit setting forchildren includesa. Allowing the child to participate in defining limitsb. Consistent enforcement of limit by entire teamc. Explaining the consequences of exceeding limitsd. Informing the child of the rule or limite. Negotiation of reasonable requests for change inlimitsf. Providing three or four cues or prompts to follow theestablished limit2. A teaching plan for the parents of a child with ADHDshould includea. Allow as much time as needed to complete any taskb. Allow the child to decide when to do homeworkc. Give instructions in short simple stepsd. Keep track of positive comments the child is givene. Provide a reward system for completion of dailytasksf. Spend time at the end of the day reviewing the child’sbehavior438

CHAPTER 20 • CHILD AND ADOLESCENT DISORDERS439CLINICAL EXAMPLEDixie, 7 years of age, has been brought by her parents to the mental health center becauseshe has been very rough with her 18-month-old brother. She cannot sit still at school or atmeals and is beginning to fall behind academically in the first grade. Her parents report thatthey have “tried everything,” but Dixie will not listen to them. She cannot follow directions,pick up toys, or get ready for school on time.After a thorough examination of Dixie and a lengthy interview with the parents, the psychiatristdiagnoses ADHD and prescribes methylphenidate (Ritalin), 10 mg in the morning,5 mg at noon, and 5 mg in the afternoon. The nurse meets with the parents to provideteaching and to answer questions before they go home.1. What teaching will the nurse include about methylphenidate?2. What information will the nurse provide about ADHD?3. What suggestions for managing the home environment might be helpful for the parents?4. What referrals can the nurse make for Dixie and her parents?

21Cognitive DisordersLearning ObjectivesAfter reading this chapter, you should be able to1. Describe the characteristics of and risk factors for cognitive disorders.Key Terms• agnosia• Alzheimer’s disease• amnestic disorder• aphasia• apraxia• confabulation• Creutzfeldt–Jakob disease• delirium• dementia• distraction• echolalia• executive functioning• going along• Huntington’s disease• Korsakoff’s syndrome• palilalia• Parkinson’s disease• Pick’s disease• reframing• reminiscence therapy• supportive touch• time away• vascular dementia2. Distinguish between delirium and dementia in terms of symptoms, course,treatment, and prognosis.3. Apply the nursing process to the care of clients with cognitive disorders.4. Identify methods for meeting the needs of people who provide care toclients with dementia.5. Provide education to clients, families, caregivers, and community membersto increase knowledge and understanding of cognitive disorders.6. Evaluate your feelings, beliefs, and attitudes regarding clients with cognitivedisorders.COGNITION IS THE BRAIN’S ability to process, retain, and use information.Cognitive abilities include reasoning, judgment, perception, attention,comprehension, and memory. These cognitive abilities are essential formany important tasks, including making decisions, solving problems, interpretingthe environment, and learning new information.A cognitive disorder is a disruption or impairment in these higher-levelfunctions of the brain. Cognitive disorders can have devastating effects onthe ability to function in daily life. They can cause people to forget thenames of immediate family members, to be unable to perform daily householdtasks, and to neglect personal hygiene (Davis, 2005).The primary categories of cognitive disorders are delirium, dementia,and amnestic disorders. All involve impairment of cognition, but they varywith respect to cause, treatment, prognosis, and effect on clients and familymembers or caregivers. This chapter focuses on delirium and dementia.It emphasizes not only the care of clients with cognitive disorders but alsothe needs of their caregivers.440Visit thePoint http://thePoint.lww.com for NCLEX-style questions, journal articles,and more!

CHAPTER 21 • COGNITIVE DISORDERS 441DELIRIUMDelirium is a syndrome that involves a disturbance of consciousnessaccompanied by a change in cognition. Deliriumusually develops over a short period, sometimes a matter ofhours, and fluctuates, or changes, throughout the course ofthe day. Clients with delirium have difficulty paying attention,are easily distracted and disoriented, and may havesensory disturbances such as illusions, misinterpretations,or hallucinations. An electrical cord on the floor mayappear to them to be a snake (illusion). They may mistakethe banging of a laundry cart in the hallway for a gunshot(misinterpretation). They may see “angels” hovering abovewhen nothing is there (hallucination). At times, they alsoexperience disturbances in the sleep–wake cycle, changesin psychomotor activity, and emotional problems such asanxiety, fear, irritability, euphoria, or apathy (AmericanPsychiatric Association [APA], 2000).An estimated 10% to 15% of people in the hospital forgeneral medical conditions are delirious at any given time.Delirium is common in older acutely ill clients. An estimated30% to 50% of acutely ill older adult clients becomedelirious at some time during their hospital stay. Risk factorsfor delirium include increased severity of physical illness,older age, and baseline cognitive impairment such asthat seen in dementia (Samuels & Neugroschl, 2005).Children may be more susceptible to delirium, especiallythat related to a febrile illness or certain medications suchas anticholinergics (APA, 2000).EtiologyDelirium almost always results from an identifiablephysiologic, metabolic, or cerebral disturbance orDSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Delirium• Difficulty with attention• Easily distractible• Disoriented• May have sensory disturbances such as illusions,misinterpretations, or hallucinations• Can have sleep–wake cycle disturbances• Changes in psychomotor activity• May experience anxiety, fear, irritability, euphoria,or apathyAdapted from DSM-IV-TR, 2000.disease or from drug intoxication or withdrawal. Themost common causes are listed in Box 21.1. Often, deliriumresults from multiple causes and requires a carefuland thorough physical examination and laboratory testsfor identification.Cultural ConsiderationsPeople from different cultural backgrounds may not befamiliar with the information requested to assess memory,such as the name of former U.S. presidents. Other culturesmay consider orientation to placement and location differently.Also, some cultures and religions, such as Jehovah’sWitnesses, do not celebrate birthdays, so clients may havedifficulty stating their date of birth. The nurse should notCLINICAL VIGNETTE: DELIRIUMOn a hot and humid August afternoon, the 911 dispatcherreceived a call requesting an ambulance for an elderly womanwho had collapsed on the sidewalk in a residential area.According to neighbors gathered at the scene, the womanhad been wandering around the neighborhood since earlymorning. No one recognized her and several people had triedto approach her to offer help or give directions. She wouldnot or could not give her name or address; much of herspeech was garbled and hard to understand. She was notcarrying a purse or identification. She finally collapsed andappeared unconscious, so they called emergency services.The woman was taken to the emergency room. She wasperspiring profusely, was found to have a fever of 103.2°F,and was grossly dehydrated. Intravenous therapy wasstarted to replenish fluids and electrolytes. A coolingblanket was applied to lower her temperature, and she wasmonitored closely over the next several hours. As thewoman began to regain consciousness, she was confusedand could not provide any useful information about herself.Her speech remained garbled and confused. Several timesshe attempted to climb out of the bed and remove her intravenousdevice, so restraints were used to prevent injuryand to allow treatment to continue.By the end of the second day in the hospital, she couldaccurately give her name, address, and some of the circumstancessurrounding the incident. She remembered she hadbeen gardening in her backyard in the sun and felt very hot.She remembered thinking she should go back in the houseto get a cold drink and rest. That was the last thing sheremembered.

442UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSBox 21.1 MOST COMMON CAUSES OF DELIRIUMPhysiologic or metabolicInfectionDrug-relatedHypoxemia, electrolyte disturbances, renal or hepatic failure, hypoglycemia or hyperglycemia,dehydration, sleep deprivation, thyroid or glucocorticoid disturbances, thiamine orvitamin B 12deficiency, vitamin C, niacin, or protein deficiency, cardiovascular shock,brain tumor, head injury, and exposure to gasoline, paint solvents, insecticides, andrelated substancesSystemic: sepsis, urinary tract infection, pneumoniaCerebral: meningitis, encephalitis, HIV, syphilisIntoxication: anticholinergics, lithium, alcohol, sedatives, and hypnoticsWithdrawal: alcohol, sedatives, and hypnoticsReactions to anesthesia, prescription medication, or illicit (street) drugsCompiled from Samuels, S. C., & Neugroschl, J. A. (2005). Delirium. In B. J. Sadock, & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1,8th ed., pp. 1054–1068). Philadelphia: Lippincott Williams & Wilkins; Ribby, K. J., & Cox, K. R. (1996). Development, implementation, and evaluation of aconfusion protocol. Clinical Nurse Specialist, 10(5), 241–247.mistake failure to know such information for disorientation(APA, 2000).Treatment and PrognosisThe primary treatment for delirium is to identify and treatany causal or contributing medical conditions. Delirium isalmost always a transient condition that clears with successfultreatment of the underlying cause. Nevertheless,some causes such as head injury or encephalitis may leaveclients with cognitive, behavioral, or emotional impairmentseven after the underlying cause resolves.PsychopharmacologyClients with quiet, hypoactive delirium need no specificpharmacologic treatment aside from that indicated for thecausative condition. Many clients with delirium, however,show persistent or intermittent psychomotor agitationthat can interfere with effective treatment or pose a risk tosafety. Sedation to prevent inadvertent self-injury may beindicated. An antipsychotic medication, such as haloperidol(Haldol), may be used in doses of 0.5 to 1 mg todecrease agitation. Sedatives and benzodiazepines areavoided because they may worsen delirium (Samuels &Neugroschl, 2005). Clients with impaired liver or kidneyfunction could have difficulty metabolizing or excretingsedatives. The exception is delirium induced by alcoholwithdrawal, which usually is treated with benzodiazepines(see Chapter 17).Other Medical TreatmentWhile the underlying causes of delirium are being treated,clients also may need other supportive physical measures.Adequate nutritious food and fluid intake speed recovery.Intravenous fluids or even total parenteral nutrition maybe necessary if a client’s physical condition has deterioratedand he or she cannot eat and drink.If a client becomes agitated and threatens to dislodgeintravenous tubing or catheters, physical restraints may benecessary so that needed medical treatments can continue.Restraints are used only when necessary and stay in placeno longer than warranted because they may increase theclient’s agitation.APPLICATION OF THE NURSINGPROCESS: DELIRIUMNursing care for clients with delirium focuses on meetingtheir physiologic and psychologic needs and maintainingtheir safety. Behavior, mood, and level of consciousnessof these clients can fluctuate rapidlythroughout the day. Therefore, the nurse must assess themcontinuously to recognize changes and to plan nursingcare accordingly.AssessmentHistoryBecause the causes of delirium are often related to medicalillness, alcohol, or other drugs, the nurse obtains a thoroughhistory of these areas. The nurse may need to obtaininformation from family members if a client’s ability toprovide accurate data is impaired.Information about drugs should include prescribedmedications, alcohol, illicit drugs, and over-the-counter medications.Although many people perceive prescribed andover-the-counter medications as relatively safe, combinations

CHAPTER 21 • COGNITIVE DISORDERS 443Nursing Care Plan | DeliriumNursing DiagnosisAcute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotoractivity, level of consciousness, and/or sleep–wake cycle.ASSESSMENT DATA• Poor judgment• Cognitive impairment• Impaired memory• Lack of or limited insight• Loss of personal control• Inability to perceive harm• Illusions• Hallucinations• Mood swingsEXPECTED OUTCOMESImmediateThe client will• Engage in a trust relationship with staff andcaregiver• Be free of injury• Increase reality contact• Cooperate with treatmentStabilizationThe client will• Establish or follow a routine for activities of dailyliving• Demonstrate decreased confusion, illusions, orhallucinations• Experience minimal distress related to confusion• Validate perceptions with staff or caregiver beforetaking actionCommunityThe client will• Return to optimal level of functioning• Manage health conditions, if any, effectively• Seek medical treatment as neededIMPLEMENTATIONNursing InterventionsDo not allow the client to assume responsibility fordecisions or actions if he or she is unsafe.If limits on the client’s actions are necessary, explainlimits and reasons clearly, within the client’sability to understand.Involve the client in making plans or decisions asmuch as he or she is able to participate.Assess the client daily or more often if needed for hisor her level of functioning.Allow the client to make decisions as much as he orshe is able.Assist the client to establish a daily routine,including hygiene, activities, and so forth.RationaleThe client’s safety is a priority. He or she may beunable to determine harmful actions or situations.The client has the right to be informed of anyrestrictions and the reasons limits are needed.Compliance with treatment is enhanced if the clientis emotionally invested in it.Clients with organically based problems tend tofluctuate frequently in terms of their capabilities.Decision making increases the client’s participation,independence, and self-esteem.Routine or habitual activities do not require decisionsabout whether or not to perform a particular task.(continued)

444UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | Delirium, cont.IMPLEMENTATIONNursing InterventionsIn a matter-of-fact manner give the client factual feedbackon misperceptions, delusions, or hallucinations(e.g., “That is a chair.”) and convey that others donot share his or her interpretations (e.g., “I don’t seeanyone else in the room.”).Teach the client about underlying cause(s) of confusionand delirium.RationaleWhen given feedback in a nonjudgmental way, theclient can feel validated for his or her feelings,while recognizing that his or her perceptions arenot shared by others.Knowledge about the cause(s) of confusion can helpthe client seek assistance when indicated.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.or standard doses of medications can produce delirium, especiallyin older adults. Box 21.2 lists types of drugs that cancause delirium. Combinations of these drugs significantlyincrease risk.Box 21.2 DRUGS CAUSING DELIRIUMAnesthesiaAnticonvulsantsAnticholinergicsAntidepressantsAntihistaminesAntihypertensivesAntineoplasticsAntipsychoticsAspirinBarbituratesBenzodiazepinesCardiac glycosidesCimetidine (Tagamet)Hypoglycemic agentsInsulinNarcoticsPropranolol (Inderal)ReserpineSteroidsThiazide diureticsAdapted from Samuels, S. C., & Neugroschl, J. A. (2005). Delirium. In B. J.Sadock, and V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1054–1068). Philadelphia: Lippincott Williamsand Wilkins.General Appearance and Motor BehaviorClients with delirium often have a disturbance of psychomotorbehavior. They may be restless and hyperactive, frequentlypicking at bedclothes or making sudden, uncoordinatedattempts to get out of bed. Conversely, clients may haveslowed motor behavior, appearing sluggish and lethargic withlittle movement.Speech also may be affected, becoming less coherent andmore difficult to understand as delirium worsens. Clientsmay perseverate on a single topic or detail, may be ramblingand difficult to follow, or may have pressured speech that israpid, forced, and usually louder than normal. At times, clientsmay call out or scream, especially at night.Mood and AffectClients with delirium often have rapid and unpredictablemood shifts. A wide range of emotional responses is possible,such as anxiety, fear, irritability, anger, euphoria, andapathy. These mood shifts and emotions usually have nothingto do with the client’s environment. When clients areparticularly fearful and feel threatened, they may becomecombative to defend themselves from perceived harm.Thought Process and ContentAlthough clients with delirium have changes in cognition,it is difficult for the nurse to assess these changesaccurately and thoroughly. Marked inability to sustainattention makes it difficult to assess thought process andcontent. Thought content in delirium often is unrelatedto the situation, or speech is illogical and difficult tounderstand. The nurse may ask how clients are feeling,and they will mumble about the weather. Thought processesoften are disorganized and make no sense.Thoughts also may be fragmented (disjointed and incomplete).Clients may exhibit delusions, believing that theiraltered sensory perceptions are real.

CHAPTER 21 • COGNITIVE DISORDERS 445Sensorium and Intellectual ProcessesThe primary and often initial sign of delirium is an alteredlevel of consciousness that is seldom stable and usuallyfluctuates throughout the day. Clients usually are orientedto person but frequently disoriented to time and place.They demonstrate decreased awareness of the environmentor situation and instead may focus on irrelevantstimuli such as the color of the bedspread or the room.Noises, people, or sensory misperceptions easily distractthem.Clients cannot focus, sustain, or shift attention effectively,and there is impaired recent and immediate memory(APA, 2000). This means the nurse may have to ask questionsor provide directions repeatedly. Even then, clientsmay be unable to do what is requested.Clients frequently experience misinterpretations, illusions,and hallucinations. Both misperceptions and illusionsare based on some actual stimuli in the environment:clients may hear a door slam and interpret it as a gunshotor see the nurse reach for an intravenous bag and believethe nurse is about to strike them. Examples of commonillusions include clients believing that intravenous tubingor an electrical cord is a snake and mistaking the nurse fora family member. Hallucinations are most often visual: clients“see” things for which there is no stimulus in reality.Some clients, when more lucid, are aware that they areexperiencing sensory misperceptions. Others, however,actually believe their misinterpretations are correct andcannot be convinced otherwise.Judgment and InsightJudgment is impaired. Clients often cannot perceive potentiallyharmful situations or act in their own best interests.For example, they may try repeatedly to pull out intravenoustubing or urinary catheters; this causes pain andinterferes with necessary treatment.Insight depends on the severity of the delirium. Clientswith mild delirium may recognize that they are confused,are receiving treatment, and will likely improve.Those with severe delirium may have no insight into thesituation.Roles and RelationshipsClients are unlikely to fulfill their roles during the courseof delirium. Most regain their previous level of functioning,however, and have no longstanding problems withroles or relationships.Self-ConceptAlthough delirium has no direct effect on self-concept, clientsoften are frightened or feel threatened. Those withsome awareness of the situation may feel helpless or powerlessto do anything to change it. If delirium has resultedfrom alcohol, illicit drug use, or overuse of prescribedmedications, clients may feel guilt, shame, and humiliationor think, “I’m a bad person; I did this to myself.” Thiswould indicate possible long-term problems with selfconcept.Physiologic and Self-Care ConsiderationsClients with delirium most often experience disturbedsleep–wake cycles that may include difficulty falling asleep,daytime sleepiness, nighttime agitation, or even a completereversal of the usual daytime waking/nighttime sleepingpattern (APA, 2000). At times, clients also ignore orfail to perceive internal body cues such as hunger, thirst,or the urge to urinate or defecate.IllusionData AnalysisThe primary nursing diagnoses for clients with deliriumare as follows:• Risk for Injury• Acute ConfusionAdditional diagnoses that are commonly selected basedon client assessment include the following:• Disturbed Sensory Perception• Disturbed Thought Processes• Disturbed Sleep Pattern• Risk for Deficient Fluid Volume• Risk for Imbalanced Nutrition: Less Than BodyRequirements

446UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSOutcome IdentificationTreatment outcomes for the client with delirium mayinclude the following:• The client will be free of injury.• The client will demonstrate increased orientation andreality contact.• The client will maintain an adequate balance of activityand rest.• The client will maintain adequate nutrition and fluidbalance.• The client will return to his or her optimal level offunctioning.InterventionPromoting the Client’s SafetyMaintaining the client’s safety is the priority focus of nursinginterventions. Medications should be used judiciouslybecause sedatives may worsen confusion and increase therisk for falls or other injuries (Samuels & Neugroschl,2005).The nurse teaches clients to request assistance for activitiessuch as getting out of bed or going to the bathroom. Ifclients cannot request assistance, they require close supervisionto prevent them from attempting activities they cannotperform safely alone. The nurse responds promptly tocalls from clients for assistance and checks clients at frequentintervals.If a client is agitated or pulling at intravenous lines orcatheters, physical restraints may be necessary. Use ofrestraints, however, may increase the client’s fears orCLIENT/FAMILY EDUCATIONfor DeliriumMonitor chronic health conditions carefully.Visit physician regularly.Tell all physicians and health care providers whatmedications are taken, including over-the-countermedications, dietary supplements, and herbalpreparations.Check with physician before taking any nonprescriptionmedication.Avoid alcohol and recreational drugs.Maintain a nutritious diet.Get adequate sleep.Use safety precautions when working with paint solvents,insecticides, and similar products.feelings of being threatened, so restraints are a last resort.The nurse first tries other strategies such as having a familymember stay with the client to reassure him or her.Managing the Client’s ConfusionThe nurse approaches these clients calmly and speaks in aclear low voice. It is important to give realistic reassuranceto clients, such as“I know things are upsetting and confusing rightnow, but your confusion should clear as you getbetter.” (validating/giving information)NURSING INTERVENTIONSfor Delirium• Promoting client’s safetyTeach client to request assistance for activities (gettingout of bed, going to bathroom).Provide close supervision to ensure safety during theseactivities.Promptly respond to client’s call for assistance.• Managing client’s confusionSpeak to client in a calm manner in a clear low voice;use simple sentences.Allow adequate time for client to comprehend andrespond.Allow client to make decisions as much as able.Provide orienting verbal cues when talking with client.Use supportive touch if appropriate.• Controlling environment to reduce sensoryoverloadKeep environmental noise to minimum (television, radio).Monitor client’s response to visitors; explain to familyand friends that client may need to visit quietly oneon one.Validate client’s anxiety and fears, but do not reinforcemisperceptions.• Promoting sleep and proper nutritionMonitor sleep and elimination patterns.Monitor food and fluid intake; provide prompts orassistance to eat and drink adequate amounts offood and fluids.Provide periodic assistance to bathroom if client doesnot make requests.Discourage daytime napping to help sleep at night.Encourage some exercise during day like sitting in achair, walking in hall, or other activities client canmanage.

CHAPTER 21 • COGNITIVE DISORDERS 447Facing clients while speaking helps to capture theirattention. The nurse provides explanations that clients cancomprehend, avoiding lengthy or too detailed discussions.The nurse phrases questions or provides directions to clientsin short, simple sentences, allowing adequate time forclients to grasp the content or to respond to a question. Heor she permits clients to make decisions as they are ableand takes care not to overwhelm or frustrate them.The nurse provides orienting cues when talking with clients,such as calling them by name and referring to the time ofday or expected activity. For example, the nurse might say,“Good morning, Mrs. Jones. I see you are awakeand look ready for breakfast.” (givinginformation)Reminding the client of the nurse’s name and role repeatedlymay be necessary, such as“My name is Sheila, and I’m your nurse today.I’m here now to walk in the hall with you.” (realityorientation)Orienting objects such as a calendar and clock in theclient’s room are useful.Often, the use of touch reassures clients and providescontact with reality. It is important to evaluate each client’sresponse to touch rather than to assume all clients welcomeit. A client who smiles or draws closer to the nursewhen touched is responding positively. The fearful clientmay perceive touch as threatening rather than comfortingand startle or draw away.Clients with delirium can experience sensory overload,which means more stimulation is coming into the brainthan they can handle. Reducing environmental stimulationis helpful because these clients are distracted and overstimulatedeasily. Minimizing environmental noises, includingtelevision or radio, should calm them. It is also important tomonitor response to visitors. Too many visitors or morethan one person talking at once may increase the client’sconfusion. The nurse can explain to visitors that the clientwill best tolerate quiet talking with one person at a time.The client’s room should be well lit to minimize environmentalmisperceptions. When clients experience illusionsor misperceptions, the nurse corrects them matter-of-factly.It is important to validate the client’s feelings of anxiety orfear generated by the misperception but not to reinforce thatmisperception. For example, a client hears a loud noise inthe hall and asks the nurse, “Was that an explosion?” Thenurse might respond,“No, that was a cart banging in the hall. It wasreally loud, wasn’t it? It startled me a littlewhen I heard it.” (presenting reality/validatingfeelings)Promoting Sleep and Proper NutritionThe nurse monitors the client’s sleep and elimination patternsand food and fluid intake. Clients may require promptingor assistance to eat and drink adequate food and fluids.It may be helpful to sit with clients at meals or to frequentlyoffer fluids. Family members also may be able to help clientsto improve their intake. Assisting clients to the bathroomperiodically may be necessary to promote eliminationif clients do not make these requests independently.Promoting a balance of rest and sleep is important ifclients are experiencing a disturbed sleep pattern. Discouragingor limiting daytime napping may improve abilityto sleep at night. It is also important for clients to havesome exercise during the day to promote nighttime sleep.Activities could include sitting in a chair, walking in thehall, or engaging in diversional activities (as possible).EvaluationUsually, successful treatment of the underlying causes ofdelirium returns clients to their previous levels of functioning.Clients and caregivers or family must understandwhat health care practices are necessary to avoid a recurrence.This may involve monitoring a chronic health condition,using medications carefully, or abstaining fromalcohol or other drugs.COMMUNITY-BASED CAREEven when the cause of delirium is identified and treated,clients may not regain all cognitive functions, or problemswith confusion may persist. Because delirium and dementiafrequently occur together, clients may have dementia. Athorough medical evaluation can confirm dementia, andappropriate treatment and care can be initiated (see thefollowing section).When delirium has cleared and any other diagnoses havebeen eliminated, it may be necessary for the nurse or otherhealth care professionals to initiate referrals to home health,visiting nurses, or a rehabilitation program if clients continueto experience cognitive problems. Various communityprograms provide such care, including adult day care orresidential care. Clients who have ongoing cognitive deficitsafter an episode of delirium may have difficulties similar tothose of clients with head injuries or mild dementia. Clientsand family members or caregivers might benefit from supportgroups to help them deal with the changes in personalityand remaining cognitive or motor deficits.DEMENTIADementia is a mental disorder that involves multiple cognitivedeficits, primarily memory impairment, and at leastone of the following cognitive disturbances (APA, 2000):• Aphasia, which is deterioration of language function

448UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERS• Apraxia, which is impaired ability to execute motorfunctions despite intact motor abilities• Agnosia, which is inability to recognize or name objectsdespite intact sensory abilities• Disturbance in executive functioning, which is theability to think abstractly and to plan, initiate, sequence,monitor, and stop complex behaviorThese cognitive deficits must be sufficiently severe toimpair social or occupational functioning and must representa decline from previous functioning.Dementia must be distinguished from delirium; if thetwo diagnoses coexist, the symptoms of dementia remaineven when the delirium has cleared. Table 21.1 comparesdelirium and dementia.Memory impairment is the prominent early sign ofdementia. Clients have difficulty learning new materialand forget previously learned material. Initially, recentmemory is impaired—for example, forgetting where certainobjects were placed or that food is cooking on thestove. In later stages, dementia affects remote memory; clientsforget the names of adult children, their lifelong occupations,and even their names.Aphasia usually begins with the inability to name familiarobjects or people and then progresses to speech that becomesvague or empty with excessive use of terms such as it orthing. Clients may exhibit echolalia (echoing what is heard)or palilalia (repeating words or sounds over and over) (APA,2000). Apraxia may cause clients to lose the ability to performroutine self-care activities such as dressing or cooking.Agnosia is frustrating for clients: they may look at a table andchair but are unable to name them. Disturbances in executivefunctioning are evident as clients lose the ability to learnMultiple cognitive deficits of dementianew material, solve problems, or carry out daily activitiessuch as meal planning or budgeting.Clients with dementia also may underestimate the risksassociated with activities or overestimate their ability tofunction in certain situations. For example, while driving,clients may cut in front of other drivers, sideswipe parkedcars, or fail to slow down when they should.Table 21.1COMPARISON OF DELIRIUM AND DEMENTIAIndicator Delirium DementiaOnset Rapid Gradual and insidiousDuration Brief (hours to days) Progressive deteriorationLevel of consciousness Impaired, fluctuates Not affectedMemory Short-term memory impaired Short- then long-term memory impaired,eventually destroyedSpeechMay be slurred, rambling, pressured,irrelevantNormal in early stage, progressive aphasia inlater stageThought processes Temporarily disorganized Impaired thinking, eventual loss of thinkingabilitiesPerception Visual or tactile hallucinations, delusions Often absent, but can have paranoia, hallucinations,illusionsMoodAnxious, fearful if hallucinating; weeping,irritableDepressed and anxious in early stage, labilemood, restless pacing, angry outbursts inlater stagesAdapted from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: APA; Ribby,K. J., and Cox, K. R. (1996). Development, implementation, and evaluation of a confusion protocol. Clinical Nurse Specialist, 10(5), 241–247.

CHAPTER 21 • COGNITIVE DISORDERS 449CLINICAL VIGNETTE: DEMENTIAJack Smith, 74, and his wife, Marion, 69, have been livingin their home and managing fairly well until lately. TheSmiths have two grown-up children who live out of townbut visit about every 2 months and at holidays and birthdays.Jack recently had a stroke and entered a rehabilitationfacility to try to learn to walk and talk again. Marion wantedto stay at home and wait for his return. When the childrenwould call to check on her, she would often be crying andconfused or frightened. On one visit, they found her lookingvery tired and dressed in a wrinkled, soiled dress. She lookedas if she had lost weight, and she couldn’t remember whatshe had eaten for breakfast or lunch.Marion’s daughter remembered that before her fatherhad the stroke, she noticed that Jack had taken over severalroutine tasks her mother had always done, such as makingthe grocery list and planning and helping to cook theirmeals. Her mother seemed more forgetful and would askthe same questions over and over and often related thesame story several times during their visit.A few weeks after Jack entered the rehab center andMarion was living at home alone, the neighbors foundMarion wandering around the neighborhood one morninglost and confused. It was now clear to her children that theirmother could not remain in her home alone and take care ofherself. It was uncertain how long Jack would need toremain at the rehabilitation center, and they were not surewhat his physical capabilities would be when he did return.Her daughter decided that Marion (and eventually Jack)would come to live with her family. They moved her in withthem, but even after getting settled at her daughter’s home,Marion continued to be confused and often did not knowwhere she was. She kept asking where Jack was and forgother grandchildren’s names. At times, she grew agitated andwould accuse them of stealing her purse or other possessions.Later, she would always find them. Marion wouldsometimes forget to go to the bathroom and would soil herclothes. She would forget to brush her hair and teeth andtake a bath and often needed help with these activities.When her daughter came home from work in the evening,the sandwich she had made for her mother was often leftuntouched in the refrigerator. Marion spent much of hertime packing her bags to go home and “see Jack.”Onset and Clinical CourseWhen an underlying, treatable cause is not present, thecourse of dementia is usually progressive. Dementia oftenis described in stages:• Mild: Forgetfulness is the hallmark of beginning, mild dementia.It exceeds the normal, occasional forgetfulnessDSM-IV-TR DIAGNOSTIC CRITERIA:Symptoms of Dementia• Loss of memory (initial stages, recent memory losssuch as forgetting food cooking on the stove; laterstages, remote memory loss such as forgetting namesof children, occupation)• Deterioration of language function (forgetting namesof common objects such as chair or table, palilalia[echoing sounds], and echoing words that are heard[echolalia])• Loss of ability to think abstractly and to plan, initiate,sequence, monitor, or stop complex behaviors (loss ofexecutive function): the client loses the ability to performself-care activitiesAdapted from DSM-IV-TR, 2000.experienced as part of the aging process. The person hasdifficulty finding words, frequently loses objects, and beginsto experience anxiety about these losses. Occupationaland social settings are less enjoyable, and the personmay avoid them. Most people remain in the communityduring this stage.• Moderate: Confusion is apparent, along with progressivememory loss. The person no longer can perform complextasks but remains oriented to person and place. Heor she still recognizes familiar people. Toward the end ofthis stage, the person loses the ability to live independentlyand requires assistance because of disorientationto time and loss of information such as address and telephonenumber. The person may remain in the communityif adequate caregiver support is available, but somepeople move to supervised living situations.• Severe: Personality and emotional changes occur. Theperson may be delusional, wander at night, forget thenames of his or her spouse and children, and requireassistance in activities of daily living (ADLs). Most peoplelive in nursing facilities when they reach this stageunless extraordinary community support is available.EtiologyCauses vary, although the clinical picture is similar formost dementias. Often, no definitive diagnosis can bemade until completion of a postmortem examination.

450UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSMetabolic activity is decreased in the brains of clients withdementia; it is not known whether dementia causesdecreased metabolic activity or if decreased metabolicactivity results in dementia. A genetic component has beenidentified for some dementias such as Huntington’s disease.An abnormal APOE gene is known to be linked withAlzheimer’s disease. Other causes of dementia are relatedto infections such as human immunodeficiency virus(HIV) infection or Creutzfeldt–Jakob disease. The mostcommon types of dementia and their known or hypothesizedcauses follow (APA, 2000; Neugroschl et al., 2005):• Alzheimer’s disease is a progressive brain disorder thathas a gradual onset but causes an increasing decline infunctioning, including loss of speech, loss of motorfunction, and profound personality and behavioralchanges such as paranoia, delusions, hallucinations, inattentionto hygiene, and belligerence. It is evidencedby atrophy of cerebral neurons, senile plaque deposits,and enlargement of the third and fourth ventricles ofthe brain. Risk for Alzheimer’s disease increases withage, and average duration from onset of symptoms todeath is 8 to 10 years. Dementia of the Alzheimer’s type,especially with late onset (after 65 years of age), mayhave a genetic component. Research has shown linkagesto chromosomes 21, 14, and 19 (APA, 2000).• Vascular dementia has symptoms similar to those ofAlzheimer’s disease, but onset is typically abrupt, followedby rapid changes in functioning; a plateau, orleveling-off period; more abrupt changes; another leveling-offperiod; and so on. Computed tomography ormagnetic resonance imaging usually shows multiplevascular lesions of the cerebral cortex and subcorticalstructures resulting from the decreased blood supply tothe brain.• Pick’s disease is a degenerative brain disease that particularlyaffects the frontal and temporal lobes and resultsin a clinical picture similar to that of Alzheimer’sdisease. Early signs include personality changes, loss ofsocial skills and inhibitions, emotional blunting, andlanguage abnormalities. Onset is most commonly 50 to60 years of age; death occurs in 2 to 5 years.• Creutzfeldt–Jakob disease is a central nervous systemdisorder that typically develops in adults 40 to 60 yearsof age. It involves altered vision, loss of coordination orabnormal movements, and dementia that usually progressesrapidly (a few months). The cause of theencephalopathy is an infectious particle resistant toboiling, some disinfectants (e.g., formalin, alcohol),and ultraviolet radiation. Pressured autoclaving orbleach can inactivate the particle.• HIV infection can lead to dementia and other neurologicproblems; these may result directly from invasionof nervous tissue by HIV or from other acquired immunodeficiencysyndrome–related illnesses such as toxoplasmosisand cytomegalovirus. This type of dementiacan result in a wide variety of symptoms ranging frommild sensory impairment to gross memory and cognitivedeficits to severe muscle dysfunction.• Parkinson’s disease is a slowly progressive neurologiccondition characterized by tremor, rigidity, bradykinesia,and postural instability. It results from loss of neuronsof the basal ganglia. Dementia has been reported inapproximately 20% to 60% of people with Parkinson’sdisease and is characterized by cognitive and motorslowing, impaired memory, and impaired executivefunctioning.• Huntington’s disease is an inherited, dominant genedisease that primarily involves cerebral atrophy, demyelination,and enlargement of the brain ventricles. Initially,there are choreiform movements that arecontinuous during waking hours and involve facialcontortions, twisting, turning, and tongue movements.Personality changes are the initial psychosocial manifestations,followed by memory loss, decreased intellectualfunctioning, and other signs of dementia. Thedisease begins in the late 30s or early 40s and may last10 to 20 years or more before death.• Dementia can be a direct pathophysiologic consequenceof head trauma. The degree and type of cognitiveimpairment and behavioral disturbance depend on thelocation and extent of the brain injury. When it occursas a single injury, the dementia is usually stable ratherthan progressive. Repeated head injury (e.g., from boxing)may lead to progressive dementia.An estimated 5 million people in the United States havemoderate to severe dementia from various causes. Worldwide,it is estimated there are 4.6 million new cases eachyear (Smith, 2008). Prevalence rises with age: estimatedprevalence of moderate to severe dementia in people olderthan 65 years is about 5%; 20% to 40% of the general populationolder than 85 years have dementia. Predictions arethat by 2050, there will be 18 million Americans withdementia (Neugroschl et al., 2005) and 114 million peoplewith dementia worldwide (Smith, 2008). Dementia ofthe Alzheimer’s type is the most common type in NorthAmerica (60% of all dementias), Scandinavia, and Europe;vascular dementia is more prevalent in Russia and Japan.Dementia of the Alzheimer’s type is more common inwomen; vascular dementia is more common in men.Cultural ConsiderationsClients from other cultures may find the questions used onmany assessment tools for dementia difficult or impossibleto answer. Examples include the names of former U.S.presidents. To avoid drawing erroneous conclusions, thenurse must be aware of differences in the person’s knowledgebase.The nurse also must be aware of different culturallyinfluenced perspectives and beliefs about elderly family

CHAPTER 21 • COGNITIVE DISORDERS 451members. In many Eastern countries and among NativeAmericans, elders hold a position of authority, respect,power, and decision making for the family; this does notchange despite memory loss or confusion. For fear ofseeming disrespectful, other family members may be reluctantto make decisions or plans for elders with dementia.The nurse must work with family members to accomplishgoals without making them feel they have betrayed therevered elder.Treatment and PrognosisWhenever possible, the underlying cause of dementia isidentified so that treatment can be instituted. For example,the progress of vascular dementia, the second most commontype, may be halted with appropriate treatment of theunderlying vascular condition (e.g., changes in diet, exercise,control of hypertension, or diabetes). Improvementof cerebral blood flow may arrest the progress of vasculardementia in some people (Neugroschl et al., 2005).The prognosis for the progressive types of dementia mayvary as described earlier, but all prognoses involve progressivedeterioration of physical and mental abilities untildeath. Typically, in the later stages, clients have minimalcognitive and motor function, are totally dependent oncaregivers, and are unaware of their surroundings or peoplein the environment. They may be totally uncommunicativeor make unintelligible sounds or attempts to verbalize.For degenerative dementias, no direct therapies havebeen found to reverse or retard the fundamental pathophysiologicprocesses. Levels of numerous neurotransmitterssuch as acetylcholine, dopamine, norepinephrine, andserotonin are decreased in dementia. This has led toattempts at replenishment therapy with acetylcholineprecursors, cholinergic agonists, and cholinesterase inhibitors.Donepezil (Aricept), rivastigmine (Exelon), andgalantamine (Reminyl) are cholinesterase inhibitors andhave shown modest therapeutic effects and temporarilyslow the progress of dementia (Table 21.2). They have noeffect, however, on the overall course of the disease.Tacrine (Cognex) is also a cholinesterase inhibitor; however,it elevates liver enzymes in about 50% of clients usingit. Lab tests to assess liver function are necessary every 1 to2 weeks; therefore, tacrine is rarely prescribed. Memantine(Namenda) is an NMDA receptor antagonist that can slowthe progression of Alzheimer’s in the moderate or severestages (Facts and Comparisons, 2009).Clients with dementia demonstrate a broad range ofbehaviors that can be treated symptomatically. Doses ofmedications are one half to two thirds lower than usuallyprescribed. Antidepressants are effective for significantdepressive symptoms; however, they can cause delirium.SSRI antidepressants are used since they have fewer sideeffects. Antipsychotics, such as haloperidol (Haldol), olanzapine(Zyprexa), risperidone (Risperdal), and quetiapine(Seroquel), may be used to manage psychotic symptoms ofdelusions, hallucinations, or paranoia, and other behaviors,such as agitation or aggression. The potential benefitof antipsychotics must be weighed with the risks, such asan increased mortality rate, primarily from cardiovascularcomplications. Due to this increased risk, the FDA has notapproved antipsychotics for dementia treatment, and thereis a black box warning issued (Box 21.3). Lithium carbonate,carbamazepine (Tegretol), and valproic acid (Depakote)help to stabilize affective lability and to diminishaggressive outbursts. Benzodiazepines are used cautiouslybecause they may cause delirium and can worsen alreadycompromised cognitive abilities (Neugroschl et al., 2005).These medications are discussed in Chapter 2.Box 21.3 WARNINGBoth conventional and atypical antipsychotics are associatedwith an increased risk of mortality in elderly patientstreated for dementia-related psychosis.Table 21.2DRUGS USED TO TREAT DEMENTIAName Dosage Range and Route Nursing ConsiderationsDonepezil (Aricept) 5–10 mg orally per day Monitor for nausea, diarrhea, and insomnia.Test stools periodically for GI bleeding.Rivastigmine (Exelon) 3–12 mg orally per day divided into two doses Monitor for nausea, vomiting, abdominalpain, and loss of appetite.Galantamine (Reminyl) 16–32 mg orally per day divided into two doses Monitor for nausea, vomiting, loss ofappetite, dizziness, and syncope.Memantine (Namenda) 10–20 mg per day divided into two doses Monitor for hypertension, pain, headache,vomiting, constipation, and fatigue.Adapted from Facts and Comparisons. (2009). Drug facts and comparisons (63rd ed.). St. Louis: Wolters Kluwer.

452UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSAPPLICATION OF THE NURSINGPROCESS: DEMENTIAThis section focuses on caring for clients with progressivedementia, which is the most common type. The nurse canuse these guidelines as indicated for clients with dementiathat is not progressive.AssessmentThe assessment process may seem confusing and complicatedto clients with dementia. They may not know or mayforget the purpose of the interview. The nurse providessimple explanations as often as clients need them, such as“I’m asking these questions so the staff can see how yourhealth is.” Clients may become confused or tire easily, sofrequent breaks in the interview may be needed. It helps toask simple rather than compound questions and to allowclients ample time to answer.A mental status examination can provide informationabout the client’s cognitive abilities such as memory, concentration,and abstract information processing. Typically,the client is asked to interpret the meaning of a proverb,perform subtraction of figures without paper and pencil,recall the names of objects, make a complete sentence, andcopy two intersecting pentagons. Although this does notreplace a thorough assessment, it gives a cursory evaluationof the client’s cognitive abilities. It is important toremember that people with severe depression or psychosismay also be unable to perform some of these cognitivetasks correctly.HistoryConsidering the impairment of recent memory, clientsmay be unable to provide an accurate and thorough historyof the onset of problems. Interviews with family,friends, or caregivers may be necessary to obtain data.General Appearance and Motor BehaviorDementia progressively impairs the ability to carry onmeaningful conversation. Clients display aphasia whenthey cannot name familiar objects or people. Conversationbecomes repetitive because they often perseverate on oneidea. Eventually, speech may become slurred, followed bya total loss of language function.The initial finding with regard to motor behavior is theloss of ability to perform familiar tasks (apraxia) such asdressing or combing one’s hair, although actual motor abilitiesare intact. Clients cannot imitate the task when othersdemonstrate it for them. In the severe stage, clients mayexperience a gait disturbance that makes unassisted ambulationunsafe, if not impossible.Some clients with dementia show uninhibited behavior,including making inappropriate jokes, neglecting personalhygiene, showing undue familiarity with strangers, or disregardingsocial conventions for acceptable behavior. Thiscan include the use of profanity or making disparagingremarks about others when clients have never displayedthese behaviors before.Mood and AffectInitially, clients with dementia experience anxiety and fearover the beginning losses of memory and cognitive functions.Nevertheless, they may not express these feelings toanyone. Mood becomes more labile over time and mayshift rapidly and drastically for no apparent reason. Emotionaloutbursts are common and usually pass quickly. Clientsmay display anger and hostility, sometimes towardother people. They begin to demonstrate catastrophicemotional reactions in response to environmental changesthat clients may not perceive or understand accurately orwhen they cannot respond adaptively. These catastrophicreactions may include verbal or physical aggression, wanderingat night, agitation, or other behaviors that seem toindicate a loss of personal control.Clients may display a pattern of withdrawal from theworld they no longer understand. They are lethargic, lookapathetic, and pay little attention to the environment orthe people in it. They appear to lose all emotional affectand seem dazed and listless.Thought Process and ContentInitially, the ability to think abstractly is impaired, resultingin loss of the ability to plan, sequence, monitor, initiate, orstop complex behavior (APA, 2000). The client loses theability to solve problems or to take action in new situationsbecause he or she cannot think about what to do. The abilityto generalize knowledge from one situation to anotheris lost because the client cannot recognize similarities ordifferences in situations. These problems with cognitionmake it impossible for the employed client to continueworking. The client’s ability to perform tasks such as planningactivities, budgeting, or planning meals is lost.As the dementia progresses, delusions of persecutionare common. The client may accuse others of stealingobjects he or she has lost or may believe he or she is beingcheated or pursued.Sensorium and Intellectual ProcessesClients lose intellectual function, which eventuallyinvolves the complete loss of their abilities. Memory deficitsare the initial and essential feature of dementia.Dementia first affects recent and immediate memory andthen eventually impairs the ability to recognize close familymembers and even oneself. In mild and moderatedementia, clients may make up answers to fill in memorygaps (confabulation). Agnosia is another hallmark ofdementia. Clients lose visual spatial relations, which isoften evidenced by deterioration of the ability to write ordraw simple objects.Attention span and ability to concentrate are increasinglyimpaired until clients lose the ability to do either.

CHAPTER 21 • COGNITIVE DISORDERS 453Clients are chronically confused about the environment,other people, and eventually themselves. Initially, they aredisoriented to time in mild dementia, time and place inmoderate dementia, and finally to self in the severe stage.Hallucinations are a frequent problem. Visual hallucinationsare most common and generally unpleasant. Clientsare likely to believe the hallucination is reality.Judgment and InsightClients with dementia have poor judgment in light of thecognitive impairment. They underestimate risks and unrealisticallyappraise their abilities, which result in a highrisk for injury. Clients cannot evaluate situations for risksor danger. For example, they may wander outside in thewinter wearing only thin nightclothes and not considerthis to be a risk.Insight is limited. Initially, the client may be aware ofproblems with memory and cognition and may worry thathe or she is “losing my mind.” Quite quickly, these concernsabout the ability to function diminish, and clientshave little or no awareness of the more serious deficits thathave developed. In this context, clients may accuse othersof stealing possessions that the clients themselves haveactually lost or forgotten.Self-ConceptInitially, clients may be angry or frustrated with themselvesfor losing objects or forgetting important things.Some clients express sadness at their bodies for gettingold and at the loss of functioning. Soon, though, clientslose that awareness of self, which gradually deterioratesuntil they can look in a mirror and fail to recognize theirown reflections.Roles and RelationshipsDementia profoundly affects the client’s roles and relationships.If the client is still employed, work performance suffers,even in the mild stage of dementia, to the point thatwork is no longer possible given the memory and cognitivedeficits. Roles as spouse, partner, or parent deteriorateas clients lose the ability to perform even routine tasks orrecognize familiar people. Eventually, clients cannot meeteven the most basic needs.Inability to participate in meaningful conversation orsocial events severely limits relationships. Clients quicklybecome confined to the house or apartment because theyare unable to venture outside unassisted. Close familymembers often begin to assume caregiver roles; this canchange previously established relationships. Grown childrenof clients with dementia experience role reversal; thatis, they care for parents who once cared for them. Spousesor partners may feel as if they have lost the previous relationshipand now are in the role of custodian.Physiologic and Self-Care ConsiderationsClients with dementia often experience disturbed sleep–wake cycles; they nap during the day and wander at night.Some clients ignore internal cues such as hunger or thirst;others have little difficulty with eating and drinking untildementia is severe. Clients may experience bladder andeven bowel incontinence or have difficulty cleaning themselvesafter elimination. They frequently neglect bathingand grooming. Eventually, clients are likely to requirecomplete care from someone else to meet these basicphysiologic needs.JudgmentData AnalysisMany nursing diagnoses can be appropriate because theeffects of dementia on clients are profound; the diseasetouches virtually every part of their lives. Commonly usednursing diagnoses include the following:• Risk for Injury• Disturbed Sleep Pattern• Risk for Deficient Fluid Volume• Risk for Imbalanced Nutrition: Less Than BodyRequirements• Chronic Confusion• Impaired Environmental Interpretation Syndrome• Impaired Memory• Impaired Social Interaction• Impaired Verbal Communication• Ineffective Role Performance

454UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSNursing Care Plan | DementiaNursing DiagnosisImpaired Memory: Inability to remember or recall bits of information or behavioral skills.ASSESSMENT DATA• Inability to recall factual information or events• Inability to learn new material or recall previouslylearned material• Inability to determine whether a behavior wasperformed• Agitation or anxiety regarding memory lossEXPECTED OUTCOMESImmediateThe client will• Respond positively to memory cues• Demonstrate decreased agitation or anxietyStabilizationThe client will• Attain an optimal level of functioning with routinetasks• Use long-term memory effectively as long as itremains intact• Verbalize or demonstrate decreased frustration withmemory lossCommunityThe client will• Maintain an optimal level of functioning• Feel respected and supportedIMPLEMENTATIONNursing InterventionsProvide opportunities for reminiscence or recall of pastevents, on a one-to-one basis or in a small group.Encourage the client to use written cues such as acalendar, lists, or a notebook.Minimize environmental changes. Determine practicallocations for the client’s possessions, and return itemsto this location after use. Establish a usual routineand alter the routine only when necessary.Provide single step instructions for the client wheninstructions are needed.Provide verbal connections about using implements.For example, “Here is a washcloth to wash your face,”“Here is a spoon you can use to eat your dessert.”Integrate reminders of previous events into currentinteractions such as “Earlier you put some clothesin the washing machine; it’s time to put them in thedryer.”RationaleLong-term memory may persist after loss of recentmemory. Reminiscence is usually an enjoyableactivity for the client.Written cues decrease the client’s need to recallappointments, activities, and so on from memory.There is less demand on memory function when structureis incorporated in the client’s environment anddaily routine.Clients with memory impairment cannot remembermultistep instructions.The client may not remember what an implement isfor; stating its related function is an approach thatcompensates for memory loss.Providing links with previous behaviors helps the clientto make connections that he or she may not beable to make independently.(continued)

CHAPTER 21 • COGNITIVE DISORDERS 455Nursing Care Plan | Delirium, cont.IMPLEMENTATIONNursing InterventionsAssist with tasks as needed, but do not “rush” to dothings for the client that he or she can still doindependently.Use a matter-of-fact approach when assuming tasksthe client can no longer perform. Do not allowthe client to work unsuccessfully at a task for anextended time.RationaleIt is important to maximize independent function, yetassist the client when memory has deterioratedfurther.It is important to preserve the client’s dignity andminimize his or her frustration with progressivememory loss.Adapted from Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatric nursing care plans (8th ed.). Philadelphia: LippincottWilliams & Wilkins.In addition, the nursing diagnoses of Disturbed ThoughtProcesses and Disturbed Sensory Perception would beappropriate for a client with psychotic symptoms. Multiplenursing diagnoses related to physiologic status alsomay be indicated based on the nurse’s assessment, such asalterations in nutrition, hydration, elimination, physicalmobility, and activity tolerance.Outcome IdentificationTreatment outcomes for clients with progressive dementiado not involve regaining or maintaining abilities tofunction. In fact, the nurse must reassess overall healthstatus and revise treatment outcomes periodically as theclient’s condition changes. Outcomes and nursing carethat focus on the client’s medical condition or deficitsare common. Current literature proposes a focus onpsychosocial care that maximizes the client’s strengthsand abilities for as long as possible. Psychosocial careinvolves maintaining the client’s independence as longas possible, validating the client’s feelings, keeping theclient involved in the environment, and dealing withbehavioral disruptions respectfully (McCabe, 2008;Ouldred & Bryant, 2008; Yuhas et al., 2006). Treatmentoutcomes for a client with dementia may include thefollowing:• The client will be free of injury.• The client will maintain an adequate balance of activityand rest, nutrition, hydration, and elimination.• The client will function as independently as possiblegiven his or her limitations.• The client will feel respected and supported.• The client will remain involved in his or hersurroundings.• The client will interact with others in the environment.InterventionPsychosocial models for care of clients with dementia arebased on the approach that each client is a unique personand remains so, even as the disease’s progression blocksthe client’s ability to demonstrate those unique characteristics.Interventions are rooted in the belief that clientswith dementia have personal strengths. They focus ondemonstrating caring, keeping clients involved by relatingto the environment and other people, and validating feelingsand dignity of clients by being responsive to them,offering choices, and reframing (offering alternative pointsof view to explain events). This is in contrast to medicalmodels of care that focus on progressive loss of functionand identity (McCabe, 2008).Nurses can use the following interventions in any settingfor clients with dementia. Education for familymembers caring for clients at home and for professionalcaregivers in residential or skilled facilities is an essentialcomponent of providing safe and supportive care.The discussion provides examples that apply to varioussettings.Promoting the Client’s SafetySafety considerations involve protecting against injury,meeting physiologic needs, and managing risks posed bythe environment, including internal stimuli such as delusionsand hallucinations. Clients cannot accuratelyappraise the environment and their abilities; therefore,they do not exercise normal caution in daily life. Forexample, the client living at home may forget food cookingon the stove; the client living in a residential caresetting may leave for a walk in cold weather without a coatand gloves. Assistance or supervision that is as unobtrusiveas possible protects clients from injury while preservingtheir dignity.

456UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSA family member might say,“I’ll sit in the kitchen and talk to you while youmake lunch” (suggesting collaboration) ratherthan “You can’t cook by yourself because youmight set the house on fire.”In this way, the nurse or caregiver supports the client’sdesire and ability to engage in certain tasks while providingprotection from injury.Clients with dementia may believe that their physicalsafety is jeopardized; they may feel threatened or suspiciousand paranoid. These feelings can lead to agitated orerratic behavior that compromises safety. Avoiding directconfrontation of the client’s fears is important. Clients withdementia may struggle with fears and suspicion throughouttheir illness. Triggers of suspicion include strangers,changes in the daily routine, or impaired memory. Thenurse must discover and address these environmental triggersrather than confront the paranoid ideas.For example, a client reports that his belongings havebeen stolen. The nurse might say,“Let’s go look in your room and see what’sthere.”and help the client to locate the misplaced or hidden items(suggesting collaboration). If the client is in a room withother people and says, “They’re here to take me away!” thenurse might say,“Those people are here visiting with someoneelse. Let’s go for a walk and let them visit.”(presenting reality/distraction)The nurse then can take the client to a quieter and lessstimulating place, which moves the client away from theenvironmental trigger.Promoting Adequate Sleep and ProperNutrition, Hygiene, and ActivityClients require assistance to meet basic physiologic needs.The nurse monitors food and fluid intake to ensure adequacy.Clients may eat poorly because of limited appetiteor distraction at mealtimes. The nurse addresses thisproblem by providing foods clients like, sitting with clientsat meals to provide cues to continue eating, havingnutritious snacks available whenever clients are hungry,and minimizing noise and undue distraction at mealtimes.Clients who have difficulty manipulating utensils may beunable to cut meat or other foods into bite-sized pieces.The food should be cut up when it is prepared, not infront of clients, to deflect attention from their inability todo so. Food that can be eaten without utensils, or fingerfoods such as sandwiches and fresh fruit, may be best. Incontrast, clients may eat too much, even ingesting inedibleitems. Providing low-calorie snacks such as carrot andcelery sticks can satisfy the desire to chew and eat withoutunnecessary weight gain. Enteral nutrition often becomesnecessary when dementia is most severe, although not allfamilies choose to use tube feedings.Adequate intake of fluids and food is also necessary forproper elimination. Clients may fail to respond to cuesindicating constipation, so the nurse or caregiver monitorsthe client’s bowel elimination patterns and intervenes withincreased fluids and fiber or prompts as needed. Urinaryelimination can become a problem if clients do not respondto the urge to void or are incontinent. Reminders to urinatemay be helpful when clients are still continent but notinitiating use of the bathroom. Sanitary pads can addressdribbling or stress incontinence; adult diapers, rather thanindwelling catheters, are indicated for incontinence. Thenurse checks disposable pads and diapers frequently andchanges soiled items promptly to avoid infection, skin irritation,and unpleasant odors. It is also important to providegood hygiene to minimize these risks.Balance between rest and activity is an essential componentof the daily routine. Mild physical activity such aswalking promotes physical health but is not a cognitivechallenge. Daily physical activity also helps clients to sleepat night. The nurse provides rest periods so clients canconserve and regain energy, but extensive daytime nappingmay interfere with nighttime sleep. The nurse encouragesclients to engage in physical activity because they may notinitiate such activities independently; many clients tend tobecome sedentary as cognitive abilities diminish. Clientsoften are quite willing to participate in physical activitiesbut cannot initiate, plan, or carry out those activities withoutassistance.Structuring the Environment and RoutineA structured environment and established routines canreassure clients with dementia. Familiar surroundings androutines help to eliminate some confusion and frustrationfrom memory loss. Providing routines and structure, however,does not mean forcing clients to conform to the structureof the setting or routines that other people determine.Rather than imposing new structure, the nurse encouragesclients to follow their usual routines and habits of bathingand dressing (Yuhas et al., 2006). For example, it is importantto know whether a client prefers a tub bath or showerand washes at night or in the morning and to include thosepreferences in the client’s care. Research has shown thatattempting to change the dressing behavior of clients mayresult in physical aggression as clients make ineffectiveattempts to resist unwanted changes. Monitoring responseto daily routines and making needed adjustments areimportant aspects of care.The nurse needs to monitor and manage the client’s toleranceof stimulation. Generally, clients can tolerate lessstimulation when they are fatigued, hungry, or stressed.

CHAPTER 21 • COGNITIVE DISORDERS 457Also, with the progression of dementia, tolerance for environmentalstimuli decreases. As this tolerance diminishes,clients need a quieter environment with fewer people andless noise or distraction.Providing Emotional SupportThe therapeutic relationship between client and nurseinvolves “empathic caring,” which includes being kind,respectful, calm, and reassuring and paying attention tothe client. Nurses use these same qualities with many differentclients in various settings. In most situations, clientsgive positive feedback to the nurse or caregiver, but clientswith dementia often seem to ignore the nurse’s efforts andmay even respond with negative behavior such as anger orsuspicion. This makes it more difficult for the nurse orcaregiver to sustain caring behavior. Nevertheless, nursesand caregivers must maintain all the qualities of the therapeuticrelationship even when clients do not seem torespond.Because of their disorientation and memory loss, clientswith dementia often become anxious and require muchpatience and reassurance. The nurse can convey reassuranceby approaching the client in a calm, supportive manner,as if nurse and client are a team—a “we can do ittogether” approach. The nurse reassures the client that heor she knows what is happening and can take care of thingswhen the client is confused and cannot do so. For example,if the client is confused about getting dressed, thenurse might say,“I’ll be glad to help you with that shirt. I’ll hold itfor you while you put your arms in the sleeves.”(offering self/suggesting collaboration)Supportive touch is effective with many clients. Touchcan provide reassurance and convey caring when wordsmay not be understood. Holding the hand of the clientwho is tearful and sad and tucking the client into bed atnight are examples of ways to use supportive touch. Aswith any use of touch, the nurse must evaluate each client’sresponse. Clients who respond positively will smileor move closer toward the nurse. Those who are threatenedby physical touch will look frightened or pull awayfrom the nurse, especially if the touch is sudden or unexpectedor if the client misperceives the nurse’s intent.Promoting Interaction and InvolvementIn a psychosocial model of dementia care, the nurse orcaregiver plans activities that reinforce the client’s identityand keep him or her engaged and involved in the businessof living (Yuhas et al., 2006). The nurse or caregiver tailorsthese activities to the client’s interests and abilities: Theyshould not be routine group activities that “everyone issupposed to do.” For example, a client with an interest inhistory may enjoy documentary programs on television; aclient who likes music may enjoy singing. Clients oftenneed the involvement of another person to sustain attentionin the activity and to enjoy it more fully. Those whohave long periods without anything to engage their interestare more likely to become restless and agitated. Clientsengaged in activities are more likely to stay calm. A widevariety of activities have proven beneficial for clients withdementia. Music, dancing, pet- or animal-assisted therapy,aromatherapy, and multisensory stimulation are examplesof activities that can be explored to maximize the client’sinvolvement with the environment and enhance the qualityof his or her life (Milev, 2008; Ouldred & Bryant, 2008;Raglio et al., 2008).Reminiscence therapy (thinking about or relating personallysignificant past experiences) is an effective interventionfor clients with dementia. Rather than lamentingthat the client is “living in the past,” this therapy encouragesfamily and caregivers also to reminisce with the client.Reminiscing uses the client’s remote memory, which isnot affected as severely or quickly as recent or immediatememory (McCabe, 2008). Photo albums may be useful instimulating remote memory, and they provide a focus onthe client’s past. Sometimes clients like to reminisce aboutlocal or national events and talk about their roles or whatthey were doing at the time. In addition to keeping clientsinvolved in the business of living, reminiscence also canbuild self-esteem as clients discuss accomplishments.Engaging in active listening, asking questions, and providingcues to continue promote successful use of this technique.Reminiscence therapy can also be effective withsmall groups of clients as they collectively remember theirearly life activities (Wang, 2007).Clients have increasing problems interacting with othersas dementia progresses. Initially, clients retain verballanguage skills, but other people may find them difficult tounderstand as words are lost or content becomes vague.The nurse must listen carefully to the client and try todetermine the meaning behind what is being said. Thenurse might say,“Are you trying to say you want to use the bathroom?”or “Did I get that right, you are hungry?”(seeking clarification)It is also important not to interrupt clients or to finishtheir thoughts. If a client becomes frustrated when thenurse cannot understand his or her meaning, the nursemight say,“Can you show me what you mean or where youwant to go?” (assisting to take action)When verbal language becomes less coherent, the nurseshould remain alert to the client’s nonverbal behavior.

458UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSWhen nurses or caregivers consistently work with a particularclient, they develop the ability to determine the client’smeaning through nonverbal behavior. For example, ifthe client becomes restless, it may indicate that he or sheis hungry if it is close to mealtime or tired if it is late in theevening. Sometimes it is impossible to determine exactlywhat the client is trying to convey, but the nurse can stillbe responsive. For example, a client is pacing and looksupset but cannot indicate what is bothering her. The nursesays,“You look worried. I don’t know what’s wrong, butlet’s go for a walk.” (making an observation/offering self)Interacting with clients with dementia often means dealingwith thoughts and feelings that are not based in realitybut arise from the clients’ suspicion or chronic confusion.Rather than attempting to explain reality or allay suspicionor anger, it is often helpful to use the techniques of distraction,time away, or going along to reassure the client.Distraction involves shifting the client’s attention andenergy to a more neutral topic. For example, the clientmay display a catastrophic reaction to the current situation,such as jumping up from dinner and saying, “Myfood tastes like poison!” The nurse might intervene withdistraction by saying,“Can you come to the kitchen with me and findsomething you’d like to eat?” or “You can leavethat food. Can you come and help me find agood program on television?” (redirection/distraction)Clients usually calm down when the nurse directs theirattention away from the triggering situation.Time away involves leaving clients for a short periodand then returning to them to re-engage in interaction.For example, the client may get angry and yell at thenurse for no discernible reason. The nurse can leave theclient for about 5 or 10 minutes and then return withoutreferring to the previous outburst. The client may havelittle or no memory of the incident and may be pleased tosee the nurse on his or her return.Going along means providing emotional reassurance toclients without correcting their misperception or delusion.The nurse does not engage in delusional ideas or reinforcethem, but he or she does not deny or confront their existence.For example, a client is fretful, repeatedly saying, “I’mso worried about the children. I hope they’re okay,” andspeaking as though his adult children were small and neededprotection. The nurse could reassure the client by saying,“There’s no need to worry; the children are justfine” (going along),which is likely to calm the client. The nurse has respondedeffectively to the client’s worry without addressing thereality of the client’s concern. Going along is a specificintervention for clients with dementia and should not beused with those experiencing delusions whose conditionsare expected to improve.The nurse can use reframing techniques to offer clientsdifferent points of view or explanations for situations orevents. Because of their perceptual difficulties and confusion,clients frequently interpret environmental stimuli asthreatening. Loud noises often frighten and agitate them.For example, one client may interpret another’s yelling asa direct personal threat. The nurse can provide an alternativeexplanation such as“That lady has many family problems, and sheyells sometimes because she’s frustrated.”(reframing)Alternative explanations often reassure clients with dementiaand help them become less frightened and agitated.EvaluationTreatment outcomes change constantly as the disease progresses.For example, in the early stage of dementia, maintainingindependence may mean that the client dresseswith minimal assistance. Later, the same client may keepsome independence by selecting what foods to eat. In thelate stage, the client may maintain independence by wearinghis or her own clothing rather than an institutionalnightgown or pajamas.The nurse must assess clients for changes as they occurand revise outcomes and interventions as needed. When aclient is cared for at home, this includes providing ongoingeducation to family members and caregivers whilesupporting them as the client’s condition worsens. See thesections that follow on the role of the caregiver and community-basedcare.COMMUNITY-BASED CAREAt least half of all nursing home residents have Alzheimer’sdisease or some other illness that causes dementia. In addition,for every person with dementia in a nursing home,two or three with similar impairments are receiving care inthe community by some combination of family members,friends, and paid caregivers.Programs and services for clients with dementia andtheir families have increased with the growing awarenessof Alzheimer’s disease, the increasing numbers of olderadults in the United States, and the fundraising efforts foreducation by noted figures (e.g., the family of former presidentRonald Reagan). Home care is available throughhome health agencies, public health agencies, and visiting

CHAPTER 21 • COGNITIVE DISORDERS 459nurses. These services offer assistance with bathing, foodpreparation, and transportation as well as with other support.Periodic nursing assessment ensures that the level ofcare provided is appropriate to the client’s current needs.Adult day care centers provide supervision, meals, support,and recreational activities in group settings. Clientsmay attend the center a few hours a week or full-time onweekdays if needed. Respite care offers in-home supervisionfor clients so that family members or caregivers canrun errands or have social time of their own.Residential facilities are available for clients who do nothave in-home caregivers or whose needs have progressedbeyond the care that could be provided at home. Theseclients usually require assistance with ADLs such as eatingand taking medications. Clients in residential facilities areoften referred for skilled nursing home placement asdementia progresses.The physician, nurse, or family can initiate referrals forcommunity-based services. Families can contact the localpublic health department or the department of human orsocial services listed in the phone book. If the client hasbeen admitted to the hospital, social services also can assistin making an appropriate referral.MENTAL HEALTH PROMOTIONResearch continues to identify risk factors for dementia.People with elevated levels of plasma homocysteine are atincreased risk for dementia. As levels of plasma homocysteineincrease, so does the risk for dementia (Selhub,2008). Because folate, vitamin B 12, and betaine are knownto reduce plasma homocysteine levels, potential therapeuticstrategies using these substances may modify or diminishthe risk for dementia. Clinical trials currently are inprogress to see if lowering homocysteine levels actuallydecreases the risk for dementia and whether taking highsupplemental doses of B vitamins slows the progression ofAlzheimer’s disease.People who regularly participate in brain-stimulatingactivities such as reading books and newspapers or doingcrossword puzzles are less likely to develop Alzheimer’sdisease than those who do not. Engaging in leisure-timephysical activity during midlife and having a large socialnetwork are associated with a decreased risk for Alzheimer’sdisease in later life (Coley et al., 2008).ROLE OF THE CAREGIVERMost family caregivers are women (72%) who are eitheradult daughters (29%) or wives (23%) of clients with cognitivedisorders. Husbands account for 13% of all caregivers.The trend toward caring for family members withdementia at home is largely the result of the high costs ofinstitutional care, dissatisfaction with institutional care,and difficulty locating suitable placements for clients withbehaviors that are sometimes disruptive and difficult tomanage. Family members identify many other reasons forbecoming primary caregivers, including the desire to reciprocatefor past assistance, to provide love and affection, touphold family values or loyalty, to meet duty or obligation,and to avoid feelings of guilt.Caregivers need to know about dementia and therequired client care as well as how client care will change asthe disease progresses. Caregivers also may be dealing withother family members who may or may not be supportiveor who may have differing expectations. Many caregivershave other demands on their time, such as their own families,careers, and personal lives. Caregivers must deal withtheir feelings of loss and grief as the health of their lovedones continually declines (Ouldred & Bryant, 2008).Caring for clients with dementia can be emotionally andphysically exhausting and stressful. Caregivers may need todrastically change their own lives, such as quitting a job, toprovide care. Caregivers may have young children as well.They often feel exhausted and as if they are “on duty”24 hours a day. Caregivers caring for parents may havedifficulty “being in charge” of their mothers or fathers (rolereversal). They may feel uncomfortable or depressed abouthaving to bathe, feed, or change diapers for parents.Role strain is identified when the demands of providingcare threaten to overwhelm a caregiver. Indications of rolestrain include constant fatigue that is unrelieved by rest,increased use of alcohol or other drugs, social isolation,inattention to personal needs, and inability or unwillingnessto accept help from others. Caregivers may feelunappreciated by other family members, as indicated bystatements such as “No one ever asks how I am!” In somesituations, role strain can contribute to the neglect orabuse of clients with dementia (see Chapter 11).Supporting the caregiver is an important component ofproviding care at home to clients with dementia. Caregiversmust have an ongoing relationship with a knowledgeablehealth professional; the client’s physician can makereferrals to other health care providers. Depending on thesituation, that person may be a nurse, care manager, orsocial worker. He or she can provide information, support,and assistance during the time that home care is provided.Caregivers need education about dementia and the type ofcare that clients need. Caregivers should use the interventionspreviously discussed to promote the client’s wellbeing,deal with deficits and limitations, and maximize thequality of the client’s life. Because the care that clients needchanges as the dementia progresses, this education by thenurse, care manager, or social worker is ongoing.Caregivers need outlets for dealing with their own feelings.Support groups can help them to express frustration,sadness, anger, guilt, or ambivalence; all these feelings arecommon. Attending a support group regularly also meansthat caregivers have time with people who understand themany demands of caring for a family member with dementia.The client’s physician can provide information aboutsupport groups, and the local chapter of the National

460UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSAlzheimer’s Disease Association is listed in the phonebook. Area hospitals and public health agencies also canhelp caregivers to locate community resources.Caregivers should be able to seek and accept assistancefrom other people or agencies. Often, caregivers believethat others may not be able to provide care as well as theydo, or they say they will seek help when they “really needit.” Caregivers must maintain their own well-being andnot wait until they are exhausted before seeking relief.Sometimes family members disagree about care for the client.The primary caregiver may believe other family membersshould volunteer to help without being asked, butother family members may believe that the primary caregiverchose to take on the responsibility and do not feelobligated to help out regularly. Whatever the feelings areamong family members, it is important for them all toexpress their feelings and ideas and to participate in caregivingaccording to their own expectations. Many familiesneed assistance to reach this type of compromise.Finally, caregivers need support to maintain personal lives.They need to continue to socialize with friends and to engagein leisure activities or hobbies rather than focus solely on theclient’s care. Caregivers who are rested, happy, and have mettheir own needs are better prepared to manage the rigorousdemands of the caregiver role. Most caregivers need to bereminded to take care of themselves; this act is not selfish butreally is in the client’s best long-term interests.RELATED DISORDERSAmnestic disorders are characterized by a disturbance inmemory that results directly from the physiologic effects ofa general medical condition or the persisting effects of asubstance such as alcohol or other drugs (APA, 2000). Thememory disturbance is sufficiently severe to cause markedimpairment in social or occupational functioning and representsa significant decline from previous functioning. Confusion,disorientation, and attentional deficits are common.Clients with amnestic disorders are similar to those withdementia in terms of memory deficits, confusion, and problemswith attention. They do not, however, have the multiplecognitive deficits seen in dementia, such as aphasia,apraxia, agnosia, and impaired executive functions.Several medical conditions can cause brain damage andresult in an amnestic disorder—for example, stroke orother cerebrovascular events, head injuries, and neurotoxicexposures, such as carbon monoxide poisoning,chronic alcohol ingestion, and vitamin B 12or thiaminedeficiency. Alcohol-induced amnestic disorder results froma chronic thiamine or vitamin B deficiency and is calledKorsakoff’s syndrome.The main difference between dementia and amnesticdisorders is that once the underlying medical cause istreated or removed, the client’s condition no longer deteriorates.Treatment of amnestic disorders focuses on eliminatingthe underlying cause and rehabilitating the clientand includes preventing further medical problems. Someamnestic disorders improve over time when the underlyingcause is stabilized. Other clients have persistent impairmentof memory and attention with minimal improvement;this can occur in cases of chronic alcohol ingestion or malnutrition(Grossman, 2005). Nursing diagnoses and interventionsare similar to those used when dealing with thememory loss, confusion, and impaired attention abilities ofclients with dementia or delirium (see Nursing Interventionsfor Dementia).NURSING INTERVENTIONSfor Dementia• Promoting client’s safety and protecting from injuryOffer unobtrusive assistance with or supervision ofcooking, bathing, or self-care activities.Identify environmental triggers to help client avoidthem.• Promoting adequate sleep, proper nutrition andhygiene, and activityPrepare desirable foods and foods client can self-feed;sit with client while eating.Monitor bowel elimination patterns; intervene withfluids and fiber or prompts.Remind client to urinate; provide pads or diapers asneeded, checking and changing them frequently toavoid infection, skin irritation, unpleasant odors.Encourage mild physical activity such as walking.• Structuring environment and routineEncourage client to follow regular routine and habits ofbathing and dressing rather than impose new ones.Monitor amount of environmental stimulation, andadjust when needed.• Providing emotional supportBe kind, respectful, calm, and reassuring; pay attentionto client.Use supportive touch when appropriate.• Promoting interaction and involvementPlan activities geared to client’s interests and abilities.Reminisce with client about the past.If client is nonverbal, remain alert to nonverbal behavior.Employ techniques of distraction, time away, goingalong, or reframing to calm clients who are agitated,suspicious, or confused.

CHAPTER 21 • COGNITIVE DISORDERS 461SELF-AWARENESS ISSUESWorking with and caring for clients withdementia can be exhausting and frustratingfor both nurse and caregiver. Teaching is afundamental role for nurses, but teaching clientswho have dementia can be especially challenging andfrustrating. These clients do not retain explanations orinstructions, so the nurse must repeat the same things continually.The nurse must be careful not to lose patience andnot to give up on these clients. The nurse may begin to feelthat repeating instructions or explanations does no goodbecause clients do not understand or remember them. Discussingthese frustrations with others can help the nurse toavoid conveying negative feelings to clients and families orexperiencing professional and personal burnout.The nurse may get little or no positive response or feedbackfrom clients with dementia. It can be difficult to dealwith feelings about caring for people who will never “getbetter and go home.” As dementia progresses, clients mayseem not to hear or respond to anything the nurse does. Itis sad and frustrating for the nurse to see clients declineand eventually lose their abilities to manage basic self-careactivities and to interact with others. Remaining positiveand supportive to clients and family can be difficult whenthe outcome is so bleak. In addition, the progressivedecline may last months or years, which adds to the frustrationand sadness. The nurse may need to deal withpersonal feelings of depression and grief as the dementiaprogresses; he or she can do so by discussing the situationwith colleagues or even a counselor.Points to Consider When Working withClients with Dementia• Remember how important it is to provide dignity forthe client and family as the client’s life ends.• Remember that death is the last stage of life. The nursecan provide emotional support for the client and familyduring this period.• Clients may not notice the caring, patience, and supportthe nurse offers, but these qualities will mean agreat deal to the family for a long time.KEY POINTS• Cognitive disorders involve disruption orimpairment in the higher functions of thebrain. They include delirium, dementia, andamnestic disorders.• Delirium is a syndrome that involves disturbed consciousnessand changes in cognition. It usually is causedby an underlying, treatable medical condition such asphysiologic or metabolic imbalances, infections, nutritionaldeficits, medication reactions or interactions,drug intoxication, or alcohol withdrawal.Critical Thinking Questions1. The nurse is working in a long-term care setting withclients with dementia. One of the ancillary staffmakes a joke about a client in the client’s presence.The nurse tells the staff person that is unacceptablebehavior. The staff person replies, “Oh, he can’t understandwhat I’m saying, and besides, he was laughingtoo. What’s the big deal?” How should this nurserespond?2. A client is newly diagnosed with dementia in theearly stages. Can the client make decisions about advancemedical directives? Why or why not? At whatpoint in the progression of dementia can the clientno longer make quality-of-life decisions?• The primary goals of nursing care for clients with deliriumare protection from injury, management of confusion, andmeeting their physiologic and psychologic needs.• Dementia is a disease involving memory loss and multiplecognitive deficits such as language deterioration(aphasia), motor impairment (apraxia), or inability toname or recognize objects (agnosia).• Dementia is usually progressive, beginning with prominentmemory loss (mild stage) and confusion and lossof independent functioning (moderate), followed bytotal disorientation and loss of functioning (severe).• Medications used to treat dementia, rivastigmine, galantamine,and donepezil, slow disease progression forabout 6 months. Other medications such as antipsychotics,antidepressants, and benzodiazepines help managesymptoms but do not affect the course of dementia.• A psychosocial model for providing care for people withdementia addresses needs for safety, structure, support,interpersonal involvement, and social interaction.• Many clients with dementia receive care at home ratherthan in institutional settings (e.g., nursing homes). Thecaregiver role (often assumed by a spouse or adult child)can be physically and emotionally exhausting and stressful;this contributes to caregiver role strain. To deal withthe exhausting demands of this role, family caregivers needongoing education and support from a health care professionalsuch as a nurse, social worker, or case manager.• Caregivers must learn how to meet the client’s physiologicand emotional needs and to protect him or herfrom injury. Areas for teaching include monitoring theclient’s health, avoiding alcohol and recreational drugs,ensuring adequate nutrition, scheduling regular checkups,getting adequate rest, promoting activity andsocialization, and helping the client to maintain independenceas much as possible.• The therapeutic relationship with clients with dementiais supportive and protective and recognizes the client’sindividuality and dignity.

462UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSINTERNET RESOURCESRESOURCE• Alzheimer’s Association• Alzheimer’s Disease Education and Referral• Alzheimer’s Info Links• Alzheimer’s Disease International• Alzheimer Society of Canada• Support and Education CaregiversINTERNET ADDRESShttp://www.alz.orghttp://www.alzheimers.orghttp://www.alzheimer-info.com/links_info.htmlhttp://www.alz.co.ukhttp://www.alzheimer.cawww.nia.nih.gov/Alzheimers/Publications/caregiverguide.htmREFERENCESAmerican Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text revision). Washington, DC:American Psychiatric Association.Coley, N., Andrieu, S., Gardette, V., Gillette-Guyonnet, S., Sanz, C.,Vellas, B., et al. (2008). Dementia prevention: Methodological explanationsfor inconsistent results. Epidemiologic Reviews, 30, 35–66.Davis, K. L. (2005). Cognitive disorders: Introduction and overview. InB. J. Sadock, & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry(Vol. 1, 8th ed., pp. 1053–1054). Philadelphia: LippincottWilliams & Wilkins.Facts and Comparisons. (2009). Drug facts and comparisons (63rd ed.).St. Louis: Wolters Kluwer.Grossman, H. (2005). Amnestic disorders. In B. J. Sadock, & V. A.Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed.,pp. 1093–1106). Philadelphia: Lippincott Williams & Wilkins.McCabe, L. (2008). A holistic approach to caring for people withAlzheimer’s disease. Nursing Standard, 22(42), 50–56.Milev, R. V. (2008). Multisensory stimulation for elderly with dementia: A24-week single-blind randomized controlled pilot study. AmericanJournal of Alzheimer’s Disease and Other Dementias, 23(4), 372–376.Neugroschl, J. A., Kolevzon, A., Samuels, S. C., et al. (2005). Dementia.In B. J. Sadock, & V. A. Sadock (Eds.), Comprehensive textbook ofpsychiatry (Vol. 1, 8th ed., pp. 1068–1093). Philadelphia: LippincottWilliams & Wilkins.Ouldred, E., & Bryant, C. (2008). Dementia care. Part 2: Understandingand managing behavioural challenges. British Journal of Nursing,17(4), 242–247.Raglio, A., Bellelli, G., Traficante, D., Gianotti, M., Ubezio, M. C., Villani,D., et al. (2008). Efficacy of music therapy in the treatment of behavioraland psychiatric symptoms of dementia. Alzheimer Disease andAssociated Disorders, 22(2), 158–162.Samuels, S. C., & Neugroschl, J. A. (2005). Delirium. In B. J. Sadock, &V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1,8th ed., pp. 1054–1068). Philadelphia: Lippincott Williams &Wilkins.Schultz, J. M., & Videbeck, S. L. (2009). Lippincott’s manual of psychiatricnursing care plans (8th ed.). Philadelphia: Lippincott Williams &Wilkins.Selhub, J. (2008). Public health significance of elevated homocysteine.Food and Nutrition Bulletin, 29(2 Suppl.), S116–S125.Smith, A. D. (2008). The worldwide challenge of the dementias: A rolefor B vitamins and homocysteine? Food and Nutrition Bulletin, 29(2Suppl.), S143–S172.Wang, J. J. (2007). Group reminiscence therapy for cognitive and affectivefunction of demented elderly in Taiwan. International Journal ofGeriatric Psychiatry, 22(12), 1235–1240.Yuhas, N., McGowan, B., Fintaine, T., et al. (2006). Psychosocial interventionsfor disruptive symptoms of dementia. Journal of PsychosocialNursing, 44(11), 34–42.ADDITIONAL READINGSBennett, D. A., Schneider, J. A., Tang, Y., Arnold, S. E., & Wilson, R. S.(2006). The effect of social networks on the relation between Alzheimer’sdisease pathology and level of cognitive function in old people: Alongitudinal cohort study. Lancet Neurology, 5(5), 406–412.Ouldred, E., & Bryant, C. (2008). Dementia care. Part 1: Guidance andthe assessment process. British Journal of Nursing, 17(3), 138–145.Sorensen, S., Duberstein, P., Gill, D., & Pinquart, M. (2006). Dementiacare: Mental health effects, intervention strategies, and clinical implications.Lancet Neurology, 5(11), 961–973.Vellas, B., Gillette-Guyonnet, S., Andriey, S. (2008). Memory healthclinics—A first step to prevention. Alzheimer’s & Dementia, 4(1Suppl.), S144–S149.Whitlatch, C. J., Judge, K., Zarit, S. H., & Femia, E. (2006). Dyadicintervention for family caregivers and care receivers in early-stagedementia. Gerontologist, 46(5), 688–694.

Chapter Study GuideMULTIPLE-CHOICE QUESTIONSSelect the best answer for each of the following questions.1. The nurse is talking with a woman who is worried thather mother has Alzheimer’s disease. The nurse knowsthat the first sign of dementia isa. Disorientation to person, place, or timeb. Memory loss that is more than ordinary forgetfulnessc. Inability to perform self-care tasks without assistanced. Variable with different people2. The nurse has been teaching a caregiver about donepezil(Aricept). The nurse knows that teaching has beeneffective by which of the following statements?a. “Let’s hope this medication will stop the Alzheimer’sdisease from progressing any further.”b. “It is important to take this medication on an emptystomach.”c. “I’ll be eager to see if this medication makes any improvementin concentration.”d. “This medication will slow the progress of Alzheimer’sdisease temporarily.”3. When teaching a client about memantine (Namenda),the nurse will include:a. Lab tests to monitor the client’s liver function areneeded.b. Namenda can cause elevated blood pressure.c. Taking Namenda will improve the client’s cognitivefunctioning.d. The most common side effect of Namenda is GIbleeding.4. Which of the following statements by the caregiver of aclient newly diagnosed with dementia requires furtherintervention by the nurse?a. “I will remind Mother of things she has forgotten.”b. “I will keep Mother busy with favorite activities aslong as she can participate.”c. “I will try to find new and different things to doevery day.”d. “I will encourage Mother to talk about her friendsand family.”5. A client with delirium is attempting to remove the intravenoustubing from his arm, saying to the nurse,“Get off me! Go away!” The client is experiencingwhich of the following?a. Delusionsb. Hallucinationsc. Illusionsd. Disorientation6. Which of the following statements indicates the caregiver’saccurate knowledge about the needs of a parentat the onset of the moderate stage of dementia?a. “I need to give my parent a bath at the same timeevery day.”b. “I need to postpone any vacations for 5 years.”c. “I need to spend time with my parent doing thingswe both enjoy.”d. “I need to stay with my parent 24 hours a day forsupervision.”7. Which of the following interventions is most appropriatein helping a client with early-stage dementia completeactivities of daily living (ADLs)?a. Allow enough time for the client to complete ADLsas independently as possible.b. Provide the client with a written list of all the stepsneeded to complete ADLs.c. Plan to provide step-by-step prompting to completethe ADLs.d. Tell the client to finish ADLs before breakfast or thenursing assistant will do them.8. A client with late moderate stage dementia has beenadmitted to a long-term care facility. Which of thefollowing nursing interventions will help the client tomaintain optimal cognitive function?a. Discuss pictures of children and grandchildren withthe client.b. Do word games or crossword puzzles with the client.c. Provide the client with a written list of daily activities.d. Watch and discuss the evening news with the client.463

464 UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSMULTIPLE RESPONSE QUESTIONSSelect all that apply.1. When assessing a client with delirium, the nurse willexpect to see:a. Aphasiab. Confusionc. Impaired level of consciousnessd. Long-term memory impairmente. Mood fluctuationsf. Rapid onset of symptoms2. Interventions for clients with dementia that follow thepsychosocial model of care include:a. Asking the client about the place where they were bornb. Correcting the client’s misperceptions or delusionc. Finding activities that engage the client’s attentiond. Introducing new topics of discussion at dinnere. Processing behavioral problems to improve copingskillsf. Providing unrelated distractions when the client isagitatedCLINICAL EXAMPLEMartha Smith, a 79-year-old widow with Alzheimer’s disease, was admitted to a nursinghome. The disease has progressed during the past 4 years to the point that she can no longerlive alone in her own house. Martha has poor judgment and no short-term memory. Shehad stopped paying bills, preparing meals, and cleaning her home. She had become increasinglysuspicious of her visiting nurse and home health aide, finally refusing to allow themin the house.After her arrival at the facility, Martha has been sleeping poorly and frequently wandersfrom her room in the middle of the night. She seems agitated and afraid in the dining roomat mealtimes, is eating very little, and has lost weight. If left alone, Martha would wear thesame clothing day and night and would not attend to her personal hygiene.1. What additional assessments would the nurse want to make to plan care for this client?2. What nursing diagnoses would the nurse identify for this client?3. Write an expected outcome and at least two interventions for each nursing diagnosis.

Answers to Chapter Study GuidesANSWER KEYChapter 1Multiple-Choice Questions1. C2. B3. A4. D5. CFill-in-the-Blank QuestionsAxis I: All major psychiatric disorders except mental retardationand personality disordersAxis II: Mental retardation, personality disorders, prominentmaladaptive personality features, defense mechanismsAxis III: Current medical conditions, contributing medicalconditionsAxis IV: Psychosocial and environmental problemsAxis V: Global Assessment of Functioning (GAF) scoreShort-Answer Questions1. Increased community-based clinics; increased screeningfor mental illness in primary care settings; screeningidentified high-risk populations; improved mentalhealth parity in insurance coverage; increased servicesin jails, prisons, and other institutional settings2. Cost containment and managed care, population diversity,community-based care3. Examples of fears include saying the wrong thing, notknowing what to do, being rejected by clients, handlingbizarre or inappropriate behavior, maintaining physicalsafety, and seeing a friend or acquaintance as a client.Chapter 2Multiple-Choice Questions1. A 5. B2. B 6. B3. D 7. C4. C 8. BFill-in-the-Blank Questions1. Atypical antipsychotic2. SSRI antidepressant3. Tricyclic antidepressant4. Anticholinergic5. Stimulant6. Anticonvulsant used as mood stabilizer7. Benzodiazepine8. Atypical antipsychoticShort-Answer Questions1. Abrupt cessation results in a rebound effect (return ofsymptoms), recurrence of the original symptoms, orpossible withdrawal symptoms. Tapering graduallyalleviates or minimizes these problems.2. A radioactive substance will be injected into the bloodstream.The client will be asked to perform “thinking”tasks while the camera takes scans of the brain working.The procedure will take 2 to 3 hours.3. Just as kindling is used to start a larger fire, mild orsmall manic mood swings can eventually trigger amajor, acute manic episode.Chapter 3Multiple-Choice Questions1. D 4. B 7. A2. D 5. A 8. A3. C 6. C 9. AFill-in-the-Blank Questions1. Carl Rogers2. Erik Erikson3. Ivan Pavlov4. Albert Ellis5. B. F. Skinner6. Carl Rogers7. Frederick Perls8. Abraham Maslow9. Viktor Frankl10. Albert Ellis11. William GlasserShort-Answer Questions1. Clients participate in group sessions with memberswho have the shared purposes of benefiting one anotherand making some change. An example is familytherapy to learn conflict resolution.2. Members gather to learn about a particular topic fromsomeone who has expertise. An example is an assertivenesstraining group.3. Members help themselves and one another to copewith some life stress, event, illness, or problem. Anexample is Survivors of Suicide (for family members ofsomeone who has committed suicide).4. This group is structured around a common experiencethat all members share and is run by the group members.An example is Alcoholics Anonymous.Chapter 4Multiple-Choice Questions1. B 5. C2. B 6. C3. C 7. C4. B 8. D465

466 ANSWERS TO CHAPTER STUDY GUIDESFill-in-the-Blank QuestionsPsychiatric social workerOccupational therapistPsychiatristVocational rehabilitation specialistShort-Answer Questions1. Double stigma, lack of family or social support, comorbidity,adjustment problems, boundary issues2. The evolving consumer household is a group-livingsituation intended to transform itself into a residencewhere the residents fulfill their own responsibilitiesand function without on-site supervision from paidstaff. It is intended to be a permanent residence for theclient.3. Deinstitutionalization, more rigid criteria for civil commitment,lack of adequate support, attitudes of policeand societyChapter 5Multiple-Choice Questions1. A 3. C2. A 4. BMultiple-Response Questions1. C, E, F2. A, C, DClinical ExampleMr. V: “I like to choose my student nurses; otherwise, Idon’t get chosen.”Nurse: “I am honored that you chose me, Mr. V. My nameis Sandy Moore, and I will be your student nurse for thenext 6 weeks. You seem to have some experience withother groups of students.” (Nurse clearly states informationabout herself and her role and acknowledgesclient’s previous experience.)Mr. V: “Oh, yeah, I’ve seen ‘em come and go, but I neverget picked to be their patient. I guess I’m too crazy forthem!” (laughs nervously)Nurse: “Well, I’m delighted you chose me. It makes mefeel honored.” (Nurse makes it clear she is glad to bewith client.)Mr. V: “Are you sure?”Nurse: “Yes. I will be here on Tuesdays from 10 AM to 3 PMfor the next 6 weeks. I hope we can identify and workon some issues together.” (provides clear parametersfor the relationship)Chapter 6Multiple-Choice Questions1. C 5. B2. A 6. C3. B 7. A4. BMultiple-Response Questions1. A, C, D, E2. D, FChapter 7Multiple-Choice Questions1. A 4. B2. B 5. C3. A 6. BMultiple-Response Questions1. B, C, F2. C, E, FShort-Answer Questions1. Culturally competent nursing care means being sensitiveto issues related to culture, race, gender, sexualorientation, social class, economic situation, and otherfactors that affect client care. It means that the nursepromotes the client’s practice of his or her beliefs (e.g.,spiritual practices), uses nonverbal communicationthat is congruent with the client, and so forth.2. Failure to successfully complete the developmentaltasks at a given stage results in a negative outcome forthat stage—such as mistrust rather than trust—andimpedes successful completion of future tasks.Successful completion of tasks sets the stage for furthersuccess at the next developmental stage.Chapter 8Multiple-Choice Questions1. B 5. C2. D 6. A3. B 7. C4. BMultiple-Response Questions1. A, C, E2. A, D, E, FShort-Answer Questions1. What does the saying “A rolling stone gathers no moss”mean to you?2. What led you to come to the clinic?3. How would you describe yourself as a person?4. If you were lost downtown, what would you do?5. In general, how are you feeling?6. Can you tell me today’s date? (time)Can you tell me where you are? (place)Can you tell me your name? (person)Clinical Example1. Give positive feedback for coming to the clinic to gethelp.Tell her it is all right to cry.

ANSWERS TO CHAPTER STUDY GUIDES467Tell the client that the nurse will sit with her until she’sready to talk.Validate the client’s feelings (i.e., “I can see you’re veryupset”).2. What is the problem as the client sees it (to gain theclient’s perception of the situation)?Has the client ever felt this way before (to determine ifthis is a new occurrence, or recurrent)?Does the client have thoughts of harming herself orothers (to determine safety)?Has the client been drinking alcohol, using drugs, ortaking medication (to assess client’s ability to thinkclearly or if there is impairment)?What kind of help does the client need (to see whatkind of help the client wants, e.g., someone to listen,help to solve a specific problem, or a referral)?3. The client is in crisis.The client is seeking help/treatment.The client is not currently stable.4. Tell the client that the nurse needs to know if the clientis safe (from suicidal ideas or self-harm urges). If theclient is safe, she can leave the clinic. If she is not safe,the nurse must ask her to stay or must call emergencyservices (911) if necessary.Chapter 9Multiple-Choice Questions1. A2. A3. B4. D5. DMultiple-Response Questions1. A, C, F2. A, B, C, FChapter 10Multiple-Choice Questions1. B2. B3. B4. C5. BMultiple-Response Questions1. D, E, F2. B, C, EChapter 11Multiple-Choice Questions1. B 5. D2. C 6. B3. C 7. A4. C 8. AMultiple-Response Questions1. A, B, C, D2. A, B, FChapter 12Multiple-Choice Questions1. B2. C3. D4. AMultiple-Response Questions1. A, C, E2. A, C, E, FChapter 13Multiple-Choice Questions1. C 5. D2. D 6. C3. D 7. C4. B 8. DMultiple-Response Questions1. A, D, E2. C, D, E, FClinical Example1. The nurse would do a thorough psychosocial assessment,as well as assess Susan’s functional abilities and impairment,Susan’s perception of her situation, willingness toaccept treatment, her safety, and coping skills.2. Susan could be treated with SSRI antidepressants, systematicdesensitization, and nonchemical methods tomanage her anxiety response, such as progressive musclerelaxation, imagery, and cognitive–behavioralreframing techniques.3. At this point, Martha’s intended helpfulness is enablingSusan to remain in her apartment without seeking helpor treatment. The nurse could suggest to Martha thatshe work with Susan’s treaters about ways she could besupportive and helpful to Susan without enabling her.Should Susan refuse treatment, Martha could make anappointment with a therapist or counselor for herself toget assistance and support.Chapter 14Multiple-Choice Questions1. D 5. A2. B 6. B3. D 7. D4. CMultiple-Response Questions1. A, B, D2. B, C, D

468 ANSWERS TO CHAPTER STUDY GUIDESClinical Example1. Additional assessment data (examples): discover contentof any command hallucinations, ask about preferencesfor hygiene (e.g., shower or bath), and determinewhether there is a thing or place that makes him feelsafe and secure.2. Disturbed thought processes: client will have 5-minuteinteractions that are reality based; client will expressfeelings and emotions.Ineffective therapeutic regimen management (medicationrefusal): client will take medication as prescribed;client will verbalize difficulties in following medicationregimen.Self-care deficit: client will shower or bathe, wash hair,and clean clothes every other day; client will wearappropriate clothing for the weather or activity.3. Disturbed thought processes: engage client in present,here-and-now topics not related to delusional ideas;focus on client’s emotions and feelings.Ineffective therapeutic regimen management: offerscheduled medications in matter-of-fact manner; allowclient to open unit-dose packets; assess for side effectsand give medications or provide nursing interventionsto relieve side effects; provide factual information tothe client: “This medication will decrease the voicesyou’re hearing.”Self-care deficit: provide supplies and privacy forhygiene activities; give feedback about body odor, dirtyclothes, and so forth; help client store extra clothingwhere he has access to it and believes it is safe.4. John might benefit from a case manager in the communityand a community support program or a clinicfor possible depot injections of his medication.Chapter 15Multiple-Choice Questions1. D 6. D2. A 7. B3. A 8. D4. C 9. A5. AMultiple-Response Questions1. A, B, F2. A, B, EClinical Example(These are examples of correct answers; others are possible.)1. It is essential that the nurse ask if June is having suicidalthoughts. If so, the nurse would assess June’slethality by finding out if she has a plan, if she hasaccess to the means to carry out the plan, and details ofher plan.2. Ineffective Coping; Ineffective Role Performance; andImpaired Social InteractionNote: Risk for Suicide would be a priority if the nursedetermined June was having suicidal thoughts.3. The client will identify past successful coping strategies;the client will carry out activities of daily living;the client will verbalize her feelings.4. Spending 1:1 interaction time with June to discuss feelingsand past coping strategies; providing encouragementand support to get up, shower, get dressed, eat,and so forth; educating June about depression and itstreatment; assisting June to identify life stressors andpossible sources of supportChapter 16Multiple-Choice Questions1. C 5. D2. A 6. C3. D 7. A4. B 8. AMultiple-Response Questions1. B, C, D2. B, C, DClinical Example(These are examples of correct answers; others are possible.)1. Risk for Self-Mutilation, Ineffective Coping2. Risk for Self-Mutilation: The client will be safe and freeof significant injury.Ineffective Coping: The client will demonstrateincreased control of impulsive behavior.3. Risk for Self-Mutilation: Discuss presence and intensityof self-harm urges with client; negotiate a no-self-harmcontract with the client; help the client to identify triggersfor self-harm behavior.Ineffective Coping: Help the client to identify feelingsby keeping a journal; discuss ways the client can usedistraction when gratification must be delayed; discussalternative ways the client can express feelings withoutan exaggerated response.4. Outpatient therapist, community support services,vocational/career counseling, self-help groupChapter 17Multiple-Choice Questions1. B 5. C2. A 6. A3. B 7. C4. DMultiple-Response Questions1. B, C, E, F2. B, E, F

ANSWERS TO CHAPTER STUDY GUIDES469Clinical Example1. Ineffective Denial: Ineffective Coping2. Ineffective Denial: The client will abstain from alcoholor drug use.Ineffective Coping: The client will identify two nonchemicalways of coping with life stressors.3. Ineffective Denial: Teach the client about the disease ofalcoholism; dispel myths about alcoholism; ask the clientabout recent life events (breakup, arrest) and therole of her drinking in those events.Ineffective Coping: Encourage the client to expressfeelings directly and openly; teach the client relaxationtechniques; role-play a situation (of the client’s choice)that has been difficult for her to handle.Chapter 18Multiple-Choice Questions1. B 5. A2. C 6. B3. A 7. D4. B 8. AMultiple-Response Questions1. A, C, D, F2. B, C, D, FClinical Example(These are examples of correct answers; others are possible.)1. Imbalanced Nutrition: Less Than Body Requirementsand Ineffective Coping2. (Nutrition) The client will eat all of her meals andsnacks with no purging behaviors. (Coping) The clientwill identify two non-food-related mechanisms.3. (Nutrition) Sit with the client while eating; monitorclient 1 to 2 hours after meals and snacks; superviseclient’s use of the bathroom. (Coping) Ask the clienthow she is feeling, and continue to focus on feelings ifthe client gives a somatic response; have the client keepa journal including emotions, feelings, and food eaten;teach the client the use of relaxation and distraction,such as music and activities.Chapter 19Multiple-Choice Questions1. B 5. A2. C 6. A3. D 7. A4. B 8. CMultiple-Response Questions1. B, C, F2. A, B, C, DClinical Example(These are examples of correct answers; others are possible.)1. Ineffective Coping, Pain, Anxiety2. The client will identify the relationship between stressand increased pain; the client will be able to performactivities of daily living.3. Have the client keep a journal about emotional feelingsand the quality or intensity of pain; teach the clientrelaxation exercises; help the client make a daily scheduleof activities, beginning with simple tasks; encouragethe client to listen to music or engage in otherdistracting activities she may enjoy; talk with the clientabout her feelings of frustration and anxiety in a sensitiveand supportive manner.4. Physical therapy, vocational rehabilitation, nutritionservices5. Support group for persons with chronic pain/pain disorder,exercise group, social or volunteer opportunitiesChapter 20Multiple-Choice Questions1. D 5. A2. A 6. B3. C 7. D4. AMultiple-Response Questions1. B, C, D2. C, D, EClinical Example(These are examples of correct answers; others are possible.)1. Ritalin is a stimulant medication that is effective for70% to 80% of children with ADHD by decreasinghyperactivity and impulsivity and improving the child’sattention. Ritalin can cause appetite suppression andshould be given after meals to encourage proper nutrition.Substantial, nutritious snacks between meals arehelpful. Giving the medication in the daytime helpsavoid the side effect of insomnia. Parents should noticeimprovements in a day or two. Notify the physician orreturn to the clinic if no improvements in behavior arenoted.2. The exact cause of ADHD is not known, but it is notdue to faulty parenting or anything the parents havedone. Taking medications will be helpful with behavioralsymptoms, but other strategies are needed as well.The medication will help control symptoms so Dixiecan participate in school, make friends, and so forth.3. Provide supervision when Dixie is with her brother, andhelp her learn to play gently with him. Do not forbid herto touch him, but teach her the proper ways to do so. GiveDixie directions in a clear, step-by-step manner, and assisther to follow through and complete tasks. Provide a quietplace with minimal distraction for activities that requireconcentration, such as homework. Try to establish aroutine for getting up and dressing, eating meals, going toschool, doing homework, and playing; don’t change the

470 ANSWERS TO CHAPTER STUDY GUIDESroutine unnecessarily. Structured expectations will beeasier for Dixie to follow. Remember to recognize Dixie’sstrengths and provide positive feedback frequently toboost her self-esteem and foster continued progress.4. The parents should contact Dixie’s teacher, principal,and guidance counselor to inform them of this diagnosisso that special education classes or tutoring can bemade available. It would also be helpful to meet withthe school nurse who will be giving Dixie her medicationat noon on school days. The nurse can refer theparents to a local support group for parents of childrenwith ADHD and provide pamphlets, books, or otherwritten materials, as well as Internet addresses if theparents have access to a computer.Chapter 21Multiple-Choice Questions1. B 5. B2. D 6. C3. B 7. A4. C 8. AMultiple-Response Questions1. B, C, F2. A, C, FClinical Example(These are examples of correct answers; others are possible.)1. What does she like to eat? What were her usual personalhygiene practices? What are her favorite activities?What personal items does she value?2. Chronic Confusion, Impaired Socialization, DisturbedSleep Pattern, Self-Care Deficits, and Risk for ImbalancedNutrition: Less Than Body Requirements3. The client will experience as little frustration as possible.Interventions: Point out objects, people, and thetime of day to prompt the client and decrease confusion.Do not ask the client to make decisions when sheis unable to; offer choices only when she can makethem.The client will interact with the nurse. The client willparticipate in going for a walk with the group.Interventions: Involve the client in solitary activitieswith the nurse initially. Structure group activities thatfocus on intact physical abilities rather than thoserequiring cognition.The client will eat 50% of meals and snacks. Interventions:Provide foods the client likes, and provide those foodsin an environment where she will be likely to eat, suchas her room or a table alone.The client will sleep 6 hours per night. Interventions:Provide a soothing nighttime routine every night (e.g.,offering a beverage, reading aloud, dimming lights).Decrease stimulation after dinner, and discourage daytimenaps.The client will participate in hygiene routines withassistance. Interventions: Try to imitate the client’shome hygiene routine (bath or shower, morning orevening), and develop a structured routine forhygiene.

Appendix ADSM-IV-TR ClassificationNOS = Not Otherwise Specified.An x appearing in a diagnostic code indicates that a specificcode number is required.An ellipsis (. . .) is used in the names of certain disordersto indicate that the name of a specific mental disorder orgeneral medical condition should be inserted whenrecording the name (e.g., 293.0 Delirium Due toHypothyroidism).Numbers in parentheses are page numbers.If criteria are currently met, one of the following severityspecifiers may be noted after the diagnosis:MildModerateSevereIf criteria are no longer met, one of the following specifiersmay be noted:In Partial RemissionIn Full RemissionPrior HistoryDISORDERS USUALLY FIRST DIAGNOSEDIN INFANCY, CHILDHOOD, ORADOLESCENCE (39)Mental Retardation (41)Note: These are coded on Axis II.317 Mild Mental Retardation (43)318.0 Moderate Mental Retardation (43)318.1 Severe Mental Retardation (43)318.2 Profound Mental Retardation (44)319 Mental Retardation; Severity Unspecified (44)Learning Disorders (49)315.00 Reading Disorder (51)315.1 Mathematics Disorder (53)315.2 Disorder of Written Expression (54)315.9 Learning Disorder NOS (56)Motor Skills Disorder (56)315.4 Developmental Coordination Disorder (56)Communication Disorders (58)315.31 Expressive Language Disorder (58)315.32 Mixed Receptive-Expressive LanguageDisorder (62)315.39 Phonological Disorder (65)307.0 Stuttering (67)307.9 Communication Disorder NOS (69)Pervasive Developmental Disorders (69)299.00 Autistic Disorder (70)299.80 Rett’s Disorder (76)299.10 Childhood Disintegrative Disorder (77)299.80 Asperger’s Disorder (80)299.80 Pervasive Developmental Disorder NOS (84)Attention-Deficit and Disruptive BehaviorDisorders (85)314.xx Attention-Deficit/Hyperactivity Disorder (85).01 Combined Type.00 Predominantly Inattentive Type.01 Predominantly Hyperactive-Impulsive Type314.9 Attention-Deficit/Hyperactivity DisorderNOS (93)312.xx Conduct Disorder (93).81 Childhood-Onset Type.82 Adolescent-Onset Type.89 Unspecified Onset313.81 Oppositional Defiant Disorder (100)312.9 Disruptive Behavior Disorder NOS (103)Feeding and Eating Disorders of Infancy or EarlyChildhood (103)307.52 Pica (103)307.53 Rumination Disorder (105)307.59 Feeding Disorder of Infancy or EarlyChildhood (107)Tic Disorders (108)307.23 Tourette’s Disorder (111)307.22 Chronic Motor or Vocal Tic Disorder (114)307.21 Transient Tic Disorder (115)Specify if: Single Episode/Recurrent307.20 Tic Disorder NOS (116)Elimination Disorders (116)–––.–– Encopresis (116)787.6 With Constipation and Overflow Incontinence307.7 Without Constipation and OverflowIncontinence307.6 Enuresis (Not Due to a General MedicalCondition) (118)Specify type: Nocturnal Only/Diurnal Only/Nocturnal and DiurnalOther Disorders of Infancy, Childhood, orAdolescence (121)309.21 Separation Anxiety Disorder (121)Specify if: Early Onset471

472 APPENDIX A • DSM-IV-TR CLASSIFICATION313.23 Selective Mutism (125)313.89 Reactive Attachment Disorder of Infancy orEarly Childhood (127)Specify type: Inhibited Type/Disinhibited Type307.3 Stereotypic Movement Disorder (131)Specify if: With Self-Injurious Behavior313.9 Disorder of Infancy, Childhood, or AdolescenceNOS (134)DELIRIUM, DEMENTIA, AND AMNESTICAND OTHER COGNITIVE DISORDERS (135)Delirium (136)293.0 Delirium Due to . . . [Indicate the General MedicalCondition] (141)–––.–– Substance Intoxication Delirium (refer toSubstance-Related Disorders for substance-specificcodes) (143)–––.–– Substance Withdrawal Delirium (refer to Substance-Related Disorders for substance-specific codes) (143)–––.–– Delirium Due to Multiple Etiologies (code each ofthe specific etiologies) (146)780.09 Delirium NOS (147)Dementia (147)294.xx* Dementia of the Alzheimer’s Type, With EarlyOnset (also code 331.0 Alzheimer’s disease onAxis III) (154).10 Without Behavioral Disturbance.11 With Behavioral Disturbance294.xx* Dementia of the Alzheimer’s Type, With LateOnset (also code 331.0 Alzheimer’s disease onAxis III) (154).10 Without Behavioral Disturbance.11 With Behavioral Disturbance290.xx Vascular Dementia (158).40 Uncomplicated.41 With Delirium.42 With Delusions.43 With Depressed MoodSpecify if: With Behavioral DisturbanceCode presence or absence of a behavioral disturbance in thefifth digit for Dementia Due to a General MedicalCondition:0 Without Behavioral Disturbance1 With Behavioral Disturbance294.1x* Dementia Due to HIV Disease (also code 042 HIVon Axis III) (163)294.1x* Dementia Due to Head Trauma (also code 854.00head injury on Axis III) (164)294.1x* Dementia Due to Parkinson’s Disease (also code332.0 Parkinson’s disease on Axis III) (164)294.1x* Dementia Due to Huntington’s Disease (also code333.4 Huntington’s disease on Axis III) (165)294.1x* Dementia Due to Pick’s Disease (also code 331.1Pick’s disease on Axis III) (165)294.1x* Dementia Due to Creutzfeldt–Jakob Disease(also code 046.1 Creutzfeldt–Jakob disease onAxis III) (166)294.1x* Dementia Due to . . . [Indicate the GeneralMedical Condition not listed above] (also code thegeneral medical condition on Axis III) (167)–––.–– Substance-Induced Persisting Dementia (refer toSubstance-Related Disorders for substance-specificcodes) (168)–––.–– Dementia Due to Multiple Etiologies (code eachof the specific etiologies) (170)294.8 Dementia NOS (171)Amnestic Disorders (172)294.0 Amnestic Disorder Due to . . . [Indicate theGeneral Medical Condition] (175)Specify if: Transient/Chronic–––.–– Substance-Induced Persisting Amnestic Disorder(refer to Substance-Related Disorders for substancespecificcodes) (177)294.8 Amnestic Disorder NOS (179)Other Cognitive Disorders (179)294.9 Cognitive Disorder NOS (179)MENTAL DISORDERS DUE TO A GENERALMEDICAL CONDITION NOT ELSEWHERECLASSIFIED (181)293.89 Catatonic Disorder Due to . . . [Indicate theGeneral Medical Condition] (185)310.1 Personality Change Due to . . . [Indicate theGeneral Medical Condition] (187)Specify type: Labile Type/Disinhibited Type/Aggressive Type/Apathetic Type/Paranoid Type/Other Type/Combined Type/Unspecified Type293.9 Mental Disorder NOS Due to . . . [Indicate theGeneral Medical Condition] (190)SUBSTANCE-RELATED DISORDERS (191)The following specifiers apply to Substance Dependence asnoted:aWith Physiological Dependence/Without PhysiologicalDependencebEarly Full Remission/Early Partial Remission/SustainedFull Remission/Sustained Partial RemissioncIn a Controlled EnvironmentdOn Agonist TherapyThe following specifiers apply to Substance-Induced Disordersas noted:1 With Onset During Intoxication/ W With Onset DuringWithdrawal

APPENDIX A • DSM-IV-TR CLASSIFICATION473Alcohol-Related Disorders (212)Alcohol Use Disorders (213)303.90 Alcohol Dependence a,b,c (213)305.00 Alcohol Abuse (214)Alcohol-Induced Disorders (214)303.00 Alcohol Intoxication (214)291.81 Alcohol Withdrawal (215)Specify if: With Perceptual Disturbances291.0 Alcohol Intoxication Delirium (143)291.0 Alcohol Withdrawal Delirium (143)291.2 Alcohol-Induced Persisting Dementia (168)291.1 Alcohol-Induced Persisting AmnesticDisorder (177)291.x Alcohol-Induced Psychotic Disorder (338).5 With Delusions I,W.3 With Hallucinations I,W291.89 Alcohol-Induced Mood Disorder I,W (405)291.89 Alcohol-Induced Anxiety Disorder I,W (479)291.89 Alcohol-Induced Sexual Dysfunction I (562)291.89 Alcohol-Induced Sleep Disorder I,W (655)291.9 Alcohol-Related Disorder NOS (223)Amphetamine (or Amphetamine-Like)–RelatedDisorders (223)Amphetamine Use Disorders (224)304.40 Amphetamine Dependence a,b,c (224)305.70 Amphetamine Abuse (225)Amphetamine-Induced Disorders (226)292.89 Amphetamine Intoxication (226)Specify if: With Perceptual Disturbances292.0 Amphetamine Withdrawal (227)292.81 Amphetamine Intoxication Delirium (143)292.xx Amphetamine-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Amphetamine-Induced Mood Disorder I,W (405)292.89 Amphetamine-Induced Anxiety Disorder I (479)292.89 Amphetamine-Induced Sexual Dysfunction I (562)292.89 Amphetamine-Induced Sleep Disorder I,W (655)292.9 Amphetamine-Related Disorder NOS (231)Caffeine-Related Disorders (231)Caffeine-Induced Disorders (232)305.90 Caffeine Intoxication (232)292.89 Caffeine-Induced Anxiety Disorder I (479)292.89 Caffeine-Induced Sleep Disorder I (655)292.9 Caffeine-Related Disorder NOS (234)Cannabis-Related Disorders (234)Cannabis Use Disorders (236)304.30 Cannabis Dependence a,b,c (236)305.20 Cannabis Abuse (236)Cannabis-Induced Disorders (237)292.89 Cannabis Intoxication (237)Specify if: With Perceptual Disturbances292.81 Cannabis Intoxication Delirium (143)292.xx Cannabis-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.89 Cannabis-Induced Anxiety Disorder I (479)292.9 Cannabis-Related Disorder NOS (241)Cocaine-Related Disorders (241)Cocaine Use Disorders (242)304.20 Cocaine Dependence a,b,c (242)305.60 Cocaine Abuse (243)Cocaine-Induced Disorders (244)292.89 Cocaine Intoxication (244)Specify if: With Perceptual Disturbances292.0 Cocaine Withdrawal (245)292.81 Cocaine Intoxication Delirium (143)292.xx Cocaine-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Cocaine-Induced Mood Disorder I,W (405)292.89 Cocaine-Induced Anxiety Disorder I,W (479)292.89 Cocaine-Induced Sexual Dysfunction I (562)292.89 Cocaine-Induced Sleep Disorder I,W (655)292.9 Cocaine-Related Disorder NOS (250)Hallucinogen-Related Disorders (250)Hallucinogen Use Disorders (251)304.50 Hallucinogen Dependence b,c (251)305.30 Hallucinogen Abuse (252)Hallucinogen-Induced Disorders (252)292.89 Hallucinogen Intoxication (252)292.89 Hallucinogen Persisting Perception Disorder(Flashbacks) (253)292.81 Hallucinogen Intoxication Delirium (143)292.xx Hallucinogen-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Hallucinogen-Induced Mood Disorder I (405)292.89 Hallucinogen-Induced Anxiety Disorder I (479)292.9 Hallucinogen-Related Disorder NOS (256)Inhalant-Related Disorders (257)Inhalant Use Disorders (258)304.60 Inhalant Dependence b,c (258)305.90 Inhalant Abuse (259)Inhalant-Induced Disorders (259)292.89 Inhalant Intoxication (259)292.81 Inhalant Intoxication Delirium (143)292.82 Inhalant-Induced Persisting Dementia (168)

474 APPENDIX A • DSM-IV-TR CLASSIFICATION292.xx Inhalant-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Inhalant-Induced Mood Disorder I (405)292.89 Inhalant-Induced Anxiety Disorder I (479)292.9 Inhalant-Related Disorder NOS (263)Nicotine-Related Disorders (264)Nicotine Use Disorder (264)305.1 Nicotine Dependence a,b (264)Nicotine-Induced Disorders (265)292.0 Nicotine Withdrawal (265)292.9 Nicotine-Related Disorder NOS (269)Opioid-Related Disorders (269)Opioid Use Disorders (270)304.00 Opioid Dependence a,b,c,d (270)305.50 Opioid Abuse (271)Opioid-Induced Disorders (271)292.89 Opioid Intoxication (271)Specify if: With Perceptual Disturbances292.0 Opioid Withdrawal (272)292.81 Opioid Intoxication Delirium (143)292.xx Opioid-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Opioid-Induced Mood Disorder I (405)292.89 Opioid-Induced Sexual Dysfunction I (562)292.89 Opioid-Induced Sleep Disorder I,W (655)292.9 Opioid-Related Disorder NOS (277)Phencyclidine (or Phencyclidine-Like)–RelatedDisorders (278)Phencyclidine Use Disorders (279)304.60 Phencyclidine Dependence b,c (279)305.90 Phencyclidine Abuse (279)Phencyclidine-Induced Disorders (280)292.89 Phencyclidine Intoxication (280)Specify if: With Perceptual Disturbances292.81 Phencyclidine Intoxication Delirium (143)292.xx Phencyclidine-Induced Psychotic Disorder (338).11 With Delusions I.12 With Hallucinations I292.84 Phencyclidine-Induced Mood Disorder I (405)292.89 Phencyclidine-Induced Anxiety Disorder I (479)292.9 Phencyclidine-Related Disorder NOS (283)Sedative-, Hypnotic-, or Anxiolytic-RelatedDisorders (284)Sedative, Hypnotic, or Anxiolytic Use Disorders (285)304.10 Sedative, Hypnotic, or AnxiolyticDependence a,b,c (285)305.40 Sedative, Hypnotic, or Anxiolytic Abuse (286)Sedative-, Hypnotic-, or Anxiolytic-InducedDisorders (286)292.89 Sedative, Hypnotic, or Anxiolytic Intoxication(286)292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal (287)Specify if: With Perceptual Disturbances292.81 Sedative, Hypnotic, or Anxiolytic IntoxicationDelirium (143)292.81 Sedative, Hypnotic, or Anxiolytic WithdrawalDelirium (143)292.82 Sedative-, Hypnotic-, or Anxiolytic-InducedPersisting Dementia (168)292.83 Sedative-, Hypnotic-, or Anxiolytic-InducedPersisting Amnestic Disorder (177)292.xx Sedative-, Hypnotic-, or Anxiolytic-InducedPsychotic Disorder (338).11 With Delusions I,W.12 With Hallucinations I,W292.84 Sedative-, Hypnotic-, or Anxiolytic-InducedMood Disorder I,W (405)292.89 Sedative-, Hypnotic-, or Anxiolytic-InducedAnxiety Disorder W (479)292.89 Sedative-, Hypnotic-, or Anxiolytic-InducedSexual Dysfunction I (562)292.89 Sedative-, Hypnotic-, or Anxiolytic-InducedSleep Disorder I,W (655)292.9 Sedative-, Hypnotic-, or Anxiolytic-RelatedDisorder NOS (293)Polysubstance-Related Disorder (293)304.80 Polysubstance Dependence a,b,c,d (293)Other (or Unknown) Substance–Related Disorders(294)Other (or Unknown) Substance Use Disorders (295)304.90 Other (or Unknown) Substance Dependence a,b,c,d(192)305.90 Other (or Unknown) Substance Abuse (198)Other (or Unknown) Substance–Induced Disorders(295)292.89 Other (or Unknown) Substance Intoxication (199)Specify if: With Perceptual Disturbances292.0 Other (or Unknown) Substance Withdrawal (201)Specify if: With Perceptual Disturbances292.81 Other (or Unknown) Substance–InducedDelirium (143)292.82 Other (or Unknown) Substance–InducedPersisting Dementia (168)292.83 Other (or Unknown) Substance–InducedPersisting Amnestic Disorder (177)292.xx Other (or Unknown) Substance–InducedPsychotic Disorder (338).11 With Delusions I,W.12 With Hallucinations I,W

APPENDIX A • DSM-IV-TR CLASSIFICATION475292.84 Other (or Unknown) Substance–Induced MoodDisorder I,W (405)292.89 Other (or Unknown) Substance–InducedAnxiety Disorder I,W (479)292.89 Other (or Unknown) Substance–Induced SexualDysfunctionI (562)292.89 Other (or Unknown) Substance–Induced SleepDisorder I,W (655)292.9 Other (or Unknown) Substance–RelatedDisorder NOS (295)SCHIZOPHRENIA AND OTHER PSYCHOTICDISORDERS (297)295.xx Schizophrenia (298)The following Classification of Longitudinal Course appliesto all subtypes of Schizophrenia:Episodic With Interepisode Residual Symptoms (specify if:With Prominent Negative Symptoms)/Episodic WithNo Interepisode Residual SymptomsContinuous (specify if: With Prominent NegativeSymptoms)Single Episode in Partial Remission (specify if: With ProminentNegative Symptoms)/Single Episode in FullRemissionOther or Unspecified Pattern.30 Paranoid Type (313).10 Disorganized Type (314).20 Catatonic Type (315).90 Undifferentiated Type (316).60 Residual Type (316)295.40 Schizophreniform Disorder (317)Specify if: Without Good Prognostic Features/With Good Prognostic Features295.70 Schizoaffective Disorder (319)Specify type: Bipolar Type/Depressive Type297.1 Delusional Disorder (323)Specify type: Erotomanic Type/Grandiose Type/Jealous Type/Persecutory Type/Somatic Type/Mixed Type/Unspecified Type298.8 Brief Psychotic Disorder (329)Specify if: With Marked Stressor(s)/WithoutMarked Stressor(s)/With Postpartum Onset297.3 Shared Psychotic Disorder (332)293.xx Psychotic Disorder Due to . . . [Indicate theGeneral Medical Condition] (334).81 With Delusions.82 With Hallucinations–––.–– Substance-Induced Psychotic Disorder (refer toSubstance-Related Disorders for substance-specificcodes) (338)Specify if: With Onset During Intoxication/WithOnset During Withdrawal298.9 Psychotic Disorder NOS (343)MOOD DISORDERS (345)Code current state of Major Depressive Disorder or Bipolar IDisorder in fifth digit:1 Mild2 Moderate3 Severe Without Psychotic Features4 Severe With Psychotic FeaturesSpecify: Mood-Congruent Psychotic Features/Mood-Incongruent Psychotic Features5 In Partial Remission6 In Full Remission0 UnspecifiedThe following specifiers apply (for current or most recent episode)to Mood Disorders as noted:aSeverity/Psychotic/Remission Specifiers/ b Chronic/ c WithCatatonic Features/ d With Melancholic Features/ e WithAtypical Features/ f With Postpartum OnsetThe following specifiers apply to Mood Disorders as noted:gWith or Without Full Interepisode Recovery/ h With SeasonalPattern/ i With Rapid CyclingDepressive Disorders (369)296.xx Major Depressive Disorder (369).2x Single Episode a,b,c,d,e,f.3x Recurrent a,b,c,d,e,f,g,h300.4 Dysthymic Disorder (376)Specify if: Early Onset/Late OnsetSpecify: With Atypical Features311 Depressive Disorder NOS (381)Bipolar Disorders (382)296.xx Bipolar I Disorder (382).0x Single Manic Episode a,c,fSpecify if: Mixed.40 Most Recent Episode Hypomanic g,h,i.4x Most Recent Episode Manic a,c,f,g,h,i.6x Most Recent Episode Mixed a,c,f,g,h,i.5x Most Recent Episode Depressed a,b,c,d,e,f,g,h,i.7 Most Recent Episode Unspecified g,h,i296.89 Bipolar II Disorder a,b,c,d,e,f,g,h,i (392)Specify (current or most recent episode):Hypomanic/Depressed301.13 Cyclothymic Disorder (398)296.80 Bipolar Disorder NOS (400)293.83 Mood Disorder Due to . . . [Indicate the GeneralMedical Condition] (401)Specify type: With Depressive Features/WithMajor Depressive–Like Episode/With Manic Features/WithMixed Features–––.–– Substance-Induced Mood Disorder (refer toSubstance-Related Disorders for substance-specificcodes) (405)

476 APPENDIX A • DSM-IV-TR CLASSIFICATIONSpecify type: With Depressive Features/WithManic Features/With Mixed FeaturesSpecify if: With Onset During Intoxication/WithOnset During Withdrawal296.90 Mood Disorder NOS (410)ANXIETY DISORDERS (429)300.01 Panic Disorder Without Agoraphobia (433)300.21 Panic Disorder With Agoraphobia (433)300.22 Agoraphobia Without History of Panic Disorder(441)300.29 Specific Phobia (443)Specify type: Animal Type/Natural EnvironmentType/Blood-Injection-Injury Type/SituationalType/Other Type300.23 Social Phobia (450)Specify if: Generalized300.3 Obsessive–Compulsive Disorder (456)Specify if: With Poor Insight309.81 Posttraumatic Stress Disorder (463)Specify if: Acute/ChronicSpecify if: With Delayed Onset308.3 Acute Stress Disorder (469)300.02 Generalized Anxiety Disorder (472)293.84 Anxiety Disorder Due to . . . [Indicate the GeneralMedical Condition] (476)Specify if: With Generalized Anxiety/With PanicAttacks/With Obsessive–Compulsive Symptoms–––.–– Substance-Induced Anxiety Disorder (refer toSubstance-Related Disorders for substance-specificcodes) (479)Specify if: With Generalized Anxiety/With PanicAttacks/With Obsessive–Compulsive Symptoms/With Phobic SymptomsSpecify if: With Onset During Intoxication/WithOnset During Withdrawal300.00 Anxiety Disorder NOS (484)SOMATOFORM DISORDERS (485)300.81 Somatization Disorder (486)300.82 Undifferentiated Somatoform Disorder (490)300.11 Conversion Disorder (492)Specify type: With Motor Symptom or Deficit/With Sensory Symptom or Deficit/With Seizuresor Convulsions/With Mixed Presentation307.xx Pain Disorder (498).80 Associated With Psychological Factors.89 Associated With Both Psychological Factors anda General Medical ConditionSpecify if: Acute/Chronic300.7 Hypochondriasis (504)Specify if: With Poor Insight300.7 Body Dysmorphic Disorder (507)300.82 Somatoform Disorder NOS (511)FACTITIOUS DISORDERS (513)300.xx Factitious Disorder (513).16 With Predominantly Psychological Signs andSymptoms.19 With Predominantly Physical Signs andSymptoms.19 With Combined Psychological and PhysicalSigns and Symptoms300.19 Factitious Disorder NOS (517)DISSOCIATIVE DISORDERS (519)300.12 Dissociative Amnesia (520)300.13 Dissociative Fugue (523)300.14 Dissociative Identity Disorder (526)300.6 Depersonalization Disorder (530)300.15 Dissociative Disorder NOS (532)SEXUAL AND GENDER IDENTITYDISORDERS (535)Sexual Dysfunctions (535)The following specifiers apply to all primary SexualDysfunctions:Lifelong Type/Acquired TypeGeneralized Type/Situational TypeDue to Psychological Factors/Due to Combined FactorsSexual Desire Disorders (539)302.71 Hypoactive Sexual Desire Disorder (539)302.79 Sexual Aversion Disorder (541)Sexual Arousal Disorders (543)302.72 Female Sexual Arousal Disorder (543)302.72 Male Erectile Disorder (545)Orgasmic Disorders (547)302.73 Female Orgasmic Disorder (547)302.74 Male Orgasmic Disorder (550)302.75 Premature Ejaculation (552)Sexual Pain Disorders (554)302.76 Dyspareunia (Not Due to a General MedicalCondition) (554)306.51 Vaginismus (Not Due to a General MedicalCondition) (556)Sexual Dysfunction Due to a General MedicalCondition (558)625.8 Female Hypoactive Sexual Desire Disorder Dueto . . . [Indicate the General Medical Condition] (558)608.89 Male Hypoactive Sexual Desire Disorder Due to . . .[Indicate the General Medical Condition] (558)607.84 Male Erectile Disorder Due to . . . [Indicate theGeneral Medical Condition] (558)

APPENDIX A • DSM-IV-TR CLASSIFICATION477625.0 Female Dyspareunia Due to . . . [Indicate theGeneral Medical Condition] (558)608.89 Male Dyspareunia Due to . . . [Indicate theGeneral Medical Condition] (558)625.8 Other Female Sexual Dysfunction Due to . . .[Indicate the General Medical Condition] (558)608.89 Other Male Sexual Dysfunction Due to . . .[Indicate the General Medical Condition] (558)–––.–– Substance-Induced Sexual Dysfunction (refer toSubstance-Related Disorders for substance-specificcodes) (562)Specify if: With Impaired Desire/With ImpairedArousal/With Impaired Orgasm/With Sexual PainSpecify if: With Onset During Intoxication302.70 Sexual Dysfunction NOS (565)Paraphilias (566)302.4 Exhibitionism (569)302.81 Fetishism (569)302.89 Frotteurism (570)302.2 Pedophilia (571)Specify if: Sexually Attracted to Males/SexuallyAttracted to Females/Sexually Attracted to BothSpecify if: Limited to IncestSpecify type: Exclusive Type/Nonexclusive Type302.83 Sexual Masochism (572)302.84 Sexual Sadism (573)302.3 Transvestic Fetishism (574)Specify if: With Gender Dysphoria302.82 Voyeurism (575)302.9 Paraphilia NOS (576)Gender Identity Disorders (576)302.xx Gender Identity Disorder (576).6 In Children.85 In Adolescents or AdultsSpecify if: Sexually Attracted to Males/SexuallyAttracted to Females/Sexually Attracted to Both/Sexually Attracted to Neither302.6 Gender Identity Disorder NOS (582)302.9 Sexual Disorder NOS (582)EATING DISORDERS (583)307.1 Anorexia Nervosa (583)Specify type: Restricting Type; Binge-Eating/Purging Type307.51 Bulimia Nervosa (589)Specific type: Purging Type/Nonpurging Type307.50 Eating Disorder NOS (594)SLEEP DISORDERS (597)Primary Sleep Disorders (598)Dyssomnias (598)307.42 Primary Insomnia (599)307.44 Primary Hypersomnia (604)Specify if: Recurrent347 Narcolepsy (609)780.59 Breathing-Related Sleep Disorder (615)307.45 Circadian Rhythm Sleep Disorder (622)Specify type: Delayed Sleep Phase Type/Jet LagType/Shift Work Type/Unspecified Type307.47 Dyssomnia NOS (629)Parasomnias (630)307.47 Nightmare Disorder (631)307.46 Sleep Terror Disorder (634)307.46 Sleepwalking Disorder (639)307.47 Parasomnia NOS (644)Sleep Disorders Related to Another MentalDisorder (645)307.42 Insomnia Related to . . . [Indicate the Axis I orAxis II Disorder] (645)307.44 Hypersomnia Related to . . . [Indicate the Axis Ior Axis II Disorder] (645)Other Sleep Disorders (651)780.xx Sleep Disorder Due to . . . [Indicate the GeneralMedical Condition] (651).52 Insomnia Type.54 Hypersomnia Type.59 Parasomnia Type.59 Mixed Type–––.–– Substance-Induced Sleep Disorder (refer toSubstance-Related Disorders for substance-specificcodes) (655)Specify type: Insomnia Type/Hypersomnia Type/Parasomnia Type/Mixed TypeSpecify if: With Onset During Intoxication/WithOnset During WithdrawalIMPULSE-CONTROL DISORDERS NOTELSEWHERE CLASSIFIED (663)312.34 Intermittent Explosive Disorder (663)312.32 Kleptomania (667)312.33 Pyromania (669)312.31 Pathological Gambling (671)312.39 Trichotillomania (674)312.30 Impulse-Control Disorder NOS (677)ADJUSTMENT DISORDERS (679)309.xx Adjustment Disorder (679).0 With Depressed Mood.24 With Anxiety.28 With Mixed Anxiety and Depressed Mood.3 With Disturbance of Conduct.4 With Mixed Disturbance of Emotions andConduct.9 UnspecifiedSpecify if: Acute/Chronic

478 APPENDIX A • DSM-IV-TR CLASSIFICATIONPERSONALITY DISORDERS (685)Note: These are coded on Axis II.301.0 Paranoid Personality Disorder (690)301.20 Schizoid Personality Disorder (694)301.22 Schizotypal Personality Disorder (697)301.7 Antisocial Personality Disorder (701)301.83 Borderline Personality Disorder (706)301.50 Histrionic Personality Disorder (711)301.81 Narcissistic Personality Disorder (714)301.82 Avoidant Personality Disorder (718)301.6 Dependent Personality Disorder (721)301.4 Obsessive–Compulsive Personality Disorder (725)301.9 Personality Disorder NOS (729)OTHER CONDITIONS THAT MAY BE AFOCUS OF CLINICAL ATTENTION (731)Psychological Factors Affecting MedicalCondition (731)316 . . . [Specified Psychological Factor] Affecting . . .[Indicate the General Medical Condition] (731)Choose name based on nature of factors:Mental Disorder Affecting Medical ConditionPsychological Symptoms Affecting MedicalConditionPersonality Traits or Coping Style Affecting MedicalConditionMaladaptive Health Behaviors Affecting MedicalConditionStress-Related Physiological Response AffectingMedical ConditionOther or Unspecified Psychological FactorsAffecting Medical ConditionMedication-Induced Movement Disorders (734)332.1 Neuroleptic-Induced Parkinsonism (735)333.92 Neuroleptic Malignant Syndrome (735)333.7 Neuroleptic-Induced Acute Dystonia (735)333.99 Neuroleptic-Induced Acute Akathisia (735)333.82 Neuroleptic-Induced Tardive Dyskinesia (736)333.1 Medication-Induced Postural Tremor (736)333.90 Medication-Induced Movement Disorder NOS(736)Other Medication-Induced Disorder (736)995.2 Adverse Effects of Medication NOS (736)Relational Problems (736)V61.9 Relational Problem Related to a Mental Disorderor General Medical Condition (737)V61.20 Parent–Child Relational Problem (737)V61.10 Partner Relational Problem (737)V61.8 Sibling Relational Problem (737)V62.81 Relational Problem NOS (737)Problems Related to Abuse or Neglect (738)V61.21 Physical Abuse of Child (738)(code 995.54 if focus of attention is on victim)V61.21 Sexual Abuse of Child (738)(code 995.53 if focus of attention is on victim)V61.21 Neglect of Child (738)(code 995.52 if focus of attention is on victim)–––.–– Physical Abuse of Adult (738)V61.12 (if by partner)V62.83 (if by person other than partner)(code 995.81 if focus of attention is on victim)–––.–– Sexual Abuse of Adult (738)V61.12 (if by partner)V62.83 (if by person other than partner)(code 995.83 if focus of attention is on victim)Additional Conditions That May Be a Focus ofClinical Attention (739)V15.81 Noncompliance With Treatment (739)V65.2 Malingering (739)V71.01 Adult Antisocial Behavior (740)V71.02 Child or Adolescent Antisocial Behavior (740)V62.89 Borderline Intellectual Functioning (740)Note: This is coded on Axis II.780.9 Age-Related Cognitive Decline (740)V62.82 Bereavement (740)V62.3 Academic Problem (741)V62.2 Occupational Problem (741)313.82 Identity Problem (741)V62.89 Religious or Spiritual Problem (741)V62.4 Acculturation Problem (741)V62.89 Phase of Life Problem (742)ADDITIONAL CODES (743)300.9 Unspecified Mental Disorder (nonpsychotic) (743)V71.09 No Diagnosis or Condition on Axis I (743)799.9 Diagnosis or Condition Deferred on Axis I (743)V71.09 No Diagnosis on Axis II (743)799.9 Diagnosis Deferred on Axis II (743)MULTIAXIAL SYSTEMAxis I Clinical Disorders/Other Conditions That MayBe a Focus of Clinical AttentionAxis II Personality Disorders/Mental RetardationAxis III General Medical ConditionsAxis IV Psychosocial and Environmental ProblemsAxis V Global Assessment of FunctioningReprinted with permission from the Diagnostic and Statistical Manual ofMental Disorders, 4th ed., Text Revision. © 2000 APA.*ICD-9-CM code valid after October 1, 2000.

Appendix BNANDA-I Approved Nursing DiagnosesThis list represents the NANDA-I approved nursing diagnoses for clinical use and testing.APPROVED NURSING DIAGNOSES,2009–2011Activity IntoleranceActivity Intolerance, Risk forIneffective Activity PlanningAirway Clearance, IneffectiveAllergy Response, LatexAllergy Response, Risk for LatexAnxietyAnxiety, DeathAspiration, Risk forAttachment, Risk for Impaired Parent/ChildAutonomic DysreflexiaAutonomic Dysreflexia, Risk forBehavior, Risk-Prone HealthRisk for BleedingBody Image, DisturbedBody Temperature, Risk for ImbalancedBowel IncontinenceBreastfeeding, EffectiveBreastfeeding, IneffectiveBreastfeeding, InterruptedBreathing Pattern, IneffectiveCardiac Output, DecreasedCaregiver Role StrainCaregiver Role Strain, Risk forReadiness for Enhanced Childbearing ProcessComfort, Readiness for EnhancedImpaired ComfortCommunication, Impaired VerbalCommunication, Readiness for EnhancedConflict, DecisionalConflict, Parental RoleConfusion, AcuteConfusion, ChronicConfusion, Risk for AcuteConstipationConstipation, PerceivedConstipation, Risk forContaminationContamination, Risk forCoping, Compromised FamilyCoping, DefensiveCoping, Disabled FamilyCoping, IneffectiveCoping, Ineffective CommunityCoping, Readiness for EnhancedCoping, Readiness for Enhanced CommunityCoping, Readiness for Enhanced FamilyDeath Syndrome, Risk for Sudden InfantDecision Making, Readiness for EnhancedDenial, IneffectiveDentition, ImpairedDevelopment, Risk for DelayedDiarrheaDignity, Risk for Compromised HumanDistress, MoralDisuse Syndrome, Risk forDiversional Activity, DeficientRisk for Disturbed Maternal/Fetal DyadRisk for Electrolyte ImbalanceEnergy Field, DisturbedEnvironmental Interpretation Syndrome, ImpairedFailure to Thrive, AdultFalls, Risk forFamily Processes, Dysfunctional: AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedFatigueFearFluid Balance, Readiness for EnhancedFluid Volume, DeficientFluid Volume, ExcessFluid Volume, Risk for DeficientFluid Volume, Risk for ImbalancedGas Exchange, ImpairedDysfunctional Gastrointestinal MotilityRisk for Dysfunctional Gastrointestinal MotilityGlucose, Risk for Unstable BloodGrieving, AnticipatoryGrieving, ComplicatedGrieving, Risk for ComplicatedGrowth and Development, DelayedGrowth, Risk for DisproportionateHealth Maintenance, IneffectiveIneffective Self Health MaintenanceHome Maintenance, ImpairedHope, Readiness for EnhancedHopelessnessHyperthermiaHypothermiaIdentity, Disturbed PersonalImmunization Status, Readiness for EnhancedIncontinence, Functional UrinaryIncontinence, Overflow UrinaryIncontinence, Reflex UrinaryIncontinence, Stress UrinaryIncontinence, Urge UrinaryIncontinence, Risk for Urge UrinaryInfant Behavior, DisorganizedInfant Behavior, Risk for DisorganizedInfant Behavior, Readiness for Enhanced OrganizedInfant Feeding Pattern, IneffectiveInfection, Risk forInjury, Risk forInjury, Risk for Perioperative-PositioningInsomniaIntracranial Adaptive Capacity, DecreasedKnowledge, Deficient (Specify)479

480 APPENDIX B • NANDA-I APPROVED NURSING DIAGNOSESKnowledge, Readiness for EnhancedLifestyle, SedentaryLiver Function, Risk for ImpairedLoneliness, Risk forMemory, ImpairedMobility, Impaired BedMobility, Impaired PhysicalMobility, Impaired WheelchairNauseaNeglect, UnilateralNeonatal JaundiceNoncomplianceNutrition, Imbalanced: Less Than Body RequirementsNutrition, Imbalanced: More Than Body RequirementsNutrition, Readiness for EnhancedNutrition, Risk for Imbalanced: More Than BodyRequirementsOral Mucous Membrane, ImpairedPain, AcutePain, ChronicParenting, Readiness for EnhancedParenting, ImpairedParenting, Risk for ImpairedPeripheral Neurovascular Dysfunction, Risk forPoisoning, Risk forPost-Trauma SyndromePost-Trauma Syndrome, Risk forPower, Readiness for EnhancedPowerlessnessPowerlessness, Risk forProtection, IneffectiveRape-Trauma SyndromeReadiness for Enhanced RelationshipReligiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forRisk for Compromised ResilienceReadiness for Enhanced ResilienceImpaired Individual ResilienceRole Performance, IneffectiveSelf-Care, Readiness for EnhancedSelf-Care Deficit, Bathing/HygieneSelf-Care Deficit, Dressing/GroomingSelf-Care Deficit, FeedingSelf-Care Deficit, ToiletingSelf-Concept, Readiness for EnhancedSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Risk for Situational LowReadiness for Enhanced Self Health ManagementSelf-MutilationSelf-Mutilation, Risk forSelf NeglectSensory Perception, Disturbed(Specify: Visual, Auditory, Kinesthetic,Gustatory, Tactile, Olfactory)Sexual DysfunctionSexuality Pattern, IneffectiveRisk for ShockSkin Integrity, ImpairedSkin Integrity, Risk for ImpairedSleep DeprivationSleep Pattern, DisturbedSleep, Readiness for EnhancedSocial Interaction, ImpairedSocial IsolationSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being, Readiness for EnhancedStress OverloadSuffocation, Risk forSuicide, Risk forSurgical Recovery, DelayedSwallowing, ImpairedTherapeutic Regimen Management, IneffectiveTherapeutic Regimen Management, Ineffective FamilyTherapeutic Regimen Management, Readiness for EnhancedThermoregulation, IneffectiveTissue Integrity, ImpairedTissue Perfusion, Ineffective CardiacTissue Perfusion, Ineffective PeripheralTransfer Ability, ImpairedTrauma, Risk forRisk for Vascular TraumaUrinary Elimination, ImpairedUrinary Elimination, Readiness for EnhancedUrinary RetentionVentilation, Impaired SpontaneousVentilatory Weaning Response, DysfunctionalViolence, Risk for Other-DirectedViolence, Risk for Self-DirectedWalking, ImpairedWanderingCopyright © 2009 by the North American Nursing DiagnosisAssociation.

Appendix CDrug Classification Under theControlled Substances ActSchedule I Drugs Schedule II Drugs Schedule III Drugs Schedule IV Drugs Schedule V DrugsOPIOIDS OPIOIDS OPIOIDS OPIOIDS OPIOIDSAcetylmethadol Alfentanil Hydrocodone syrup Pentazocine BuprenorphineHeroin Codeine Paregoric Propoxyphene DiphenoxylateNormethadone Fentanyl plus atropineMany othersHydromorphoneLevorphanolMeperidineMethadoneMorphineOpium tinctureOxycodoneOxymorphoneSufentanilPSYCHEDELICS PSYCHOSTIMULANTS STIMULANTS STIMULANTSBufotenin Amphetamine Benzphetamine DiethylpropionDiethyltryptamine Cocaine Phendimetrazine FenfluramineDimethyltryptamine Dextroamphetamine MazindolIbogaine Methamphetamine Pemolined-Lysergic acid Methylphenidate Phenterminediethylamide (LSD) PhenmetrazineMescaline3,4-Methylenedioxymethamphetamine(MDMA)PsilocinPsilocybinCANNABIS BARBITURATES BARBITURATES BARBITURATESDERIVATIVES Amobarbital Aprobarbital MephobarbitalHashish Pentobarbital Butabarbital MethohexitalMarijuana Secobarbital Methabarbital PhenobarbitalTalbutalThiamylalThiopentalOTHERS CANNABINOIDS MISCELLANEOUS BENZODIAZEPINESMethaqualone Dronabinol (THC) DEPRESSANTS AlprazolamPhencyclidine Nabilone Glutethimide ChlordiazepoxideGammahydroxybutyric Methyprylon Clonazepamacid (GHB)ANABOLICClorazepateSTEROIDSDiazepamFluoxymesterone EstazolamMethyltestosterone FlurazepamNandroloneHalazepamOxandroloneLorazepamStanozololTestosteroneMidazolamOxazepamPrazepamQuazepamTemazepamTriazolamMISCELLANEOUSDEPRESSANTSChloral hydrateEthchlorvynolEthinamateMeprobamateParaldehydeDrugs in Schedule I have a high potential for abuse and have no approved medical use in the United States. Drugs in Schedules II through V all have approved usesand are classified based on their abuse potential. Schedule II drugs have a higher potential for abuse.Schedule V drugs have the lowest potential for abuse.481

Appendix DCanadian Standards of Psychiatric andMental Health Nursing Practice (3rd ed.)BELIEFS/VALUESPsychiatric and mental health nurses believe• Psychiatry and mental health is a specialized area ofnursing practice, education, and research.• Practice involves the promotion of mental health andthe prevention, treatment, and management of mentaldisorders.• The therapeutic relationship, based on trust and mutualrespect, is central to practice.• That alleviation of stigma and discrimination associatedwith mental illness is of paramount importance.• In the conduct and utilization of research for improvementin care.• In social action to promote political and social awarenessto influence health and organizational policy.• In working in collaborative relationships with the individual,family, community, populations, and social agencies.• That a holistic approach is essential to understand theunique experience of the client and that outcomes arefundamentally intertwined with all other health andsocial outcomes.• In equitable access to culturally competent care.• In reflective ethical practice and a commitment to continuouslearning.• In the protection of human rights in context to civilcommitment and relevant aspects of jurisprudence.• In advocating for practice environments that facilitateand ensure safe and positive work relationships.• In fostering a legacy of moral and visionary nursingleaders.• In the Code of Ethics for Registered Nurses.STANDARD I: PROVIDES COMPETENTPROFESSIONAL CARE THROUGH THEDEVELOPMENT OF A THERAPEUTICRELATIONSHIPA primary goal of psychiatric and mental health nursing isthe promotion of mental health and the prevention or diminutionof mental disorder. The development of a therapeuticrelationship is the foundation from where the psychiatricand mental health nurse can “enter into partnerships withclients, and through the use of the human sciences, and theart of caring, develop helping relationships” (CanadianNurses Association [CNA], 1997, p. 43).The nurse is expected to demonstrate competence in atherapeutic relationship by the following:1. Assesses and clarifies the influences of personalbeliefs, values, and life experience on the therapeuticrelationship and distinguishes between social andtherapeutic relationships4822. Works in partnership with the client, family, and relevantothers to determine goal-directed needs andestablishes an environment that is conducive to goalachievement3. Uses a range of therapeutic verbal and nonverbal communicationskills that include empathy, active listening,observing, genuineness, and curiosity4. Recognizes the influence of culture, class, ethnicity,language, stigma, and social exclusion on the therapeuticprocess and negotiates care that is sensitive tothese influences5. Mobilizes and advocates for resources that increaseclients’ and families’ access to mental health servicesand that improve community integration6. Understands and responds to human reactions to distressand loss of control that may be expressed asanger, anxiety, fear, grief, helplessness, hopelessness,and humor7. Guides the client through behavioral, developmental,emotional, or spiritual change while acknowledgingand supporting the client’s participation, responsibility,and choices in own care8. Supports the client’s and family’s sense of resiliency,self-esteem, power, and hope through continuity oftherapeutic relationship, on a 1:1 basis or within agroup context9. Fosters mutuality of the relationship by reflectivelycritiquing therapeutic effectiveness through clientand family responses, clinical supervision, and selfevaluation10. Understands the nature of chronic illness and appliesthe principles of health promotion and disease preventionwhen working with clients and familiesSTANDARD II: PERFORMS/REFINESCLIENT ASSESSMENTS THROUGH THEDIAGNOSTIC AND MONITORINGFUNCTIONEffective assessment, diagnosis, and monitoring is centralto the nurse’s role and is dependent on theory, as well as onunderstanding the meaning of the health or illness experiencefrom the perspective of the client. This knowledge,integrated with the nurse’s conceptual model of nursingpractice, provides a framework for processing client dataand for developing client-focused plans of care. The nursemakes professional judgments regarding the relevance andimportance of this data and acknowledges the client as avalued and respected partner throughout the decisionmakingprocess.The nurse is expected to demonstrate competence in themental health assessment tools, for example, mental status

APPENDIX D • CANADIAN STANDARDS OF PSYCHIATRIC AND MENTAL HEALTH NURSING PRACTICE (3RD ED.)483exam and recovery principles, in various workplaces. Thenurse explains to the client the assessment process andcontent and provides feedback for all of the following:1. Collaborates with clients and with other members ofthe health-care team to gather holistic assessmentsthrough observation, examination, interview, and consultationwhile being attentive to issues of confidentialityand pertinent legal statutes2. Documents and analyzes baseline data to identify healthstatus, potential for wellness, health-care deficits, potentialfor danger to self and others; alterations in thoughtcontent and/or process, affect behavior, communication,and decision-making abilities; substance use anddependency; and history of trauma and/or abuse (emotional,physical, sexual, or verbal abuse; neglect)3. Formulates and documents a plan of care in collaborationwith the client and with the mental health team,recognizing variability in the client’s ability to participatein the process4. Refines and extends client assessment information byassessing and documenting significant change(s) in theclient’s status and by comparing new data with thebaseline assessment and intermediate client goals5. Continuously assesses status and anticipates potentialproblems and risks. Collaborates with the client toexamine his/her environment for risk factors: self-care,housing, and nutrition; economic, psychological, andsocial. Utilizes assessment data to identify potential risksto client and others. Advocates and practices for interventionsthat are appropriate to risk type and level6. Determines most appropriate and available therapeuticmodality that will potentially best meet client’s needsand assists the client to access these resourcesSTANDARD III: ADMINISTERS ANDMONITORS THERAPEUTIC INTERVENTIONSDue to the nature of mental health problems and mentaldisorders, there are unique practice issues confronting thepsychiatric and mental health nurse in the assessment phaseand the administration of therapeutic interventions. Safetyin psychiatric and mental health nursing has unique meaningsince many clients are at risk for harm to self and/orothers and/or for self-neglect. Clients may not be mentallycompetent to participate in all aspects of decision making.However, every effort must be made to include the client. Incollaboration with the client, the psychiatric–mental health(PMH) nurse needs to be alert to adverse reactions, as clients’ability to self-report may be impaired.The PMH nurse uses evidence-based and experientialknowledge from nursing, health sciences, and relatedmental health disciplines to both select and tailor nursinginterventions. The nurse1. Utilizes and evaluates evidence-based interventions toprovide safe, effective, and efficient nursing care2. Provides information to clients and families/significantothers about care and treatment, ensuring thatthe client consents to such information being sharedon an ongoing basis3. Assists, educates, and empowers clients to selectchoices that will support positive changes in theiraffect, cognition, behavior, and/or relationships, evenwhen some of these choices may involve a level of riskas assessed by the clinical team (CNA, 1997, p. 68)4. Supports clients to draw on own assets and resources forself-care, activities of daily living, mobilizing resources,and mental health promotion (CNA, 1997, p. 68)5. Makes discretionary clinical decisions, using knowledgeof client’s unique responses and paradigm cases,for example, frequency of client contact in the community,as the basis for the decision6. Uses appropriate technology to perform safe, effective,and efficient nursing intervention (CNA, 1997, p. 68)7. Administers medications accurately and safely, monitoringtherapeutic responses, reactions, untowardeffects, toxicity, and potential incompatibilities withother medications or substances; provides medicationeducation with appropriate content and in accordancewith workplace policies8. Assesses client responses to deficits in activities ofdaily living and mobilizes resources in response toclient’s capabilities and offers alternatives whenappropriate9. Provides support and assists with protection for clientsexperiencing difficulty with self-protection10. Utilizes therapeutic elements of group process11. Incorporates knowledge of family dynamics and culturalvalues and beliefs about families in the provisionof care12. Collaborates with the client, health-care providers,and community to access and coordinate resourcesand seeks feedback from the client and others regardinginterventions13. Incorporates knowledge of community needs orresponses in the provision of care14. Encourages and assists clients to seek out supportgroups for mutual aid and support15. Assesses the client’s response to, and perception of,nursing and other therapeutic interventionsSTANDARD IV: EFFECTIVELY MANAGESRAPIDLY CHANGING SITUATIONSThe effective management of rapidly changing situations isessential in critical circumstances that may be termed psychiatricemergencies. These situations include self-harm andassaultive behaviors and rapidly changing mental healthstates. This domain also includes evidence-based assessmentand screening for risk factors and referral related topsychiatric illnesses and social problems, that is, substanceabuse, violence/abuse, and suicide/homicide (Society for

484 APPENDIX D • CANADIAN STANDARDS OF PSYCHIATRIC AND MENTAL HEALTH NURSING PRACTICE (3RD ED.)Education and Research in Psychiatric–Mental HealthNursing, 1996, p. 41).The nurse1. Utilizes the therapeutic relationship throughout themanagement of rapidly changing situations2. Assesses the client using a comprehensive holisticapproach for actual or potential health problems,issues, risk factors, and or crisis/emergency/catastrophicsituations, for example, psychotic episode,neuroleptic malignant syndrome, acute onset of extrapyramidal side effects, substance abuse, violence/abuseand suicide/homicide, drug toxicity, and delirium3. Knows resources required to manage actual andpotential crisis/emergency/catastrophic situations andplans access to these resources4. Monitors client safety and utilizes continual assessmentto detect early changes in client status and intervenesaccordingly5. Implements timely, age-appropriate, client-specific crisis/emergency/catastrophicinterventions as necessary6. Commences critical procedures, that is, suicide precautions,emergency restraint, elopement precautions,and infectious disease management, when necessaryin an institutional and a community setting by usingappropriate community support systems, for example,police, ambulance services, crisis response resources7. Coordinates care to prevent errors and duplication ofefforts where rapid intervention is imperative8. Utilizes a least-restraint approach to care9. Develops adequate documentation of the crisis/emergency/catastrophicintervention plan10. Evaluates the effectiveness of the rapid responses andmodifies critical plans as necessary11. In collaboration with the client, facilitates the involvementof the family and significant others to assist inthe identification of the precipitates of the crisis/emergencyevent and plans to minimize risk of recurrence12. Participates in “debriefing” process, for example,reviews critical event and/or emergency situation,with team (including client and family) and otherservice providers13. Utilizes safety measures to protect self, colleagues,and clients from potentially abusive situations in thework environment, for example, harassment, psychologicalabuse, physical aggression14. Implements appropriate protocols for disasters15. Participates in educational, organizational, and institutionalactivities that improve client safety in thepractice settingSTANDARD V: INTERVENES THROUGH THETEACHING–COACHING FUNCTIONAll nurse–client interactions are potentially teaching/learning situations. The PMH nurse attempts to understandthe life experience of the client and uses thisunderstanding to support and promote learning related tohealth and personal development. The nurse provideshealth promotion information to individuals, families,groups, populations, and communities. The nurse1. In collaboration with the client, determines clients’learning needs2. Plans and implements, with the client, health promotioneducation while considering the context of the client’s lifeexperiences; considers readiness, culture, literacy, language,preferred learning style, and resources available3. Engages with the client to explore available optionsand resources to build knowledge to make informedchoices related to health needs and to navigate the system,as needed4. Facilitates the client’s search for ways to find meaningin his or her experience5. Incorporates knowledge of a wide variety of learningmodels and principles, for example, health promotionmodels, adult-learning principles, stages of development,cultural competence, and health beliefs models,when creating opportunities for clients6. Provides relevant information, guidance, and supportto the client’s significant others7. Documents the teaching/learning process (assessment,plan, implementation, client involvement, and evaluation)8. Determines, with the client, the effectiveness of theeducational process and collaboratively develops oradapts the ways to meet learning needs9. Engages in teaching/learning opportunities as partnerswith community agencies and consumer and familygroupsSTANDARD VI: MONITORS AND ENSURESTHE QUALITY OF HEALTH-CAREPRACTICESThe nurse has a responsibility to advocate for the client’sright to receive the least restrictive form of care and torespect and affirm the client’s right to self-determination ina safe, fair, and just (equitable) manner.Mental health care occurs under the provisions of provincial/territorialMental Health Acts and related legislation.It is essential for the PMH nurse to be informedregarding the interpretation of relevant legislation and itsimplications for nursing practice.The nurse1. Identifies work place cultures (philosophy, attitudes,values, and beliefs that impact the nurse’s ability toperform with skill, safety, and compassion) and takesaction as appropriate2. Explores how the determinants of health that impact onthe health of the community, for example, poverty, malnutrition,and unsafe housing, affect mental healthnursing practice

APPENDIX D • CANADIAN STANDARDS OF PSYCHIATRIC AND MENTAL HEALTH NURSING PRACTICE (3RD ED.)4853. Understands current and relevant legislation, for example,privacy laws, and the implications for nursing practice4. Expands and incorporates knowledge of innovationsand changes in mental health and psychiatric nursingpractice to ensure safe and effective care5. Ensures and documents ongoing review and evaluationof psychiatric and mental health nursing care activities6. Understands and questions the interdependent functionsof the team within the overall plan of care7. Advocates for the client within the context of organizationaland professional parameters and family andcommunity interests8. Advocates for changes and improvements to the system/organizationalstructures in keeping with the principlesof delivering safe, ethical, and competent care9. Recognizes the dynamic changes in health care locallyand globally and, in collaboration with stakeholders,develops strategies to manage these changes, for example,considers changes in determinants of health thatimpact the community, terrorism, decline of industriesSTANDARD VII: PRACTICES WITHINORGANIZATIONAL AND WORK-ROLESTRUCTUREThe PMH nurse role is assumed within organizationalstructures, in both community and institutional contexts,through the provision of psychiatric mental health care.For the PMH nurse, the ethic of care is based on reflectiveand evidence-based practice judgments within complexand dynamic situations. The increasing move of mentalhealth/psychiatric treatment into the community necessitatesthe PMH nurse to be knowledgeable and skilfulin collaborative care planning and implementation,mental health promotion, social action, and communityconsultation.The nurse1. Works in collaborative partnerships with clients/families and other stakeholders to facilitate healingenvironments that ensure the safety, support, andrespect for all persons2. Understands quality outcome indicators and strivesfor continuous quality improvement3. Actively participates with nurses to sustain and promotea climate that supports ethical practice and theestablishment of a moral community (Varcoe, Rodney,& McCormick, 2003)4. Participates in supporting a climate of trust that sponsorsopenness and encourages questioning of the status quoand the reporting of incompetent care (CNA, 2002)5. Seeks to utilize constructive and collaborativeapproaches to resolve differences impacting careamong members of the health-care team (CNA, 2002)6. Actively participates in developing, implementing,and critiquing mental health policy for communityand institutional settings7. Supports the contribution of leadership, as it occurswithin the advanced practice role, to effective care andtreatment8. Practices independently within legislated scope ofpractice9. Supports and participates in mentoring and coachingnew graduates10. Utilizes knowledge of collaborative strategies forsocial action in working with consumer and advocacygroupsREFERENCESCanadian Nurses Association [CNA]. (1997, June). National nursingcompetency project. Final report. Ottawa, Ontario: Author.CNA. (2002). Code of ethics for registered nurses. Ottawa, Ontario:Author.Society for Education and Research in Psychiatric-Mental HealthNursing. (1996). Educational preparation for psychiatric-mental healthnursing practice. Pensacola, FL: Author.Varcoe, C., Rodney, P., & McCormick, J. (2003). Health care relationshipsin context: An analysis of three ethnographies. QualitativeHealth Research, 13(7), 957–973.Standard Committee of the Canadian Federation of Mental HealthNurses. (2005). Canadian standards of psychiatric mental healthnursing practice (3rd ed.). Ottawa, Ontario: Canadian NursesAssociation.

Appendix ECanadian Drug Trade NamesSORTED BY DRUG CLASS*NA means no Canadian Trade Name is available.ANTIPSYCHOTICSGeneric Name U.S. Trade Name Canadian Trade NameChlorpromazine Thorazine Chlorprom, Chlorpromanyl, Largactil, Novo-Chlorpromazine,Apo-ChlorpromazineClozapine Clozaril, Fazaclo Clozaril, Gen-clozapine, Rhoxal, ClozapineDroperidol Inapsine NAFluphenazine Prolixin Apo-Fluphenazine, Moditen, PMS-Fluphenazine, ModecateHaloperidol Haldol Apo-Haloperidol, Novo-Peridol, PeridolLoxapine Loxitane Loxapac, PMS-Loxapine, Apo-Loxitane, Nu-LoxitaneMesoridazine Serentil SerentilMolindone Moban MobanOlanzapine Zyprexa, Zydis Zyprexa, ZydisPerphenazine Trilafon Apo-Perphenazine, PhenazineProchlorperazine Compazine, Compro Stemetil, PMS-Prochlorperazine, Nu-Prochlor, CompazineQuetiapine Seroquel SeroquelRisperidone Risperdal RisperdalThioridazine Mellaril Apo-Thioridazine, MellarilThiothixene Navane NavaneTrifluoperazine Stelazine Apo-Trifluoperazine, Novo-Trifluoperazine, PMS-Trifluoperazine,TerfluzineZiprasidone Geodon GeodonANTIDEPRESSANTSGeneric Name U.S. Trade Name Canadian Trade NameAmitriptyline Elavil Levate, NovotriptynBupropion Wellbutrin, Zyban Wellbutrin, ZybanCitalopram Celexa CelexaClomipramine Anafranil Apo-Clomipramine, Gen-Clomipramine, Novo-Clopamine,AnafranilDesipramine Norpramin, Pertofrane Apo-Desipramine, Novo-Desipramine, Nu-Desipramine,PMS-Desipramine, Norpramin, Alti-DesipramineDuloxetine Cymbalta NADoxepin Sinequan, Prudoxin, Zonalon Alti-Doxepin, Apo-Doxepin, Novo-Doxepin, Triadapin,ZonalonEscitalopram Lexapro NAFluoxetine Prozac, Sarfem Apo-Fluoxetine, Novo-Fluoxetine, Alti-Fluoxetine, Prozac,PMS-Fluoxetine, FXT, Gen-Fluoxetine, Rhoxal-FluoxetineFluvoxamine Luvox Apo-Fluvoxamine, Luvox, Alti-Fluvoxamine, Novo-Fluvoxamine, Nu-Fluvoxamine, Rhoxal-fluvoxamineImipramine Tofranil Apo-Imipramine, Impril, TofranilIsocarboxazid Marplan NAMaprotiline Ludiomil Novo-MaprotilineMirtazapine Remeron RemeronNefazodone Serzone Apo-Nefazodone, Lin-Nefazodone, Serzone 5HT486

APPENDIX E • CANADIAN DRUG TRADE NAMES487ANTIDEPRESSANTSGeneric Name U.S. Trade Name Canadian Trade NameNortriptyline Aventyl, Pamelor Apo-Nortriptyline, Norventyl, PMS-Nortriptyline,Gen-Nortriptyline, Nu-Nortriptyline, AventylParoxetine Paxil PaxilPhenelzine Nardil NardilSertraline Zoloft Apo-Sertraline, Gen-Sertraline, Novo-Sertraline,Nu-Sertraline, PMS-Sertraline, ratio-Sertraline, ZoloftTranylcypromine Parnate ParnateTrazodone Desyrel Alti-Trazodone, Apo-Trazodone, Nu-Trazodone, Desyrel,Gen-Trazodone, Novo-Trazodone, PMS-TrazodoneVenlafaxine Effexor EffexorANTIMANIC AND MOOD STABILIZERSGeneric Name U.S. Trade Name Canadian Trade NameCarbamazepine Tegretol, Epitol, Equerto Apo-Carbamazepine, Novo-Carbamaz, Nu-Carbamazepine,PMS-Carbamazepine, Taro-CarbamazepineGabapentin Neurontin PMS Gabapentin, Neurontin, Apo-Gabapentin, Novo-Gabapentin, Nu-GabapentinLamotrigine Lamictal Apo-Lamotrigine, Lamictal, PMS-Lamotrigine, ratio-LamotrigineLithium Lithane, Eskalith, Lithobid Carbolith, Duralith, Lithizine, PMS-Lithium Carbonate, Apo-LithiumOxcarbazepine Trileptal TrileptalTopiramate Topamax TopamaxValproic acid Depakote, Valproate, Depakene Alti-Divalproex, Deproic, Epival, Gen-Divalproex, Novo-Divalproex,Nu-Divalproex, PMS-Valproic acid, Rhoxal-valproicANXIOLYTICSGeneric Name U.S. Trade Name Canadian Trade NameAlprazolam Xanax Apo-Alpraz, Novo-Alprazol, Nu-Alpraz, Xanax TSBuspirone BuSpar Apo-Buspirone, Buspirex, Gen-Buspirone, Lin-Buspirone,Novo-Buspirone, Nu-Buspirone, PMS-Buspirone, BuSparChlordiazepoxide Librium Apo-Chlordiazepoxide, CoraxClonazepam Klonopin Apo-Clonazepam, Clonapam, Gen-Clonazepam, Rivotril,Novo-Clonazepam, Nu-ClonazepamClorazepate Tranxene Apo-Chlorazepate, Novo-ClopateDiazepam Valium, Diastat Apo-Diazepam, Diazemuls, Valium, DiastatEstazolam ProSom NAFlurazepam Dalmane SomnolHydroxyzine Atarax, Vistaril Apo-Hydroxyzine, Novo-HydroxyzineLorazepam Ativan Apo-Lorazepam, Novo-Lorazem, Nu-Loraz, Ativan, Riva-LorazepamMeprobamate Miltown Apo-Meprobamate, NovomeproMidazolam Versed Apo-MidazolamOxazepam Serax Apo-Oxazepam, Novoxapam, Zapex, OxpramTemazepan Restoril Apo-Temazepam, Novo-TemazepamDRUGS USED WITH DEMENTIAGeneric Name U.S. Trade Name Canadian Trade NameDonepezil Aricept AriceptRivastigmine Exelon ExelonTacrine Cognex NA

488 APPENDIX E • CANADIAN DRUG TRADE NAMESDRUGS USED FOR ADHDGeneric Name U.S. Trade Name Canadian Trade NameAtomoxetine Strattera NAAmphetamine Adderall NAAmphetamine, long-acting Adderall XR NADexmethylphenidate Focalin NADextroamphetamine Dexedrine DexedrineMethylphenidate Ritalin PMS-Methylphenidate, RiphenidateMethylphenidate, long-acting Concerta, Metadate CD, Ritalin LA NAPemoline Cylert NADRUGS USED TO TREAT SIDE EFFECTSGeneric Name U.S. Trade Name Canadian Trade NameAmantadine Symmetrel Endantadine, Gen-AmantadineAtenolol Tenormin Apo-Atenolol, Gen-Atenolol, Novo-Atenol, TenolinBenztropine Cogentin Apo-Benztropine, CogentinBiperiden Akineton AkinetonDiphenhydramine Benadryl (Multiple OTC names) Allerdryl, Allernix, BenadrylProcyclidine Kemadrin PMS Procyclidine, ProcyclidTrihexyphenidyl Artane Apo-TrihexDRUGS USED IN SUBSTANCE ABUSEGeneric Name U.S. Trade Name Canadian Trade NameClonidine Catapres Apo-Clonidine, Dixarit, Nu-Clonidine, Novo-Chonidine,CatapresDisulfiram Antabuse NANaltrexone ReVia, Depade, Trexan ReViaOndansetron Zofran NAOndansetron Hydrochloride Zofran NADihydrateALPHABETICAL LISTING BY CANADIAN DRUG NAMECanadian Trade NameGeneric NameAllerdrylAllernixAlti-DesipramineAlti-DoxepinAlti-FluoxetineAlti-FluvoxamineAlti-TrazodoneAlti-ValproicAnafranilApo-AlprazApo-AtenololApo-BenztropineApo-BuspironeDiphenhydramineDiphenhydramineDesipramineDoxepinFluoxetinFluvoxamineTrazodoneValproic acidClomipramineAlprazolamAtenololBenztropineBuspirone

APPENDIX E • CANADIAN DRUG TRADE NAMES489ALPHABETICAL LISTING BY CANADIAN DRUG NAME (Continued)Canadian Trade NameApo-CarbamazepineApo-ChlorazepateApo-ChlordiazepoxideApo-ChlorpromazineApo-ClomipramineApo-ClonazepamApo-ClonidineApo-DesipramineApo-DiazepamApo-DoxepinApo-FluoxetineApo-Fluphenazine ModitenApo-FluvoxamineApo-GabapentinApo-HaloperidolApo-HydroxyzineApo-ImipramineApo-LamotrigineApo-LithiumApo-LorazepamApo-LoxitaneApo-MidazolamApo-MeprobamateApo-NefazodoneApo-NortriptylineApo-OxazepamApo-PerphenazineApo-SertralineApo-TemazepamApo-ThioridazineApo-TrazodoneApo-TrifluoperazineApo-TrihexAriceptAtivanAventylBuSparBuspirexCarbolithChlorpromChlorpromanylClonapamClozarilCogentinCompazineComproCoraxDeproicDesyrelDexedrineDiastatDiazemulsDivalproexDixaritDuralithEndantadineGeneric NameCarbamazepineClorazepateChlordiazepoxideChlorpromazineClomipramineClonazepamClonidineDesipramineDiazepamDoxepinFluoxetineFluphenazineFluvoxamineGabapentinHaloperidolHydroxyzineImipramineLamotrigineLithiumLorazepamLoxitaneMidazolamMeprobamateNefazodoneNortriptylineOxazepamPerphenazineSertralineTemazepamThioridazineTrazodoneTrifluoperazineTrihexyphenidylDonepezilLorazepamNortriptylineBuspironeBuspironeLithiumChlorpromazineChlorpromazineClonazepamClozapineBenztropineProchlorperazineProchlorperazineChlordiazepoxideValproic acidTrazodoneDextroamphetamineDiazepamDiazepamValproic acidClonidineLithiumAmantadine(continued)

490 APPENDIX E • CANADIAN DRUG TRADE NAMESALPHABETICAL LISTING BY CANADIAN DRUG NAME (Continued)Canadian Trade NameEffexorEpitrolEpivalEquertoExelonFXTGen-AmantadineGen-AtenololGen-BuspironeGen-ClomipramineGen-ClonazepamGen-ClozapineGen-DivalproexGen-FluoxetineGen-NortriptylineGen-SertralineGen-TrazodoneGeodonImprilLamictalLargactilLevateLin-BuspironeLin-NefazodoneLithizineLoxapacLuvoxMellarilModecateModitenNardilNavaneNeurontinNorpraminNorventylNovo-AlprozolNovo-AtenolNovo-BuspironeNovo-CarbamazNovo-ChlorpromazineNovo-ClonazepamNovo-ClopamineNovo-ClopateNovo-DesipramineNovo-DivalproexNovo-DoxepinNovo-FluoxetineNovo-FluvoxamineNovo-GabapentinNovo-HydroxyzineNovo-LorazemNovo-MaprotilineNovomeproNovo-PeridolNovopramineNovo-SertralineNovo-TemazepamGeneric NameVenlafaxineCarbamazepineValproic acidCarbamazepineRivastigmineFluoxetineAmantadineAtenololBuspironeClomipramineClonazepamClozapineValproic acidFluoxetineNortriptylineSertralineTrazodoneZiprasidoneImipramineLamotrigineChlorpromazineAmitriptylineBuspironeNefazodoneLithiumLoxapineFluvoxamineThioridazineFlupheazineFluphenazinePhenelzineThiothixeneGabapentinDesipramineNortriptylineAlprazolamAtenololBuspironeCarbamazepineChlorpromazineClonazepamClomipramineClorazepateDesipramineValproic acidDoxepinFluoxetineFluvoxamineGabapentinHydroxyzineLorazepamMaprotilineMeprobamateHaloperidolImipramineSertralineTemazepam

APPENDIX E • CANADIAN DRUG TRADE NAMES491ALPHABETICAL LISTING BY CANADIAN DRUG NAME (Continued)Canadian Trade NameNovo-TrifluoperazineNovo-TrazodoneNovotriptynNovoxapamNu-AlprazNu-BuspironeNu-CarbamazepineNu-ClonazepamNu-ClonidineNu-DesipramineNu-DivalproexNu-FluvoxamineNu-GabapentinNu-LorazNu-LoxitaneNu-NortriptylineNu-PromchlorNu-SertralineNu-TrazodoneParnatePaxilPeridolPhenazinePMS BenztropinePMS-BuspironePMS-CarbamazepinePMS-DesipraminePMS-FluoxetinePMS-FluphenazinePMS GabapentinPMS-LamotriginePMS-Lithium CarbonatePMS-LoxapinePMS-MethylphenidatePMS-NortriptylinePMS-ProchlorperazinePMS ProcyclidinePMS-SertralinePMS-TrazodonePMS-TrifluoperazinePMS-Valproic acidProcyclidProzacratio-Lamotrigineratio-SertralineRemeronRestorilRhoxal-clozapineRhoxal-fluoxetineRhoxal-fluvoxamineRhoxal-valproicRiphenidateRisperdalRiva-LorazepamRivotrilSerentilSerzone5HTGeneric NameTrifluoperazineTrazodoneAmitriptylineOxazepamAlprazolamBuspironeCarbamazepineClonazepamClonidineDesipramineValproic acidFluvoxamineGabapentinLorazepamLoxitaneNortriptylineProchlorperazineSertralineTrazodoneTranylcypromineParoxetineHaloperidolPerphenazineBenztropineBuspironeCarbamazepineDesipramineFluoxetineFluphenazineGabapentinLamotrigineLithiumLoxapineMethylphenidateNortriptylineProchlorperazineProcyclidineSertralineTrazodoneTrifluoperazineValproic acidProcyclidineFluoxetineLamotrigineSertralineMirtazapineTemazepamClozapineFluoxetineFluvoxamineValproic acidMethylphenidateRisperidoneLorazepamClonazepamMesoridazineNefazodone(continued)

492 APPENDIX E • CANADIAN DRUG TRADE NAMESALPHABETICAL LISTING BY CANADIAN DRUG NAME (Continued)Canadian Trade NameSomnolStemetilTaro-CarbamazepineTenolinTerfluzineTofranilTopamaxTriadapinTrileptalValiumVivolWellbutrinXanax TSZapexZoloftZonalonZybanZydisZyprexaGeneric NameFlurazepamProchlorperazineCarbamazepineAtenololTrifluoperazineImipramineTopiramateDoxepinOxcarbazepineDiazepamDiazepamBupropionAlprazolamOxazepamSertralineDoxepinBupropionOlanzapineOlanzapine

Appendix FMexican Drug Trade NamesMexican Trade Name Generic Name Mexican Trade Name Generic NameAbilifyActiniumAkinetonAlboralAltrulineAluprexAnafranilAtivanAropaxCarbazepCarbazinaCarbolitClopsineClostedolCryovalDehydrobenzperidolDepakeneDormicumEfexorEpivalEranzExelonFluoxacFlupazineHaldolHaloperilHipokinonKenoketLamictalLargactilLeponexAripiprazoleOxcarbazepineBiperidenDiazepamSertralineSertralineChlomipramineLorazepamParoxetineCarbamazepineCarbamazepineLithiumClozapineCarbamazepineValproic acidDroperidolValproic acidMidazolamVenlafaxineValproic acidDonepezilRivastigmineFluoxetineTrifluoperazineHaloperidolHaloperidolTrihexyphenidylClonazepamLamotrigineChlorpromazineClozapineLeptilanLeptopsiqueLitheumLuvoxMellarilNeugeronNeurontinNeurosineOrtopsiquePacitranPaxilProzacRemeronRisperdalRivotrilSeropramSeroquelSinestronSiquialStelazineTaloprimTasedanTofranilTopamaxTranxeneTrileptalTzoaliValiumValprocidWellbutrinZyprexaValproic acidPerphenazineLithiumFluvoxamineThioridazineCarbamazepineGabapentinBuspironeDiazepamDiazepamParoxetineFluoxetineMirtazapineRisperidoneClonazepamCitalopramQuetiapineLorazepamFluoxetineTrifluoperazineImipramineEstazolamImipramineTopiramateChlorazepateOxcabazepineDiphenhydramineDiazepamValproic acidBupropionOlanzapine493

Appendix GSleep DisordersSleep disorders are organized into four categories: primarysleep disorders, sleep disorder related to another mentaldisorder, sleep disorder due to a general medical condition,and substance-induced sleep disorder.Primary sleep disorders are those disorders not attributableto another cause and include dyssomnias andparasomnias.Dyssomnias are primary disorders of initiating or maintainingsleep or excessive sleepiness and are characterizedby abnormalities in the amount, quality, or timing of sleep.• Primary insomnia—Difficulty initiating or maintainingsleep or nonrestorative sleep that lasts for 1 month andcauses significant distress or impairment in social,occupational, or other important areas of functioning.Estimates are 1–10% of the general adult populationand up to 25% of the elderly suffer from primaryinsomnia. Treatment modalities include sleep hygienemeasures (see Sleep Hygiene Measures box), cognitive–behavioral techniques, and medication.• Primary hyperinsomnia—Excessive sleepiness for atleast 1 month that involves either prolonged sleep episodesor daily daytime sleeping that causes significantdistress or impairment in functioning. Major sleepepisodes may be 8–12 hours long, and the person hasdifficulty waking. Daytime naps leave the personunrefreshed on awakening. Treatment with stimulantmedication is often effective.• Narcolepsy—Excessive sleepiness characterized byrepeated, irresistible sleep attacks. After sleeping 10–20minutes, the person is briefly refreshed until the nextsleep attack. Sleep attacks can occur at opportunetimes, such as during important work activities orwhile driving a car. People with narcolepsy may alsoexperience cataplexy (sudden episodes of bilateral,reversible loss of muscle tone that last for seconds tominutes) or recurrent intrusions of REM sleep in thesleep–wake transitions, manifested by paralysis of voluntarymuscles or dream-like hallucinations. Treatmentincludes stimulant medication, modafinil (Provigil),and behavioral structuring, such as scheduling naps atconvenient times.• Breathing-related sleep disorders—Sleep disruption leadingto excessive sleepiness or, less commonly, insomnia,caused by abnormalities in ventilation duringsleep. These disorders include obstructive sleep apnea(repeated episodes of upper airway obstruction), centralsleep apnea (episodic cessation of ventilation withoutairway obstruction), and central alveolar hypoventilation(hypoventilation resulting in low arterial oxygenlevels). Central sleep apnea is more common inthe elderly while obstructive sleep apnea and centralalveolar hypoventilation are commonly seen in obeseindividuals. The primary treatments for breathingrelatedsleep disorders are surgical, such as tracheotomy,and use of a continuous positive airway pressure(CPAP) machine during sleep.• Circadian rhythm sleep disorder (formerly sleep–wakeschedule disorder)—Persistent or recurring sleep disruptionresulting from altered functioning of circadianrhythm or a mismatch between circadian rhythm andexternal demands. Subtypes include delayed sleepphase (person’s own circadian schedule is incongruentwith needed timing of sleep, such as an individualbeing unable to sleep or remain awake during sociallyacceptable hours as a result of a work schedule or thelike); jet lag (conflict of sleep–wake schedule and anew time zone); shift work (conflict between circadianrhythm and demands of wakefulness for shift work);and unspecified (circadian rhythm pattern is longerthan 24 hours despite environmental cues, resulting invarying sleep problems). Sleep hygiene measures (seeSleep Hygiene Measures box), melatonin, and brightlight therapy can be effective treatments. Bright lighttherapy consists of being exposed to bright light whenwakefulness is initiated and avoiding bright lightswhen sleep is desired.Parasomnias are disorders characterized by abnormalbehavioral or psychological events associated with sleep,specific sleep stages, or sleep–wake transition. These disordersinvolve activation of physiological systems, such asthe autonomic nervous system, motor system, or cognitiveprocesses, at inappropriate times, as during sleep.• Nightmare disorder—Repeated occurrence of frighteningdreams that lead to waking from sleep. The dreamsare often lengthy and elaborate, provoking anxiety orterror and causing the individual to have troublereturning to sleep and to experience significant distressand, sometimes, lack of sleep. There is no widelyaccepted treatment.• Sleep terror disorder—Repeated occurrence of abruptawakenings from sleep associated with a panickyscream or cry. Children with sleep terror disorder areconfused and upset upon awakening and have nomemory of a dream either at the time of awakening orin the morning. Initially, the child is difficult to fullyawaken or console. Sleep terror disorder tends to goaway in adolescence.• Sleepwalking disorder—Repeated episodes of complexmotor behavior initiated during sleep, including gettingout of bed and walking around. Persons appeardisoriented and confused and, on occasion, may becomeviolent. Usually they return to bed on their own or can494

APPENDIX G • SLEEP DISORDERS495SLEEP HYGIENE MEASURESEstablish a regular schedule for going to bed andarising.Avoid sleep deprivation, and the desire to “catch up” byexcessive sleeping.Do not eat large meals before bedtime; however, a lightsnack is permissible, even helpful.Avoid daytime naps, unless necessitated by advancedage or physical condition.Exercise daily, particularly in the late afternoon or earlyevening, as exercise before retiring may interfere withsleep.Minimize or eliminate caffeine and nicotine ingestion.Do not look at the clock while lying in bed.Keep the temperature in the bedroom slightly cool.Do not drink alcohol in an attempt to sleep; it will worsensleep disturbances and produce poor quality sleep.Do not use bed for reading, working, watching television,and so forth.If you are worried about something, try writing it downon paper and assigning a designated time to deal withit—then, let it go.Soft music, relaxation tapes, or “white noise” may behelpful; experiment with different methods to find thosethat are beneficial for you.be guided back to bed. Sleepwalking occurs most oftenin children between 4 and 8 years, and it tends to dissipateby adolescence. No treatment is required.Sleep disorders related to another mental disorder mayinvolve insomnia or hypersomnia. Mood disorders, anxietydisorders, schizophrenia, and other psychotic disordersare often associated with sleep disturbances. Treatmentof the underlying mental disorder is indicated to resolvethe sleep disorder.Sleep disorder due to a general medical condition mayinvolve insomnia, hypersomnia, parasomnias, or a combinationof these attributable to a medical condition. Thesesleep disturbances may result from degenerative neurologicalillnesses, cerebrovascular disease, endocrine conditions,viral and bacterial infections, coughing, or pain.Sleep disturbances of this type may improve with treatmentof the underlying medical condition or may betreated symptomatically with medication for sleep.Substance-induced sleep disorder involves prominentdisturbance in sleep due to the direct physiologic effects ofa substance, such as alcohol, other drugs, or toxins. Insomniaand hypersomnia are most common. Treatment ofthe underlying substance use or abuse generally leads toimprovement in sleep.Adapted from DSM-IV-TR (2000) and Mendelson, W. (2005). Sleepdisorders. In B. J. Sadock and V. A. Sadock (Eds.). Comprehensivetextbook of psychiatry (8th ed., pp. 2022–2034). Philadelphia: LippincottWilliams & Wilkins.

Appendix HSexual and Gender Identity DisordersDSM-IV-TR (2000) identifies three groups of sexual andgender identity disorders: sexual dysfunctions (desire,arousal, orgasmic, pain, and dysfunction due to a medicalcondition); paraphilias (exhibitionism, fetishism, frotteurism,pedophilia, masochism, sadism, transvestic fetishism,and voyeurism), and gender identity disorders. These disordersare usually identified in primary care or outpatientsettings and treated with individual, couple/partner, orgroup psychotherapy. Occasionally, when the diagnosiscoincides with behavior defined as criminal, that is, manyof the paraphilias, individuals get involved in the legalsystem.SEXUAL DYSFUNCTIONSSexual dysfunction is characterized by a disturbance in theprocesses of the sexual response cycle or by pain associatedwith sexual intercourse. The sexual response cycleconsists of desire, excitement, orgasm, and resolution.Sexual dysfunction may be due to psychological factorsalone or a combination of psychological factors and amedical condition.Sexual desire disorders involve a disruption in the desirephase of the sexual response cycle.• Hypoactive sexual desire disorder—Characterized by adeficiency or absence of sexual fantasies and desire forsexual activity that causes marked distress or interpersonaldifficulty.• Sexual aversion disorder—Involves aversion to andactive avoidance of genital sexual contact with a sexualpartner that causes marked distress or interpersonaldifficulty. The individual reports anxiety, fear, or disgustwhen confronted by a sexual opportunity with apartner.Sexual arousal disorders are a disruption of the excitementphase of the sexual response cycle.• Female sexual arousal disorder—Persistent or recurrentinability to attain or to maintain, until completion ofthe sexual activity, an adequate lubrication–swellingresponse of sexual excitement, which causes markeddistress or interpersonal difficulty.• Male erectile disorder—Persistent or recurrent inabilityto attain or maintain, until completion of the sexualactivity, an adequate erection, which causes markeddistress or interpersonal difficulty.Orgasmic disorders are disruptions of the orgasm phaseof the sexual response cycle.• Female orgasmic disorders—Persistent or recurrentdelay in, or absence of, orgasm following a normalsexual excitement phase, which causes marked distressor interpersonal difficulty.• Male orgasmic disorder—Persistent or recurrent delayin, or absence of, orgasm following a normal sexualexcitement phase, which causes marked distress orinterpersonal difficulty.• Premature ejaculation—Persistent or recurrent onset oforgasm and ejaculation with minimal sexual stimulationbefore, on, or shortly after penetration and beforethe person wishes it, causing marked distress or interpersonaldifficulty.Sexual pain disorders involve pain associated with sexualactivity.• Dyspareunia—Genital pain associated with sexualintercourse causing marked distress or interpersonaldifficulties. It can occur in both males and females, andsymptoms range from mild discomfort to sharp pain.• Vaginismus—Persistent or recurrent involuntary contractionsof the perineal muscles surrounding the outerthird of the vagina when vaginal penetration withpenis, finger, tampon, or speculum is attempted, causingmarked distress or interpersonal difficulties. Thecontraction may range from mild (tightness and milddiscomfort) to severe (preventing penetration).Sexual dysfunction due to a general medical conditionis presence of clinically significant sexual dysfunctionthat is exclusively due to the physiological effects of amedical condition. It can include pain with intercourse,hypoactive sexual desire, erectile dysfunction, orgasmicproblems, or other problems as previously described. Theindividual experiences marked distress or interpersonaldifficulty related to the symptoms.Substance-induced sexual dysfunction is clinically significantsexual dysfunction resulting in marked distress orinterpersonal difficulty caused by the direct physiologicaleffects of a substance (drug of abuse, medication, or toxin).It may involve impaired arousal, impaired orgasm, or sexualpain.PARAPHILIASParaphilias are recurrent, intensely sexually arousingfantasies, sexual urges, or behaviors generally involving(1) nonhuman objects, (2) the suffering or humiliation ofone’s self or partner, or (3) children or other nonconsentingpersons. For pedophilia, voyeurism, exhibitionism,and frotteurism, the diagnosis is made if the person hasacted on these urges or if the urges or fantasies causemarked distress or interpersonal difficulty. For sexual sadism,the diagnosis is made if the person has acted onthese urges with a nonconsenting person or if the urges,fantasies, or behaviors cause marked distress or interpersonaldifficulty. For the remaining paraphilias, the diagnosis496

APPENDIX H • SEXUAL AND GENDER IDENTITY DISORDERS497is made if the behavior, sexual urges, or fantasies cause clinicallysignificant distress or impairment in social, occupational,or other important areas of functioning.• Exhibitionism—Exposure of the genitals to a stranger,sometimes involving masturbation; usually occursbefore age 18 and is less severe after age 40.• Fetishism—Use of nonliving objects (the fetish) toobtain sexual excitement and/or achieve orgasm.Common fetishes include women’s underwear, bras,lingerie, shoes, or other apparel. The person mightmasturbate while holding or rubbing the object. Itbegins by adolescence and tends to be chronic.• Frotteurism—Touching and rubbing against a nonconsentingperson, usually in a crowded place from whichthe person with frotteurism can make a quick escape,such as public transportation, a shopping mall, or acrowded sidewalk. The individual rubs his genitalsagainst the victim’s thighs and buttocks or fondles herbreasts or genitalia with his hands. Acts of frottageoccur most often between the ages of 15 and 25; frequencydeclines after that.• Pedophilia—Sexual activity with a prepubescent child(generally 13 years or younger) by someone at least 16years old and 5 years older than the child. It caninclude an individual undressing the child and lookingat the child; exposing himself or herself; masturbatingin the presence of the child; touching and fondling thechild; fellatio; cunnilingus; or penetration of the child’svagina, anus, or mouth with the individual’s fingers orpenis or with foreign objects, with varying amounts offorce. Contact may involve the individual’s own children,stepchildren or relatives, or strangers. Many individualswith pedophilia do not experience distressabout their fantasies, urges, or behaviors.• Sexual masochism—Recurrent, intensely sexually arousingfantasies, sexual urges, or behaviors involving theact of being humiliated, beaten, bound, or otherwisemade to suffer. Some individuals act on masochisticurges by themselves, others with a partner.• Sexual sadism—Recurrent, intensely sexually arousingfantasies, sexual urges, or behaviors involving acts inwhich the psychological or physical suffering of thevictim is sexually arousing to the person. It can involvedomination (caging the victim or forcing victim tocrawl, beg, plead), restraint, spanking, beating, electricalshock, rape, cutting, and, in severe cases, tortureand death. Victims may be consenting (those withsexual masochism) or nonconsenting.• Transvestic fetishism—Recurrent, intensely sexuallyarousing fantasies, sexual urges, or behaviors involvingcross-dressing by a heterosexual male.• Voyeurism—Recurrent, intensely sexually arousing fantasies,sexual urges, or behaviors involving the act ofobserving an unsuspecting person who is naked, in theprocess of undressing, or engaging in sexual activity.Voyeurism usually begins before age 15, is chronic, andmay involve masturbation during the voyeuristicbehavior.GENDER IDENTITY DISORDERGender identity disorder is diagnosed when an individualhas a strong and persistent cross-gender identification;that is, when an individual has the desire to be, or insiststhat he or she is of, the other sex, accompanied by thepersistent discomfort of his or her assigned sex or a senseof inappropriateness in the gender role of that assignedsex. The person experiences clinically significant distressor impairment in social, occupational, or other importantareas of functioning. In boys, there is a preoccupation withtraditionally feminine activities, a preference for dressingin girls’ or women’s clothing and an expressed desire to bea girl or grow up to be a woman. Girls may resist parentalattempts to have them wear dresses or other feminine attire,wear boys’ clothing, have short hair, ask to be calledby a boy’s name, and express the desire to grow a penis andgrow up to be a man.Adapted from American Psychiatric Association. (2000). DSM-IV-TR.Washington, D.C.: Author.

Glossary of Key TermsAbnormal Involuntary Movement Scale (AIMS): tool used toscreen for symptoms of movement disorders (side effects ofneuroleptic medications)abstract messages: unclear patterns of words that often containfigures of speech that are difficult to interpretabstract thinking: ability to make associations or interpretationsabout a situation or commentabuse: the wrongful use and maltreatment of another personacceptance: avoiding judgments of the person, no matter whatthe behaviorACCESS Demonstration Project: initiated to assess whether or notmore integrated systems of service delivery enhance the qualityof life of homeless people with serious mental disabilitiesacculturation: altering cultural values or behaviors as a way toadapt to another cultureacting out: an immature defense mechanism by which the persondeals with emotional conflicts or stressors through actionsrather than through reflection or feelingsactive listening: concentrating exclusively on what the clientsays, refraining from other internal mental activitiesactive observation: watching the speaker’s nonverbal actions ashe or she communicatesacute stress disorder: diagnosis is appropriate when symptomsappear within the first month after the trauma and do not persistlonger than 4 weeksadvocacy: the process of acting in the client’s behalf when he orshe cannot do soaffect: the outward expression of the client’s emotional stateagnosia: inability to recognize or name objects despite intact sensoryabilitiesagoraphobia: fear of being outside; from the Greek fear of themarketplaceakathisia: intense need to move about; characterized by restlessmovement, pacing, inability to remain still, and the client’s reportof inner restlessnessalexithymia: difficulty identifying and expressing feelingsalogia: a lack of any real meaning or substance in what the clientsaysAlzheimer’s disease: a progressive brain disorder that has agradual onset but causes an increasing decline in functioning,including loss of speech, loss of motor function, and profoundpersonality and behavioral changes such as those involvingparanoia, delusions, hallucinations, inattention to hygiene,and belligerenceamnestic disorder: characterized by a disturbance in memorythat results directly from the physiologic effects of a generalmedical condition or from the persisting effects of a substancesuch as alcohol or other drugsanergia: lack of energyanger: a normal human emotion involving a strong, uncomfortable,emotional response to a real or perceived provocationanhedonia: having no pleasure or joy in life; losing any sense ofpleasure from activities formerly enjoyedanorexia nervosa: an eating disorder characterized by the client’srefusal or inability to maintain a minimally normal bodyweight, intense fear of gaining weight or becoming fat, significantlydisturbed perception of the shape or size of the body,and steadfast inability or refusal to acknowledge the existenceor seriousness of a problemanticholinergic effects: dry mouth, constipation, urinary hesitancyor retention, dry nasal passages, and blurred near vision;commonly seen as side effects of medicationanticipatory grieving: when people facing an imminent lossbegin to grapple with the very real possibility of the loss ordeath in the near futureantidepressant drugs: primarily used in the treatment of majordepressive illness, anxiety disorders, the depressed phase ofbipolar disorder, and psychotic depressionantipsychotic drugs: also known as neuroleptics; used to treat thesymptoms of psychosis such as the delusions and hallucinationsseen in schizophrenia, schizoaffective disorder, and themanic phase of bipolar disorderantisocial personality disorder: characterized by a pervasivepattern of disregard for and violation of the rights ofothers and with the central characteristics of deceit andmanipulationanxiety: a vague feeling of dread or apprehension; it is a responseto external or internal stimuli that can have behavioral, emotional,cognitive, and physical symptomsanxiety disorders: a group of conditions that share a key featureof excessive anxiety, with ensuing behavioral, emotional, cognitive,and physiologic responsesanxiolytic drugs: used to treat anxiety and anxiety disorders,insomnia, OCD, depression, posttraumatic stress disorder,and alcohol withdrawalaphasia: deterioration of language functionapraxia: impaired ability to execute motor functions despiteintact motor abilitiesassault: involves any action that causes a person to fear beingtouched, without consent or authority, in a way that is offensive,insulting, or physically injuriousassertive community treatment (ACT): community-based programsthat provide many of the services that are necessary forsuccessful community living; includes case management,problem-solving, social skills training, support, teaching on a24/7 basisassertiveness training: techniques using statements to identifyfeelings and communicate needs and concerns to others; helpsthe person negotiate interpersonal situations, fosters selfassurance,and ultimately assists the person to take more controlover life situationsasylum: a safe refuge or haven offering protection; in the UnitedStates, became a term used to describe institutions for thementally illattachment behaviors: affectional bonds with significant othersattention deficit hyperactivity disorder (ADHD): characterizedby inattentiveness, overactivity, and impulsivenessattentive presence: being with the client and focusing intentlyon communicating with and understanding him or herattitudes: general feelings or a frame of reference around whicha person organizes knowledge about the worldautistic disorder: a pervasive developmental disorder characterizedby impairment of growth and development milestones, such asimpaired communication with others, lack of social relationshipseven with parents, and stereotyped motor behaviors498

GLOSSARY OF KEY TERMS499automatism: repeated, seemingly purposeless behaviors often indicativeof anxiety, such as drumming fingers, twisting locks ofhair, or tapping the foot; unconscious mannerismautonomy: the person’s right to self-determination and independenceavoidance behavior: behavior designed to avoid unpleasant consequencesor potentially threatening situationsavoidant personality disorder: characterized by a pervasive patternof social discomfort and reticence, low self-esteem, andhypersensitivity to negative evaluationbattery: involves harmful or unwarranted contact with a client;actual harm or injury may or may not have occurredbehavior modification: a method of attempting to strengthen adesired behavior or response by reinforcement, either positiveor negativebehaviorism: a school of psychology that focuses on observablebehaviors and what one can do externally to bring aboutbehavior changes. It does not attempt to explain how the mindworks.beliefs: ideas that one holds to be truebeneficence: refers to one’s duty to benefit or to promote goodfor othersbereavement: refers to the process by which a person experiencesgriefbinge eating: consuming a large amount of food (far greater thanmost people eat at one time) in a discrete period of usually2 hours or lessBlack Box Warning: medication package inserts must have ahighlighted box, separate from the text, that contains a warningabout the life-threatening or otherwise serious side effect(s)of the medicationblackout: an episode during which the person continues to functionbut has no conscious awareness of his or her behavior atthe time nor any later memory of the behavior; usually associatedwith alcohol consumptionblunted affect: showing little or a slow-to-respond facial expression;few observable facial expressionsbody dysmorphic disorder: preoccupation with an imagined orexaggerated defect in physical appearancebody image: how a person perceives his or her body, that is, amental self-imagebody image disturbance: occurs when there is an extreme discrepancybetween one’s body image and the perceptions ofothers and extreme dissatisfaction with one’s body imagebody language: a nonverbal form of communication: gestures,postures, movements, and body positionsborderline personality disorder: pervasive and enduring patternof unstable interpersonal relationships, self-image, and affect;marked impulsivity; frequent self-mutilation behaviorbreach of duty: the nurse (or physician) failed to conform tostandards of care, thereby breaching or failing the existingduty; the nurse did not act as a reasonable, prudent nursewould have acted in similar circumstancesbroad affect: displaying a full range of emotional expressionsbulimia nervosa: an eating disorder characterized by recurrentepisodes (at least twice a week for 3 months) of binge eatingfollowed by inappropriate compensatory behaviors to avoidweight gain such as purging (self-induced vomiting or use oflaxatives, diuretics, enemas, or emetics), fasting, or excessivelyexercisingcase management: management of care on a case-by-case basis,representing an effort to provide necessary services while containingcost; in the community, case management services includeaccessing medical and psychiatric services and providingassistance with tasks of daily living such as financial management,transportation, and buying groceriescatatonia: psychomotor disturbance, either motionless or excessivemotorcatharsis: activities that are supposed to provide a release forstrong feelings such as anger or ragecausation: action that constitutes a breach of duty and was thedirect cause of the loss, damage, or injury; in other words, theloss, damage, or injury would not have occurred if the nursehad acted in a reasonable, prudent mannercharacter: consists of concepts about the self and the external worldchild abuse: the intentional injury of a childcircumstantial thinking: term used when a client eventuallyanswers a question but only after giving excessive, unnecessarydetailcircumstantiality: the use of extraneous words and long, tediousdescriptionscliché: an expression that has become trite and generally conveysa stereotypeclient-centered therapy: focused on the role of the client, ratherthan the therapist, as the key to the healing processclosed body positions: nonverbal behavior such as crossed legsand arms folded over chest that indicate the listener may befailing to listen, defensive, or not acceptingclosed group: structured to keep the same members in the groupfor a specified number of sessionsclubhouse model: community-based rehabilitation; an “intentionalcommunity” based on the belief that men and womenwith serious and persistent psychiatric disability can and willachieve normal life goals when given the opportunity, time,support, and fellowshipcodependence: a maladaptive coping pattern on the part of familymembers or others that results from a prolonged relationshipwith the person who uses substancescognitive–behavioral techniques: techniques useful in changingpatterns of thinking by helping clients to recognize negativethoughts and to replace them with different patterns of thinking;include positive self-talk, decatastrophizing, positivereframing, and thought stoppingcognitive therapy: focuses on immediate thought processing:how a person perceives or interprets his or her experience anddetermines how he or she feels and behavescommand hallucinations: disturbed auditory sensory perceptionsdemanding that the client take action, often to harm self or others,and are considered dangerous; often referred to as “voices”communication: the processes that people use to exchangeinformationcompensatory behaviors: for clients with eating disorders, actionsdesigned to counteract food intake, such as purging(vomiting), excessively exercising, and using/abusing laxativesand diureticscomplicated grieving: a response outside the norm and occurringwhen a person is void of emotion, grieves for prolongedperiods, or has expressions of grief that seem disproportionateto the eventcompulsions: ritualistic or repetitive behaviors or mental actsthat a person carries out continuously in an attempt to neutralizeanxietycomputerized tomography (CT): a diagnostic procedure inwhich a precise x-ray beam takes cross-sectional images(slices) layer by layerconcrete message: words that are as clear as possible whenspeaking to the client so that the client can understand the

500 GLOSSARY OF KEY TERMSmessage; concrete messages are important for accurate informationexchangeconcrete thinking: when the client continually gives literal translations;abstraction is diminished or absentconduct disorder: characterized by persistent antisocial behaviorin children and adolescents that significantly impairs theirability to function in social, academic, or occupational areasconfabulation: clients may make up answers to fill in memorygaps; usually associated with organic brain problemsconfidentiality: respecting the client’s right to keep private anyinformation about his or her mental and physical health andrelated careconfrontation: technique designed to highlight the incongruencebetween a person’s verbalizations and actual behavior; used tomanage manipulative or deceptive behaviorcongruence: occurs when words and actions matchcongruent message: when communication content and processesagreecontent: verbal communication; the literal words that a personspeakscontext: the environment in which an event occurs; includes thetime and the physical, social, emotional, and culturalenvironmentscontract: includes outlining the care the nurse will give, thetimes the nurse will be with the client, and acceptance of theseconditions by the clientcontrolled substance: drug classified under the Controlled SubstancesAct; includes opioids, stimulants, benzodiazepines,anabolic steroids, cannabis derivatives, psychedelics, andsedativesconversion disorder: sometimes called conversion reaction; involvesunexplained, usually sudden deficits in sensory ormotor function related to an emotional conflict the client experiencesbut does not handle directlycountertransference: occurs when the therapist displaces ontothe client attitudes or feelings from his or her past; process thatcan occur when the nurse responds to the client based on personal,unconscious needs and conflictsCreutzfeldt–Jakob disease: a central nervous system disorderthat typically develops in adults 40 to 60 years of age and involvesaltered vision, loss of coordination or abnormal movements,and dementiacriminalization of mental illness: refers to the practice of arrestingand prosecuting mentally ill offenders, even for misdemeanors,at a rate four times that of the general population inan effort to contain them in some type of institution wherethey might receive needed treatmentcrisis: a turning point in an individual’s life that produces anoverwhelming emotional response; individual is confrontinglife circumstance or stressor that cannot be managed throughcustomary coping strategiescrisis intervention: includes a variety of techniques, based onthe assessment of the individual in crisis, to assist in resolutionor management of the stressor or circumstancecues (overt and covert): verbal or nonverbal messages that signalkey words or issues for the clientculturally competent: being sensitive to issues related to culture,race, gender, sexual orientation, social class, economic situation,and other factorsculture: all the socially learned behaviors, values, beliefs, andcustoms, transmitted down to each generation, as well as apopulation’s ways of thinking that guide its members’ views ofthemselves and the worldcycle of violence: a typical pattern in domestic battering: violence;honeymoon or remorseful period; tension-building;and, finally, violence; this pattern continually repeats itselfthroughout the relationshipdate rape (acquaintance rape): sexual assault that may occur ona first date, on a ride home from a party, or when the twopeople have known each other for some timeday treatment: treatment programs in which clients attend duringthe day and return home or to the community at nightdecatastrophizing: a technique that involves learning to assesssituations realistically rather than always assuming a catastrophewill happendefense mechanisms: cognitive distortions that a person usesunconsciously to maintain a sense of being in control of a situation,to lessen discomfort, and to deal with stress; also calledego defense mechanismsdeinstitutionalization: a deliberate shift in care of the mentallyill from institutional care in state hospitals to care in communitybasedfacilities and through community-based servicesdelirium: a syndrome that involves a disturbance of consciousnessaccompanied by a change in cognitiondelusion: a fixed, false belief not based in realitydementia: a mental disorder that involves multiple cognitivedeficits, initially involving memory impairment with progressivedeterioration that includes all cognitive functioningdenial: defense mechanism; clients may deny directly having anyproblems or may minimize the extent of problems or actualsubstance usedeontology: a theory that says ethical decisions should be basedon whether or not an action is morally right with no regard forthe result or consequencesdependent personality disorder: characterized by a pervasiveand excessive need to be taken care of, which leads to submissiveand clinging behavior and fears of separationdepersonalization: feelings of being disconnected from himselfor herself; the client feels detached from his or her behaviordepot injection: a slow-release, injectable form of antipsychoticmedication for maintenance therapydepressive personality disorder: characterized by a pervasivepattern of depressive cognitions and behaviors in variouscontextsderealization: client senses that events are not real, when, in fact,they aredetoxification: the process of safely withdrawing from asubstanceDiagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR): taxonomy published by the APA; the DSM-IV-TRdescribes all mental disorders and outlines specific diagnosticcriteria for each based on clinical experience and researchdiagnostic axes: the five axes that comprise diagnosis underDSM-IV-TR criteria; include major mental illnesses, mentalretardation or personality disorders, medical illnesses, psychosocialstressors, and global assessment of functioning(GAF)directive role: asking direct, yes/no questions and usingproblem-solving to help the client develop new coping mechanismsto deal with present, here-and-now issuesdisease conviction: preoccupation with the fear that one has aserious diseasedisease phobia: preoccupation with the fear that one will get aserious diseasedisenfranchised grief: grief over a loss that is not or cannot bemourned publicly or supported socially

GLOSSARY OF KEY TERMS501dissociation: a subconscious defense mechanism that helps aperson protect his or her emotional self from recognizing thefull effects of some horrific or traumatic event by allowing themind to forget or remove itself from the painful situation ormemorydissociative disorders: have the essential feature of a disruptionin the usually integrated functions of consciousness, memory,identity, or environmental perception; include amnesia, fugue,and dissociative identity disorderdistance zones: amount of physical space between peopleduring communication; in the United States, Canada, andmany Eastern European nations, four distance zones are generallyobserved: intimate zone, personal zone, social zone,and public zonedistraction: involves shifting the client’s attention and energy toa different topicdopamine: a neurotransmitter located primarily in the brainstem; has been found to be involved in the control of complexmovements, motivation, cognition, and regulation of emotionalresponsesdream analysis: a primary method used in psychoanalysis;involves discussing a client’s dreams to discover their truemeaning and significancedual diagnosis: the client with both substance abuse and anotherpsychiatric illnessduty: existence of a legally recognized relationship, that is, physicianto client, nurse to clientduty to warn: the exception to the client’s right to confidentiality;when health-care providers are legally obligated to warnanother person who is the target of the threats or plan by theclient, even if the threats were discussed during therapy sessionsotherwise protected by confidentialitydysphoric: mood that involves unhappiness, restlessness, andmalaisedystonia: extrapyramidal side effect to antipsychotic medication;includes acute muscular rigidity and cramping, a stiff or thicktongue with difficulty swallowing, and, in severe cases, laryngospasmand respiratory difficulties; also called dystonicreactionsecholalia: repetition or imitation of what someone else says;echoing what is heardechopraxia: imitation of the movements and gestures of someonean individual is observingeducation group: a therapeutic group; provides information tomembers on a specific issue: for instance, stress management,medication management, or assertiveness trainingefficacy: refers to the maximal therapeutic effect a drug canachieveego: in psychoanalytic theory, the balancing or mediating forcebetween the id and the superego; represents mature and adaptivebehavior that allows a person to function successfully inthe worldelder abuse: the maltreatment of older adults by family membersor caretakerselectroconvulsive therapy (ECT): used to treat depression inselect groups such as clients who do not respond to antidepressantsor those who experience intolerable medication sideeffects at therapeutic dosesemotion-focused coping strategies: techniques to assist clientsto relax and reduce feelings of stressempathy: the ability to perceive the meanings and feelings ofanother person and to communicate that understanding tothat personenabling: behaviors that seem helpful on the surface but actuallyperpetuate the substance use of another, for example, a wifewho calls to report her husband has the flu and will miss workwhen he is actually drunk or hungoverencopresis: the repeated passage of feces into inappropriateplaces, such as clothing or the floor, by a child who is at least4 years of age either chronologically or developmentallyenmeshment: lack of clear role boundaries between personsenuresis: the repeated voiding of urine during the day or at nightinto clothing or bed by a child at least 5 years of age eitherchronologically or developmentallyenvironmental control: refers to a client’s ability to control thesurroundings or direct factors in the environmentepinephrine: derivative of norepinephrine, the most prevalentneurotransmitter in the nervous system, located primarily inthe brain stem, and plays a role in changes in attention,learning and memory, sleep and wakefulness, and moodregulationethical dilemma: a situation in which ethical principles conflictor when there is no one clear course of action in a givensituationethics: a branch of philosophy that deals with values of humanconduct related to the rightness or wrongness of actions and tothe goodness and badness of the motives and ends of suchactionsethnicity: concept of people identifying with one another basedon a shared heritageeuthymic: normal or level moodevolving consumer household (ECH): a group-living situationin which the residents make the transition from a traditionalgroup home to a residence where they fulfill their own responsibilitiesand function without on-site supervision from paidstaffexecutive functioning: the ability to think abstractly and to plan,initiate, sequence, monitor, and stop complex behaviorexploitation: phase of nurse–client relationship, identified byPeplau, when the nurse guides the client to examine feelingsand responses and to develop better coping skills and a morepositive self-image; this encourages behavior change anddevelops independence; part of the working phaseexposure: behavioral technique that involves having the clientdeliberately confront the situations and stimuli that he or sheis trying to avoidextrapyramidal side effects: reversible movement disordersinduced by antipsychotic or neuroleptic medicationeye contact: looking into the other person’s eyes duringcommunicationfactitious disorders: characterized by physical symptoms thatare feigned or inflicted for the sole purpose of drawing attentionto oneself and gaining the emotional benefits of assumingthe sick rolefalse imprisonment: the unjustifiable detention of a client, suchas the inappropriate use of restraint or seclusionfamily therapy: a form of group therapy in which the client andhis or her family members participate to deal with mutualissuesfamily violence: encompasses domestic or partner battering;neglect and physical, emotional, or sexual abuse of children;elder abuse; and marital rapefear: feeling afraid or threatened by a clearly identifiable, externalstimulus that represents danger to the personfidelity: refers to the obligation to honor commitments andcontracts

502 GLOSSARY OF KEY TERMSflat affect: showing no facial expressionflight of ideas: excessive amount and rate of speech composed offragmented or unrelated ideas; racing, often unconnected,thoughtsflooding: a form of rapid desensitization in which a behavioraltherapist confronts the client with the phobic object (either apicture or the actual object) until it no longer produces anxietyflushing: reddening of the face and neck as a result of increasedblood flowfree association: a method in psychoanalysis used to gain accessto subconscious thoughts and feelings in which the therapisttries to uncover the client’s true thoughts and feelings by sayinga word and asking the client to respond quickly with thefirst thing that comes to mindgenuine interest: truly paying attention to the client, caringabout what he or she is saying; only possible when the nurse iscomfortable with himself or herself and aware of his or herstrengths and limitationsgoing along: technique used with clients with dementia; providingemotional reassurance to clients without correcting theirmisperceptions or delusionsgrief: subjective emotions and affect that are a normal responseto the experience of lossgrieving: the process by which a person experiences griefgrounding techniques: helpful to use with the client who is dissociatingor experiencing a flashback; grounding techniques remindthe client that he or she is in the present, as an adult, and is safegroup therapy: therapy during which clients participate in sessionswith others; the members share a common purpose andare expected to contribute to the group to benefit others and toreceive benefit from others in returnhalf-life: the time it takes for half of the drug to be eliminatedfrom the bloodstreamhallucinations: false sensory perceptions or perceptual experiencesthat do not really existhallucinogen: substances that distort the user’s perception of realityand produce symptoms similar to psychosis includinghallucinations (usually visual) and depersonalizationhardiness: the ability to resist illness when under stresshierarchy of needs: a pyramid used to arrange and illustratethe basic drives or needs that motivate people; developed byAbraham Maslowhistrionic personality disorder: characterized by a pervasivepattern of excessive emotionality and attention seekinghomeostasis: a state of equilibrium or balancehostility: an emotion expressed through verbal abuse, lack of cooperation,violation of rules or norms, or threatening behavior;also called verbal aggressionhumanism: focuses on a person’s positive qualities, his or hercapacity to change (human potential), and the promotion ofself-esteemHuntington’s disease: an inherited, dominant gene disease thatprimarily involves cerebral atrophy, demyelination, and enlargementof the brain ventricleshypertensive crisis: a life-threatening condition that can resultwhen a client taking MAOIs ingests tyramine-containing foodsand fluids or other medicationshypochondriasis: preoccupation with the fear that one has aserious disease or will get a serious diseasehypomania: a period of abnormally and persistently elevated,expansive, or irritable mood lasting 4 days; does not impair theability to function and does not involve psychotic featureshysteria: refers to multiple, recurrent physical complaints withno organic basisid: in psychoanalytic theory, the part of one’s nature that reflectsbasic or innate desires such as pleasure-seeking behavior, aggression,and sexual impulses; the id seeks instant gratification;causes impulsive, unthinking behavior; and has no regardfor rules or social convention.ideas of reference: client’s inaccurate interpretation that generalevents are personally directed to him or her, such as hearing aspeech on the news and believing the message has personalmeaningimpulse control: the ability to delay gratification and to thinkabout one’s behavior before actinginappropriate affect: displaying a facial expression that is incongruentwith mood or situation; often silly or giddy regardlessof circumstancesincongruent message: when the communication content andprocess disagreeindividual psychotherapy: a method of bringing about change ina person by exploring his or her feelings, attitudes, thinking,and behavior; it involves a one-to-one relationship betweenthe therapist and the clientinhalant: a diverse group of drugs including anesthetics, nitrates,and organic solvents that are inhaled for their effectsinjury or damage: the client suffered some type of loss, damage,or injuryinsight: the ability to understand the true nature of one’ssituation and accept some personal responsibility for thatsituationinterdisciplinary (multidisciplinary) team: treatment groupcomposed of individuals from a variety of fields or disciplines;the most useful approach in dealing with the multifacetedproblems of clients with mental illnessintergenerational transmission process: explains that patternsof violence are perpetuated from one generation to the nextthrough role modeling and social learninginternalization: keeping stress, anxiety, or frustration insiderather than expressing them outwardlyintimate partner violence: the mistreatment, misuse, or abuse ofone person by another in the context of a close, personal, orcommitted relationshipintimate relationship: a relationship involving two people whoare emotionally committed to each other; both parties are concernedabout having their individual needs met and helpingeach other to meet needs as well; the relationship may includesexual or emotional intimacy as well as sharing of mutualgoalsintimate zone: space of 0 to 18 inches between people; theamount of space comfortable for parents with young children,people who mutually desire personal contact, or people whispering;invasion of this intimate zone by anyone else is threateningand produces anxietyintoxication: use of a substance that results in maladaptivebehaviorjudgment: refers to the ability to interpret one’s environment andsituation correctly and to adapt one’s behavior and decisionsaccordinglyjustice: refers to fairness, or treating all people fairly and equallywithout regard for social or economic status, race, sex, maritalstatus, religion, ethnicity, or cultural beliefskindling process: the snowball-like effect seen when minor seizureactivity seems to build up into more frequent and severeseizures

GLOSSARY OF KEY TERMS503Korsakoff’s syndrome: type of dementia caused by long-term,excessive alcohol intake that results in a chronic thiamine orvitamin B deficiencyla belle indifference: a seeming lack of concern or distress; a keyfeature of conversion disorderlabile: rapidly changing or fluctuating, such as someone’s moodor emotionslatency of response: refers to hesitation before the client respondsto questionsleast restrictive environment: treatment appropriate to meet theclient’s needs with only necessary or required restrictionslimbic system: an area of the brain located above the brain stemthat includes the thalamus, hypothalamus, hippocampus, andamygdala (although some sources differ regarding the structuresthat this system includes)limit-setting: an effective technique that involves three steps:stating the behavioral limit (describing the unacceptable behavior),identifying the consequences if the limit is exceeded,and identifying the expected or desired behaviorloose associations: disorganized thinking that jumps from oneidea to another with little or no evident relation between thethoughtsmagnetic resonance imaging (MRI): diagnostic test used to visualizesoft tissue structures; energy field is created with a magnetand radio waves, and then converted into a visual imagemalingering: the intentional production of false or grossly exaggeratedphysical or psychological symptomsmalpractice: a type of negligence that refers specifically to professionalssuch as nurses and physiciansmanaged care: a concept designed to purposely control the balancebetween the quality of care provided and the cost of thatcaremanaged care organizations: developed to control the expenditureof insurance funds by requiring providers to seek approvalbefore the delivery of caremania: a distinct period during which mood is abnormally andpersistently elevated, expansive, or irritablemental disorder: defined by DSM-IV-TR as a clinically significantbehavioral or psychological syndrome or pattern that occursin an individual and that is associated with present distress(e.g., a painful symptom) or disability (i.e., impairment in oneor more important areas of functioning) or with a significantlyincreased risk of suffering death, pain, disability, or an importantloss of freedommental health: a state of emotional, psychological, and socialwellness evidenced by satisfying relationships, effective behaviorand coping, positive self-concept, and emotional stabilitymetaphor: a phrase that describes an object or a situation bycomparing it to something else familiarmild anxiety: a sensation that something is different and warrantsspecial attentionmilieu therapy: the concept involves clients’ interactions withone another, that is, practicing interpersonal relationshipskills, giving one another feedback about behavior, and workingcooperatively as a group to solve day-to-day problemsmoderate anxiety: the disturbing feeling that something is definitelywrong; the person becomes nervous or agitatedmood: refers to the client’s pervasive and enduring emotionalstatemood disorders: pervasive alterations in emotions that are manifestedby depression or mania or bothmood-stabilizing drugs: used to treat bipolar disorder by stabilizingthe client’s mood, preventing or minimizing the highsand lows that characterize bipolar illness, and treating acuteepisodes of maniamourning: the outward expression of griefMunchausen’s by proxy: when a person inflicts illness or injuryon someone else to gain the attention of emergency medicalpersonnel or to be a hero for “saving” the victimMunchausen’s syndrome: a factitious disorder where the personintentionally causes injury or physical symptoms to self to gainattention and sympathy from health-care providers, family,and othersnarcissistic personality disorder: characterized by a pervasivepattern of grandiosity (in fantasy or behavior), need for admiration,and lack of empathynegative reinforcement: involves removing a stimulus immediatelyafter a behavior occurs so that the behavior is more likelyto occur againneglect: malicious or ignorant withholding of physical, emotional,or educational necessities for the child’s well-beingnegligence: an unintentional tort that involves causing harm byfailing to do what a reasonable and prudent person would doin similar circumstancesneologisms: invented words that have meaning only for theclientneuroleptic malignant syndrome (NMS): a potentially fatal,idiosyncratic reaction to an antipsychotic (or neuroleptic) drugneuroleptics: antipsychotic medicationsneurotransmitter: the chemical substances manufactured in theneuron that aid in the transmission of information throughoutthe bodynondirective role: using broad openings and open-ended questionsto collect information and help the client to identify anddiscuss the topic of concernnonmaleficence: the requirement to do no harm to others eitherintentionally or unintentionallynonverbal communication: the behavior that accompanies verbalcontent, such as body language, eye contact, facial expression,tone of voice, speed and hesitations in speech, grunts andgroans, and distance from the listenernorepinephrine: the most prevalent neurotransmitter in the nervoussystemno self-harm contract: a client promises to not engage in self-harmand to report to the nurse when he or she is losing controlobsessions: recurrent, persistent, intrusive, and unwantedthoughts, images, or impulses that cause marked anxiety andinterfere with interpersonal, social, or occupational functionobsessive–compulsive personality disorder: characterized by apervasive pattern of preoccupation with perfectionism, mentaland interpersonal control, and orderliness at the expense offlexibility, openness, and efficiencyoff-label use: a drug will prove effective for a disease that differsfrom the one involved in original testing and FDA approvalopen group: an ongoing group that runs indefinitely; membersjoin or leave the group as they need tooperant conditioning: the theory that says people learn theirbehavior from their history or past experiences, particularlythose experiences that were repeatedly reinforcedopioid: controlled drugs; often abused because they desensitizethe user to both physiologic and psychological pain andinduce a sense of euphoria and well-being; some are prescribedfor analgesic effects but others are illegal in the United Statesorientation phase: the beginning of the nurse–client relationship;begins when the nurse and client meet and ends whenthe client begins to identify problems to examine

504 GLOSSARY OF KEY TERMSpain disorder: has the primary physical symptom of pain, whichgenerally is unrelieved by analgesics and greatly affected bypsychological factors in terms of onset, severity, exacerbation,and maintenancepalilalia: repeating words or sounds over and overpanic anxiety: intense anxiety, may be a response to a lifethreateningsituationpanic attack: between 15 and 30 minutes of rapid, intense, escalatinganxiety in which the person experiences great emotionalfear as well as physiologic discomfortpanic disorder: composed of discrete episodes of panic attacks,that is, 15 to 30 minutes of rapid, intense, escalating anxiety inwhich the person experiences great emotional fear as well asphysiologic discomfortparanoid personality disorder: characterized by pervasive mistrustand suspiciousness of othersparataxic mode: begins in early childhood as the child begins toconnect experiences in sequence; the child may not make logicalsense of the experiences and may see them as coincidenceor chance events; the child seeks to relieve anxiety by repeatingfamiliar experiences, although he or she may not understandwhat he or she is doingParkinson’s disease: a slowly progressive neurologic conditioncharacterized by tremor, rigidity, bradykinesia, and posturalinstabilitypartial hospitalization program (PHP): structured treatment at anagency or a facility for clients living in the community; designedto help clients make a gradual transition from being an inpatientto living independently or to avoid hospital admissionparticipant observer: the therapist’s role, meaning that the therapistboth participates in and observes the progress of therelationshippassive-aggressive personality disorder: characterized by a negativeattitude and a pervasive pattern of passive resistance todemands for adequate social and occupational performancepatterns of knowing: the four patterns of knowing in nursing areempirical knowing (derived from the science of nursing), personalknowing (derived from life experiences), ethical knowing(derived from moral knowledge of nursing), and aestheticknowing (derived from the art of nursing); provide the nursewith a clear method of observing and understanding every clientinteractionpersonal zone: space of 18 to 36 inches; a comfortable distancebetween family and friends who are talkingpersonality: an ingrained, enduring pattern of behaving and relatingto self, others, and the environment; includes perceptions,attitudes, and emotionspersonality disorders: diagnosed when personality traits becomeinflexible and maladaptive and significantly interfere with howa person functions in society or cause the person emotionaldistresspervasive developmental disorders: characterized by pervasiveand usually severe impairment of reciprocal social interactionskills, communication deviance, and restricted, stereotypicalbehavioral patternsphase of disorganization and despair: the point in the grievingprocess when the bereaved person begins to understand theloss’s permanencephase of numbing: beginning of the grieving process; the commonfirst response to the news of a loss is to be stunned, asthough not perceiving realityphase of reorganization: at the end of the grieving process, whenthe bereaved person begins to reestablish a sense of personalidentity, direction, and purpose for livingphase of yearning and searching: the point in the grievingprocess when the person begins to recognize the reality of thelossphenomena of concern: describe the 12 areas of concern thatmental health nurses focus on when caring for clientsphobia: an illogical, intense, and persistent fear of a specificobject or social situation that causes extreme distress and interfereswith normal functioningphysical abuse: ranges from shoving and pushing to severe batteringand choking and may involve broken limbs and ribs,internal bleeding, brain damage, and even homicidephysical aggression: behavior in which a person attacks or injuresanother person or that involves destruction of propertypica: persistent ingestion of nonnutritive substances such aspaint, hair, cloth, leaves, sand, clay, or soilPick’s disease: a degenerative brain disease that particularlyaffects the frontal and temporal lobes and results in a clinicalpicture similar to that of Alzheimer’s diseasepolydipsia: excessive water intakepolysubstance abuse: abuse of more than one substancepositive reframing: a cognitive–behavioral technique involvingturning negative messages into positive onespositive regard: unconditional, nonjudgmental attitude thatimplies respect for the personpositive reinforcement: a reward immediately following a behaviorto increase the likelihood that the behavior will berepeatedpositive self-talk: a cognitive–behavioral technique in which theclient changes thinking about the self from negative topositivepositron emission tomography (PET): a diagnostic test used toexamine the function of the brain by monitoring the flow ofradioactive substances that are injected into the bloodstreamposttraumatic stress disorder: a disturbing pattern of behaviordemonstrated by someone who has experienced a traumaticevent: for example, a natural disaster, a combat, or an assault;begins 3 or more months following the traumapotency: describes the amount of a drug needed to achieve maximumeffectpreconception: the way one person expects another to behave orspeak; often a roadblock to the formation of an authenticrelationshippressured speech: unrelenting, rapid, often loud talking withoutpausesprimary gain: the relief of anxiety achieved by performing thespecific anxiety-driven behavior; the direct external benefitsthat being sick provides, such as relief of anxiety, conflict, ordistressproblem-focused coping strategies: techniques used to resolveor change a person’s behavior or situation or to manage lifestressorsproblem identification: part of the working phase of the nurse–client situation, when the client identifies the issues or concernscausing problemsprocess: in communication, denotes all nonverbal messages thatthe speaker uses to give meaning and context to the messageprototaxic mode: characteristic of infancy and childhood thatinvolves brief, unconnected experiences that have no relationshipto one another; adults with schizophrenia exhibit persistentprototaxic experiencesproverbs: old adages or sayings with generally accepted meaningsproxemics: the study of distance zones between people duringcommunication

GLOSSARY OF KEY TERMS505pseudoparkinsonism: a type of extrapyramidal side effect ofantipsychotic medication; drug-induced parkinsonism; includesshuffling gait, masklike facies, muscle stiffness (continuous) orcogwheeling rigidity (ratchet-like movements of joints),drooling, and akinesia (slowness and difficulty initiatingmovement)psychiatric rehabilitation: services designed to promote the recoveryprocess for clients with mental illness; not limited tomedication management and symptom control; includes personalgrowth reintegration into the community, increased independence,and improved quality of lifepsychoanalysis: focuses on discovering the causes of the client’sunconscious and repressed thoughts, feelings, and conflictsbelieved to cause anxiety and helping the client to gain insightinto and resolve these conflicts and anxieties; pioneered bySigmund Freud; not commonly seen todaypsychoimmunology: examines the effect of psychosocial stressorson the body’s immune systempsychological abuse (emotional abuse): includes name-calling,belittling, screaming, yelling, destroying property, and makingthreats as well as subtler forms such as refusing to speak to orignoring the victimpsychomotor agitation: increased body movements and thoughtspsychomotor retardation: overall slowed movements; a generalslowing of all movements; slow cognitive processing and slowverbal interactionpsychopharmacology: the use of medications to treat mentalillnesspsychosis: cluster of symptoms including delusions, hallucinations,and grossly disordered thinking and behaviorpsychosocial interventions: nursing activities that enhance theclient’s social and psychological functioning and improvesocial skills, interpersonal relationships, and communicationpsychosomatic: used to convey the connection between themind (psyche) and the body (soma) in states of health andillnesspsychotherapy: therapeutic interaction between a qualified providerand a client or group designed to benefit persons experiencingemotional distress, impairment, or illness; therapist’sapproach is based on a theory or combination of theoriespsychotherapy group: the goal of the group is for members tolearn about their behaviors and to make positive changes intheir behaviors by interacting and communicating with othersas members of a grouppsychotropic drugs: drugs that affect mood, behavior, and thinkingthat are used to treat mental illnesspublic zone: space of 12 to 25 feet; the acceptable distance betweena speaker and an audience, between small groups, andamong others at informal functionspurging: compensatory behaviors designed to eliminate food bymeans of self-induced vomitingrace: a division of humankind possessing traits that are transmittedby descent and sufficient to identify it as a distinct humantyperape: a crime of violence, domination, and humiliation of thevictim expressed through sexual meansrebound: temporary return of symptoms; may be more intensethan original symptomsreframing: cognitive–behavioral technique in which alternativepoints of view are examined to explain eventsreligion: an organized system of beliefs about one or more allpowerful,all-knowing forces that govern the universe and offerguidelines for living in harmony with the universe and othersreminiscence therapy: thinking about or relating personally significantpast experiences in a purposeful manner to benefit theclientrepressed memories: memories that are buried deeply in thesubconscious mind or repressed because they are too painfulfor the victim to acknowledge; often relate to childhoodabuseresidential treatment setting: long-term treatment provided in aliving situation; vary according to structure, level of supervision,and services providedresilience: defined as having healthy responses to stressful circumstancesor risky situationsresourcefulness: involves using problem-solving abilities andbelieving that one can cope with adverse or novel situationsresponse prevention: behavioral technique that focuses ondelaying or avoiding performance of rituals in response toanxiety-provoking thoughtsrestraining order: legal order of protection obtained to prohibitcontact between a victim and a perpetrator of abuserestraint: the direct application of physical force to a person,without his or her permission, to restrict his or her freedom ofmovementrestricted affect: displaying one type of emotional expression,usually serious or somberruminate: to repeatedly go over the same thoughtssatiety: satisfaction of appetiteschizoid personality disorder: characterized by a pervasive patternof detachment from social relationships and a restrictedrange of emotional expression in interpersonal settingsschizotypal personality disorder: characterized by a pervasivepattern of social and interpersonal deficits marked by acutediscomfort with and reduced capacity for close relationships aswell as by cognitive or perceptual distortions and behavioraleccentricitiesseasonal affective disorder (SAD): mood disorder with twosubtypes; in one, most commonly called winter depression orfall-onset SAD, people experience increased sleep, appetite,and carbohydrate cravings; weight gain; interpersonal conflict;irritability; and heaviness in the extremities beginning in lateautumn and abating in spring and summer; the other subtype,called spring-onset SAD, is less common and includes symptomsof insomnia, weight loss, and poor appetite lasting fromlate spring or early summer until early fallseclusion: the involuntary confinement of a person in a speciallyconstructed, locked room equipped with a security window orcamera for direct visual monitoringsecondary gain: the internal or personal benefits received fromothers because one is sick, such as attention from family members,comfort measures, and being excused from usual responsibilitiesor tasksself-actualized: describes a person who has achieved all theneeds according to Maslow’s hierarchy and has developed hisor her fullest potential in lifeself-awareness: the process by which a person gains recognitionof his or her own feelings, beliefs, and attitudes; the process ofdeveloping an understanding of one’s own values, beliefs,thoughts, feelings, attitudes, motivations, prejudices, strengths,and limitations and how these qualities affect othersself-concept: the way one views oneself in terms of personalworth and dignityself-disclosure: revealing personal information such as biographicalinformation and personal experiences, ideas,thoughts, and feelings about oneself

506 GLOSSARY OF KEY TERMSself-efficacy: a belief that personal abilities and efforts affect theevents in our livesself-help group: members share a common experience, but thegroup is not a formal or structured therapy groupself-monitoring: a cognitive–behavioral technique designed tohelp clients manage their own behaviorsense of belonging: the feeling of connectedness with or involvementin a social system or environment of which a person feelsan integral partserotonin: a neurotransmitter found only in the brainserotonin syndrome: uncommon but potentially life-threateningdisorder called serotonin or serotonergic syndrome; characterizedby agitation, sweating, fever, tachycardia, hypotension,rigidity, hyperreflexia, confusion, and, in extreme cases, comaand death; most commonly results from a combination of twoor more medications with serotonin-enhancing properties,such as taking MAOI and SSRI antidepressants at the sametime or too close togethersevere anxiety: an increased level of anxiety when more primitivesurvival skills take over, defensive responses ensue, andcognitive skills decrease significantly; person with severe anxietyhas trouble thinking and reasoningsexual abuse: involves sexual acts performed by an adult on achild younger than 18 yearssingle photon emission computed tomography (SPECT): a diagnostictest used to examine the function of the brain by followingthe flow of an injected radioactive substancesocial network: groups of people whom one knows and withwhom one feels connectedsocial organization: refers to family structure and organization,religious values and beliefs, ethnicity, and culture, all of whichaffect a person’s role and, therefore, his or her health and illnessbehaviorsocial relationship: primarily initiated for the purpose of friendship,socialization, companionship, or accomplishment of atasksocial support: emotional sustenance that comes from friends,family members, and even health-care providers who help aperson when a problem arisessocial zone: a space of 4 to 12 feet, which is the distance acceptablefor communication in social, work, and business settingssocioeconomic status: refers to one’s income, education, andoccupationsodomy: anal intercoursesomatization: the transference of mental experiences and statesinto bodily symptomssomatization disorder: characterized by multiple, recurrentphysical symptoms in a variety of bodily systems that have noorganic or medical basissomatoform disorders: characterized as the presence of physicalsymptoms that suggest a medical condition without a demonstrableorganic basis to account fully for themspirituality: a client’s beliefs about life, health, illness, death, andone’s relationship to the universe; involves the essence of aperson’s being and his or her beliefs about the meaning of lifeand the purpose for livingspontaneous remission: natural recovery that occurs withouttreatment of any kindspouse or partner abuse: see intimate partner violencestalking: repeated and persistent attempts to impose unwantedcommunication or contact on another personstandards of care: authoritative statements by professional organizationsthat describe the responsibilities for which nurses areaccountable; the care that nurses provide to clients meets setexpectations and is what any nurse in a similar situation would dostereotypic movements: repetitive, seemingly purposeless movements;may include waving, rocking, twirling objects, bitingfingernails, banging the head, biting or hitting oneself, or pickingat the skin or body orificesstimulants: drugs that stimulate or excite the central nervoussystemstress: the wear and tear that life causes on the bodysubconscious: thoughts or feelings in the preconscious orunconscious level of awarenesssubstance abuse: can be defined as using a drug in a way that isinconsistent with medical or social norms and despite negativeconsequencessubstance dependence: includes problems associated withaddiction, such as tolerance, withdrawal, and unsuccessfulattempts to stop using the substancesuicidal ideation: thinking about killing oneselfsuicide: the intentional act of killing oneselfsuicide precautions: removal of harmful items; increased supervisionto prevent acts of self-harmsuperego: in psychoanalytic theory, the part of a person’s naturethat reflects moral and ethical concepts, values, and parentaland social expectations; therefore, it is in direct opposition tothe idsupport group: organized to help members who share a commonproblem to cope with itsupportive touch: the use of physical touch to convey support,interest, caring; may not be welcome or effective with all clientssurvivor: view of the client as a survivor of trauma or abuserather than as a victim; helps to refocus client’s view of himselfor herself as being strong enough to survive the ordeal, whichis a more empowering image than seeing oneself as a victimsyntaxic mode: begins to appear in school-aged children andbecomes more predominant in preadolescence; the personbegins to perceive himself or herself and the world within thecontext of the environment and can analyze experiences in avariety of settingssystematic desensitization: behavioral technique used to helpovercome irrational fears and anxiety associated with aphobiatangential thinking: wandering off the topic and never providingthe information requestedtapering: administering decreasing doses of a medication leadingto discontinuation of the drugtardive dyskinesia: a late-onset, irreversible neurologic sideeffect of antipsychotic medications; characterized by abnormal,involuntary movements such as lip smacking, tongueprotrusion, chewing, blinking, grimacing, and choreiformmovements of the limbs and feettemperament: refers to the biologic processes of sensation,association, and motivation that underlie the integration ofskills and habits based on emotiontermination or resolution phase: the final stage in the nurse–client relationship; it begins when the client’s problems areresolved and concludes when the relationship endstherapeutic communication: an interpersonal interactionbetween the nurse and the client during which the nursefocuses on the client’s specific needs to promote an effectiveexchange of informationtherapeutic community or milieu: beneficial environment; interactionamong clients is seen as beneficial, and treatmentemphasizes the role of this client-to-client interaction

GLOSSARY OF KEY TERMS507therapeutic nurse–client relationship: professional, planned relationshipbetween client and nurse that focuses on clientneeds, feelings, problems, and ideas; interaction designed topromote client growth, discuss issues, and resolve problems;includes the three phases of orientation: working (identificationand exploitation) and termination (resolution)therapeutic play: play techniques are used to understand thechild’s thoughts and feelings and to promote communicationtherapeutic relationship: see therapeutic nurse–client relationshiptherapeutic use of self: nurses use themselves as a therapeutictool to establish the therapeutic relationship with clients andto help clients grow, change, and healthought blocking: stopping abruptly in the middle of a sentenceor train of thought; sometimes client is unable to continue theideathought broadcasting: a delusional belief that others can hear orknow what the client is thinkingthought content: what the client actually saysthought insertion: a delusional belief that others are puttingideas or thoughts into the client’s head; that is, the ideas arenot those of the clientthought process: how the client thinksthought stopping: a cognitive–behavioral technique to alter theprocess of negative or self-critical thought patternsthought withdrawal: a delusional belief that others are taking theclient’s thoughts away and the client is powerless to stop ittic: a sudden, rapid, recurrent, nonrhythmic, stereotyped motormovement or vocalizationtime away: involves leaving clients for a short period and thenreturning to them to reengage in interaction; used in dementiacaretime orientation: whether or not one views time as precise orapproximate; differs among culturestime-out: retreat to a neutral place to give the opportunity toregain self-controltolerance: the need for increased amount of a substance to producethe same effecttolerance break: very small amounts of a substance will produceintoxicationtort: a wrongful act that results in injury, loss, or damageTourette’s disorder: involves multiple motor tics and one ormore vocal tics, which occur many times a day for more than1 yeartransference: occurs when the client displaces onto the therapistattitudes and feelings that the client originally experienced inother relationships; it is common for the client unconsciouslyto transfer to the nurse feelings he or she has for significantothers12-step program: based on the philosophy that total abstinenceis essential and that alcoholics need the help and support ofothers to maintain sobrietyunknowing: when the nurse admits she does not know the clientor the client’s subjective world, this opens the way for a trulyauthentic encounter; the nurse in a state of unknowing is opento seeing and hearing the client’s views without imposing anyof his or her values or viewpointsutilitarianism: a theory that bases ethical decisions on the “greatestgood for the greatest number”; primary consideration is onthe outcome of the decisionutilization review firms: developed to control the expenditure ofinsurance funds by requiring providers to seek approval beforethe delivery of carevalues: abstract standards that give a person a sense of right andwrong and establish a code of conduct for livingvascular dementia: has symptoms similar to those of Alzheimer’sdisease, but onset is typically abrupt and followed by rapidchanges in functioning, a plateau or leveling-off period, moreabrupt changes, another leveling-off period, and so onveracity: the duty to be honest or truthfulverbal communication: the words a person uses to speak to oneor more listenerswaxy flexibility: maintenance of posture or position over timeeven when it is awkward or uncomfortablewithdrawal: new symptoms resulting from discontinuation ofdrug or substancewithdrawal syndrome: refers to the negative psychological andphysical reactions that occur when use of a substance ceases ordramatically decreasesword salad: flow of unconnected words that convey no meaningto the listenerworking phase: in the therapeutic relationship, the phasewhere issues are addressed, problems identified, and solutionsexplored; nurse and client work to accomplish goals;contains Peplau’s phases of problem identification andexploitation

IndexPage numbers followed by b indicate box; those followed by f indicate figure; those followed by t indicate table.AAbility to concentrate, 143Abnormal involuntary movement scale (AIMS), 259, 259bAbsolute neutrophil count (ANC), 29Abstract messages, 101Abstract thinking, 144Abusechild, 185–188. See also Child abuseclinical picture of, 181cycle of, 184elder, 188–190intimate partner violence, 182–185physical, 182defined, 182in elder, 190, 190bin spouse, 182posttraumatic stress disorder (PTSD) related to, 194–196psychological, 182in child, 186defined, 182in spouse, 182self-awareness issues, 202sexual, 186Acamprosate (Campral), 37, 359Acceptance, 83, 207ACCESS. See Access to Community Care and Effective Servicesand Support (ACCESS)Access to Community Care and Effective Services and Support(ACCESS), 6, 71Acculturation, defined, 211Acetylcholine, 21, 21tACT. See Assertive community treatment (ACT)Acting out, 168Active listeningin therapeutic communication, 100–101Acute confusion, 443. See also DeliriumAcute dystonia, 27Acute stress disorder, 233in PTSD, 194Adaptive denial, 218ADHD. See Attention deficit hyperactivity disorder(ADHD)Adjustment disorders, 232Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477Adolescents. See also Child and adolescent disorderswith depression, 284eating disorders. See Eating disordersmental illness, 5suicidal risk, 31, 313Adult foster care, 68Advocacy, defined, 93Advocate, nurses as, 93–94Aesthetic knowing, 86, 86tAffectin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303blunted, 142in borderline personality disorder, 333broad, 142in conduct disorder, 425defined, 142in delirium, 444in dementia, 452in depression, 290in eating disorders, 382–383flat, 142inappropriate, 142in OCD, 243in panic disorder, 237in psychosocial assessment, 141b, 142in PTSD, 199restricted, 142in schizophrenia, 261in somatoform disorders, 401Affective disorders. See Mood disordersAfrican Americansbereavement rituals of, 211cultural considerations, 125t, 126t, 129, 211Age, in client response to illness, 120, 121tAggressive behaviorcommunity-based care, 176–177cultural considerations, 169etiology, 167–168nurshing process, 170–173assessment, 173–174data analysis, 174evaluation, 176intervention, 174–176outcome identification, 174phases of, 174tphysical, 166related disorders, 168treatment of, 169–170Agnosia, 447. See also DementiaAgoraphobia, 232, 233tAgranulocytosis, 260AIMS. See Abnormal involuntary movementscale (AIMS)Akathisia, 27, 257Alarm reaction stage, of stress, 227Alcohol abuse, in family violence, 182Alcoholics anonymous, twelve steps of, 358bAlcoholismAlcohol Use Disorders Identification Test (AUDIT),363, 363bclinical course, 350508

INDEX509Clinical Institute Withdrawal Assessment ofAlcohol Scale, 353b–354bDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 473family considerations, 350, 365intoxication and overdose, 352mental health promotion, 366–367older adults and, 366parental, 365psychopharmacology, 359–360, 360tspontaneous remission, 350withdrawal and detoxification, 352–353Alcohol Use Disorders Identification Test (AUDIT),363, 363bAlexithymia, defined, 385Alogia, defined, 262Alprazolam (Xanax), 35t, 230t, 235tAlternative medical systems, 59Alzheimer’s disease, 25, 450PET of patient with, 23, 23fAmerican Indianscultural considerations, 125t, 126t, 129American Nurses Association (ANA), 8Code of Ethics, 160, 162b, 163standards of care, 8, 9b–10bAmerican Psychiatric Association (APA)mental disorder defined by, 3Amitriptyline (Elavil), 30t, 287tAmnestic disorders, 460. See also Cognitive disordersDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 472Amok, 169Amoxapine (Asendin), 30t, 286, 287tAmphetamines, 35–36, 37tabuse of, 355Amygdala, 19ANA. See American Nurses Association (ANA)ANC. See Absolute neutrophil count (ANC)Anergia, 280Anger. See also Aggressive behavioronset and clinical course, 167related disorders, 168suppression of, 167Anger attacks, 168Anhedonia, 261Anorexia nervosa, 377–379binge eating, 374clinical course, 377defined, 377Diagnostic and Statistical Manual of Mental Disorders,(DSM-IV-TR), 374bpsychopharmacology, 379purging, 378risk factors, 375ttreatment, 378–379Antianxiety drugs, 34–35, 35t, 230tabuse of, 354–355benzodiazepines, 34–35, 35tCanadian drugs, 487client teaching, 35listing of, 35tmechanism of action, 34side effects, 34–35Anticholinergic side effects, 28Anticipatory grieving, defined, 205Anticonvulsant drugs, for bipolar disorder, 301–302carbamazepine (Tegretol), 302, 302tclonazepam (Klonopin), 302, 302tgabapentin (Neurontin), 302, 302ttopiramate (Topamax), 302, 302tvalproic acid (Depakote), 302, 302tAntidepressant drugs, 29–32, 30tatypical, 286, 288tCanadian drugs, 486–487client teaching, 32cyclic, 285, 286listing of, 30toverdose, 289side effects, 31in dementia, 451drug interactions, 32listing of, 30tmechanism of action, 31monoamine oxidase inhibitors (MAOI), 286, 287, 288tdrug interactions, 32, 289bfood interactions, 31–32, 32blisting of, 30tmechanism of action, 31overdose of, 289bside effects, 31–32selective serotonin reuptake inhibitors (SSRI)drug interactions, 32listing of, 30t, 286tmechanism of action, 31, 285side effects, 31side effects of, 31–32suicide risk and, 31tetracyclic, 286tricyclic, 285, 286, 287tAntipsychotic drugs, 25–29, 26t, 256, 257tfor aggressive behavior, 169–170Canadian drugs, 486client and family education, 29for dementia, 451depot injection, 26mechanism of action, 25–26for schizophrenia, 254, 255, 256, 257side effects, 26–29, 258tanticholinergic, 28client and family education, 273textrapyramidal symptoms (EPS), 26–27, 257, 258, 258tneuroleptic malignant syndrome (NMS), 27–28, 260seizures, 258t, 260tardive dyskinesia (TD), 28, 258t, 259weight gain, 28, 258tAntisocial behavior, in children. See Conduct disorderAntisocial personality disorder, 327–332care plan for, 329–330client and family education, 332defined, 327Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 327b

510 INDEXAntisocial personality disorder (cont.)interventions, 324tnursing proccss, 327–332assessment, 327–328data analysis, 328evaluation, 328, 331–332intervention, 328, 331–332outcome identification, 328symptoms of, 324tAnxietyHamilton rating scale for, 238blevels of, 228, 229tmild, 228moderate, 228Anxiety disordersacute stress disorder, 233, 247care plan for, 230–231community-based care, 235cultural considerations of, 234defined, 226Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476elder considerations of, 235etiology, 232–234generalized anxiety disorder, 233, 246incidence, 232mental health promotion, 235–236obsessive–compulsive disorder (OCD), 227, 233onset and clinical course, 232panic disorder, 236–240phobias, 240–242posttraumatic stress disorder, 233, 246–247as response to stress, 227–229symptoms of, 233treatment of, 234–235, 235tAnxiety levelsin therapeutic relationship, 51–52, 51tAnxiolytics. See Antianxiety drugsAPA. See American Psychiatric Association (APA)Aphasia, 447. See also DementiaApproval, in therapeutic communication, 105tApraxia, 448. See also DementiaArab Americanscultural considerations by, 125t, 126t, 129–130Aripiprazole (Abilify), 26, 26tArousal disorder, sexual, 496ASAP. See Assaulted staff action program (ASAP)Asperger’s disorder, 413Assault, 161Assaulted staff action program (ASAP), 176Assertive communication, 114–115Assertive community treatment (ACT), 67, 70–71, 70bAssertiveness training, 234Assessmentin aggressive behavior, 173–174of attention deficit hyperactivity disorder (ADHD), 418–419components ofgeneral appearance, 141b, 142history, 140–142, 141binterview, 140judgment and insight, 141b, 144mood and affect, 142motor behavior, 141b, 142roles and relationships, 141b, 145self care, 141b, 145self-concept, 141b, 144–145sensorium and intellectual processes, 141b, 143–144sensory-perceptual alterations, 141b, 144thought process and content, 141b, 142–143of conduct disorder, 425data analysis, 145, 147of delirium, 442, 444–445of dementia, 452–453factors influencing, 139global assessment of functioning (GAF), 148, 149bmental status exam, 148, 150psychiatric diagnoses, 148psychological tests, 147, 148, 148tself-awareness issues, 150of somatoform disorders, 401–402, 401bof suicide risk, 143, 143bAssisted suicide, 312. See also SuicideAsylum, 4Atomoxetine, 36Attachment behaviors, 207Attention deficit hyperactivity disorder (ADHD), 411b,414–422adult, 415, 416bCanadian drugs used in, 488care plan for, 420–421causes of, 415–416client and family education, 422, 422bclinical course, 415cultural considerations, 416defined, 414drugs to treatment, 37bDSM-IV-TR, 471nursing process, 418–422assessment, 418–419data analysis, 419evaluation, 422intervention, 418b, 419–422outcome identification, 419psychopharmacology, 416–417, 417trisk factors of, 416strategies at school and home for, 417, 418symptoms of, 415btreatment of, 416–418Attentive presence, 215Attitudesdefined, 84self-awareness of, 84Atypical antidepressants, 286, 288tAUDIT. See Alcohol Use Disorders Identification Test (AUDIT)Auditory hallucinations, 265Autistic disorder, 412–413Automatisms, 142, 237Autonomy, and ethics, 161Avoidance, in therapeutic relationships, 93Avoidance behavior, 236Avoidant personality disorderclinical course, 338–339

INDEX511defined, 338interventions, 324t, 339symptoms, 324tAxon, 19BBailey, Harriet, 8Barbituratesabuse of, 354Battery, 161Behavioral theorieson anxiety disorders, 234Pavlov’s classical conditioning, 53Skinner’ operant conditioning, 53–54Behaviorism, 53Behavior modification, 53Beliefsabout healthin client response to illness, 125cultural considerations, 125tBeneficence, 161Benzodiazepines, 5, 34–35, 35t, 451in aggressive behavior, 169client teaching, 35listing of, 35tmechanism of action, 34side effects, 34–35substance abuse, 354Bereavement, 205BID. See Body identity integrity disorder (BIID)Binge eating disorder, 374Biologically based therapies, 60Biologic theoriesof mood disordersgenetic, 283neurochemical, 283neuroendocrine, 283of somatoform disorders, 396Bipolar disorder, 298–308client and family education, 307–308, 307bclinical course, 299Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 475–476mania. See Manianursing process, 303–308assessment of, 303–304data analysis, 304evaluation, 308intervention, 304–306, 307–308outcome identification, 304psychopharmacology, 301–302anticonvulsant drugs, 301–302lithium, 301psychotherapy, 302, 303Black box warning, 25Blackout, 350Bleuler, Eugene, 4–5Blunted affect, 142, 261defined, 261Board and care homes, 68, 68bBody dysmorphic disorder, 394, 401Body identity integrity disorder (BIID), 395Body language, in communication, 108–109Borderline personality disordernursing processdata analysis, 334Borderline personality disorder, 332–336client and family education, 336bdefined, 332Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 332binterventions, 324tnursing process, 332–336assessment, 332–334evaluation, 336interventions, 334–336outcome identification, 334symptoms, 324tBouffée délirante, 169, 256Boundariesin borderline personality disorder, 335in therapeutic communication, 99–100in therapeutic relationship, 91–92, 92tBowlby’s phases of grieving, 207Brainanatomy of, 18–19, 18fstructures of, 19fBrain imaging techniques, 21–23, 22tlimitations of, 22types of, 22–23Brain stem, 18f, 19, 19fBreach of duty, 161Breathing-related sleep disorders, 494Brief psychotic disorder, 254Broad affect, 142Bulimia nervosacare plan, 380b–382bcognitive–behavioral therapy for, 379defined, 379Diagnostic and Statistical Manual of Mental Disorders,(DSM-IV-TR), 379bpsychopharmacology, 380risk factors, 375ttreatment, 379–380Bupropion, 30t, 32Bupropion (Wellbutrin), 286, 288tBuspirone (BuSpar), 34, 35t, 230t, 235tCCAM. See Complementary and alternative medicine(CAM)Cambodianscultural considerations, 125t, 126t, 130Canadian drug names, 486–492Canadian Standards of Psychiatric and Mental Health NursingPractice, 482–485Cannabis sativa, abuse of, 355–356Carbamazepinein aggressive behavior, 169

512 INDEXCarbamazepine (Tegretol), 302, 302tas mood stabilizer, 33–34Caregiver, nurses as, 93Care planfor antisocial personality disorder, 329–330for anxiety disorders, 230–231for attention deficit hyperactivity disorder (ADHD), 420–421for bulimia nervosa, 380b–382bfor conduct disorder, 426–427for delirium, 443–444for dementia, 454–455for grieving, 220–221for hypochondriasis, 397–400for schizophrenia, 263–264for somatoform disorders, 397–400for substance abuse, 361b–362bCarper’s patterns of nursing knowledge, 86, 86bCase management, 7CAT. See Computed axial tomography (CAT)Catatonia, 261Catharsis, 167Causation, 161Cenesthetic hallucinations, 265Central nervous system (CNS)brain stem, 18f, 19, 19fcerebellum, 18–19, 18f, 19fcerebrum, 18, 18f, 19flimbic system, 19Cerebellum, 18–19, 18f, 19fCerebrum, 18, 18f, 19fChemical dependence, 349Child abuseassessment of, 187clinical picture of, 187intervention of, 187–188treatment of, 187–188types of, 186–187Child and adolescent disordersattention deficit hyperactivity disorder (ADHD), 411b,414–422adult, 415, 416bcare plan for, 420–421causes of, 415–416client and family education, 422, 422bclinical course, 415cultural considerations, 416defined, 414nursing process, 418–422psychopharmacology, 416–417, 417trisk factors of, 416symptoms of, 415btreatment of, 416–418communication disorders, 411b, 412conduct disorder, 411b, 422–429care plan for, 426–427causes of, 424classification, 423clinical course, 423–424community-based care for, 429cultural considerations, 424defined, 422–423nursing process, 425–429symptoms of, 423btreatment of, 424–425elimination disorders, 411b, 434feeding and eating disordersfeeding disorder, 433–434pica, 433rumination disorder, 433learning disorders, 411b, 412mental retardation, 411–412, 411bmotor skills disorders, 411b, 412oppositional defiant disorder (ODD), 429, 433pervasive developmental disorders, 411bAsperger’s disorder, 413autistic disorder, 412–413childhood disintegrative disorder, 413Rett’s disorder, 413reactive attachment disorder, 435selective mutism, 435self-awareness issues, 435separation anxiety disorder, 434–435SNAP-IV teacher and parent rating scale, 430–432bstereotypic movement disorder, 435tic disorders, 411b, 434Tourette’s disorder, 434Childhood and Society, 48Childhood disintegrative disorder, 413Chinesebereavement rituals, 212cultural considerations, 125t, 126t, 130, 212Chlorazepate (Tranxene), 35t, 235tChlordiazepoxide (Librium), 34, 35t, 230t,235t, 360tChlorpromazine (Thorazine), 5Chronic motor disrorder, 434Circadian rhythm sleep disorders, 494Circumstantiality, defined, 109Circumstantial thinking, 142Citalopram (Celexa), 286tClassical conditioning, 53Client and family educationabout antipsychotic drugs, 29in antisocial personality disorders, 332, 332bin borderline personality disorder, 336bconduct disorder, 429, 429bdelirium, 446bin eating disorders, 386, 386bmania, 307bsomatoform disorders, 402–403, 403bin substance abuse, 365bClient-centered therapy, 52–53Clinical Institute Withdrawal Assessment of AlcoholScale, 353b–354bClonazepam (Klonopin), 33, 35t, 230t, 235t, 302Clonidine (Catapres), 34Closed groups, 58Clozapine (Clozaril), 25, 26t, 29in agranulocytosis, 260in tardive dyskinesia, 259Clubhouse modelfor psychiatric rehabilitation, 70

INDEX513CNS. See Central nervous system (CNS)Cocaine, abuse of, 355, 473Code of Ethics, American Nurses Association (ANA),160, 162b, 163Cognition, defined, 440Cognitive disordersamnestic disorders, 460categories of, 440defined, 440deliriumcare plan, 443–444causes of, 441, 442bclient and family education, 446bcommunity-based care for, 447cultural considerations, 441, 442defined, 441nursing process, 443–447treatment of, 442vs. dementia, 448tdementiacaregiver issues, 459–460care plan for, 454–455causes of, 449–450community-based care for, 458–459cultural considerations, 450–451defined, 447nursing process, 452–458risk factors for, 459self-awreness issues, 461stages of, 449symptoms of, 449treatment of, 451types of, 447–448vs. delirium, 448tDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 472Cognitive therapy, 54–55Command hallucinations, 265Communication. See also Therapeutic communicationnonverbalbody language, 108–109defined, 98eye contact, 109facial expression, 108silence, 109skills for, 107–109vocal cues, 109verbaldefined, 98skills for, 101–107Communication disorders, 411b, 412Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Community-based careaggressive behavior and, 176–177in anxiety disorders, 235current states of, 6–7for delirium, 447for dementia, 458–459in eating disorders, 387in personality disorders, 343for schizophrenia, 274for somatoform disorders, 404in substance abuse, 366in therapeutic communication, 115Community Mental Health Centers Construction Act, 5Community support services, 60Community violence, 193–194Compensation, as ego defense mechanism, 46tComplementary and alternative medicine (CAM), 59Complementary medicine, 59Complicated grieving, 213–215risk factors, 214–215susceptibility to, 214uniqueness of, 215Compulsions, 242Computed axial tomography (CAT), 22Computed tomography (CT), brain imagingtechniques, 22, 22fConcentrate, ability to, 143Concrete messages, 101Conduct disorder, 411b, 422–429care plan for, 426–427causes of, 424classification, 423client and family education, 429, 429bclinical course, 423–424community-based care for, 429cultural considerations, 424defined, 422–423nursing process, 425–429assessment, 425data analysis, 427evaluation, 429intervention, 426–427, 427–429, 428boutcome identification, 427symptoms of, 423btreatment of, 424–425Congress passed the Mental Health Parity Act, 8Congruence, 81Conscious, in psychoanalytic theory, 44Context, in therapeutic communication, 110Control issues, in family violence, 181–182Controlled substancedrug classification under Act, 481Conversion, as ego defense mechanism, 46tConversion disorder, 393, 394Coping strategies, for somatoform disorders,403, 404Corpus callosum, 18Cost containment, managed care and, 7–8Countertransference, 45, 47Creative play, 417, 418Creutzfeldt–Jakob disease, 450Criminalization of mental illness, 72Crisis, stages of, 55“Crisis hostel,” concept of, 66Crisis intervention, 55–56Crisis phase, in aggressive behavior, 175CT. See Computed tomography (CT)Cubanscultural considerations by, 125t, 126t, 130

514 INDEXCuesin communication, 109covert, 107overt, 107vocal, 109Cultural assessment, 125, 125b, 126–127tbiologic variations, 128communication, 128environmental control, 128physical distance, 128social organization, 128time orientation, 128Cultural considerationsin ADHD, 416of anxiety disorders, 234in client response to illnessbeliefs about health, 125, 125tbeliefs about illness, 125tsocioeconomic status, 128–129conduct disorder, 424delirium, 441, 442dementia, 450–451eating disorders, 377by ethnic groupAfrican Americans, 125t, 126t, 129American Indians, 125t, 126t, 129Arab Americans, 125t, 126t, 129–130Chinese, 125t, 126t, 130Combodians, 125t, 126t, 130Cubans, 125t, 126t, 130Filipinos, 125t, 126t, 130–131Haitians, 125t, 127t, 131Japanese Americans, 125t, 127t, 131Mexican Americans, 125t, 127t, 131Puerto Ricans, 125t, 127t, 131–132Russians, 125t, 127t, 132South Asians, 125t, 127t, 132Vietnamese, 125t, 127t, 132in mental illness, 8nurse’s role and, 132–133personality disorders, 322in psychopharmacology, 37–38psychosocial theories and, 56substance abuse, 351–352in therapeutic communication, 110–111Culturally competent nursing, 124Culture, defined, 119–120Culture-bound syndromes, 396tCyclic antidepressants, 285, 286listing of, 30toverdose, 289side effects, 31Cyclothymic disorder, 282Cystic fibrosis, 23DDamage, 161Data analysisin aggressive behavior, 174antisocial personality disorder, 328attention deficit hyperactivity disorder (ADHD), 419bipolar disorder, 304borderline personality disorder, 334conduct disorder, 427for delirium, 445for dementia, 453, 455depression, 294eating disorders, 383grieving, 218obsessive–compulsive disorder (OCD), 243posttraumatic stress disorder (PTSD), 200in schizophrenia, 267somatoform disorders, 402substance abuse, 364Day treatment programs, 68Decatastrophizing, 234Defense mechanisms, 234Deinstitutionalization, 5Deliriumcare plan for, 443–444causes of, 441, 442bclient and family education, 446bcommunity-based care for, 447cultural considerations, 441, 442defined, 441Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 472drug-induced, 442b, 444bnursing process, 443–447assessment, 442, 444–445data analysis, 445evaluation, 447interventions, 443–444, 446–447, 447boutcome identification, 446psychopharmacology, 442symptoms of, 441btreatment of, 442vs. dementia, 448tDelirium tremens (DT), 352Delusional disorder, 254Delusions, 142defined, 263types of, 265bDementiaAlzheimer’s disease, 450Canadian drugs used in, 487caregiver issues, 459–460care plan for, 454–455causes of, 449–450community-based care for, 458–459Creutzfeldt–Jakob disease, 450cultural considerations, 450–451defined, 447–448Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 472drugs used for, 451, 451tHuntington’s disease, 450mild, 449moderate, 449nursing process, 452–458assessment, 452–453data analysis, 453, 455evaluation, 458

INDEX515intervention, 454–455, 455–458outcome identification, 455Parkinson’s disease, 450Pick’s disease, 450risk factors for, 459self-awreness issues, 461severe, 449stages of, 449symptoms of, 449treatment of, 451types of, 450vascular, 450vs. delirium, 448tDendrites, 19Denial, as ego defense mechanism, 46tDeontology, 161Department of Health and Human Services (DHHS), 6Dependent personality disorder, 339–340clinical course, 339defined, 339interventions, 324t, 339–340symptoms, 324tDepersonalization, 233, 237, 266Depersonalization disorder, 196Depot injection, antipsychotic drugs, 26, 256Depression, 281care plan for, 291–293clinical course, 284Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 475electroconvulsive therapy (ECT), 287, 288–289Hamilton rating scale for, 295–296tinvestigational treatment, 290nursing process, 290–298assessment of, 290, 293–294data analysis, 294evaluation, 298intervention, 291–293, 294, 296–298, 297boutcome identification, 294psychopharmacology, 285–287, 286t, 287t, 288tpsychotherapy for, 289symptoms of, 285bDepressive personality disorder, 341–342clinical course, 341defined, 341interventions, 324t, 341–342symptoms, 324tDerealization, 233, 236Desipramine (Norpramine), 287tDesire disorders, sexual dysfunctions, 496Detoxification, 349alcohol, 352–353anxiolytics, 355hallucinogens, 357hypnotics, 355inhalants, 357marijuana, 356opioids, 356sedatives, 355stimulants, amphetamines and cocaine, 355Developmental coordination disorder, 412Developmental theories, 47–48Erikson’s psychosocial stages, 47–48, 48tPiaget’s cognitive stages, 48Development stagesErikson’s psychosocial, 47–48, 48tFreud’s psychosexual, 45, 47tgroups, 57Piaget’s cognitive, 48Dextroamphetamine (Dexedrine), 35–36, 37tDHHS. See Department of Health and Human Services(DHHS)Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 3–4classification, 471–478multiaxial classification system, 3–4objectives of, 3Diazepam (Valium), 34, 35t, 230t, 235t, 258tDirective role, in therapeutic communication, 112Disenfranchised grief, 213Displacement, as ego defense mechanism, 46tDissociation, 195as ego defense mechanism, 46tDissociative amnesia, 196Dissociative disorders, 195Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476Dissociative fugue, 196Dissociative identity disorder, 196Disulfiram (Antabuse), 36–37Dix , Dorothea, 4Dopamine, 20, 21tDopamine receptors, antipsychotics effects on, 25Dopamine system stabilizers, 25Doxepin (Sinequan), 287tDramatic play, 417Dream analysis, 45Droperidol (Inapsine), 29Drug abuse, in family violence, 182Drug interactionsantidepressant drugs and, 32DSM-IV-TR. See Diagnostic and Statistical Manual of MentalDisorders, 4th edition, Text Revision (DSM-IV-TR)DT. See Delirium tremens (DT)Dual diagnosissubstance abuse and, 360–362Duchenne’s muscular dystrophy, 23Duloxetine (Cymbalta), 286, 288tDyspareunia, 496Dyssomnias, 494Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477Dysthymic disorder, 282Dystonia, acute, 27Dystonic reactions, 257EEating attitudes test, 384bEating disorders, 372–388anorexia nervosa, 377–379binge eating, 374clinical course, 377defined, 377

516 INDEXEating disorders (cont.)Diagnostic and Statistical Manual of Mental Disorders,(DSM-IV-TR), 374bpsychopharmacology, 379purging, 378risk factors, 375ttreatment, 378–379binge eating disorder, 374bulimia nervosacare plan, 380b–382bcognitive–behavioral therapy for, 379defined, 379Diagnostic and Statistical Manual of Mental Disorders,(DSM-IV-TR), 379bpsychopharmacology, 380risk factors, 375ttreatment, 379–380categories of, 373–375client and family education, 386, 386bcommunity-based care, 387cultural considerations, 377Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477etiology, 375–377family considerations, 376–377mental health promotion, 387night eating disorder, 374nursing process, 380, 382–387assessment, 382–383data analysis, 383evaluation, 387interventions, 385–388, 385boutcome identification, 383, 385obesity, 372overview of, 372–373risk factors for, 375tself-awareness issues, 387–388Eating disorders, in children and adolescents. See Feedingand eating disordersEcholalia, 261, 448Edema, 22Education, nurse’s role in, 24, 24fEducation groups, 59Efficacy, of drug, 24Ego, 44, 45fEgo defense mechanisms, 45, 46t–47tElder abuse, 188–190assessment of, 189clinical picture of, 189intervention, 189–190treatment of, 189–190Elder considerations, for schizophrenia, 274Electroconvulsive therapy (ECT), 8for depression, 287, 288–289Elimination disorders, 411b, 434Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Ellis, Albert, rational emotive therapy, 54t, 55Emotional support, in dementia, 457Emotion-focused coping strategies, 403, 404Empathy, in therapeutic relationship, 82, 82fEmpowerment, in therapeutic communication,113–114Encopresis, 434Energy therapies, 60Engel’s stages of grieving, 207Enuresis, 434Epinephrine, 20, 21tEPS. See Extrapyramidal side effects (EPS); Extrapyramidalsymptoms (EPS)Erectile disorder, 496Escalation phase, in aggressive behavior, 175bEscitalopram (Lexapro), 286tEthical decision making, 163Ethical dilemmas, 162Ethicscode of, 160, 162b, 163defined, 161principles of, 161–162self-awareness issues, 163Ethnic group, cultural considerations byAfrican Americans, 125t, 126t, 129American Indians, 125t, 126t, 129Arab Americans, 125t, 126t, 129–130Cambodians, 125t, 126t, 130Chinese, 125t, 126t, 130Cubans, 125t, 126t, 130Filipinos, 125t, 126t, 130–131Haitians, 125t, 127t, 131Japanese Americans, 125t, 127t, 131Mexican Americans, 125t, 127t, 131Puerto Ricans, 125t, 127t, 131–132Russians, 125t, 127t, 132South Asians, 125t, 127t, 132Vietnamese, 125t, 127t, 132Executive functioning, 448Exhaustion stage, stress, 227Exhibitionism, 497Existential theories, 54–55, 54tcognitive therapy, 54–55Gestalt therapy, 54t, 55logotherapy, 54t, 55rational emotive therapy, 54t, 55reality therapy, 54t, 55Exploitation phase, of therapeutic relationship, 50t, 51Exposure, 233, 242Expressive language disorder, 412Extrapyramidal symptoms (EPS), 26–27, 257acute dystonia, 27akathisia, 27drugs to treatment, 27tpseudoparkinsonism, 27Eye contact, in communication, 109FFacial expression, in communication, 108Factitious disorders, 395Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476Falling-out episodes, 396tFalse imprisonment, 161

INDEX517Family considerationsin eating disorders, 376–377in schizophrenia, 260in substance abuse, 350, 365Family education, 59. See also Client and familyeducationFamily input, in psychosocial assessment, 140Family structure, in cultural assessment, 125,126–127tFamily therapy, 58–59Family violencecharacteristics of, 181–182, 181bchild. See Child abusecultural considerations, 182elder. See Elder abuseinitmate partner. See Intimate partner violenceFDA. See U.S. Food and Drug Administration (FDA)Fear, 233, 236Feeding and eating disordersDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471feeding disorder, 433–434pica, 433rumination disorder, 433Female orgasmic disorders, 496Female sexual arousal disorder, 496Fetishism, 497Fidelity, 161Filipinoscultural considerations, 125t, 126t, 130–131, 212Fixation, as ego defense mechanism, 46tFlat affect, 142, 261Flight of ideas, 142, 281Flooding, 241Fluoxetine (Prozac), 30, 285, 286tFlurazepam (Dalmane), 34, 35tFrankl, Viktor, logotherapy, 54t, 55Free association, in psychoanalytic theory, 45Freud, Sigmund, 393psychoanalytic theory, 44–45, 45f, 47treatment of mental disorders and, 4–5Freudian slip, 45Friendship-warmth touch, 100Frontal lobe, 18, 18f, 19fFrotteurism, 497Functional-professional touch, 100GGABA. See Γ-aminobutyric acid (GABA); Gamma-aminobutyricacid (GABA)Gabapentin (Neurontin), 33, 302, 302tGamma-aminobutyric acid (GABA), 232Gender identity disorders, 497Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477General adaptation syndrome, 227General appearancein ADHD, 418in antisocial personality disorder, 327, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 444in dementia, 452in depression, 290in eating disorders, 382in OCD, 243in panic disorder, 237in psychiatric disorder related to abuse andviolence, 196in psychosocial assessment, 141b, 142in schizophrenia, 261in somatoform disorders, 401in substance abuse, 364Generalized anxiety disorder, 233, 246Genetic and heredity considerationsof anxiety disorders, 232mental illness and, 23–24of mood disorders, 283schizophrenia, 255Genuine interestin therapeutic relationship, 81–82Gestalt therapy, 54t, 55Ghost sickness, 256Ginkgo biloba, 38Glasser, William, 54t, 55Global Assessment of Functioning, 3Glutamate, 21, 21tGoing along, 458Grandiose delusions, 265bGrief. See also Grievingclinical vignette, 210bdisenfranchised, 213responses tobehavioral, 210cognitive, 209emotional, 209–210physiologic, 211spiritual, 210Grieving, 205–232anticipatory, 205care plan for, 220–221complicated, 213–215complicated grieving, 213–215risk factors, 214–215susceptibility to, 214uniqueness of, 215cultural considerations, 211–213dimensions of, 208–211nursing processassessment, 215–218data analysis, 218evaluation, 222interventions, 218–220, 219toutcome identification, 218process, 206–207self-awareness issues, 222stages of, 208tsymptoms of, 216btasks of, 208theories of, 207–208, 208t

518 INDEXGrounding techniques, 200Groups, 57–59closed, 58defined, 57development stages of, 57leadership, 57–58open, 58roles in, 58therapy in, 58–59Group therapyeducation groups, 59family, 58–59family education, 59psychotherapy, 58self-help groups, 59support groups, 59Gustatory hallucinations, 265HHaitiansbereavement rituals, 212cultural considerations, 125t, 127t, 131, 212Haldol (decanoate haloperidol), 26Half-life, of drug, 24Hallucinations, 144, 265Hallucinogens, abuse of, 356–357Haloperidol (Haldol), 5in aggressive behavior, 169Hamilton rating scale, for depression, 295–296tHealth, defined by WHO, 2–3Health Care Finance Administration, 8Healthy People 2010 Mental Health Objectives, 7bHippocampus, 19Hispanic Americansbereavement rituals, 212cultural considerations, 212Histamine, 21, 21tHistrionic personality disorder, 337clinical course, 337defined, 337interventions, 324t, 337symptoms, 324tHomelessness, mental illness and, 6, 71Homeostasis, 215Hospitalization, 66–67case management, 67discharge planning, 67dual diagnosis, 67legal considerationsinvoluntary, 157mandatory outpatient treatment, 158release, 157long stays, 66–67partial, 68, 68bscheduled, 66short stays, 66Hostility, 166Human Genome Project, 23Humanism, 52Humanistic theories, 52–53Maslow’s hierarchy of needs, 52, 52fRogers’s client-centered therapy, 53–54Huntington’s disease, 23, 450Hwa-byung, 169, 396tHydroxyzine (Vistaril), 34Hyperarousal, 194Hyperinsomnia, 494Hypertensive crisis, 286Hypnotics, abuse of, 354–355Hypoactive sexual desire disorder, 496Hypochondriasis, 394care plan for, 397–400Hypomania, 282Hypothalamus, 19Hysteria, 392–393IId, 44, 45fIdeas of reference, 142–143, 266Identification, as ego defense mechanism, 46tIdentification phase, of therapeutic relationship, 50t, 51IES. See Institute of Education Sciences (IES)Imipramine (Tofranil), 287tImmune system, mental illness and, 24Immunovirologic factors, schizophrenia, 255–256Impulse controlin aggressive behavior and, 169defined, 169Impulse-control disordersDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477Inappropriate affect, 142Indirectly acting amines, 36Individual factors, in mental healthage, 120, 121tgenetics and heredity, 120, 121hardiness, 122health practices, 121physical health, 121psychosocial development, 120, 120tresilience, 122–123resourcefulness, 122–123response to drugs, 121–122self-efficacy, 122spirituality, 123Individual psychotherapy, 56–57Infection causes, of mental illness, 24Inhalants, abuse of, 357Injury, 161Inpatient hospital treatment. See HospitalizationInsightin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 445in dementia, 453in depression, 293in eating disorders, 383

INDEX519in OCD, 243in panic disorder, 238in psychiatric disorder related to abuse and violence, 199in psychosocial assessment, 141b, 144in schizophrenia, 266in somatoform disorders, 402in substance abuse, 364Insomnia, 494Institute of Education Sciences (IES), 193Insulin shock therapy, 8Intellectual functioning, 144Intellectualization, as ego defense mechanism, 46tIntellectual processesin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 445in dementia, 452–453in depression, 293in eating disorders, 383in OCD, 243in panic disorder, 238in psychiatric disorder related to abuse and violence, 199in psychosocial assessment, 141b, 143–144in schizophrenia, 265–266in somatoform disorders, 402in substance abuse, 364Intentional torts, 161Interdisciplinary teams, 72–73, 73bIntergenerational transmission process, 182Internalizationdefined, 395in somatoform disorders, 395Interpersonal factorsfamily support, 124sense of belonging, 123–124social networks, 124social support, 124Interpersonal Relations in Nursing, 8Interpersonal Techniques: The Crux of Psychiatric Nursing, 8Interpersonal theories, 48–52on anxiety disorders, 234Peplau’s therapeutic relationship, 50–52, 50f, 50tSullivan’s life stages, 48–50, 49tIntervention, in aggressive behavior, 174Interview, for psychosocial assessment, 140Intimate partner violenceassessment of, 184clinical picture, 183–184interventions, 184–185treatment, 184–185Intimate relationship, 87Intoxication, 349alcohol, 352anxiolytics, 354hallucinogens, 356–357hypnotics, 354inhalants, 357marijuana, 355–356opioids, 356sedatives, 354stimulants, amphetamines and cocaine, 355Introjection, as ego defense mechanism, 46tInvestigational treatment, for depression, 290Isocarboxazid (Marplan), 30t, 288tJJapanese Americanscultural considerations, 125t, 127t, 131, 212JCAHO. See Joint Commission on Accreditation of HealthcareOrganizations ( JCAHO)Joint Commission on Accreditation of Healthcare Organizations( JCAHO), 176Judgmentin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 445in dementia, 453in depression, 293in eating disorders, 383in OCD, 243in panic disorder, 238in psychiatric disorder related to abuse and violence, 199in psychosocial assessment, 141b, 144in schizophrenia, 266in somatoform disorders, 402in substance abuse, 364Justice, 161KKava, 38Khmer, 130Kindling, defined, 283Kinesthetic hallucinations, 265Knowing, patterns of, 85–86Koro, 234, 396tKorsakoff’s syndrome, 460Kraepelin, Emil, 4–5Kubler-Ross’s stages of grieving, 207LLa belle indifférence, 394Lamotrigine (Lamictal), 33Language disorder, 412Latency of response, 261, 290Leadershipgroup, 57–58Learning disorders, 411b, 412Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Legal considerationsclient’s rights, 156–157confidentiality, 159–160conservatorship, 158

520 INDEXLegal considerations (cont.)duty to warn, 160hospitalizationinvoluntary, 157mandatory outpatient treatment, 158release, 157insanity defense, 160least restrictive environment, 158–159malpractice, 160–161nursing liability, 160–161restraints, 158seclusion, 158–159torts, 160–161Levomethadyl (Orlaam), 359, 360tLibido, 45Life stagesSullivan’s, 48–50, 49tLithium, 5in aggressive behavior, 169for bipolar disorders, 301toxicity, 301–302, 306tdosage, 33mechanism of action, 33side effects, 33–34Locura, 256Logotherapy, 54t, 55Loose associations, 143Lorazepamin aggressive behavior, 169Lorazepam (Ativan), 27t, 35t, 169, 230t, 258, 360Losstypes of, 206Love-intimacy touch, 100MMADD. See Mothers Against Drunk Driving (MADD)Magnetic resonance imaging (MRI), of brain, 22Malingering, 394Managed carecost containment and, 7–8defined, 7Mania, 281client and family education, 307bnursing interventions, 304bsymptoms of, 301bManic episode, 281–282diagnosis of, 299nursing process, 303–308assessment of, 303–304data analysis, 304evaluation, 308intervention, 304–306, 307–308outcome identification, 304onset and clinical course, 299psychodynamic theories, 282Manipulative and body-based therapies, 60MAOIs. See Monoamine oxidase inhibitors (MAOIs)Marijuana, abuse of, 355–356Maslow, Abrahamhierarchy of needs, 52self-actualization, 52Material abusein elder, 190, 190bMaternity blues, 282Medicaid, 8Medical conditionsDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 478psychological factors affecting, 478sexual dysfunctions, 496sleep disorders, 495Medicare, 8Medication. See PsychopharmacologyMedication managementfor antipsychotics, 273tfor schizophrenics, 272Medulla oblongata, 18f, 19, 19fMellow, June, 8Memory, assessment of, 143Memory impairment, and dementia, 448. See also DementiaMental disorderdefined by American Psychiatric Association (APA), 3Mental healthdefined, 2–3factors, 3Mental health promotionin anxiety disorders, 235–236eating disorders, 387in personality disorders, 343in schizophrenia, 274–275substance abuse, 366–367Mental illnesscommunity-based care, 6–7cost containment and, 7–8cultural considerations, 8current state of, 5–8defined, 3factors influencing, 4future objectives, 6, 7bhistorical perspectives, 4–5ancient times, 4community-based care, 5institutions, 4psychopharmacology, 5treatment, 4–5homelessness and, 6, 71Mental retardation, 411–412, 411bDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Meperidine, 31Meprobamate (Miltown, Equanil), 230t, 235tMesoridazine (Serentil), 29Methylphenidate, 36, 37tMexican Americanscultural considerations by, 125t, 127t, 131Mexican drug trade names, 493Midbrain, 18f, 19Mild anxiety, 228Milieu therapy, 66Sullivan’s, 48–50Mind–body interventions, 59Mirtazapine (Remeron), 286, 288t

INDEX521Mixed receptive-expressive language disorder, 412Moderate anxiety, 228Monoamine oxidase inhibitors (MAOI), 286, 287, 288tdrug interactions, 32, 289bfood interactions, 31–32, 32blisting of, 30tmechanism of action, 31overdose of, 289bside effects, 31–32Moodin abuse and violence, 199in ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425defined, 142in delirium, 444in dementia, 452in depression, 290in eating disorders, 382–383in OCD, 243in panic disorder, 237in psychosocial assessment, 141b, 142in schizophrenia, 261in somatoform disorders, 401Mood disordersbipolar disorder, 298–308clinical course, 299nursing process, 303–308psychopharmacology, 301–302psychotherapy, 302, 303categories of, 281–282community-based care, 312–313concept of, 280–281cultural considerations, 284Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 475–476etiology ofbiologic theories, 283psychodynamic theories, 283–284major depressive disorder, 281clinical course, 284electroconvulsive therapy (ECT), 287, 288–289investigational treatment, 290nursing process, 290–298psychopharmacology, 285–287, 286t, 287t, 288tpsychotherapy for, 289symptoms of, 285bmental health promotion, 313related disorders, 282self-awareness issues, 313–314substance-induced, 282suicide. See SuicideMood-stabilizing drugs, 32–34anticonvulsant drugs, 301–302, 302tanticonvulsants as, 32–33client teaching, 34dosage, 33lithium, 32–33, 301toxicity, 301–302, 306tmechanism of action, 33side effects, 33–34Mothers Against Drunk Driving (MADD), 59Motor behaviorin ADHD, 418in antisocial personality disorder, 327, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 444in dementia, 452in depression, 290in eating disorders, 382in OCD, 243in panic disorder, 237in psychiatric disorder related to abuse and violence, 196in psychosocial assessment, 141b, 142in schizophrenia, 261in somatoform disorders, 401in substance abuse, 364Motor skills disorders, 411b, 412Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Mourning, 206MRI. See Magnetic resonance imaging (MRI)Multiaxial systemDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 478Munchausen syndrome, 395Muslim Americansbereavement rituals, 212cultural considerations, 212Myasthenia gravis, 21NNAMI. See National Alliance for the Mentally Ill (NAMI)NANDA-I approved nursing diagnoses for clinical use andtesting, 479–480Narcissistic personality disorderclinical course, 337–338defined, 337interventions, 324t, 338symptoms, 324tNarcolepsy, 494National Alliance for the Mentally Ill (NAMI), 59National Center for Complementary and Alternative Medicine(NCCAM), 59National Center for Education Statistics (NCES), 193National Institute of Mental Health (NIMH), 5Native Americanscultural considerations, 212NCCAM. See National Center for Complementary andAlternative Medicine (NCCAM)NCES. See National Center for EducationStatistics (NCES)Nefazodone, 32Nefazodone (Serzone), 286, 288tNeglect indicators, 190, 190bNervous systemcentral, 18–19

522 INDEXNervous system (cont.)limbic system, 19neurotransmitters, 19–21Neuroanatomic factorsschizophrenia, 255Neurobiologic theoriesabout mental illness causesgenetic, 23–24infection, 24psychoimmunology, 24in aggressive behavior, 168Neurochemical factorsschizophrenia, 255Neurochemical theoriesanxiety disorders, 232, 234of mood disorders, 283Neuroendocrine theories, of mood disorders, 283Neuroleptic malignant syndrome(NMS), 27–28, 260Neuroleptics. See Antipsychotic drugsNeurotransmission, 19–20, 20fabnormal, 20, 20fNeurotransmitters, 19–21acetylcholine, 21, 21tdefined, 19–20dopamine, 20, 21tepinephrine, 20, 21tfunctions of, 19–20, 20fgamma-aminobutyric acid (GABA), 21, 21tglutamate, 21, 21thistamine, 21, 21tnorepinephrine, 20, 21tserotonin, 21, 21tNight eating disorder, 374Nightmare disorder, 494NIMH. See National Institute of MentalHealth (NIMH)NMS. See Neuroleptic malignant syndrome (NMS)Nonbenzodiazepine, 34Nondirective role, in therapeuticcommunication, 111–112Nonmaleficence, 161Nonverbal communicationdefined, 98skills for, 107–109Norepinephrine, 20, 21tNortriptyline (Pamelor), 287tNo-self-harm contracts, 311Nurserole ofin research and education, 24, 24fin therapeutic relationship, 51Nursing diagnosis. See Data analysisNursing Mental Diseases, 8Nursing Therapy, 8Nutritional considerationsin bipolar disorder, 305in delirium, 447in dementia, 456in eating disorders, 385, 386in schizophrenia, 272OObesity, 372Observationin therapeutic communication, 100–101Obsessions, 242Obsessive-compulsive disorder (OCD), 24Obsessive–compulsive disorder(OCD), 227client/family education, 246bdata analysis, 243evaluation, 246intervention, 245–246, 246bnursing process, 243onset and clinical course, 242treatment, 242–243Obsessive-compulsive personality disorder, 340–341clinical course, 340–341defined, 340interventions, 324t, 341symptoms, 324tOccipital lobe, 18, 18f, 19fOCD. See Obsessive-compulsive disorder (OCD); Obsessive–compulsive disorder (OCD)Oculogyric crisis, 27ODD. See Oppositional defiant disorder (ODD)Olanzapine (Zyprexa), 28Older adultspersonality disorders in, 342Olfactory hallucinations, 265Open groups, 58Operant conditioning, 53–54principles of, 53Opioids, abuse of, 356Opisthotonus, 27Oppositional defiant disorder (ODD), 429, 433Orgasmic disorders, 496Orientation, defined, 143Orientation phase, of therapeutic relationship, 50t, 51Orthodox Jewish Americanscultural considerations, 212–213Outcry, 207, 208tOverdosealcohol, 352anxiolytics, 354hallucinogens, 356–357hypnotics, 354inhalants, 357marijuana, 355–356opioids, 356sedatives, 354stimulants, amphetamines and cocaine, 355Oxazepam (Serax), 35t, 230t, 235tOxcarbazepine (Trileptal), 33PPain disorders, 394management of, 396, 397sexual dysfunctions, 496Palilalia, 448

INDEX523Paliperidone (Invega), 25, 26tPanic anxiety, 236Panic attacks, 233Panic disorder, 236–240clinical course, 236–237nursing processassessment, 237–239data analysis for, 239evaluation, 240intervention, 239–240outcome identification, 239symptoms of, 233treatment of, 237Paranoid delusions, 265bParanoid personality disorderclinical course, 324–325defined, 324interventions, 324t, 325symptoms, 324tParaphilias, 496–497Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477Parasomnias, 494Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477Parietal lobe, 18, 18f, 19fParkinson’s disease, 450symptoms of, 27Paroxetine (Paxil), 286tPartial hospitalization programs (PHP), 68, 68bPartner abuse. See also Intimate partner violencedos and don’ts of working with victims of, 185tPassive-aggressive personality disorderclinical course, 342defined, 342interventions, 324t, 342symptoms, 324tPATH. See Projects for Assistance in Transition fromHomelessness (PATH)Pavlov, Ivanclassical conditioning, 53Pedophilia, 497Peplau, Hildegard, 8on anxiety levels, 51–52, 51ton therapeutic relationship, 50–51, 50tPeriod of enlightenment, 4Perls, Frederick, 54t, 55Persecutory delusions, 265bPersonality, components of, 44–45, 45fPersonality disorders, 319–343antisocial, 327–332care plan for, 329–330client and family education, 332bdefined, 327interventions, 324tnursing proccss, 327–332symptoms of, 324tavoidantclinical course, 338–339defined, 338interventions, 324t, 339symptoms, 324tborderline, 332–336client and family education, 336bdefined, 332interventions, 324tnursing process, 332–336symptoms, 324tcategories of, 320cluster A, 324–327cluster B, 320, 327–338cluster C, 320, 338–341community-based care, 343cultural considerations, 322defined, 319dependent, 339–340clinical course, 339defined, 339interventions, 324t, 339–340symptoms, 324tdepressive, 341–342clinical course, 341defined, 341interventions, 324t, 341–342symptoms, 324tDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 478etiology, 321–322histrionic, 337clinical course, 337defined, 337interventions, 324t, 337symptoms, 324tmental health promotion, 343narcissisticclinical course, 337–338defined, 337interventions, 324t, 338symptoms, 324tobsessive–compulsive, 340–341clinical course, 340–341defined, 340interventions, 324t, 341symptoms, 324tin older adults, 342paranoidclinical course, 324–325defined, 324interventions, 324t, 325symptoms, 324tpassive-aggressiveclinical course, 342defined, 342interventions, 324t, 342symptoms, 324tpsychopharmacology, 322–323, 323tpsychotherapy, 323schizoidclinical course, 325–326defined, 325interventions, 324t, 326symptoms, 324t

524 INDEXPersonality disorders (cont.)schizotypalclinical course, 326defined, 326interventions, 324t, 326–327symptoms, 324tself-awareness issues, 343treatment, 322–323Pervasive developmental disorders, 411bAsperger’s disorder, 413autistic disorder, 412–413childhood disintegrative disorder, 413DSM-IV-TR, 471Rett’s disorder, 413PET. See Positron emission tomography (PET)Phillippe Pinel, 4Phobias, 240–242defined, 240onset and clinical course, 241socialsymptoms of, 233symptoms of, 233treatment of, 241–242Phonologic disorder, 412PHPs. See Partial hospitalization programs (PHP)Physical abuse, 182defined, 182in elder, 190, 190bin spouse, 182Physical aggression, 166Piaget, Jeancognitive development stages, 48Pica, 433Pick’s disease, 450Pineal body, 18Play therapy, 417Polydipsia, 267Polysubstance abuse, 349Pons, 18f, 19, 19fPositive reframing, 234Positive regardin therapeutic relationship, 83Positron emission tomography (PET), 22–23, 23fPostcrisis phase, in aggressive behavior, 176Postpartum blues, 282Postpartum psychosis, 282Posttraumatic stress disorder (PTSD), 180, 194–195,233, 246–247acute stress disorder in, 194defined, 194intervention, 196nursing processassessment, 196, 199, 200data analysis, 200evaluation, 201–202intervention, 200–201, 200boutcome identification, 200Statistical Manual of Mental Disorders, 194symptoms of, 195ttreatment, 196Potency, of drug, 24Power issues, in family violence, 181–182Preconscious, in psychoanalytic theory, 44–45Premature ejaculation, 496Pressured speech, 281Primary gain, 236Primary gains, in somatoform disorders, 395Prisoners, mental illness and, 72Problem-focused coping strategies, 403, 404Problem-solvingin therapeutic communication, 113–114Projection, as ego defense mechanism, 46tProjects for Assistance in Transition from Homelessness(PATH), 71Prolixin (decanoate fluphenazine), 26Propranolol, 34Proxemics, 99Pseudoparkinsonism, 257Pseudoparkinsonism, 27Psychiatric nursingareas of practice, 11bhistorical prespectives, 8–9phenomena of concern, 9, 9bself-awareness issues, 12–13standards of care, 8–9, 9b–10bstudent concerns, 11–12, 11fPsychiatric rehabilitation, 60Psychiatric rehabilitationassertive community treatment (ACT), 70–71, 70bclubhouse model for, 70community support for, 69defined, 69goals of, 69bPsychoanalytic theory, 44–47, 45fon anxiety disorders, 234countertransference, 45, 47current practice, 47dream analysis, 45ego defense mechanisms, 45, 46t–47tfree association, 45personality components, 44–45, 45fpsychosexual development stages, 45, 47tsubconscious thoughts, 44–45transference, 45Psychodynamic theories, of mood disorders,283–284Psychoimmunology, 24Psychological abuse, 182in child, 186defined, 182in spouse, 182Psychomotor agitation, 290Psychomotor retardation, 142, 261, 290Psychopharmacology, 24–37antianxiety drugs, 34–35, 35tantidepressant drugs, 29–32, 30tantipsychotic drugs, 25–29, 26tcultural considerations, 37–38development of, 5disulfiram (Antabuse), 36–37mood-stabilizing drugs, 32–34self-awareness issues, 38

INDEX525stimulants, 35–36, 37ttreatment guidelines, 25Psychosexual development, Freud’s stages of,45, 47tPsychosis, 253Psychosocial abusein elder, 190, 190bPsychosocial interventions, nursing, 60Psychosocial nursingin public health and home care, 73–74Psychosocial theories, 43–61in aggressive behavior, 169behavioral theories, 53–54crisis intervention, 55–56cultural considerations, 56developmental theories, 47–48, 48texistential theories, 54–55, 54thumanistic theories, 52–53interpersonal theories, 48–52psychoanalytic theories, 44–45, 45f, 47self-awareness issues, 60–61of somatoform disorders, 395Psychosomatic, defined, 392Psychosurgery, 8Psychotherapybipolar disorder, 302, 303depression, 289group, 57–59groups, 58individual, 56–57personality disorders, 323Psychotropic drugs, 5, 24PTSD. See Posttraumatic stress disorder (PTSD)Puerto Ricanscultural considerations by, 125t, 127t, 131–132QQi-gong, 256RRapeassessment of, 192common myths, 192bdefined, 190dynamics of, 191–192intervention, 192–193treatment, 192–193Rational emotive therapy, 54t, 55Rationalization, as ego defense mechanism, 46tReaction formation, as ego defense mechanism, 46tReactive attachment disorder, 435Reality therapy, 54t, 55Recovery, defined, 211Recovery phase, in aggressive behavior, 176Referential delusions, 265bReframing, 455, 458Regression, as ego defense mechanism, 46tReinforcementnegative, 54in operant conditioning, 54positive, 54Relapseearly signs of, 271bRelationships. See also Therapeutic relationshipintimate, 87social, 86–87therapeutic, 87Relationship violence, warning sign of, 193bReligious delusions, 265bReminiscence therapy, for dementia, 457Reorganization, 211Repressed memories, 196Repression, as ego defense mechanism, 46tResearch, nurse’s role in, 24, 24fResidential treatment settings, 68, 68bResistance, as ego defense mechanism, 46tResistance stage, stress, 227Resolution phase, of therapeutic relationship,50t, 51Response prevention, 242Restraining order, 184Restricted affect, 142Rett’s disorder, 413Revolving door effect, 5Richards, Linda, 8Risperidone (Risperdal), 25, 26tRogers, Carlclient-centered therapy, 52–53Roles and relationshipsin ADHD, 419in antisocial personality disorder, 328in bipolar disorder, 303–304in borderline personality disorder, 334in conduct disorders, 425in delirium, 445in dementia, 453in depression, 294in eating disorders, 383in OCD, 243in panic disorder, 239in psychiatric disorder related to abuse and violence,199–200in psychosocial assessment, 141b, 145in schizophrenia, 266in somatoform disorders, 402in substance abuse, 364Rumination disorder, 433Russianscultural considerations by, 125t, 127t, 132SSAD. See Seasonal affective disorder (SAD)Sangue dormido (sleeping blood), 396tSchizoaffective disorder, 253Schizoid personality disorderclinical course, 325–326defined, 325interventions, 324t, 326symptoms, 324t

526 INDEXSchizophrenia, 5career plan for, 263–264client / family education, 271t, 273tclinical course, 253–254community-based care, 274cultural considerations, 256Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 252, 475elder considerations, 274etiology, 254–256mental health promotion, 274–275negative or soft symptoms, 252nursing processassessment, 260–266data analysis, 267evaluation, 273–274intervention, 268–273, 268toutcome identification, 267–268positive or hard symptoms, 252psychopharmacology, 256drug listing, 257tmaintenance therapy, 256–257side effects, 257, 258t, 259–260psychosocial treatment, 260related disorders, 254treatment, 256–260types of, 252–253unusual speech patterns of clients with, 262bSchizophreniform disorder, 254Schizotypal personality disorderclinical course, 326defined, 326interventions, 324t, 326–327symptoms, 324tSeasonal affective disorder (SAD), 282Secondary gains, 236in somatoform disorders, 395Sedatives, abuse of, 354–355Seizures, 260Selective mutism, 435Selective serotonin reuptake inhibitors (SSRI), 235drug interactions, 32listing of, 30t, 286tmechanism of action, 31, 285side effects, 31Self, therapeutic use of, 84–85Self-actualization, 52Self-awarenessof attitudes, 84of beliefs, 84cultural considerations, 84, 84bdefined, 12in therapeutic relationship, 83–86of values, 83–84Self-awareness issuesassessment, 150child and adolescent disorders, 435with eating disorders, 387–388ethics, 163mood disorders, 313–314personality disorders, 343with personality disorders, 343in psychiatric nursing, 12–13with psychopharmacology, 38psychosocial theories and, 60–61somatoform disorders, 404with substance abuse, 367–368suicide, 314with therapeutic communication, 115–116therapeutic relationship and, 94–95treatment settings, 74Self carein ADHD, 419in antisocial personality disorder, 328in bipolar disorder, 304in borderline personality disorder, 334in conduct disorders, 425in delirium, 445in dementia, 453in depression, 294in eating disorders, 383in OCD, 243in panic disorder, 239in psychiatric disorder related to abuse and violence,199–200in psychosocial assessment, 141b, 145in schizophrenia, 266–267, 272for schizophrenics, 272in somatoform disorders, 402Self-conceptin ADHD, 418–419in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333–334in conduct disorders, 425in delirium, 445in dementia, 453in depression, 293–294in eating disorders, 383in OCD, 243in panic disorder, 238–239in psychiatric disorder related to abuse and violence, 199in psychosocial assessment, 141b, 144–145in schizophrenia, 266in somatoform disorders, 402in substance abuse, 364Self-help groups, 59Sensoriumin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425in delirium, 445in dementia, 452–453in depression, 293in eating disorders, 383in OCD, 243in panic disorder, 238in psychiatric disorder related to abuse andviolence, 199in psychosocial assessment, 141b, 143–144

INDEX527in schizophrenia, 265–266in somatoform disorders, 402in substance abuse, 364Sensory-perceptual alterations, in psychosocial assessment, 144Separation anxiety disorder, 232, 434–435Serotonin, 21, 21tSerotonin syndrome, 32, 289bSertraline (Zoloft), 286tSevere anxiety, 228Sexual abuse, in child, 186Sexual arousal disorders, 496Sexual-arousal touch, 100Sexual aversion disorder, 496Sexual desire disorders, 496Sexual disordersDiagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476–477paraphilias, 496–497sexual dysfunctions, 496Sexual dysfunctionsarousal disorders, 496desire disorders, 496Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476–477orgasmic disorders, 496pain disorders, 496related to medical conditions, 496substance-induced, 496Sexual masochism, 497Sexual pain disorders, 496Sexual sadism, 497Shared psychotic disorder, 254Shenjing shuariuo, 396, 396tSide effectsantianxiety drugs, 34–35anticholinergic drugs, 28antidepressant drugs, 31–32antipsychotic drugs, 26–29, 258tanticholinergic, 28client and family education, 273textrapyramidal symptoms (EPS), 26–27, 257, 258, 258tneuroleptic malignant syndrome (NMS), 27–28, 260seizures, 258t, 260tardive dyskinesia (TD), 28, 258t, 259weight gain, 28, 258tbenzodiazepines, 34–35Canadian drugs used in, 488cyclic antidepressants, 31lithium, 33–34monoamine oxidase inhibitors (MAOI), 31–32mood-stabilizing drugs, 33–34selective serotonin reuptake inhibitors (SSRI), 31stimulants, 36Silence, in communication, 109Single photon emission computed tomography (SPECT), 22–23Skinner, B. F.operant conditioning, 53–54Sleep apnea, 494Sleep attacks, 494Sleep disorders, 494–495breathing-related, 494circadian rhythm, 494Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 477dyssomnias, 494hyperinsomnia, 494insomnia, 494narcolepsy, 494nightmare disorder, 494parasomnias, 494related to medical condition, 495sleep hygiene measures, 495sleep terror disorder, 494sleepwalking disorder, 494–495substance-induced, 495Sleep hygiene measures, 495Sleep terror disorder, 494Sleepwalking disorder, 494–495SNAP-IV teacher and parent rating scale, for child andadolescent disorders, 430–432bSocial class, in client response to illness, 128–129Social phobia, 233Social-polite touch, 100Social relationship, 86–87Social Security Disability Income (SSDI), 5Social skillsfor schizophrenics, 272Socioeconomic status, in client response to illness, 128–129Sodomy, 183Somatic delusions, 265bSomatization, defined, 393Somatization disorder, 393Somatoform disorders, 392–405biologic theories of, 396body dysmorphic disorder, 394care plan for, 397–400client and family education, 402–403, 403bclinical course of, 394community-based care for, 404conversion disorder, 393, 394coping strategies for, 403, 404cultural considerations, 396Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 476DSM-IV-TR diagnostic criteria, 393etiology of, 395–396factitious disorder, 395hypochondriasis, 394, 397–400malingering, 394mental health promotion, 404Munchausen syndrome, 395nursing processassessment, 401–402, 401bdata analysis, 402evaluation, 404intervention, 397–400, 402–404, 402boutcome identification, 402pain disorder, 394psychosocial theories of, 395self-awareness issues, 404somatization disorder, 393treatment of, 396–397, 397t

528 INDEXSouth Asianscultural considerations by, 125t, 127t, 132Specific phobia, 233SPECT. See Single photon emission computed tomography(SPECT)Spiritual considerationsin therapeutic communication, 110Spouse abuse. See Intimate partner violenceSSDI. See Social Security Disability Income (SSDI)SSI. See Supplemental Security Income (SSI)SSRI. See Selective serotonin reuptake inhibitor (SSRI); Selectiveserotonin reuptake inhibitors (SSRI)St. John’s wort, 38Stalking, 185Stereotypic movement disorder, 435Stimulants, 35–36abuse of, 355client teaching, 36dosage, 36, 37tmechanism of action, 36side effects, 36Stress, 227–232alarm reaction stage, 227exhaustion stage, 227in mental illness, 24related illness, 231resistance stage, 227Student concerns, related to psychiatric nursing, 11–12, 11fSubconscious thoughts, in psychoanalytic theory, 44–45Sublimation, as ego defense mechanism, 46tSubstance abuse, 348–368alcohol, 352–353Canadian drugs in, 488cannabis, 355–356care plan for, 361b–362bclinical course, 350community-based care, 366cultural considerations, 351–352defined, 349–350Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 349, 352b, 472–475dual diagnosis, 360–362etiology, 350–351hallucinogens, 356–357in health professionals, 367inhalants, 357mental health promotion, 366–367nursing process, 363–366assessment, 363–364client and family education, 365bdata analysis, 364evaluation, 366intervention, 365–366, 365boutcome identification, 364in older adults, 366opioids, 356psychopharmacology, 359–360, 360trelated disorders, 350sedatives, hypnotics, and anxiolytics, 354–355self-awareness issues, 367–368stimulants amphetamines and cocaine, 355treatment, 357–361treatment programs, 358–359, 359btypes of, 349–350Substance dependence, 349Substance-induced anxiety disorder, 232Substance-induced mood disorder, 282Substance-induced sexual dysfunction, 496Substance-induced sleep disorders, 495Substitution, as ego defense mechanism, 47tSuicidal ideation, 308, 310bSuicide, 308–312assisted, 312attempted, 308defined, 308family response, 311–312incidence, 308myths and facts about, 309bnurse’s response, 312self-awareness issues, 314Suicide precautions, 294, 311Suicide riskantidepressant drugs and, 31, 313bassessment of, 308, 310–311in elders, 312interventions, 311mental health promotion, 313outcome identification, 311support system for, 311Sullivan, Harry Stacklife stages, 48–50, 49tmilieu therapy, 48–50Superego, 44, 45fSupplemental Security Income (SSI), 5Support groups, 59Supportive touch, for dementia, 457Support systemfor suicide risk, 311Suppression, as ego defense mechanism, 47tSurvivors, 181Sympathyin therapeutic relationship, 82, 82fSynapse, 19Systematic desensitization, 54, 241TTactile hallucinations, 265Talk therapy, 66Tangential thinking, 143Tardive dyskinesia (TD), 28, 259TD. See Tardive dyskinesia (TD)Teacher, nurses as, 93Temazepam (Restoril), 34, 35tTemporal lobe, 18, 18f, 19fTetracyclic antidepressants, 286Thalamus, 19Therapeutic communication, 98–116active listening in, 100–101clarification, 113community-based care, 115context in, 110

INDEX529cultural considerations, 110–111defined, 99directive role, 112distance zones in, 99empowerment in, 113–114goals of, 111–112interpreting cues, 107meaning and, 109–110nondirective role, 111–112nonverbal communication skills, 107–109observation in, 100–101privacy in, 99–100problem-solving in, 113–114questions, 112–113self-awareness issues, 115–116spiritual considerations, 110techniques for, 101, 102t–104t, 105techniques to avoid, 105, 105t–106ttouch in, 100verbal communication skills, 101–107Therapeutic community, 49–50Therapeutic nurse– patient relationship, 50–51, 51tTherapeutic play, 417Therapeutic relationship, 80–95anxiety levels in, 51–52, 51tbehaviors to avoid, 91–93avoidance, 93client dependency, 92inappropriate boundaries, 91–92nonacceptance, 93sympathy, 92components of, 81–86acceptance, 83empathy, 82, 82fgenuine interest, 81–82positive regard, 83self-awareness, 83–86trust, 81, 81bconfidentiality in, 90duty to warn in, 90nurse–client contracts, 89–90nurse’s role in, 51, 93–94patterns of knowing in, 85–86phases of, 50t, 51orientation, 87–90, 88ttermination, 88t, 91working, 88t, 90–91self-awareness issues, 94–95self-disclosure in, 90therapeutic use of self, 84–85transference in, 91warnings signs of abuse, 93bThioridazine (Mellaril), 29Thought blocking, 143Thought blocking, defined, 262Thought broadcasting, defined, 262Thought contentin abuse and violence, 199in ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425defined, 142in delirium, 444in dementia, 452in depression, 290, 293in eating disorders, 383in OCD, 243in panic disorder, 237, 238in psychosocial assessment, 141b, 142–143in schizophrenia, 261, 262in somatoform disorders, 401, 402in substance abuse, 364Thought insertion, 143, 262Thought processin ADHD, 418in antisocial personality disorder, 328in bipolar disorder, 303in borderline personality disorder, 333in conduct disorders, 425defined, 142in delirium, 444in dementia, 452in depression, 290, 293in eating disorders, 383in OCD, 243in panic disorder, 237, 238in psychiatric disorders related to abuse and violence, 199in psychosocial assessment, 141b, 142–143in schizophrenia, 261, 262in somatoform disorders, 401, 402in substance abuse, 364Thought withdrawal, 143Thought withdrawal, defined, 262Tic disorders, 411b, 434Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR), 471Time away, 458TMS. See Transcranial magnetic stimulation (TMS)Tolerance, drug, 350Tolerance break, 350Topiramate (Topamax), 33, 302, 302tTorticollis, 27Touchin therapeutic communication, 100types of, 100Tourette’s disorder, 434Transcranial magnetic stimulation (TMS), 290Transference, 45Transitional discharge model, 69Transvestic fetishism, 497Trazodone, 32Treatment Advocacy Center, 6Treatment modalitiescommunity-based care, 56complementary and alternative medicine (CAM),59–60groups, 57–59defined, 57development stages, 57leadership, 57–58

530 INDEXTreatment modalities (cont.)roles in, 58therapy in, 58–59individual psychotherapy, 56–57psychiatric rehabilitation, 60Treatment settings, 66–69hospitalization, 66–67partial hospitalization, 68, 68bresidential, 68–69, 68bself-awareness issues, 74transitional care, 69Triazolam (Halcion), 34, 35tTriazolam (Halcion), 34, 35tTricyclic antidepressants, 285, 286, 287tTriggering phase, 167Trustin therapeutic relationship, 81trusting behaviors, 81bUUnconscious, in psychoanalytic theory, 45Undoing, as ego defense mechanism, 47tU.S. Food and Drug Administration (FDA), 24–250Utilitarianism, 161Utilization review firms, 7VVaginismus, 496Valerian, 38Valproatein aggressive behavior, 169Valproic acid (Depakote), 32–33, 302, 302tValues clarification exercise, 85bValues clarification process, 83–84, 83fVascular dementia, 450Venlafaxine desvenlafaxin, 32Venlafaxine (Effexor), 286, 288tVeracity, 161Verbal communicationdefined, 98skills for, 101–107Vietnamesecultural considerations, 125t, 127t, 132, 212Violenceclinical picture of, 181community, 193–194cycle of, 184familycharecteristics of, 181–182, 181bcultural considerations of, 182elder. See Elder abusespouse. See Intimate partner violenceintimate partner, 183–185Visual hallucinations, 265Vocal cues, in communication, 109Voyeurism, 497WWarning indicators from caregiver, 190, 190bWaxy flexibility, 142, 252Weight gain, due to antipsychotics, 28, 258tWithdrawalalcohol, 352–353anxiolytics, 355hallucinogens, 357hypnotics, 355inhalants, 357marijuana, 356opioids, 356sedatives, 355stimulants, amphetamines and cocaine, 355Withdrawal syndrome, 349Word salad, 143, 261World Health Organizationhealth defined by, 2–3YYale-Brown obsessive–compulsive scale, 244b–245bZZar, 256Ziprasidone (Geodon), 26t, 27

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