Exam 3 Trauma, Stressor-Related, Dissociative, and Psychiatric Disorders Review

Trauma- and Stressor-Related Disorders

  • Traumatic Event Exposure Timeline and Trajectory:

    • 3 Days3\,\text{Days} to 1 Month1\,\text{Month} post-exposure: Acute Stress Disorder (ASD).
    • >1 Month> 1\,\text{Month} duration post-exposure: Posttraumatic Stress Disorder (PTSD).

  • Acute Stress Disorder (ASD):

    • Duration: Symptoms persist for 3 days3\,\text{days} to 1 month1\,\text{month} following exposure to a traumatic event.
    • Clinical Presentation: Alterations in concentration, anger, dissociative amnesia, headache, irritability, and nightmares.
    • Primary Treatment: Psychotherapy.

  • Posttraumatic Stress Disorder (PTSD):

    • Diagnostic Criterion: Diagnosed when traumatic stress symptoms persist for more than 1 month1\,\text{month}.
    • Precipitating Trauma Criteria: Trauma must involve violent or accidental events accompanied by a threat of perceived death, or involve repeated/extreme trauma exposure.
    • Risk Factors: Severe trauma exposure, Adverse Childhood Experiences (ACEs), lack of social support, previous psychiatric history, and ongoing stress.
    • Core Nursing Interventions: Promoting safety, teaching relaxation techniques, and encouraging expression of feelings.

  • Four Primary DSM-5 Symptom Clusters of PTSD:

    1. Re-experiencing / Intrusion: Uninvited memories, nightmares, and flashbacks (reliving trauma with vivid sensory details).
    2. Avoidance: Active avoidance of external triggers (places, people) and internal thoughts.
    3. Hyperarousal / Reactivity: High alert, irritability, exaggerated startle response, poor concentration, and insomnia.
    4. Negative Alterations in Cognition/Mood: Persistent negative beliefs, anhedonia (inability to feel pleasure), and emotional numbing.

  • Adult PTSD Presentation:

    • Definition: Persistent re-experiencing of a highly traumatic event involving actual or threatened death, serious injury, or threat to physical integrity of self or others.
    • Patient Response: Characterized by intense fear, helplessness, or horror during or after the event.
    • Precipitating Trauma Examples:
      • Direct Trauma: Military combat, hostage/POW experiences, crime-related events (assault, rape, mugging, bombing), natural disasters (floods, earthquakes, tornadoes), and human disasters (car, plane, or train accidents).
      • Indirect Exposure: Hearing about traumatic events happening to a loved one (e.g., diagnosis of a terminal illness).
      • Occupational/Repeated Trauma: First responders experiencing repeated or extreme exposure to traumatic events.

  • Adverse Childhood Experiences (ACEs):

    • Clinical Significance: An increased number of ACEs directly correlates with an increased risk for developing severe medical and psychiatric conditions in adulthood.

  • Common Secondary Nursing Diagnoses for PTSD:

    • Anxiety (ranging from moderate to panic level)
    • Impaired Coping
    • Social Isolation
    • Insomnia / Sleep Deprivation
    • Hopelessness
    • Chronic Low Self-Esteem
    • Self-Care Deficit

  • Outcomes Identification (Planning Goals):

    • Manage Anxiety: Patient will demonstrate effective strategies to reduce anxiety to a manageable level.
    • Increase Self-Esteem: Patient will express positive self-statements and acknowledge personal strengths.
    • Improve Ability to Cope: Patient will utilize healthy coping mechanisms to manage intrusive thoughts and traumatic triggers.

  • Treatment Modalities & Pharmacotherapy for PTSD:

    • First-Line FDA-Approved Medications: Sertraline (Zoloft) and Paroxetine (Paxil) (SSRIs).
    • Alpha-2 Adrenergic Agonists: Clonidine (Catapres) is indicated for hyperarousal, nightmares, severe sleep disturbances, and intrusive symptoms. Blood pressure (BP) must be checked prior to administration because it lowers blood pressure.
    • Psychotherapy Modalities:
      • Eye Movement Desensitization and Reprocessing (EMDR): Combines trauma processing with bilateral sensory stimulation (eye movements, taps) to integrate dysfunctional memories. The patient holds radlers in their hands during treatment.
      • Cognitive Processing Therapy (CPT): Targets and reframes unhelpful trauma-related beliefs ("stuck points").
      • Prolonged Exposure (PE): Systematic, repeated exposure (imaginal and in vivo) to avoided triggers to promote habituation.

  • Evaluation Criteria for PTSD Treatment Effectiveness:

    • Patient recognizes symptoms related to trauma.
    • Patient is able to use new strategies to cope with anxiety.
    • Patient experiences no flashbacks or intrusive thoughts about the event.
    • Patient can sleep adequately without nightmares.
    • Patient can assume usual roles and maintain satisfying interpersonal relationships.

  • PTSD in Children:

    • Symptom Variations: Nightmares are more common. Cognition and mood alterations occur. Somatic symptoms (headache, stomachache) are MORE COMMON than in adults. Dramatic mood swings (rage, numbing, etc.) are frequent.
    • Contributing Factors: External factors, parent modeling, cultural expectations, and ACEs.
    • Nursing Priority: Establish trust and safety through therapeutic relationships.
    • Pediatric Pharmacotherapy: SSRIs.
    • Pediatric Psychotherapy: EMDR, CBT, and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).
      • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Integrates trauma-sensitive cognitive behavioral interventions with stress management. While widely used in pediatric populations, it is also effective for adults.
    • Pediatric Evaluation Criteria:
      • The child's safety is maintained.
      • Anxiety has been reduced and stress is handled in a healthy way.
      • Emotions and behavior are appropriate.
      • The child achieves normal developmental milestones for age.
      • The child can seek out adults for nurturing and help when needed.

Adjustment Disorders and Attachment Disorders

  • Adjustment Disorder:

    • Trigger: Triggered by common non-life-threatening stressors (e.g., divorce, job loss, chronic illness) rather than traumatic events.
    • Timeline: Symptoms occur within 3 months3\,\text{months} of the stressor (must be diagnosed immediately).
    • Complicated Grieving Subtype: A specialized subtype of adjustment disorder occurring in the 12 months12\,\text{months} post-loss, marked by intense yearning, preoccupation, and severe sorrow.

  • Attachment Disorders:

    • Definition: Psychiatric conditions in children caused by grossly inadequate nurturing/bonding environments prior to 8 months8\,\text{months} of age.
    • Assessments: Complete medical evaluation to rule out physical causes, followed by a comprehensive psychiatric assessment.
    • Interventions: Therapy must involve both the child and caregiver (individual and family therapy).
    • Core Goal: Strengthen the caregiver-child relationship and ensure a safe, stable environment.

Dissociative Disorders and Trauma-Informed Care

  • Dissociative Disorders Overview:

    • Etiology: Unconscious response to adverse trauma characterized by a severe interruption of consciousness.
    • Risk Factors: Childhood sexual, physical, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms.

  • Depersonalization / Derealization Disorder:

    • Core Feature: Recurrent feelings of detachment.
    • Depersonalization: Feeling like an outside observer of one's own body or self.
    • Derealization: Feeling as if external surroundings are dreamlike, unreal, or distant.

  • Dissociative Amnesia:

    • Core Feature: Inability to recall personal information after trauma.
    • Dissociative Fugue Subtype: Sudden, unexpected travel away from home accompanied by an inability to recall one's identity; the patient may assume a new identity entirely.

  • Dissociative Identity Disorder (DID):

    • Definition: Presence of 22 or more distinct personality states (alters) that recurrently control behavior. Rare condition strongly associated with severe sexual, physical, or psychological trauma in childhood.
    • Host: The primary personality state; not initially aware of alters, but may eventually become aware.
    • Alternate Personality / Alter: Has its own distinct pattern, personality, and memory.
    • Switching / Transitioning: Occurs during times of stress; may be dramatic or barely noticeable.
    • Identity Recovery: After a few weeks to a few months, patients may remember their former identities.
    • Assessment: Personal life events, history of trauma/head injury/epilepsy, memory and orientation assessment, and suicide/self-harm risk.
    • Treatment Modalities:
      • Psychoeducation: Education about the diagnosis, coping skills, and stress management (grounding, relaxation).
      • Psychotherapy: Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR).
    • Nursing Priority: Establish safety, build trust, manage anxiety through grounding techniques, and support long-term integration of personalities.

  • Trauma-Informed Care Framework (The 4 R's):

    • Definition: A framework that emphasizes recognizing and responding to the effects of all types of trauma.
    • 1. Realize: Realize the widespread impact of trauma.
    • 2. Recognize: Recognize signs and symptoms in clients, families, and staff.
    • 3. Respond: Respond by fully integrating trauma knowledge into practice, procedures, and policies.
    • 4. Resist: Resist re-traumatizing individuals (client, family, and all involved).

Somatic Symptom Disorders and Related Conditions

  • Somatic Symptom Disorder:

    • Definition: Multiple distressing physical symptoms (e.g., pain, fatigue, GI issues) accompanied by high functional impairment and excessive health anxiety.
    • Key Feature: Symptoms are involuntary.
    • Nursing Strategies: Building a supportive therapeutic relationship, assessing stressors, and educating patients about symptom management.

  • Illness Anxiety Disorder:

    • Definition: Preoccupation and fear of having a serious illness despite having mild or absent physical symptoms.
    • Diagnostic Duration: Symptoms must persist for at least 6 months6\,\text{months}.
    • Essential Nursing Strategies: Establishing a therapeutic relationship, setting limits on illness-related discussions, and encouraging social engagement.
    • Treatment: Cognitive Behavioral Therapy (CBT), SSRIs, and supportive reassurance.

  • Conversion Disorder (Functional Neurological Symptom Disorder):

    • Definition: Neurological deficits (paralysis, blindness, seizures, gait disturbances) without an underlying physiological or organic cause.
    • Etiology: Symptoms are involuntary and are often preceded by emotional stress.
    • La Belle Indifférence: A classic feature where the patient displays a striking lack of emotional concern regarding the severity of their physical deficit.
    • General Nursing Care: Build trust in the therapeutic relationship first; avoid direct confrontation about physical symptoms; promote adaptive coping strategies.
    • Advanced Practice & Specialized Modalities:
      • Body-Oriented Therapy: Focuses on the mind-body connection.
      • Hypnosis: Accesses underlying conflicts and modifies symptom perception.
      • Dialectical Behavior Therapy (DBT): Targets emotion regulation and distress tolerance.
    • Nursing Strategies: Assess for current stressors, promote resilient coping, and apply CBT concepts to reframe stressors.

  • Factitious Disorder:

    • Definition: Intentional fabrication or induction of physical or psychiatric symptoms to assume the sick role and satisfy emotional needs/attention (symptoms are voluntary).
    • Nursing Care: Ensuring patient safety, monitoring for self-inflicted harm, and collaborating with a multidisciplinary team to provide supportive therapy.

  • Factitious Disorder Imposed on Another:

    • Definition: Caregiver fabricates or induces illness in a dependent.
    • Legal Consideration: Considered a severe form of abuse requiring mandatory Child Protective Services (CPS) reporting.

  • Malingering:

    • Definition: Conscious, voluntary fabrication of illness driven by external secondary gains (e.g., financial compensation, avoiding military service or prison, obtaining disability or opioids).
    • Classification: Not categorized as a psychiatric disorder.
    • Comorbidities: Frequently associated with antisocial, narcissistic, and borderline personality disorders.

  • Key Nursing Interventions for Somatic Disorders:

    • Acknowledge Distress: Validate the patient's physical distress without reinforcing or debating false medical beliefs.
    • Avoid Direct Confrontation: Never challenge the reality of the symptoms or directly confront factitious symptoms aggressively, as this causes treatment refusal or "doctor shopping".
    • Set Boundaries & Redirect: Allow a limited, pre-determined amount of time during sessions to discuss physical complaints, then redirect the conversation to emotional coping, stressors, and daily functional activities.
    • Minimize Secondary Gains: Educate families to avoid over-accommodating behaviors that reinforce helplessness; avoid unnecessary diagnostic testing.

Older Adult Mental Health and Pain Management Guidelines

  • Older Adult Mental Health & Care Considerations:

    • Aging & Function: Chronological age alone does not define function; however, aging involves limited regenerative abilities, higher susceptibility to disease, role changes, loss, and diminished senses.
    • Depression vs. Confusion: Depression is common after cardiac events and strokes. It is frequently confused with dementia or delirium.
    • Suicide Risk: Older adults face an increased suicide risk with age. For every completed suicide, there are 3 to 43\text{ to }4 attempts in this population. Passive suicidal ideation (e.g., refusing food or life-sustaining medications) is common.
    • Anxiety Management: Fear of falling is a major driver of anxiety. First-line treatments include SSRIs and Cognitive Behavioral Therapy (CBT). Benzodiazepines must be used with extreme caution due to fall and confusion risks.
    • Caregiver Support & Abuse Prevention: Single caregivers face higher risks for caregiver burden and burnout, increasing the risk of elder abuse.
      • Respite Care: Planned, short-term admissions to a nursing facility or in-home care allowing primary caregivers a break.
      • Adult Day Care Programs: Daytime health screening, social activities, and meals that allow older adults to maintain community ties while giving families daytime relief.

  • Pharmacological Pain Management Guidelines in Older Adults:

    • Assessment Tools: Scales like FACES and PAINAD are specifically helpful for patients with cognitive impairment.
    • Dosing Principle: Start analgesics at one-fourth to one-half (14 to 12\frac{1}{4}\text{ to }\frac{1}{2}) the standard adult dose and titrate upward slowly due to altered pharmacokinetics and longer duration of action.
    • Around-the-Clock (ATC) Administration: Administer oral analgesics ATC when starting pain management, converting to as-needed (PRN) later based on pain status.
    • Acute Confusion Assessment: Postoperative confusion is more frequently caused by unrelieved pain rather than opiate use. Assess for contributing factors before discontinuing pain medications.
    • Acetaminophen vs. NSAIDs: Acetaminophen is effective for pain (non-inflammatory), avoiding the GI bleeding, stroke, and myocardial infarction risks associated with NSAIDs. Long-term use carries a risk of end-stage renal disease.
    • Opioid Risks: Avoid opioids for non-cancer-related chronic pain due to risks of fractures, hospitalization, and mortality. Always monitor for constipation daily.

Neurocognitive Disorders: Dementia and Alzheimer's Disease

  • Dementia Overview:

    • Definition: A broad term used to describe progressive deterioration of cognitive functioning and global impairment of intellect.
    • Differential Assessment: Important to rule out depression or medical causes. Never assume cognitive decline is a normal part of aging.
    • Typical Age-Related Changes vs. Signs of Dementia:
      1. Sometimes forgetting names or appointments (Typical age-related change vs. Dementia).
      2. Developing a specific way of doing something and becoming irritable when routine is disrupted (Typical age-related change vs. Dementia).
      3. Trouble understanding visual images (Sign of Dementia).
      4. Decreased or poor judgment (Sign of Dementia).

  • Alzheimer's Disease Key Risk Factors & Etiology:

    • Risk Factors: Genetics, cardiovascular disease, head injury, Traumatic Brain Injury (TBI), unhealthy diet, and lack of social engagement; most individuals are ≥65 years of age\ge 65\,\text{years of age} (late onset).
    • Pathophysiology: Deficiency of acetylcholine; what little neurotransmitter remains is rapidly destroyed by the enzyme acetylcholinesterase.

  • Stages of Alzheimer's Disease:

    • Early (Mild): Difficulty with recent memory, impaired learning, apathy, and depression.
    • Middle (Moderate): Visual/spatial and language deficits, psychotic features, agitation, and wandering.
    • Late (Severe): Gait disturbance, poor judgment, disorientation, confusion, incontinence, difficulty speaking, swallowing, and walking.

  • Key Terminology in Neurocognitive Disorders:

    • Confabulation: Creating false stories/answers to replace lost memories to protect self-esteem (an unconscious defense mechanism, not intentional lying).
    • Perseveration: Persistent repetition of a word, phrase, or gesture.
    • Aphasia: Loss of language ability.
    • Apraxia: Loss of purposeful, learned motor movements.
    • Agnosia: Inability to recognize familiar objects or sensory stimuli.
    • Sundowning: Deterioration of mood and increased agitation in the late afternoon/evening.

  • Pharmacotherapy for Alzheimer's Disease:

    • Cholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine): Inhibit acetylcholinesterase to increase available acetylcholine. Used for mild to moderate stages (Donepezil is also approved for severe stage). Side effects include nausea, vomiting, diarrhea, bradycardia, and syncope.
    • NMDA Receptor Antagonist (Memantine / Namenda): Regulates glutamate activity to prevent neurotoxicity; used in moderate-to-severe stages.
    • Antipsychotic Black Box Warning: Off-label antipsychotics carry a Black Box Warning for increased mortality in older adults with dementia; use non-pharmacological interventions first and apply "start low, go slow".

  • Mild vs. Major Neurocognitive Disorders:

    • Mild Neurocognitive Disorders:
      • Cognitive Decline: Noticeable, manageable decline in 1+1+ domains (attention, executive function, memory, language, motor, or social cognition).
      • Identification & Confirmation: Reported by patient, informant, or clinician; verified via standardized neuropsychological testing or reliable clinical evaluation.
      • Independence: Daily independence remains intact (e.g., managing finances/medications).
      • Compensatory Effort: May require extra effort, strategies, or minor assistance for complex tasks.
    • Major Neurocognitive Disorders:
      • Cognitive Decline: Significant decline in 1+1+ domains (attention, executive function, memory, language, motor, or social cognition).
      • Identification & Confirmation: Reported by patient, informant, or clinician; verified via standardized neuropsychological testing or reliable clinical evaluation.
      • Loss of Independence: Cognitive deficits hinder independent daily living, requiring assistance with complex tasks (e.g., managing finances, medications).

Pediatric and Adolescent Psychiatric Conditions

  • Assessment & Resilience in Pediatrics:

    • Resilience: Inborn strengths enabling a child to handle stress. Features include adaptability, social intelligence, problem-solving skills, and the ability to distance oneself from parental emotional chaos. Represents the relationship between inborn strength and success in handling stressful situations.
    • Assessment Sources: Mental Status Exam (MSE), interviewing, observing, and interacting with the child.
    • Denver II Developmental Screening: Assesses Personal-Social, Fine Motor-Adaptive, Language, and Gross Motor skills.

  • Therapeutic Modalities in Pediatrics:

    • Play Therapy: Essential for young children to express emotions and process conflicts.
    • Bibliotherapy: Using age-appropriate books and stories to help children relate to characters and process traumatic feelings safely.
    • Expressive Art Therapy: Nonverbal means of expressing difficult emotions.
    • Journaling: Expressing feelings, setting, and evaluating goals.
    • Music Therapy: Used to improve physical, psychological, cognitive, behavioral, and social functioning.
    • Family Therapy: Helps the family develop goals, provides education, and gains insight.

  • Pediatric Safety & Behavioral Interventions:

    • Safety Principle: Teamwork equals safety.
    • Hierarchy: Use least restrictive interventions first; verbal de-escalation; offering medications to help regain control.
    • Time Out / Quiet Room: Time out duration is NOT based on time.

  • Autism Spectrum Disorder (ASD):

    • Definition: Neurodevelopmental impairment marked by deficits in social communication/interaction alongside restricted, repetitive patterns of behavior, interests, or activities.
    • Onset: Typically appears during the first 3 years3\,\text{years} of life.
    • Medications for Agitation/Aggression: Risperidone and Aripiprazole (Second-Generation Antipsychotics).

  • Attention-Deficit/Hyperactivity Disorder (ADHD):

    • Definition: Inappropriate degrees of inattention, impulsivity, and hyperactivity present in at least 22 settings (e.g., home and school).
    • Subtypes: Combined (inattentive and hyperactive), Inattentive (inattentive and distractible), Hyperactive-Impulsive (hyperactive and impulsive).
    • Clinical Presentation: Low frustration tolerance, temper outbursts, labile mood, poor school performance, peer rejection, low self-esteem, inability to finish tasks.
    • CNS Stimulants:
      • Therapeutic Effect: Responses are often dramatic—increases attention and task-directed behavior while reducing impulsivity, distractibility, and restlessness. Highly addictive.
      • Medication Examples: Focalin (Dextroamphetamine), Ritalin (Methylphenidate), Adderall (mixed salts), Vyvanse (Lisdexamfetamine dimesylate).
      • Administration: Give in the morning!
      • Side Effects: Insomnia, appetite suppression, weight loss, headache, elevated HR, elevated BP.
    • Non-Stimulants:
      • Indications: Preferable for individuals with anxiety, active abuse disorders, or tic disorders.
      • Medication Examples: Atomoxetine, Clonidine, Guanfacine.
      • Side Effects: GI upset, reduced appetite, weight loss, urinary retention, dizziness, fatigue, insomnia, increased BP, increased HR, potential liver damage.
      • Boxed Warning: Caution with depression—associated with increased suicidal ideation.
    • Therapeutic Engagement & Evaluation: Family is actively engaged in therapy. Evaluation assesses symptoms/severity, school performance, medication administration, safety, and family understanding.

  • Tourette's Disorder & Tic Disorders:

    • Tourette's Disorder: Multiple motor tics AND at least one vocal tic present for more than 1 year1\,\text{year} (chronic condition).
    • Tic Disorders Overview: Sudden, nonrhythmic, rapid motor movements or vocalizations (can change over time). Occur before age 1818 with onset between ages 4 to 64\text{ to }6. Symptoms peak in early adolescence and diminish into adulthood. Creates risk for low self-esteem, self-consciousness, and peer rejection.
    • Comorbidities: Coexists with depression, obsessive-compulsive disorder (OCD), and ADHD. Note: CNS stimulants can worsen tics (Guanfacine can be used).
    • Behavioral Therapy: Comprehensive Behavioral Intervention for Tics (CBIT) uses habit reversal training to perform an incompatible muscular response when the tic urge builds.
    • Deep Brain Stimulation (DBS): Applied when conservative treatment fails. Fine wires threaded to affected brain areas deliver electrical impulses; turned on to control tics, turned off while sleeping.

  • Communication Conditions:

    • Receptive Language Disorder: Difficulty understanding and following directions; poorer prognosis; usually presents before age 33. Causes include hearing loss, neuro/brain injury, cleft palate, IDD, or unknown factors.
    • Expressive Language Disorder: Difficulty communicating, finding the right words, forming sentences, and using gestures.
    • Social Communication Disorder: Problems using verbal and nonverbal means for social interaction.
      • Differential Diagnosis: Must rule out Autism Spectrum Disorder (ASD).
      • Distinguishing Feature: Social Communication Disorder lacks the restricted/repetitive patterns of behavior, interests, or activities seen in ASD.
    • Developmental Coordination Disorder: Impairment in motor skill development with coordination below developmental age interfering with academic performance. Symptoms include delayed sitting or walking, difficulty jumping, or difficulty performing tasks such as tying shoelaces.

  • Specific Learning Disorders:

    • Dyslexia: Persistent difficulty in reading.
    • Dyscalculia: Difficulty in mathematics.
    • Dysgraphia: Difficulty in written expression.
    • Demographics: Higher rates observed in individuals with lower family education, poverty, and male gender.

  • Intellectual Disability (IDD):

    • Impairment Domains: Intellectual functioning (reasoning, problem solving, abstract thinking), Social functioning (communication, social cues), and Daily functioning (age-appropriate ADLs).
    • Etiology: Problems during pregnancy/labor, chromosomal disorders, environmental causes related to neglect.
    • Pharmacotherapy: When medications are prescribed, they are used to manage comorbid psychiatric conditions (e.g., ADHD) or behavioral disturbances (e.g., agitation, aggression, self-injury).

Impulse Control Disorders and Behavioral Management

  • Core Management Principle: The earlier the intervention, the better.

  • Oppositional Defiant Disorder (ODD):

    • Definition: Persistent pattern of angry/irritable mood, argumentative/defiant behavior, and vindictiveness (grudges) toward authority figures.
    • Behavioral Boundary: Patients bend boundaries but do NOT break them; does not involve severe aggression or property destruction. Patients can grow out of this condition.
    • Diagnosis & Impairment: Typically diagnosed around age 88. Causes extreme difficulty attending school and forming friendships.
    • Risk Factors: Insecure attachment, chaotic caregiving or harsh/neglectful families (ACEs), child abuse, lack of structure.
    • Treatment Modalities: Target needs of child and family. Help child manage anger, improve problem-solving, develop techniques to reduce impulsivity, and improve social interactions. Interventions include parent training, group therapy, CBT, anger management, and medications to manage comorbidities and anger/aggression.

  • Conduct Disorder (CD):

    • Definition: Persistent pattern of behaviors where the rights of others are violated and societal norms/rules are disregarded. Patients crave excitement and do not worry about consequences.
    • Etiology: Associated with parental rejection, neglect, and harsh discipline.
    • Four Behavioral Categories:
      1. Aggression to people and animals.
      2. Destruction of property (arson, vandalism).
      3. Deceitfulness or theft.
      4. Serious rule violations (truancy, running away).
    • Callous-Unemotional Subset: Characterized by a lack of remorse, empathy, or emotional depth; strong predictor for adult Antisocial Personality Disorder (ASPD).
    • Subtype Onsets:
      • Childhood-Onset: Onset before age 1010; higher male predominance, worse prognosis.
      • Adolescent-Onset: Absence of symptoms prior to age $$10$.
    • Treatment Consideration: Most successful treatment includes parental involvement. If parents have antisocial traits, they are less likely to participate.

  • Intermittent Explosive Disorder (IED):

    • Definition: Recurrent, impulsive outbursts of unprovoked physical or verbal aggression out of proportion to the stressor. Main problem is emotion regulation (patient cannot control behavior).
    • Physiological & Health Markers: Increased normal inflammatory markers, increased testosterone, and physical health comorbidities (hypertension, diabetes).
    • Etiology: Exposure to violence at a young age, childhood sexual or physical abuse.
    • The Four-Stage Cycle of IED:
      1. Tension & Arousal: Rapid escalation of agitation following a minor trigger.
      2. Explosive Outburst: Direct or indirect verbal/physical aggression (property destruction, physical assault).
      3. Immediate Relief: Instantaneous sense of catharsis, release, or satisfaction right after the act.
      4. Delayed Remorse: Subsided rage followed by genuine guilt, embarrassment, and realization of negative consequences.
    • Treatment: Psychotherapy combined with pharmacotherapy yields the best results.

  • Behavioral Management Techniques:

    • Limit Setting: State expectations clearly, calmly, and consistently before or during misbehavior.
    • Behavioral Contract: Written agreement outlining specific behaviors, rewards, and consequences.
    • Planned Ignoring: Deliberately ignoring non-dangerous, attention-seeking behaviors while praising positive actions.
    • Simple Restitution: Requiring the patient to repair environmental or relational damage caused by their behavior (e.g., cleaning up a mess).
    • Touch & Distance: Maintain personal space; avoid physical touch, as disruptive patients often misinterpret touch as threatening.

Personality Disorders: Clusters A, B, and C

  • Personality Disorders Overview & Clusters:

    • Cluster A (Odd or Eccentric): Paranoid, Schizoid, Schizotypal.
    • Cluster B (Dramatic, Emotional, Erratic): Histrionic, Narcissistic, Borderline, Antisocial.
    • Cluster C (Anxious or Fearful): Avoidant, Dependent, Obsessive-Compulsive.
    • Etiological Risk Factors: Trauma, neglect, modeling, and the Diathesis-Stress Model (genetic vulnerability + temperament + stress).

  • Cluster A Personality Disorders:

    • Paranoid Personality Disorder:
      • Features: Longstanding distrust/suspiciousness, hypervigilance (intense alertness), hostility, jealousy, controlling behavior.
      • Nursing: Clear/straightforward explanations, neutral/kind affect, avoid being overly friendly, set limits on threatening behavior.
      • Treatment: CBT (1st line), reality testing; short-term Valium for agitation, 2nd generation antipsychotics for paranoia.
    • Schizoid Personality Disorder:
      • Features: Lifelong social withdrawal, restricted emotional expression, no desire for close relationships.
      • Nursing: Respect need for isolation (do not force socialization), avoid being too nice/friendly, protect from ridicule.
      • Treatment: Psychotherapy, SSRI antidepressants, 2nd generation antipsychotics (to assist with emotional expressiveness).
    • Schizotypal Personality Disorder:
      • Features: Magical thinking, odd beliefs/speech, extreme social anxiety, paranoid thoughts. Patients do not blend with the crowd; they desire relationships but do not know how to form them.
      • Nursing: Respect need for space, assess for depression/suicide, monitor strange beliefs.
      • Treatment: Psychotherapy; low-dose antipsychotics (risperidone, olanzapine) for psychotic-like symptoms.

  • Cluster B Personality Disorders:

    • Histrionic Personality Disorder:
      • Features: "Drama queen" presentation; excitable, dramatic, attention-seeking, provocative, low frustration tolerance. Things are important to them until suddenly they are not. Relationships do not last because patients lack insight into their personal role in breakups (partners feel overwhelmed or frustrated by insensitivity).
      • Nursing: Keep interactions professional (maintain boundaries), use concrete language, model assertiveness, assess suicidality.
      • Treatment: Psychotherapy (individual therapy is preferred over group therapy if patient is disruptive), Dialectical Behavior Therapy (DBT).
    • Narcissistic Personality Disorder:
      • Features: Entitlement, grandiosity masking weak self-esteem, intense fear of abandonment/shame, arrogant affect. Occurs more frequently in males than females.
      • Nursing: Remain neutral, avoid power struggles or directly challenging grandiose statements, role-model empathy.
      • Treatment: CBT, Lithium for mood swings, antidepressants (difficult to treat because the person must confront their problems).
    • Borderline Personality Disorder (BPD):
      • Features: MOST SEVERE personality disorder. Unstable mood and relationships, identity distortion, severe impulsivity, chronic suicidal ideation/self-harm (used as a coping mechanism), splitting (rapid black-and-white thinking; viewing people/situations as all good or all bad), emotional lability (moving rapidly from one emotional extreme to another).
      • Nursing: Relationships form quickly (strict boundaries required); maintain a matter-of-fact approach; assess for recent loss or abuse history.
      • Treatment: Dialectical Behavior Therapy (DBT - priority treatment for suicidal behavior), CBT, Lithium for chronic suicidality and aggressive symptoms.
    • Antisocial Personality Disorder (ASPD):
      • Features: Deceitful, manipulative, callous (lacks remorse/empathy), disinhibited (high risk-taking, disregard for responsibility, impulsivity), disregard for safety and rules, common criminal history and substance misuse. Main concern is gaining personal power or pleasure. Absence of remorse or guilt except when facing punishment.
      • Nursing: Set clear, realistic boundaries and consequences; guard against manipulation; assess for suicide and homicide risk.
      • Treatment: Mood stabilizers (Lithium, Valproic Acid), CBT, Mentalization-Based Therapy (MBT), group anger management, SSRIs for anxiety.

  • Cluster C Personality Disorders:

    • Avoidant Personality Disorder:
      • Features: Extreme sensitivity to rejection, social inhibition, strong feelings of inferiority.
      • Nursing: Friendly, accepting, and reassuring approach; provide assertiveness training; avoid pushing into intense social settings prematurely.
      • Treatment: Assertiveness training, individual/group therapy, anti-anxiety medications.
    • Dependent Personality Disorder:
      • Features: Submissive, clinging, overwhelming need to be taken care of, highly vulnerable to exploitation. High incidence in abusive relationships (would rather be abused than be alone).
      • Nursing: Assist in identifying current stressors, manage countertransference from heavy client demands, use therapeutic relationships to practice assertiveness.
      • Treatment: CBT, SSRIs/SNRIs for comorbid anxiety or depression.
    • Obsessive-Compulsive Personality Disorder (OCPD):
      • Features: Preoccupation with order, control, and perfectionism; stubbornness and indecisiveness.
      • Key Distinction from OCD: OCPD patients believe their strict rules and standards are correct and desirable (ego-syntonic), whereas OCD patients perceive their obsessions/compulsions as unreasonable (ego-dystonic).
      • Nursing Interventions:
        • Avoid Power Struggles: Guard against control battles to protect the therapeutic alliance and prevent patient anxiety/resistance.
        • Prepare for Disruptions: Anticipate high distress with unexpected routine changes; offer reassurance to minimize stress.
        • Provide Structure & Time: Maintain a clear schedule while allowing extra time for ritualistic behaviors.
        • Identify Unhealthy Coping: Help patients recognize maladaptive behaviors and build healthier coping strategies.
      • Treatment: Group therapy, CBT, Anafranil (clomipramine), fluoxetine (Prozac), fluvoxamine (Luvox).