Mental Health 2.1

Mental Health

Stress

• Eustress: Normal and beneficial stress that motivates us to solve problems and meet goals.
• Distress: Stress that causes emotional and physical problems.
• Stress Response: A survival mechanism where the mind and body prepare to meet a threat; also known as "fight or flight."

Stress Response Mechanism

1. Brain: Initiates the stress response.

2. Pituitary Gland: Releases Adrenocorticotropic Hormone (ACTH).

3. Bloodstream: ACTH travels through the bloodstream.

4. Adrenal Glands: Stimulated by ACTH to release Cortisol and Adrenaline.

   • Cortisol:
     • Converts Glycogen to Glucose, increasing blood sugar levels.
   • Adrenaline:
     • Increases Blood Pressure.
     • Causes Tunnel Vision.
     • Increases Sweating.
     • Accelerates Heart Rate.
     • Speeds up Breathing.
     • Slows down Digestion.

Post-Traumatic Stress Disorder (PTSD)

• Can occur in individuals exposed to severe trauma outside the range of normal human experience.

  • Examples: physical abuse, torture, sexual assault, natural disasters, war, accidents, terrorist events.

• Can also occur in people who have witnessed an unbearable event.

Four Categories of Symptoms of PTSD

1. Intrusive Re-experiencing of Trauma

   • Flashbacks
   • Recurrent Nightmares
   • Unwanted Distressing Memories
   • Strong Physical and Emotional Responses of Distress

2. Avoidance

   • Attempting to avoid anything that might cause recall of the event

3. Alteration in Arousal

   • Increased Irritability
   • Angry Outbursts
   • Self-Destructive Behavior
   • Exaggerated Startle Response
   • Hypervigilance
   • Sleep Difficulties

4. Persistent Negative Alterations in Cognition and Mood

   • Distorted Cognitions about Self and Others
   • Excessive Fear
   • Guilt
   • Feelings of Detachment

PTSD in Children

• Frequent displays of irritability and negativity
• Disinterest in previously enjoyed activities
• Expressing the feeling that "something bad is going to happen"
• Self-isolation from peers
• Clinging to their teacher

Dissociative Symptoms of PTSD

• Depersonalization: Feeling detached from one's mental processes or body, like being an outside observer of oneself (feeling like you’re in a dream). Experiencing a disconnection from one's mind, self, or body.
• Derealization: Persistent or recurrent experiences of unreality of surroundings (the outside world feels unreal).

Risk Factors & Comorbid Conditions

• Pre-traumatic Risk Factors for PTSD:

  • Age at traumatic event
  • Female gender
  • Personal or family history of psychiatric illness
  • Lower education level

• Cardiovascular (CV) disease, bipolar disorder, and major depressive disorder significantly increase risk for PTSD.

• Veterans:

  • Younger age
  • Female gender
  • Lower education
  • Racial minority status
  • Lower ranking, longer deployments & higher number of deployments

• Associated with PTSD:

  • Cancer
  • Diabetes
  • Obesity
  • Angina
  • Hypertension
  • Gastrointestinal (GI) disorders
  • Arthritis
  • Susceptibility to infection
  • Abnormalities in thyroid

• Psychiatric comorbidities:

  • Depressive disorders
  • Anxiety disorders
  • Substance-related disorders
  • Increased risk for suicide

• Traumatic Brain Injuries (TBIs)

PTSD: Assessment

• Focus on safety due to increased risk for suicide and must assess this risk first
• Assess the presence of substance use and/or withdrawal
• When patient is leaving an abusive relationship, ensure safety, and do not disclose if patient was discharged

PTSD: Diagnosis

• Nightmares
• Physical injuries from trauma
• Feeling overwhelmed with small stressors
• Feeling sad, isolating, crying
• Impaired sleep
• Abuse injury
• Difficulty coping
• Impaired psychosocial status
• Risk for depressed mood
• Risk for injury

PTSD: Planning & Implementation

• Psychotherapy

  • Cognitive Processing Therapy (CPT): Teaches the patient how to evaluate and change upsetting thoughts since the trauma.
  • Prolonged Exposure (PE) Therapy: Teaches the patient to gradually approach trauma-related memories, feelings, and situations that have been avoided since the trauma.
  • Eye Movement Desensitization & Reprocessing (EMDR): The patient focuses on eye movements, hand taps, and sounds when thinking about the trauma.
  • Somatic Experiencing (SE): Helps patient move from “fight, flight, or freeze” to a more calm state by tuning into surroundings

• Psychopharmacology

  • Sertraline & paroxetine: FDA-approved.
  • Off-label: SSRIs (fluoxetine) and SNRIs (venlafaxine).
  • Anticonvulsants - Topiramate.
  • Prazosin - helps with hypervigilance and nightmares.

PTSD: Implementation Cont.

• Stay with patient to offer reassurance and emotional safety
• Address survivor’s guilt, depression, and anxiety by providing a therapeutic relationship to share concerns
• Help patient recognize avoidance behaviors and develop strategies to increase social supports
• Provide interventions to help with sleep and find ways to cope with anger related to sleep disturbances, angry outbursts, and reckless behaviors

Acute Stress Disorder

• Occurs after experiencing a traumatic event or repeatedly witnessing a violent or traumatic event
• Differs from PTSD in that symptoms resolve within 1 month

Compassion Fatigue/Secondary Traumatic Stress

• Becoming indirectly traumatized when trying to help a person who has experienced primary traumatic stress

Dissociative Disorders

• Hallmark: Disturbance in the normally well-integrated continuum of consciousness, memory, identity, and perception

• Dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety, usually related to trauma

  • Symptoms of dissociation are present in many mental health disorders, with close association to borderline personality disorder

• No delusional thinking or hallucinations

• Risk factors:

  • Children exposed to longer-term physical, sexual, or emotional abuse
  • Natural disasters and combat

• Biological factors:

  • Under-activation of prefrontal cortex (rational thought) & anterior cingulate cortex (emotional regulation & cognitive control)
  • Overactivation of amygdala (emotional processing & memory)
  • Brain tumors & epilepsy: altered perception of self

• Genetic factors:

  • Patient's family histories increase risk for dissociative symptoms

• Psychosocial factors:

  • Children may learn that dissociation helped with coping and continues into adulthood

Types of Dissociative Disorders

• Depersonalization/Derealization Disorder:

  • Recurrent periods of feeling unreal, detached, outside of the body, numb, or dreamlike or experiencing a distorted sense of time or visual perception.

• Dissociative Amnesia/Dissociative Amnesia with Fugue:

  • Inability to recall information about the self, usually traumatic in nature.
  • Memory impairment may be selective for the traumatic event, time period, or entire life.
  • With fugue: associated with amnesia for one’s identity or other important autobiographical info
    • May present as bewildered wandering or purposeful travel.

• Dissociative Identity Disorder:

  • Formerly known as multiple personality disorder.
  • Disruption of identity by two or more distinct personality states or alternate personalities (alters).
    • Each alter has its own personality & memories (different handwriting, clothing, etc.)
  • Loss of sense of self.
  • Alterations in affect, behavior, memory, and functioning, leading to “loss of time” from minutes to weeks.
  • Associated with severe and repetitive childhood abuse and/or trauma

Dissociative Disorders: Assessment

• Complete history and physical assessment first to rule out head injury, brain diseases, temporal lobe epilepsy, substance use, or extreme sleep deprivation

• Psychiatric assessment:

  • History of abuse (especially childhood abuse)
  • Missing blocks of time
  • Reported feelings of unreality, being in a dreamlike state, not feeling like self
  • Unrecognized handwriting
  • Finding clothes or items with no memory of purchasing
  • Friends report patient acts like a different person sometimes
  • Instances of SI or SH with no memory
  • Clinician-observed switching of alters

• Dissociative Experiences Scale II: self-screening tool

• Comorbid conditions and secondary effects:

  • Safety concerning suicide and self-harm
  • Acute anxiety, panic attacks, flashbacks, sleep disturbances
  • Depressive disorders, anxiety disorders, SUDs, personality disorders

Dissociative Disorders: Diagnosis

• Disturbed personal identity
• Impaired cognition
• Altered perception
• Risk for suicide/self-harm/violence
• Sudden travel from home with an inability to recall previous identity
• Inability to explain actions or behaviors when in an altered state
• Alterations in consciousness, memory, or identity
• Feelings of suicide or self-harm ideation or harm to others in one or more personalities (alters)

Dissociative Disorders: Outcomes Identification

• Short-term outcomes (Patient will):

  • Refrain from injuring self
  • Report a decrease in perceived stress
  • Plan coping strategies for stressful situations
  • Report comfort with role expectations
  • Verbalize a clear sense of personal identity

• Long-term outcomes (Patient will):

  • Consistently use coping strategies to manage stress without dissociation
  • Resume daily activities and maintain relationships
  • Process trauma safely within therapy
  • Demonstrate self-efficacy and manage care with reduced external support

Dissociative Disorders: Planning & Implementation

• Support participation in therapy

• Use mindfulness

• Grounding techniques

• Daily journal

• Psychotherapy:

  • CBT
  • DBT
  • EMDR

• Create a safe environment that is quiet, structured, & supportive

• No specific medications, but antidepressants and anxiolytics are given for comorbid symptoms

Anxiety

• A feeling of apprehension, uneasiness, uncertainty, and dread related to a real or perceived threat but where the source is unknown.
• 19.1% of US adults had an anxiety disorder in the past year
• Women have an increased rate of anxiety disorders compared to men

Fear

• A reaction to a specific danger

Normal Anxiety

• Adaptive life force that is necessary for survival

Pathological Anxiety

• The intensity of the emotional response is out of proportion to the threat
• The emotional response persists after the threat is resolved
• The emotional response becomes generalized to benign situations

Levels of Anxiety

• Mild Anxiety:

  • Normal experience in everyday living
  • Problem-solving becomes more effective, able to grasp more information
  • Restlessness, mild irritability, nail-biting, finger tapping

• Moderate Anxiety:

  • Able to perceive reality
  • Greatly reduced perceptual field
  • Overly focused on one detail or may focus on scattered details
  • Learning and problem-solving are significantly affected
  • Increased severity of somatic symptoms (hyperventilation, sense of dread)

• Severe Anxiety:

  • Perceptual field narrows
  • Selective inattention - person blocks processed information
  • Learning and problem-solving can still take place
  • Tension, pounding heart, increased HR & RR, voice tremors

• Panic Level:

  • Most extreme - leads to disturbed behavior
  • Not able to process events in the environment and can lose touch with reality
  • Confusion, screaming, extreme withdrawal, hallucinations, erratic behavior
  • Panic Attack: Shakiness, dilated pupils, restlessness, irritability, tachycardia, hyperventilation

Interventions for Mild to Moderate Anxiety

• Identify anxiety: "You look upset." Validate observations with the patient & start to work with them to lower anxiety.
• Assess the patient's level of anxiety. The nurse can provide care appropriate to the level of anxiety.
• Use nonverbal language to demonstrate interest. Verbal and nonverbal messages should be consistent. The presence of an interested person provides a stabilizing focus.
• Encourage the patient to talk about feelings and concerns. When concerns are stated aloud, problems can be discussed, and feelings of isolation decreased. Avoid closing off avenues of communication that are important for the patient.
• Focus on patient’s concerns. When staff anxiety increases, changing the topic or offering advice is common but leaves the person isolated.
• Ask questions to clarify what is being said: "I'm not sure what you mean. Give me an example." Increased anxiety results in the scattering of thoughts. Clarifying helps the patient identify thoughts and feelings.
• Help the patient identify thoughts or feelings before the onset of anxiety: "What were you thinking right before you started to feel anxious?" The patient is assisted in identifying thoughts and feelings, and problem-solving is facilitated.
• Encourage problem-solving with the patient. The patient may need help with this. Increase sense of control and self-sufficiency while decreasing anxiety.
• Assist in developing alternative solutions to a problem through role-play or modeling behaviors. The patient is encouraged to try alternative behaviors and solutions to gain confidence and develop alternate strategies to reduce anxiety.
• Explore behaviors that have worked in the past. Encourages successful coping mechanisms and strengths.
• Provide outlets for dissipating excess energy (walking, exercising). Physical activity can provide relief of built-up tension & increases endorphin levels.

Interventions for Severe to Panic Levels of Anxiety

• Maintain a calm manner. Anxiety is communicated interpersonally. The quiet calm of the nurse can serve to calm the patient. The presence of anxiety can escalate the patient.
• Always remain with the person experiencing an acute severe to panic level of anxiety. Alone with immense anxiety, a person feels abandoned. A caring face may be the patient's only contact with reality.
• Minimize environmental stimuli. Move to a quitter setting and stay with the patient. Helps minimize distractions and triggers that can further escalate.
• Use clear and simple statements. You may need to repeat statements. A person experiencing a severe to panic level of anxiety has difficulty concentrating and processing info.
• Use a low-pitched voice; speak slowly. A high-pitched voice can convey anxiety. Low pitch decreases anxiety.
• Reinforce reality if distortions occur (hallucinations). Anxiety can be reduced by focusing on and validating what is happening in the environment.
• Listen for themes in communication. In severe to panic level anxiety, verbal communication themes may be the only indication of the patient's thoughts or feelings.
• Attend to physical and safety needs when necessary (warmth, fluids, pain). High levels of anxiety may obscure the patient's awareness of physical needs. Because safety is an overall goal, physical limits may need to be set: "You may not hit or yell at anyone here." A person who is out of control is often terrorized. You must offer protection for the patient and others.
• Provide opportunities for gross muscle motor movement and exercise (walk/pace). Helps channel and dissipate tension and may temporarily lower anxiety.
• When a person is constantly moving or pacing, offer high-calorie fluids. Dehydration and exhaustion must be prevented.
• Assess the need for medication. Exhaustion and physical harm to self and others must be prevented.

Medications Causing Anxiety

• Prescription:

  • Asthma meds (albuterol, salmeterol)
  • BP meds- methyldopa
  • Hormones (birth control)
  • Stimulants- methylphenidate, lisdexamfetamine, amphetamine salts
  • Steroids- cortisone, dexamethasone, prednisone
  • Thyroid medicines
  • Phenytoin, levodopa, quinidine

• Nonprescription:

  • Meds that contain caffeine- Anacin, Empirin, Excedrin, No-Doz, cough medicines
  • Decongestants, Sudafed, phenylephrine

• Illegal drugs:

  • Cocaine, crack, methamphetamine

Neurobiology

• Limbic system; “emotional brain”: amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, cingulate gyrus

  • Scanning the environment for threat-relevant cues and assessing the magnitude of the threat
  • Initiating the body’s readiness to respond by eliciting the fight-or-flight (and freeze) response
  • Terminating reactivity after external stressors subside and restore the nervous system to a state of homeostasis

• Frontal cortex: cognitive interpretations (potential threat)

• Hypothalamus: activation of the stress response (fight-or-flight and freeze)

• Hippocampus: associated with memory related to fear responses

• Amygdala: fear, especially related to phobic and PDs

Neurochemical Mediators of Anxiety & Medications

• Serotonin (5-HT):

  • Decreased levels in anxiety disorders
  • SSRIs increase levels in the brain - 1st line of medication
    • Have a rapid onset of action and fewer SE
  • Serotonin helps regulate mood, sleep, sexual desire, and appetite

• Norepinephrine (NE):

  • Increased levels in anxiety disorders and/or is poorly regulated
  • Noradrenergic drugs (propranolol, clonidine) - lowers anxiety
  • NE plays a role in sensitization, fear conditioning, stress response

• GABA:

  • Diminished benzodiazepine receptor sensitivity in anxiety disorders
  • GABA slows neural transmission = calming effect
  • Antianxiety agents, sedative-hypnotics (ambien), general anesthetics, anticonvulsants (gabapentin)
  • Benzodiazepines - short-term basis only; risk for addiction, cognitive decline, falls, mortality

Panic Disorders

• Consists of recurrent and unexpected, “out of the blue” panic attacks

• The panic attack is the key feature of panic disorders

• Panic attack: sudden onset of extreme apprehension of fear, usually associated with feelings of impending doom: “I am going to die”

  • Occur suddenly (not necessarily in response to a stressor)
  • Can last 1 to 30 minutes
  • Normal function is suspended
  • Perceptual field is severely limited, misinterpretation of reality

Phobias

• High levels of anxiety in response to specific objects (dogs, spiders, heights, etc)

• Severe anxiety provoked by exposure to a social situation (performance, fear of eating in front of others) resulting in feelings of humiliation

• Propranolol often used for performance anxiety

• An intense, excessive fear of being in places or situations where help may not be available, and escape may be difficult or embarrassing

• Must include two of the following:

  • Using public transportation
  • Being in open spaces
  • Being in enclosed spaces
  • Standing in line or being in a crowd
  • Being outside of the home alone

• Types:

  • Specific phobias
  • Social phobias
  • Agoraphobia

Generalized Anxiety Disorder (GAD)

• Characterized by excessive anxiety and worry about a number of events and activities

• Three of the following must be present:

  • Restlessness
  • Fatigue
  • Poor concentration
  • Irritability
  • Muscle tension
  • Sleep disturbance

• Worry must persist for most days during a 6-month period

• Examples of worries:

  • Inadequacy in interpersonal relationships
  • Job responsibilities
  • Finances
  • Health of family members

• Leads to disturbances in relationships and family life, impaired functioning at work, and disturbances in social roles

• Limbic system in a perpetual state of alertness

• Decision-making is difficult because of poor concentration and dread making a mistake

Obsessive-Compulsive Disorder (OCD)

• Chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that the person feels the urge to repeat over and over.

• Can be extremely disabling and painful

• Usually begins in late teens to early 20s

• Neurological etiology: hyperactivity in the prefrontal cortex, dysfunction in basal ganglia and cingulum, dysregulation of serotonin levels (SSRIs are used to treat OCD)

• Symptoms:

  • Obsessions: thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind (e.g., fear of hurting a loved one, fear of contamination, needing to have things in perfect order)
  • Compulsions: ritualistic behaviors that individuals feel driven to perform in an attempt to reduce anxiety (repetitive hand washing, checking a door multiple times); rituals can be time-consuming

Anxiety Disorders (ADs) & OCD: Assessment

• A seven-question self-report tool for adults (GAD-7)
• A twenty-question self-report questionnaire that identifies symptoms of anxiety in adults (The Clinically Useful Anxiety Outcome Scale - CUXOS)
• A 14-question self-report tool for adults and adolescents (Hamilton Rating Scale for Anxiety - HAM-A)
• Generalized Anxiety Disorder Screener (GAD-7)

Anxiety Disorders (ADs) & OCD: Planning/Implementation

• Use therapeutic communication, milieu therapy, promotion of self-care activities, supportive counseling, health teaching, and health promotion

• Identify community resources that can offer specialized treatment that is proven to be effective

• Identify relevant community support groups for patients and significant others

• Teach the patient about anxiety disorders and OCD

• Support medication adherence through medication teaching

• Teach the patient about how to promote sleep (warm bath, decrease screen time, etc.)

• Teach the patient about available smartphone apps to help with relaxation or meditation

• Psychotherapy:

  • CBT: identify the negative thought, challenge it, and replace it
  • Acceptance and commitment therapy (ACT): committing to make changes in behavior
  • Mindfulness-based stress reduction (MBSR): learning how detach from anxious thoughts

Somatic Symptom Disorders (SSDs)

• Included in the most controversial areas of psychiatry

• Characteristics:

  • Presence of one or more physical symptoms
  • Often present with numerous symptoms (headaches, back pain, lack of sleep, GI upset, chronic tiredness) with an unknown source
  • Symptoms are not intentional or under conscious control of the patient

• Prevalence:

  • More common in women (10x) than in men
  • Most often diagnosed in children with a history of a traumatic event

• Impair occupational and social function

• Leads to expensive and repetitive medical examinations due to focus on physical complaints

• Theory:

  • Genetic: first-degree relative
  • Psychological: difficulty with expressing distress verbally, living around an ill family member
  • Cognitive: result of negative, distorted, and catastrophic thoughts
  • Interpersonal: ACEs & loneliness

Types of SSDs

• Somatic Symptom Disorder:

  • Medical findings are lacking or less than expected for the magnitude of the complaint
  • History includes multiple treatments, surgeries, chronic pain, etc.
  • Lower back pain most common complaint

• Illness Anxiety Disorder:

  • Formerly known as hypochondriasis
  • Preoccupied with having or developing a serious illness
  • High level of anxiety related to health that severely impairs functioning
  • ECT has been found to be helpful

• Functional Neurological Disorder:

  • AKA conversion disorder
  • Chronic or brief symptoms of altered voluntary motor or sensory function
  • Ex: sudden paralysis of limbs, seizure-like episodes, speech issues after a stressful event

Factitious Disorders

• Factitious Disorder Imposed on Self (Formerly Munchausen Syndrome):

  • Intentionally faking symptoms in order to assume the “sick role”
  • No obvious external benefits (financial gain, avoiding work, criminal prosecution)

• Malingering: intentionally faking or exaggerating symptoms for an obvious benefit (money, housing, medications, etc.)

• Factitious Disorder Imposed on Another (Munchausen by proxy):

  • Deliberate fabrication of symptoms or injury is imposed on another person, often a child or dependent victim (Ex: Gypsy Rose)

Personality Disorders (PDs)

• Defined as an enduring pattern of inner experience and behavior that deviates from the individual’s culture
• Patients with PDs have inflexible and unpredictable personality traits
• Maladaptive patterns in cognition, emotional responses, interpersonal functioning, and impulse control = distress or impairment in functioning
• Often unaware that their personality traits are the root cause of the problems they are experiencing and often blame others (which can be challenging for HCPs)
• Often occur with other PDs, mental disorders (SUD, depression, eating disorders), and medical conditions
• Abnormalities in the frontal, temporal, and parietal lobes of the brain, in addition to disturbances in serotonin, GABA, and glutamate
• Childhood trauma is a significant risk factor for the development of any PD
• Splitting: everything (people, actions, objects) is either good or bad; “black and white” thinking

Three Personality Disorder

• Cluster A: The Odd, Eccentric Cluster

  • Paranoid Personality Disorder
  • Schizoid Personality Disorder
  • Schizotypal Personality Disorder

• Cluster B: The Dramatic, Unpredictable Cluster

  • Antisocial Personality Disorder
  • Borderline Personality Disorder
  • Histrionic Personality Disorder
  • Narcissistic Personality Disorder

• Cluster C: The Anxious, Fearful Cluster

  • Avoidant Personality Disorder
  • Dependent Personality Disorder
  • Obsessive-compulsive Personality Disorder

Cluster A PDs

• Reduced capacity for close relationships (and avoids them)
• Cognitive and perceptual distortions, peculiar behavior, odd speech
• Schizotypal PD: odd thoughts/beliefs, magical thinking, ideas of reference, inappropriate affect, suspicious of others, paranoid thinking
• Paranoid PD: pervasive, persistent, and inappropriate suspiciousness and distrust of others; hostile, irritable, angry mood and affect (give space when this is present); suspect others are deceiving them, reluctance to confide in others, perceives non-existent attacks, inability to forgive perceived insults
• Schizoid PD: inability to establish relationships with others and a restricted range of emotions in interpersonal settings; eccentric, isolated, lonely, takes pleasure in few things; flat affect, emotional “coldness”, indifferent to praise or criticism, little desire for intimacy

Cluster B PDs

• Antisocial PD: persistent disregard for and violation of the rights of others, with a lack of remorse for actions or hurting others; sense of entitlement, little restraint to behavior, little responsibility for behavior; may engage in criminal behaviors, persistent lying, deception, conning, reckless disregard for the safety of others, physical aggressiveness
• Histrionic PD: pattern of excessive emotionality and attention-seeking; manipulate others through self-dramatization, theatricality, exaggerated expression of emotion; "center of attention"; inappropriate and sexually seductive behavior, sudden emotional shifts, constant need for attention
• Borderline PD: ongoing patterns of difficulty with self-regulation, and inability to sooth oneself in times of stress; unstable and intense relationships, unstable self-image, impulsivity, chronic feelings of emptiness, frantic efforts to avoid abandonment, intense anger, impulse behaviors, self-harm; often mistaken for bipolar disorder
• Narcissistic PD: maladaptive response characterized by a person’s grandiose sense of self-importance; preoccupation with fantasies of unlimited success, arrogance, expects special treatment; lack of empathy, exploitation of others, blame others for problems they have caused, envious of successes or possessions of others

Cluster C PDs

• Avoidant PD: high levels of anxiety and outward signs of fear with feelings of low self-worth; hypersensitive to criticism or rejection, avoids socialization, fearful of rejection, strong desire for affection, socially inept, personally unappealing, reluctant to take risks
• Obsessive-Compulsive PD: preoccupied with orderliness and mental and interpersonal control at the expense of openness or efficiency; pervasive pattern of perfection and inflexibility; preoccupied with rules and details, rigid perfectionism, reluctant to delegate tasks, devoted to work and school, financially stingy, difficult to part with personal objects, experience distress when not in control
• Dependent PD: fearful or reluctant to express disagreement for fear of rejection and loss of support; fearful that they are incapable of surviving if left alone and have an excessive need to be taken care of; excessively submissive, difficulty making decisions without advice, lack of self-confidence, need others to be in charge, fearful to express disagreement, inability to complete anything on their own

Caring for Patients with PDs

• Acting in a suspicious manner: Help the patient feel safe emotionally and explain reasons for actions in a matter-of-fact manner.
• Lacks the ability to trust: Give the patient a sense of control over what is happening by giving the patient choices when possible.
• Is hypersensitive to criticism yet has no strong sense of autonomy: Teach/model new interpersonal skills by building on existing skills.
• Falsely attributes malevolent intentions to the nurse or others: Discuss how these cognitive distortions and present facts in a matter-of-fact manner.
• Insults or threatens the nurse or caregiver: Ignore insults or sarcasm but set limits on abusive language or threats of violence while continuing to provide care.
• Reports feeling hurt or rejected by others: Allow the patient to discuss the situation. Listen to understand the situation. Educate the patient.