mental health

Chapter 18: Personality Disorders

1. Discuss the maladaptive or dysfunctional personality traits exhibited by individuals with a personality disorder

a. Negative behaviors such as being manipulative, dishonest, deceitful, or lying: strategies to gain control, attention, or personal benefit, often at the expense of others. Lie compulsively or twist the truth to suit their needs, w little to no concern of consequence 

b. Anger and/or hostility: easily provoked, harbors grudge, reacts w intense anger

c. Irritable, labile moods: shift from happiness to rage or despair

d. Lack of guilt or remorse: harm others, emotionally, physically, or financially w/o regret

e. Impulsivity, poor judgment: act w/o considering consequence, engaging in reckless spending, substance abuse, risk sex, self harm

f. Irresponsible: fail to honor work obligation, financial commitments, parental duties 

g. Risk-taking, thrill-seeking behaviors: seek excitement or dominance, often w/o fear or concern for potential harm to themselves or others

2. Differentiate between the major diagnoses of personality disorders:

CLUSTER A: ODD OR ECCENTRIC DISORDER

a. Paranoid personality disorder: pervasive mistrust & suspiciousness of others; interpret clothes actions as potentially harmful 

b. Schizoid personality disorder: pervasive pattern of detachment from social relationship and a restricted range of emotional expression in interpersonal setting (FLAT / doesn't care about relationship)

c. Schizotypal personality disorder: pervasive pattern of social and interpersonal deficits marked by acute discomfort w and reduce capacity for close relationships as well as by cognitive or perceptual distortion and behavioral eccentricities (hard time w relationship and DOES CARE)

CLUSTER B: DRAMATIC, EMOTIONAL, OR ERRATIC DISORDER

d. Antisocial personality disorder: disregard for violation of rights of others

e. Borderline personality disorder: instability in relationships, self image, & emotions (fear of abandonment, impulsivity 

f. Histrionic personality disorder: excessive emotionality and attention seeking

g. Narcissistic personality disorder: grandiosity, need for admiration, lack of empathy

CLUSTER C: ANXIOUS OR FEARFUL DISORDER

h. Avoidant personality disorder : social inhibition, feeling of inadequacy, hypersensitivity to criticism 

i. Dependent personality disorder: excessive need to be taken care of, leading to submissive and clinging behavior 

j. Obsessive personality disorder: preoccupation with orderliness, perfectionism & control

3. Describe the diagnostic criteria for Borderline Personality Disorder: 

1. frantic efforts to avoid real or imagined abandonment

2. Pattern of unstable and intense interpersonal relationship characterized by altering between extremes of idealization and devaluation

3. Identity disturbance

4. Impulsivity in at least 2 areas that are potentially self damaging 

5. Recurrent suicidal hebavior, gestures, or threats, or self mutilatating behavior 

6. Affective instability due to a marked reactivity of mood

7. Chronic feeling of emptiness

8. Inappropriate intense anger or difficulty controlling anger

9. Transient, stress-related paranoid ideation or severe dissociative symptoms 

4. Differentiate the following theories for the etiology of Personality Disorders:

a. Biological Theories: personality develops through the interaction of hereditary disposition and environmental influence 

b. Psychodynamic Theories: concept about the self & the world that develop over time, influenced by life event, cultures & social learning

5. Describe the mechanism of action, side effects, special nursing considerations and how the following medications used to treat personality disorders may affect the older adult or clients with renal and liver impairment:

a. Aggression/Impulsivity

• lithium

• Anticonvulsant mood stabilizers

• Benzodiazepines

b. Mood Dysregulation

• Lithium

• Anticonvulsant mood stabilizers

• Antipsychotics

• Selective Serotonin Reuptake Inhibitors (SSRI’s)

• Monamine Oxidase Inhibitors (MAOI’s)

c. Psychotic symptoms

• Antipsychotics

d. Anxiety

• Selective Serotonin Reuptake Inhibitors (SSRI’s)

• Monamine Oxidase Inhibitors (MAOI’s)

e. Antipsychotics

6. Describe the behavioral strategies used to treat personality disorders:

a. Teach social skills: improve interpersonal effectiveness & reduce social isolation or conflict

b. Reshaping thinking patterns: identity and modify distorted, negative, or irrational beliefs that drive maladaptive behavior 

c. Teach time structuring: increase stability, reduce impulsivity, & promote goal-oriented behavior

d. Group Therapy: improve self-awareness & social functioning through feedback and shared experiences 

7. Describe nursing interventions for clients living with personality disorders and their families: promote safety, helping client cope and control emption, cognitive restructuring techniques, structural time, teaching social and effective communication skills, entering therapeutic relationship

8. Discuss pertinent education topics for clients living with personality disorders and their families.

9. Analyze your feelings, beliefs, and attitudes regarding personality disorders in order to remain therapeutic with clients and their families.

Chapter 16: Schizophrenia

1. Differentiate between the positive and negative symptoms of Schizophrenia.

  • Positive: ambivalence(mixed feelings), associated looseness, delusions, echopraxia(involuntary repetition of another person movement or actions), flight of ideas, hallucinations, ideas of reference, perseveration, bizarre behavior 

  • Negative: alogia(speaks little), anhedonia (no emotion), apathy, asociality(antisocial behavior), blunted affect, catatonia(immobility), flat affect, avolition of lack of volition, inattention

2. Differentiate between the major types of Schizophrenia and mood disorders:

a. Schizophrenia: bizarre thoughts, perceptions, emotions, movement, & behavior

b. Schizophreniform Disorder: pt exhibits an acute, reactive psychosis of at least 1 mo but <6mo necessary to meet the dx criteria for schizophrenia 

c. Schizoaffective Disorder: dx when the client is severely ill and has a mixture of psychotic & mood symptoms (has s/s of schizophrenia and a mood disorder)

3. Identify the diagnostic criteria for Schizophrenia: schizophreniform for more >6mo 

4. Differentiate the following Biologic Theories for the etiology of Schizophrenia.

  1.  Genetic Factors: Genetically transmitted? Children with one biological parent with schizophrenia has 15% risk, identical twins have 50%

  2.  Neuroanatomic: less brain tissue & CNS, enlarged ventricles, cortical atrophy, decreased glucose metabolism & O2 in frontal cortex, decrease pain volume, abnormal functions in frontal & temporal lobes

  3.  Neurochemical Factors: alteration in neurotransmitters, prominent theory r/t excess dopamine

  4. Immunovirology Factors: exposure to a virus or the body’s immune response to a virus could alter the brain's physiology 

5. Differentiate the following Speech Patterns associated with Schizophrenia:

a. Clang associations: rhyming

b. Neologisms: making up a word

c. Verbigeration: stereotype repetition of words or phrases

d. Echolalia: imitating something (echoing)

e. Stilted Language: elevating language (excessive)

f. Perseveration: saying the same topic over and over again (trying to change the topic)

g. Word Salad: words that do not match (random works)

h. Latency response: taking 30 seconds to respond 

6. Differentiate between the following types of Delusions:

a. Persecutory/Paranoid: others are planning to harm the pt or are spying, following, ridiculing, or belittle them

b. Grandiose: pt claims an associate w famous people or celebrities 

c. Religious: calints to be a significant religious figure or prophet 

d. Somatic: generally vague and unrealistic beliefs about their health or body functions

e. Sexual: pt belief that their sexual behavior is known to others; they are rapist, prostitute

f. Nihilistic: belief that their organs do not exist or are rotting away

g. Referential: idea of reference; television show, music, or newspaper have special meaning for them

  • Types of hallucinations 

    • Auditory: most common; hearing sounds, most often voices, talking to or about pt

    • Command: auditory; voices that demand the client to take action (hard other or self); dangerous

    • Visual: 2nd most common; seeing images that do not exist at all (dead person)

    • Olfactory: smells or odors

    • Tactile: sensation

    • Gustatory: taste; metallic or bitter or specific taste

    • Cenesthetic: feeling body function that are usually undetachable (urine formation)

    • Kinesthetic: occurs when pt is motionless but reports the sensation of bodily movement (floating above the ground)

7. Describe nursing interventions for clients living with Schizophrenia and their families.

8. Describe the mechanism of action, side effects, special nursing considerations and how the following medications used to treat Schizophrenia may also affect the older adult and clients with renal and liver impairment:

  1. First Generation Antipsychotics:

  •  chlorpromazine (Thorazine)

    • MOA: blocks dopamine D2 receptors 

    • Side Effects: sedation, orthostatic hypotension, anticholinergic effect, tardive dyskinesia, weight gain

    • Nursing Consideration:

  • haloperidol (Haldol)

  1.  Second-generation “atypical” antipsychotics:

  • olanzapine (Zyprexa)

  • quetiapine (Seroquel)

  • risperidone (Risperdal)

  • ziprasidone (Geodon)

9. Differentiate between the following side effects from antipsychotic medications:

  • Extrapyramidal side effects

    •  Dystonia: involuntary muscle contractions leading to abnormal posture, movements & sometimes pain

    •  Pseudoparkinsonism: appears early in course tx (shuffling gain, maslike face, muscle stiffness, rigidity, drooling, akinesia) 

    •  Akathisia: appears early in course of tx (restless movement, pacing)

  •  Tardive dyskinesia: late appearing SE of antipsychotic medication; irreversible (drug of choice Clozapine (Clozaril)

  •  Neuroleptic malignant syndrome: emergent; rigidity, high fever, elevated creatinine phosphokinase; can be cause by any antipsychotic medications 

  •  Seizures: not common; associated w high doses

  • Agranulocytosis: failure of bone marrow to produce adequate WBC; sudden onset (fever, malaise, ulcerative sore throat, leukopenia)

10. Describe the mechanism of action, side effects, special nursing considerations and how the following medications are used to treat Extrapyramidal side effects:

  • benztropine (Cogentin)

    • MOA: anticholinergic; blocks muscarinic receptors in the CNS, including imbalance between dopamine & acetylcholine 

    • Side Effects: dry mouth, constipation, urinary retention, blurred vision, confusion, elevated HR

    • Nursing Consideration: monitor for signs of toxicity, use cautiously in older adults due to increase risk of cognitive impairment

    • Use in EPS: effective or Parkinsonism-type EPS (tremors, bradykinesia)

  • amantadine (Symmetrel)

    • MOA: dopaminergic agent; enhances dopamine release & inhibits dopamine reuptake 

    • Side Effects: nausea, dizziness, insomnia, confusion, hallucination, peripheral edema

    • Nursing Consideration: monitor neuropsychiatric side effects, orthostatic hypotension, taper off gradually to avoid w/d

    • Use in EPS: parkinsonism and something drug-induced dyskinesia

  • diphenhydramine (Benadryl)

    • MOA: antihistamine w strong anticholinergic properties that help restore dopamine-acetylcholine balance in the brain 

    • Side Effects: drowsiness,dry mouth,dizziness, confusion, urinary retention

    • Nursing Consideration: monitor for sedation

    • Use in EPS: acute dystonic reaction (muscle spasm)

  •  diazepam (Valium)

    • MOA: benzodiazepine to enhance GABA, leading to muscle relaxation and sedation

    • Side Effects: drowsiness, dizziness, fatigue, confusion, dependence, respiratory depression

    • Nursing Consideration: monitor for resp depression & sedation, avoid abrupt discontinuation to prevent w/d

    • Use in EPS: helpful w akathisia & sometime dystonia due to muscle relaxation

  •  lorazepam (Ativan)

    • MOA: benzodiazepine that enhance BAGA activity leading to sedative, muscle relaxant effects

    • Side Effects: sedation, dizziness, weakness, dependence, respiratory depression

    • Nursing Consideration: monitor or over sedation, short ½ life, caution in hepatic impairment

    • Use in EPS: effective in treating akathisia & acute dystonia

  •  propranolol (Inderal)

    • MOA: non-selective-beta-blocker that reduce adrenergic activity

    • Side Effects: bradycardia, hypotension, fatigue, dizziness, bronchospasm 

    • Nursing Consideration: monitor HR & BP, cautiously in pt w asthma & COPD, do not discontinue abrupt 

    • Use in EPS: most effective akathisia, characterized by motor restlessness & agitation

11. Describe the behavioral strategies used to manage Schizophrenia.

12. Discuss pertinent education topics for clients and their families with Schizophrenia.

13. Analyze your feelings, beliefs, and attitudes regarding Schizophrenia in order to remain therapeutic with clients and their families