Anxiety

is a normal state of dread, tension, and unease. It is considered a nor

mal response to stress or uncertain situations. Prolonged or intense periods of
anxiety may suggest an anxiety disorder. A disorder may also be indicated if:
Anxiety occurs without an external threat (“free-floating” anxiety)
Anxiety impairs daily functioning
Commonly perceived stressors:
Stressors might be classified as:
1. Maturational stressors - experiences expected as part of the normal process
es of growth and devt. for most individuals.
Most individuals start school, leave school, develop relationships, beco
me employed, support families, lose loved ones, and prepare for their deaths. Th
ese stressors can be anticipated and plans can be made.
2. Situational stressors - less predictable, and specific actions are taken onl
y when the threat is eminent or after the event has occurred.
Ex. Acute illness, accidents, natural disasters, disasters of human ori
gins (terrorist attacks, war), divorce, layoff from work, and chronic illness.
Levels of Anxiety
Mild +1
Moderate +2
Severe +3
Panic +4
Symptoms:
Psychological symptoms may include:
Worry or dread
Obsessive or intrusive thoughts
Sense of imminent danger or catastrophe
Fear or panic
Restlessness
Irritability
Impatience
Ambivalence
Trouble concentrating
Physical symptoms may include:
Rapid or irregular heartbeat
Sweating, especially the palms
Dry mouth
Flushing or blushing
Muscle tension
Shortness of breath
Lightheadedness or faintness
Difficulty sleeping
Shaking
Choking sensation
Frequent urination
Nausea or vomiting
Diarrhea
Constipation
Feeling of "butterflies" in the stomach
Sexual difficulties
Tingling sensations
 Nail biting or other habitual behavior
ANXIETY-RELATED DISORDERS
1. Generalized Anxiety Disorder
Criteria:
a. Excessive worry and anxiety.
b. Difficulty in controlling the worry.
c. Anxiety and worry are evident in 3 or more of the following:
- Restlessness
- Decreased ability to concentrate
- Fatigue
- Muscle tension
- Irritability
- Disturbed sleep
Risk Factors - A risk factor is something that increases your chance of getting
a disease or condition.
Risk factors for GAD include:
Sex: female
Family member with an anxiety disorder
Long-term exposure to abuse, poverty, or violence
Low-self esteem
Poor coping skills
Smoking or other substance abuse
Increase in stress
Psychological symptoms include:
Excessive ongoing worrying and tension
Feeling tense or edgy
Irritability, overly stressed
Difficulty concentrating, mind going "blank"
Stress
Physical symptoms include:
Fatigue
Muscle tension
Headaches
Trembling
Difficulty sleeping
Restlessness
Shortness of breath
Sweating
Stomach ache (abdominal pain)
Heart palpitations
Choking sensation
Diarrhea
Nausea
Nursing Interventions to Reduce Anxiety:
1. Provide a calm and quiet environment.
R: To identify and reduce stimulation, which includes exposure
to situations and interactions with other patients that might provoke
anxiety.
2. Ask patients to identify what and how they feel.
R: To help patients increase their recognition of what is happe
ning to them.
3. Encourage patients to describe and discuss their feelings with you.
R: To help patients increase their awareness of the connection
between feelings and behaviors.
4. Help patients identify possible causes of their feelings.
R: To assist patients in connecting their feelings with earlier
experiences.
Nursing Interventions to Reduce Anxiety:
• Listen carefully for patients’ expressions of helplessness and hopelessn
ess.
R: To assess for self-harm; patients’ might be suicidal because they wa
nt to escape their pain and do not think that they will ever feel better.
6. Ask patients whether they feel suicidal or have a plan to hurt themselves.
R: To assess for self-harm and to initiate suicide precautions, if nece
ssary.
7. Involve patients in activities such as going for walks or playing recrea
tional games.
R: To help patients release nervous energy and to discourage preoccupat
ion with the self
Meds:
Antidepressants, like SSRIs and selective serotonin-norepinephrine reupt
ake inhibitors (SSNRIs).
Because GAD is a chronic disorder, antidepressants are better th
an benzodiazepines due to possibility of dependency and tolerance with long-term
use of benzodiazepines.

2. Panic Disorder
Characterized by recurrent and unpredictable bursts of terror known as p
anic attacks. A panic attack is accompanied by physical symptoms that may feel s
imilar to a heart attack or other life-threatening condition.

Panic Disorder
Intense anxiety often develops between episodes of panic. As panic attac
ks become more frequent, people begin avoiding situations that could trigger the
m. Panic attacks can lead to agoraphobia, which is the fear of unknown places.
Panic Disorder
Causes
Scientists continue to look for the exact cause or causes of panic disorder. It
is believed to be related to:
Family history
Other biological factors
Stressful life events
Increased sensitivity to physical sensations
Panic Disorder
Risk Factors - a risk factor is something that increases your chance of
getting a disease or condition.
Sex: female
Age: young adult
History of another anxiety disorder
Family history of panic disorders
Panic Disorder
Criteria:
a. Recurrent, unexpected panic attacks.
b. Panic attacks followed by a month or more of worry about having addi
tional attacks, worry about the results of the attacks, and behavior changes rel
ated to the attacks.
c. Panic disorder possibly accompanied by agoraphobia
Panic Disorder
Treatment
The goal of treatment is to decrease the frequency and intensity of panic attack
s. Your doctor or mental health care specialist will provide treatment. The foll
owing treatments may be provided:
Panic Disorder
Cognitive-Behavioral Therapy
This can prepare patients for situations that may trigger panic attacks. Therapy
focuses on:
Learning how to recognize what causes your fears
Gradually changing distorted thinking patterns to more healthful ones
Breathing exercises that increase relaxation
Reducing fear and feelings of terror
Panic Disorder
Medications
Your doctor or mental health care specialist may prescribe one or more of the ff
:
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Proz
ac) and sertraline (Zoloft)
Panic Disorder
Anti-anxiety Medicines (Benzodiazepines)
Alprazolam (Xanax)
Clonazepam (Klonopin)
Lorazepam (Ativan)
Panic Disorder
Nursing Management
a. Stay with the patient who is having a panic attack and acknowledge t
he patient’s discomfort.
b. Maintain a calm style and demeanor.
c. Speak in short, simple sentences, and give one direction at a time i
n a calm tone of voice.
d. If patient is hyperventilating, provide a brown paper bag and focus
on breathing with the patient.
Panic Disorder
• Allow patients to pace or cry, which enables the release of tension and
energy.
• Communicate to patients that you are in control and will not let anythin
g happen to them.
g. Move or direct patients to a quieter, less stimulating environment. Do not t
ouch these patients; touching can increase feelings of panic.
h. Ask patients to express their perceptions or fears about what is happening t
o them. Rationale: To help patients reduce anxiety to a more manageable and com
fortable level.
Panic Disorder
Dietary Changes
Some people find that avoiding caffeine (found in coffee, tea, chocolate, colas,
diet sodas) may help reduce panic attacks.
3. Obsessive Compulsive Disorder
A ritualistic behavior to control anxiety
Thoughts = OBSESSIONS
Actions = COMPULSIONS
Obsessive-compulsive disorder (OCD) is an anxiety disorder. The person s
uffers from unwanted repetitive thoughts and behaviors. These obsessive thoughts
and compulsive behaviors are very difficult to overcome. If severe and untreate
d, OCD can destroy the ability to function at work, school, or home.
Frontal lobe
Causes
Tourette syndrome
Trichotillomania—the repeated urge to pull out scalp hair, eyelashes, ey
ebrows, or other body hair
Body dysmorphic disorder—imaginary or exaggerated defects in appearance
Eating disorders (such as bulimia or anorexia nervosa)
Hypochondriasis
Substance abuse
Risk Factors
A risk factor is something that increases your chance of getting a disea
se or condition. Risk factors include:
Age: late adolescence, early adulthood
Family members with a history of OCD
Other anxiety disorders
Depression
Tourette syndrome
Personality disorder
Attention deficit disorder

Symptoms
Obsessions—unwanted, repetitive, and intrusive ideas, impulses, or image
s
Compulsions—repetitive behaviors or mental acts to reduce the distress a
ssociated with obsessions
People with OCD may know that their thoughts and behaviors do not make s
ense. And they would like to avoid or stop them. But they are often unable to bl
ock their obsessive thoughts or compulsions.
Common obsessions:
Persistent fears that harm may come to self or a loved one
Unreasonable concern with being contaminated
Unacceptable religious, violent, or sexual thoughts
Excessive need to do things correctly or perfectly
Common compulsions:
Excessive checking of door locks, stoves, water faucets, light switches,
etc.
Repeatedly making lists, counting, arranging, or aligning things
Collecting and hoarding useless objects
Repeating routine actions a certain number of times until it feels just
right
Unnecessary rereading and rewriting
Mentally repeating phrases
Repeatedly washing hands
Treatments include:
Medications
Selective serotonin reuptake inhibitors (SSRIs) reduce OCD symptoms by a
ffecting the neurotransmitter serotonin. This function is independent of their a
ntidepressant effects. SSRIs include:
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Behavior Therapy (Exposure and Response Prevention)
 This helps you gradually confront the feared object or obsession without
giving in to the compulsive ritual linked to it.
Nursing care:
Ensure that basic needs of food, rest, and grooming are met.
R: Patients are too busy to attend to these tasks. Reminders and specifi
c directions are usually necessary.
2. Provide patients with time to perform rituals.
R: Patients need to keep anxiety in check. Later, work to decrease the
rituals by setting limits, but never take away a ritual, or panic might ensue.
3. Explain expectations, routines, and changes.
R: To prevent an increase or escalation of anxiety.

Be empathic toward patients and be aware of their need to perform ritual

s.
R: To convey acceptance and understanding.
5. Assist patients with connecting behaviors and feelings.
R: To promote the ability to identify and understand feelings.
6. Structure simple activities, games, or tasks for patients.
R: To help patients focus on alternatives to their thoughts and actions.
7. Reinforce and recognize positive nonritualistic behaviors.
R: To increase patient’s self-esteem and self-worth.

4. Phobias
Phobic Disorders
3 Types:
1. Agoraphobia without history of panic disorder; a fear of being in pu
blic or open spaces, places, or situations in which escape might be difficult or
help might not be available – for example, if the person should faint.
2. Social phobia: fear of being humiliated, scrutinized, or embarrasse
d in public – for example, choking while eating in front of others or stumbling
while dancing in view of others.
3. Specific phobia: fear of a specific object or situations that is no
t either of the above – for example, fear of animals, flying, or heights.
Nursing care
1. Accept patients and their fears with a noncritical attitude.
2. Provide and involve patients in activities that do not increase anxi
ety but increase involvement, rather than promote avoidance.
3. Help patients with physical safety and comfort needs.
4. Help patients recognize that their behavior is a method of avoiding
anxiety.
Medication
Meds traditionally have no effect on avoidant behaviors. SSRIs are used
to reduce anxiety and depression and block panic attacks, if any.
5. PTSD
Post-traumatic stress disorder (PTSD) is an anxiety disorder that develo
ps after a traumatic event. PTSD has also been called shell shock or battle fati
gue.
Causes
The exact cause of PTSD is unknown. PTSD is triggered by exposure to a t
raumatic event. Situations in which a person feels intense fear, helplessness, o
r horror are considered traumatic. PTSD has been reported in people who experien
ced:
War
Rape
Physical assault
 Earthquakes
Fire
Sexual abuse
Motor vehicle accidents
Symptoms
People with PTSD experience symptoms of anxiety. These symptoms fall int
o three categories:
Re-experiencing of the event
Dreams/nightmares
Flashbacks
Anxious reactions to reminders of the event
Hallucinations
Avoidance
Avoiding close emotional contact with family and friends
Avoiding people or places that are reminders of the event
Loss of memory about the event
Feelings of detachment, numbness
Arousal
Difficulty falling or staying asleep
Anger and irritability
Difficulty concentrating
Being easily startled
Criteria
1. Exposure to a traumatic event involving threat of death/injury to self or oth
ers, or actual injury to self or others.
2. Responses of horror, helplessness, or fear.
3. Dissociative symptoms during or immediately after the event:
- Absence of emotions, numbing, detachment.
- Decreased awareness or surroundings (in a daze).
- Derealization or depersonalization.
- Amnesia.
4. Reexperiencing or reliving the traumatic event: distressing thoughts, dreams
, flashbacks, illusions.
5. Avoidance of stimuli related to trauma: feelings, thoughts, people, conversa
tions, places, and activities; distress when exposed to reminders of the event.
6. Increased arousal or anxiety: sleep disturbance, hypervigilance, startle res
ponse, irritability, restlessness, decreased concentration.
7. Impairment or distress in functioning – occupational, social, or other impor
tant areas.
8. Onset: Within 4 weeks after the event.
9. Duration: 2 days to 4 weeks.
Risk factors:
Not everyone who experiences a traumatic event will develop PTSD. Sympto
ms of PTSD are more likely to occur if the person has:
Previous traumatic experiences
A history of being physically abused
Poor coping skills
Lack of social support
Existing ongoing stress
A social environment that produces shame, guilt, stigmatization, or self
-hatred
Alcohol abuse
Family psychiatric history
Types of PTSD
PTSD is categorized according to when symptoms occur and how long they l
ast. There are three types of PTSD:
 Acute—symptoms last between one and three months after the event
Chronic—symptoms last more than three months after the event
Delayed onset—symptoms don t appear until at least six months after the
event
Treatment
There is no definitive treatment nor is there a cure for PTSD. A variety
of therapies can help relieve symptoms. You will not begin treatment for PTSD u
ntil after you are completely removed from the traumatic event. You will first r
eceive treatment for severe depression, suicidal tendencies, drug or alcohol abu
se.
Cognitive Behavior Therapy
Many mental health concerns are caused by a combination of physiological
and emotional triggers. CBT can help patients cope by decreasing the effects of
emotional triggers.
Exposure Therapy
The therapist brings back the imagery of the event in a safe place. He o
r she will gradually guide you through a visualization. Re-experiencing the trau
ma in a controlled environment can help you let go of fear and gain control over
the anxiety.
In a recent randomized controlled study involving 288 female military pe
rsonnel suffering from PTSD, prolong exposure was significantly more effective a
t relieving, and even resolving, PTSD symptoms than supportive (non-CBT) therapy
after 10 weekly sessions. *
Group Therapy
Meeting in a group with other survivors of trauma can be an effective an
d powerful form of therapy for PTSD sufferers.
Medication
Medication may help with anxiety, depression, and insomnia.
Usually antidepressants known as selective serotonin reuptake inhibitors
(SSRIs) are prescribed.
Anti-anxiety medications may be used in the short term and/or beta-block
ers in the long term to calm some of the physical symptoms of severe PTSD.
Prevention
The events that trigger PTSD cannot be predicted or prevented. However,
there are some factors that might prevent PTSD from developing after the event.
Debriefing—a group meeting with trained facilitators. This allows those
affected to talk about their thoughts, feelings, and reactions.
Social support—A network of social support can make a difference in how
people react to trauma
Avoid using nicotine or other drugs, and drink alcohol in moderation
Nursing Management
Moderate level of Anxiety
- Recognize anxiety
- Insight into the anxiety
- Cope with the threat
- Promote relaxation response
Severe/Panic level of Anxiety
- Establish a trusting relationship
- Self-awareness
- Protect patient
- Modify environment
- Encourage activity
Physiological Responses, Somatoform and Eating Disorders
Basic Concepts
• The relationship between the mind and body
• All illnesses have a psychological component: Physical disorders have a
psychological component and mental disorders, a physical component
Stress Theory
• Alarm Reaction – the immediate response to a stressor in a localized are
a.
• Stage of Resistance – the body adapts and functions at a lower than opti
mal level, requiring a greater than usual expenditure of energy for survival.
• Stage of Exhaustion – the adaptive mechanisms become worn out and then f
all. The negative effect of the stressor spreads to the entire organism.
Assessment:
• Physical conditions affected by psychological factors:
– Cardiovascular – migraine, hypertension, angina, tension headache
– Musculoskeletal – rheumatoid arthritis, low back pain
– Respiratory – hyperventilation, asthma
– Gastrointestinal – anorexia nervosa, peptic ulcer, irritable bowel syndr
ome, obesity
– Skin - eczema, pruritus
– Genitourinary - impotence, frigidity, PMS
– Endocrinological – hyperthyroidism, diabetes
Psychological
• Some people have physical symptoms without organic impairment called som
atoform disorders
Somatization Disorder
• The person has the physical symptoms, allowing him to be taken of and to
avoid the demands of adult responsibility.
• Secondary gain – related to the gratification of dependency needs is a p
owerful deterrent to change in many patients.
Conversion Disorder
• There is a loss or alteration of physical functioning. Symptoms of some
physical illnesses appear without any underlying organic cause.
• Primary Gain – is that the patient is unable to carry out his impulses.
He also may experience secondary gain in the form of attention, manipulation oth
ers, freedom from responsibilities and economic benefits.
Conversion s/sx may include:
• Sensory symptoms: numbness, blindness, or deafness
• Motor symptoms: paralysis, tremors, mutism
• Visceral symptoms: urinary retention, headaches, difficulty breathing
– Patients display little anxiety or concern about the conversion symptom
and its resulting disability. The classic term for this is la belle indifference

Hypochondriasis
• There is a fear of illness of belief that one has an illness. Has an exa
gerrated concern with physical health that is not based on any real organic diso
rders. Uses information about the diseases to convince himself that he is ill o
r about to become ill.
• Unlike in conversion reaction, no actual loss of distortion of function
occurs. Appears worried and anxious about the symptoms. A chronic behavior patte
rn by a history of visits to numerous practitioners.
• If a person fakes an illness(conscious decision), the behavior is called
malingering. This is usually done to avoid responsibilities the person views as
burdensome.
Body Dysmorphic Disorder
• The person with normal appearance is concerned about having a physical d
efect.
Pain Disorder
• Psychological factors play an important role in the onset, severity, or
maintenance of pain.
Sleep Disorders
1. Insomnia – disorders of initiating sleep.
Anxiety and depression are major causes.
2. Hypersomnia – disorders of excessive somnolence.
Includes narcolepsy, sleep apnea, and nocturnal movement disorders such
as restless legs.
3. Disorders of the sleep-wake schedule, characterized by normal sleep occurring
at the wrong time.
These are transient disturbances associated with jet lag and work shift
changes. Usually self-limited and resolve as the body readjusts to a new sleep-w
ake schedule.
4. Parasomnia – disorders associated with sleep stages.
Includes sleepwalking, night terrors, nightmares, restless legs syndrome
and enuresis.
Often experienced by children and can have significant effect on functio
ning and well-being.
Consequences of sleep disorders:
• Reduced productivity
• Lowered cognitive performance
• Increased likelihood of accidents
• Higher morbidity and mortality risks.
• Depression
• Decreased quality of life
Sleep Hygiene Behavior Strategies
1. Maintain a regular bedtime and wake-up time 7x a week.
2. Exercise daily to aid sleep initiation and maintenance
3. Schedule time to wind down and relax before bed
4. Try relaxation exercises before bedtime
5. Avoid worrying when trying to fall asleep.
6. Guard against night time interruptions
7. Earplugs may help with noisy partner
8. Bedroom should be dark, quiet, cool and comfortable.
9. Create a comfortable bed
10. A warm bath or warm drink before bed helps some people fall asleep.
11. Excessive hunger or fullness may interfere with sleep. Avoid large meals bef
ore bed.
12. Avoid caffeine, excessive fluid intake, stimulating drugs and excessive alco
hol in the evening and before bed.
13. Do not eat, read, work, or watch TV in bed.
14. Excessive napping may make it difficult for some people to fall asleep.
15. Maintain a reasonable weight. Excessive weight may result in daytime fatigue
and sleep apnea.
16. Get out of bed and engage in other activities if not able to fall asleep.
Evaluation
• Decrease visits to MD’s with physical symptoms.
• Decrease use of medications and more positive coping mechanisms.
Anorexia Nervosa
• Fear of obesity
• Feels fat when thin
• Loss of at least 25% of original weight
• Refusal of maintain minimal body weight
• Amenorrhea for 3 cycles
Anorexia….
• A person with anorexia initially begins dieting to lose weight. Over tim
e, the weight loss becomes a sign of mastery and control. The drive to become th
inner is actually secondary to concerns about control and/or fears relating to o
ne s body.
Who is at risk for anorexia?
• Many experts consider people for whom thinness is especially desirable,
or a professional requirement (such as athletes, models, dancers, and actors), t
o be at risk for eating disorders such as anorexia nervosa.
What causes anorexia?
• Although no organic cause for anorexia has been identified, some evidenc
e points to a dysfunction in the part of the brain (hypothalamus) which regulate
s certain metabolic processes. Other studies have suggested that imbalances in n
eurotransmitter levels in the brain may occur in people suffering from anorexia.
How is anorexia diagnosed?
• There are four basic criteria for the diagnosis of anorexia nervosa that
are characterized as:
• The refusal to maintain body weight at or above a minimally normal weigh
t for age and height. Body weight less than 85% of the expected weight is consid
ered minimal.
• An intense fear of gaining weight or becoming fat, even though the perso
n is underweight.
• Self-perception that is grossly distorted and weight loss that is not ac
knowledged.
• In women who have already begun their menstrual cycle, at least three co
nsecutive periods are missed (amenorrhea), or menstrual periods occur only after
a hormone is administered.

How is anorexia treated?

• A gain of between one to three pounds per week is a safe and attainable
goal when malnutrition must be corrected.
• The overall treatment of anorexia, however, must focus on more than weig
ht gain.
• Different kinds of psychological therapy have been employed to treat peo
ple with anorexia. Individual therapy, cognitive behavior therapy, group therapy
, and family therapy have all been successful in treatment of anorexia.
• Nutritional education provides a healthy alternative to weight managemen
t for the patient. Group counseling or support groups often assist the individua
l in the recovery process. The ultimate goal of treatment should be for the indi
vidual to accept herself/himself and lead a physically and emotionally healthy l
ife.
Prognosis:
• The prognosis of anorexia is variable, with some people making a full re
covery. Others experience a fluctuating pattern of weight gain followed by a rel
apse, or a progressively deteriorating course over many years.
Bulimia
• is characterized by episodes of secretive excessive eating (bingeing) fo
llowed by inappropriate methods of weight control, such as self-induced vomiting
(purging), abuse of laxatives and diuretics, or excessive exercise

Criteria
• Binge eating (sense of lack of control over eating a large amount of foo
d)
• Compensatory behavior to prevent weight gain (self-induced vomiting, lax
atives, diuretics, enemas, fasting, excessive exercise.
• Twice a week episodes for 3 months.

Bulimia Nervosa and Binge Eating

• A person which eats too much is designated as either bulimia nervosa (if
the person can keep a normal weight) or binge eating disorder (if the person is
overweight.
• The secrecy of bulimia stems from the shame that bulimics often attach t
o the disorder. Binge eating is not triggered by intense hunger. It is a respons
e to depression, stress, or other feelings related to body weight, shape, or foo
d. Binge eating often brings on a feeling of calm or happiness (euphoria), but t
he self-loathing because of the overeating soon replaces the short-lived euphori
a.
How is bulimia treated?
• Treatment can be managed by either a physician, psychiatrist, or in some
cases, a clinical psychologist.
• The successful treatment of bulimia is often multidisciplinary involving
both medical and psychological approaches.
• The goals of treatment are to restore physical health and normal eating
patterns.
Medications
• A number of antidepressant medications have been shown to be beneficial
in the treatment of bulimia. Several studies have demonstrated that fluoxetine (
Prozac), a member of the selective serotonin reuptake inhibitor (SSRI) class of
antidepressants, has been effective in the treatment of bulimia.
• Small frequent feedings
• Monitor I/O and bowel functions
• Monitor weight gain and lab results
• Encourage expression of feelings
• Set realistic expectations of self
• Encourage participation in activities
• Stay with client during mealtimes, and at least one hour after eating
• Accompany to bathroom after eating
Do not…
• Indicate feelings of shock, disbelief, or disgust
• Confront and judge hostilities and anger if they occur
• Discuss and explain food diet
• Compare clients behavior and appearance to others
• Allow longer than 30 min. mealtime
Personality Disorder
• Personality disturbances that come together to create a pervasive patter
n of behavior and inner experience that is quite different from the norms of the
culture
• They have disturbances in self-image
• Decreased ability to have successful relationships
Cluster A
• Odd and eccentric behaviors
• Paranoid
• Schizoid
Cluster A
PARANOID
• Suspiciousness caused by lack of trust
• Interprets remarks as demeaning or threatening
• Potential for loss of control and violence
• Management
• Establish a trusting relationship. Be professional, honest, and non-intr
usive
• Clear, simple explanations
• Do not involve in group therapy that involve confrontation
Schizoid Personality
• Very shy, cold and aloof.
• Lacks desire for close relationships, appears detached, lack of sexual e
xperiences
• Avoids activities
• Fantasies of imaginary relationships substitute for real relationships

Management
• Offer support, kindness, gentle suggestions to involve in activities
• Socializing activities, vocational counseling and assistance
• Low doses of neuroleptic drugs for anxiety
Management….
• The medication that is most recently used to treat the negative symptoms
is Risperidone. Before this, there was no psychotropic medication that made an
impact on the negative symptoms. Low doses of Risperdone or Olanzapine also work
for the social deficits and blunted affect
DRUG CLASS AND MECHANISM:
Risperidone.
Affects the way the brain works by interfering with communication among
the brain s nerves. Nerves communicate with each other by making and releasing c
hemicals called neurotransmitters. The neurotransmitters travel to other nearby
nerves where they attach to receptors on the nerves. The attachment of the neuro
transmitters either stimulates or inhibits the function of the nearby nerves. Ri
speridone blocks several of the receptors on nerves including dopamine type 2, s
erotonin type 2, and alpha 2 adrenergic receptors. It is believed that many psyc
hotic illnesses are caused by abnormal communication among nerves in the brain a
nd that by altering communication through neurotransmitters, risperidone can alt
er the psychotic state. Risperidone was approved by the FDA in December, 1993.
Cluster B
• Dramatic or Erratic Personality
• Antisocial
• Borderline
• Narcissistic
• Histrionic
Antisocial Personality
• Violates the rights of others, lack of guilt or remorse
• Aggressive behavior, engages in illegal activities
• Irresponsible in work and with finances, impulsive, reckless
Risk factors
• Substance abuse
• Attention deficit hyperactivity disorder (ADHD)
• A history of childhood physical, sexual, or emotional abuse
• Neglect; deprivation or abandonment; associating with peers who engage i
n antisocial behavior;
• A parent who is either antisocial or alcoholic
Antisocial Personality
• Management
• Set limits
• Help patient be aware of consequences of his behavior
• Avoid moralizing, assist in verbalizing anxious feelings and depression
A client with antisocial personality disorder tells a nurse, “ life has been ful
l of problems since childhood”. Which of the ff situations would the nurse explo
re in the assessment?
• Birth defects
• Distracted easily
• Hypoactive behavior
• Substance abuse
Which of the ff behaviors by a client with antisocial personality disorder alert
s a nurse to the need for teaching related interaction skills?
• Frequently crying
• Having panic attacks
• Avoiding social activities
• Failing to follow social norms
Borderline Personality
• Unstable mood and interpersonal relationship, disturbed body image.
• Lack of self identity
• Impulsiveness
• Marked shift from depression to irritability, anxiety, anger, suicidal t
hreats
• Self mutilating behavior
• Chronic feelings of boredom
• Frantic efforts to avoid real or imagined abandonment
Splitting
Allow pt. to perceive external objects as all good or all bad
Due to borderline pt’s inability as a child to separate from the mother
and become individualized
Person is unable to master concepts of both positive and negative feelin
gs, thoughts and perceptions
Using splitting, the pt externalized the internal conflict and manipulat
es the staff to act out the pt’s internal conflict.
Cont…
Limit setting is reassuring to the pt.
Clinical supervision and a cohesive staff group are useful in avoiding g
etting caught in counter transference issues.
Psyche Nursing Intervention
Communication skills
Establish trusting relationship
Increase clients self esteem
Reality orientation
Maintain safe environment
Provide structure
Problem solving
Limit setting
Decision making
Behavior modification
Family intervention

Narcissistic Personality
Narcissistic
• Grandiose self-importance, fantasies of unlimited power, success, or bri
lliance.
• Believes he is special, needs to be admired.
• Sense of entitlement (deserves to be given special treatment)
• Takes advantage of others for his own benefit, lacks empathy
• Arrogant, envious of others.
Causes
• Dysfunctional childhood as excessive pampering, extremely high expectati
ons, abuse or neglect.
• Genetics or psychobiology — the connection between the brain and behavio
r and thinking.
Risk factors:
• An oversensitive temperament as a young child
• Overindulgence and overvaluation by parents
• Excessive admiration that is never balanced with realistic feedback
• Unpredictable or unreliable caregiving from parents
• Severe emotional abuse in childhood
• Being praised for perceived exceptional looks or talents by adults
• Learning manipulative behaviors from parents
Criteria for narcissistic personality disorder to be diagnosed include:
• Having an exaggerated sense of self-importance
• Being preoccupied with fantasies about success, power or beauty
• Believing that you are special and can associate only with equally speci
al people
• Requiring constant admiration
• Having a sense of entitlement
• Taking advantage of others
• Inability to recognize needs and feelings of others
• Being envious of others
• Behaving in an arrogant or haughty manner
Complications
If left untreated, can include:
• Substance abuse
• Alcohol abuse
• Depression
• Suicidal thoughts or behavior
• Eating disorders, particularly anorexia nervosa
• Relationship difficulties
• Problems at work or school
Treatment and drugs:
• Cognitive behavioral therapy. In general, cognitive behavioral therapy h
elps you identify unhealthy, negative beliefs and behaviors and replace them wit
h healthy, positive ones.
• Family therapy. Family therapy typically brings the whole family togethe
r in therapy sessions. You and your family explore conflicts, communication and
problem-solving to help cope with relationship problems.
• Group therapy. Group therapy, in which you meet with a group of people w
ith similar conditions, may be helpful by teaching you to relate better with oth
ers. This may be a good way to learn about truly listening to others, learning a
bout their feelings and offering support.
Narcissistic
Management
• Supportive confrontation
• Set limits, be consistent
• Focus on the here and now to decrease patients use of fantasy
Histrionic Personality
• Uses physical appearance to become center of attention
• Displays sexually seductive or provocative behaviors
• Dramatic expression of emotion. Uses speech to impress others but lacks
depth
• Easily influenced by others
• Exaggerates degree of intimacy with others
Histrionic Personality
• Management
• Positive reinforcement for unselfish or other-centered behaviors
• Provide support for independent problem solving and daily functioning
Psyche Nursing Intervention
• Communication skills
• Establish trusting relationship
• Increase clients self esteem
• Reality orientation
• Maintain safe environment
• Provide structure
• Problem solving
• Limit setting
• Decision making
• Behavior modification
• Family intervention