CHAPTER 15 : Obsessive–Compulsive and Related 2.

Trichotillomania
Disorders ● Chronic repetitive hair-pulling, is a self-soothing
behavior that can cause distress and functional
Terms impairment.
● Obsessions are recurrent, persistent, intrusive, and ● Common: Females
unwanted thoughts,images, or impulses ● Treatment: behavioral therapy
● Compulsions are ritualistic or repetitive behaviors or
mental acts that a person carries out 3. Hoarding Disorder
● Body dysmorphic disorder or BDD is a ● progressive, debilitating, compulsive disorder
preoccupation with an imagined or slight defect in ● Hoarding involves excessive acquisition of animals or
physical appearance that causes significant distress apparently useless things, cluttered living spaces
● Elective cosmetic surgery is sought repeatedly to “fix ● Common: Females / Ages 20-30
the flaw" ● Treatments: CBT / Self-help groups
● Exposure involves assisting the client in deliberately
confronting the situations 4. Onychophagia
● Response prevention focuses on delaying or avoiding ● chronic nail-biting, is a self-soothing behavior
performance of rituals ● Common: Childhood, decrease behavior by age 18
● Ineffective Coping is the inability to form a valid ● Treatment: Selective-serotonin reuptake inhibitors
appraisal of stressor, inadequate choices of practiced (SSRIs)
responses
5. Kleptomania
DSM-5 Related Disorders ● compulsive stealing, is a reward-seeking (thrill of
1. Dermatillomania stealing) behavior
● Excoriation disorder / skin-picking ● Common: Females (with comorbid diagnoses)
● It is an attempt of people to soothe or comfort ● Treatment: Lack of standardized treatment but has
themselves, not that picking itself is necessarily a longer therapy of 10-12 sessions
positive sensation.
● Alternative therapies: yoga, acupuncture, 6. Oniomania
biofeedback ● compulsive buying, is an acquisition type of reward-
seeking behavior
● pleasure is in acquiring the purchased object rather
than any subsequent enjoyment of its use
 ● Common: Female / College Students ● CBT is a successful treatment: first line treatment
● Compulsive shopping - runs in families who have high
comorbidity for depression and substance abuse Cultural Considerations of OCD
● Shame and guilt are prominent feelings
7. Body identity integrity disorder (BIID) ● Christian and Muslim, may have a heightened sense of
● This condition is also known as amputee identity personal guilt (about their symptoms)
disorder and apotemnophilia or “amputation love.”
● The term is given to people who feel “overcomplete,” or Treatment of OCD
alienated from a part of their body and desire 1. Selective - Serotonin Reuptake Inhibitors (SSRIs)
amputation. Antidepressants
Note: People with BIID resort to actions such as packing the ● fluvoxamine (Luvox)
limb in dry ice until the damage is so advanced that ● sertraline (Zoloft),
amputation becomes a medical necessity, or in some cases, These are first-line choices.
amputation is done. ● followed by venlafaxine (Effexor).
2. Second - Generation Antipsychotics (Atypical)
● risperidone (Risperdal)
Obsessive-Compulsive Disorder ● quetiapine (Seroquel)
● For males, it starts in childhood ● or olanzapine (Zyprexa)
● For females, commonly begins in 20s
● It can start in childhood and often lasts into adulthood. Note: Children and adolescents with OCD also respond well to
● SYMPTOM: wax and wane over time, increasing behavioral therapy and SSRI
during periods of stress antidepressants, even when symptoms are treatment
refractory.
Etiology of OCD
● Arise from Aaron Beck’s cognitive approach to Nursing Interventions
emotional disorders 1. Observe the client's eating, drinking and elimination
Aaron Beck's Cognitive Approach pattern - The client may be unaware of its physical
(1) believing one’s thoughts are overly important needs, thus assist them.
(2) perfectionism and the intolerance of uncertainty 2. Monitor sleep patterns and assist - Comfort measures
(3) inflated personal responsibility (from a strict moral or and sleep medications
religious upbringing) and overestimation of the threat posed by 3. Allow extra time for activities - Thoughts may
one’s thoughts. interfere with or lengthen the time
 4. Provide opportunities - As the client is limited to ● ongoing overwhelming feelings of anxiety
complex behavior, give him/her the time to enjoy ● look sad and anxious
activities that can enhance self-esteem Thought Processes and Content
5. Encourage client to participate in follow-up therapy - ● arising from nowhere during the middle of normal
Clients often experience long-term difficulties in activities
dealing with obsessive thoughts ● intact intellectual functioning
● difficulty concentrating or paying attention when
obsessions are strong
Yale-Brown Obsessive–Compulsive Scale ● no impairment of memory
1. Time occupied by obsessive thoughts
2. Interference due to obsessive thoughts Judgment and Insight
3. Distress associated with obsessive thoughts ● recognizes that the obsessions are irrational, but he or
4. Resistance against obsessions she cannot stop them
5. Degree of control over obsessive thoughts Self-Concept
6. Time spent performing compulsive behaviors ● “going crazy"
7. Interference due to compulsive behaviors ● powerlessness
8. Distress associated with compulsive behavior Roles and Relationships
9. Resistance against compulsions ● As the time spent performing rituals increases, the
10. Degree of control over compulsive behavior client’s ability to fulfill life roles successfully decreases.
Physiological and Self-Care Considerations
Note: ● trouble sleeping
Mild : (<1 hour/day) ● loss of appetite or unwanted weight loss
Moderate : (1–3 hours/day)
Severe : (>3 and up to 8 hours/day) Interventions
Extreme : (>8 hours/day) ● Offer encouragement to manage anxiety responses
● Validate feelings
● Encourage the client to talk about the feelings
General Appearance and Motor Behavior ● Relaxation techniques such as deep breathing,
● tense, anxious, worried, and fretful progressive muscle relaxation, and guided imagery
● difficulty relating symptoms because of embarrassment ● Not to interrupt or to attempt to stop the ritual
● "out of the ordinary" ● Gradually decrease time for the client to carry out
Mood and Affect ritualistic behaviors
 ● Emphasize medication compliance as an important ● Word salad — jumbled words and phrases that are
part of treatment disconnected or incoherent and make no sense to the
● Avoid giving advice such as, “Just think of something listener
else" ● Echolalia — repetition or imitation of what someone
else says
Note: ● Latency of response — refers to hesitation before the
● Self-help methods alone may not produce optimal client responds to questions (30-45 seconds)
results, they might be the only type of treatment that ● Loss of ego boundaries — describes the client’s lack
people who are shamed and stigmatized by their of a clear sense of where his or her own body, mind,
OCD symptoms will be willing to seek. and influence end
● Onset of OCD after age 50 is rare. ● Polydipsia — (excessive water intake)

Study Chapter Guide ! Schizophrenia

● distorted and bizarre thoughts, perceptions
CHAPTER 16: Schizophrenia ● disease process with many different varieties and
symptoms, much like the varieties of cancer
Terms peak incidence of onset
● Psychosis — disordered thinking ● Men: 15 to 25 years old
● Catalepsy — waxy flexibility ● Women: 25 to 35 years old
● Neuroanatomy — brain structure ● Onset: abrupt or insidious
● Neurochemistry — activity of people with ● Immediate-Term Course Clinical Patterns
schizophrenia 1. ongoing psychosis and never fully recovers
● Akathisia — is characterized by restless movement, 2. episodes of psychotic symptoms that alternate with
pacing, inability to remain still, and the client’s report of episodes of relatively complete recovery
inner restlessness ● Long-Term Course Clinical Patterns
● Catatonia — restless and unable to sit still, exhibit 1. Over time, the disease becomes less disruptive
agitation and pacing, or appear unmoving
● Echopraxia — imitate the movements and gestures of Note:
someone whom he or she is observing ● Approximately ⅓ to ½ of clients with schizophrenia
● Psychomotor retardation — a general slowing of all relapse within 1 year of an acute episode.
movements ● Early development of disease — worse outcomes
● Fetal position — immobile, curled into a ball
2 Symptoms Major Categories Flat affect: Absence of any facial expression
1. positive or hard symptoms/signs Avolition or lack of volition: Absence of will, ambition, or
2. negative or soft symptoms/signS drive
Inattention: Inability to concentrate or focus on a topic or
Positive or Hard Symptoms activity,regardless of its importance
Ambivalence: Holding seemingly contradictory beliefs
Associative looseness: Fragmented or poorly related Schizoaffective disorder
thoughts and ideas ● diagnosed when the client is severely ill and has a
Delusions: Fixed false beliefs mixture of psychotic and mood symptoms
Echopraxia: Imitation of the movements and gestures Flight ● both schizophrenia and a mood disorder
of ideas: Continuous flow of verbalization in which the person ● Best first choice for treatment : second- generation
jumps rapidly from one topic to another antipsychotics / atypical
Hallucinations: False sensory perceptions
Ideas of reference: False impressions that external events RELATED DISORDERS
have special meaning for the person
Perseveration: Persistent adherence to a single idea or topic; 1. Schizophreniform Disorder
verbal repetition of a sentence, word, or phrase; resisting ● Acute, reactive psychosis for less than the 6 months
attempts to change the topic ● If symptoms persist over 6 months, the diagnosis is
Bizarre behavior: Outlandish appearance or clothing; changed to schizophrenia
repetitive or stereotyped, seemingly purposeless movements;
unusual social or sexual 2. Catatonia
behavior ● Excessive motor activity or virtual immobility and
motionlessnes
Negative or Soft Symptoms ● Include extreme negativism, mutism, peculiar
Alogia: Tendency to speak little (poverty of content) movements, echolalia, or echopraxia
Anhedonia: Feeling no joy or pleasure from life Apathy:
Feelings of indifference toward something Asociality: Social 3. Delusional disorder
withdrawal, few or no relationships, lack of closeness ● One or more non bizarre delusions— that is, the focus
Blunted affect: Restricted range of emotional feeling of the delusion is believable
Catatonia: Psychologically induced immobility occasionally ● persecutory, erotomanic, grandiose
marked by periods of agitation or excitement; the client seems
motionless
 4. Brief psychotic disorder ● One biologic parent with schizophrenia have a 15%
● sudden onset of at least one psychotic symptom, such risk
as delusions, hallucinations, or disorganized speech ● Both biologic parents with schizophrenia have a 35%
● lasts from 1 day to 1 month risk
Note:
5. Shared psychotic disorder (folie à deux) ● Genetic risk of schizophrenia is — polygenic, meaning
● Two people share a similar delusion several genes contribute to the development
● context of a close relationship with someone who has ●
psychotic delusions 2. Neuroanatomic and Neurochemical Factors
● FINDINGS: less brain tissue and cerebrospinal fluid
6. Schizotypal personality disorder ● CT scans: enlarged ventricles in the brain and cortical
● odd, eccentric behaviors atrophy
● 20% of persons with this personality disorder will ● Positron emission tomography: glucose metabolism
eventually be diagnosed with schizophrenia and oxygen are diminished in the frontal cortical
structures of the brain
ETIOLOGY ● positive signs of schizophrenia (temporal lobe), such
as psychosis
● Studies on pathologic structure associated with the ● negative signs of schizophrenia (frontal lobe), such as
disease, largely through autopsy — a site was not lack of volition or motivation and anhedonia
discovered ● most prominent neurochemical: dopamine and
● Interpersonal theorists suggested that schizophrenia serotonin
resulted from — dysfunctional relationships in early ● excess dopamine as a cause
life and adolescence ● clozapine — reduce negative signs of schizophrenia
● Therapists believe that schizophrenia results from —
dysfunctional parenting or family dynamic 3. Immunovirologic Factors
● cytokines — may have a role in the development of
major psychiatric disorders such as schizophrenia
Biologic Theories ● HIGH RATES: children born in crowded areas in cold
weather, conditions *according to research
1. Genetic Factor
● Identical twins have a 50% risk of schizophrenia
● Fraternal twins have only a 15% risk
Culture-bound Syndromes ● conventional, or first-generation, antipsychotic
medications — dopamine antagonists
1. Bouffée délirante ● atypical, or second-generation, antipsychotic
● found in West Africa and Haiti medications — both dopamine and serotonin
● sudden outburst of agitated and aggressive behavior antagonists
2. Ghost sickness first-generation antipsychotics — target the positive
● Native American tribes signs of schizophrenia
● preoccupation with death second-generation antipsychotics — not only diminish
3. Jikoshu-kyofu positive symptoms but also lessen the negative signs of lack of
● fear of offending others by emitting foul body odor volition
● first described in Japan in the 1960s
4. Locura Depot injections, for Maintenance Therapy
● chronic psychosis experienced by Latinos in the United ● Fluphenazine (Prolixin) in decanoate and enanthate
States and Latin America preparations
● incoherence, agitation ● Haloperidol (Haldol) in decanoate
5. Qi-gong psychotic reaction ● Risperidone (Risperdal Consta)
● acute, time-limited episode characterized by ● Paliperidone (Invega Sustenna)
dissociative, paranoid, or other psychotic symptoms ● Olanzapine (Zyprexa Relprevv)
that occur after participating in the Chinese folk health- ● Aripiprazole (Abilify Maintena)
enhancing practice of qi-gong
6. Zar Note:
● experience of spirits possessing a person, is seen in ● Medication effects: last 2 to 4 weeks
Ethiopia, Somalia, Egypt, Sudan, Iran, and other North ● Actions
African and Middle Eastern societies fluphenazine — 7 to 28 days
● afflicted person may laugh, shout, wail, bang his or her haloperidol — 4 weeks
head on a wall ● second-generation LAIs are more effective than oral
forms of the medication in controlling negative
TREATMENT symptoms

Neuroleptics — prescribed primarily for their efficacy in neurologic side effects

decreasing psychotic symptom ● (acute dystonic reactions, akathisia, and parkinsonism)
● tardive dyskinesia
 ● seizures ● Orthostatic hypotension — rise slowly from sitting or
● neuroleptic malignant syndrome lying positions; wait to ambulate until no longer dizzy or
nonneurologic side effects light-headed
● weight gain
● sedation Extrapyramidal Side Effects
● photosensitivity 1. Dystonic reactions
● anticholinergic symptoms ● spasms in discrete muscle groups
● compromise the client’s airway,causing a medical
Side Effects of Antipsychotic Medications and Nursing emergency
Interventions ● extremely frightening and painful for the client
Acute treatment
● Dystonic reactions — Administer medications as ● diphenhydramine (Benadryl) — given either
ordered / reassure if frightened intramuscularly or intravenously
● Tardive dyskinesia — report occurrence or score ● benztropine (Cogentin) — given intramuscularly
increase Note:
● Neuroleptic malignant syndrome — Stop all ● Akathisia — uncomfortable with these sensations and
antipsychotic medications; notify physician may stop taking the antipsychotic medication
● Seizures — stop medication / protect client from injury ● Simpson–Angus scale for EPS
during seizure; provide reassurance and privacy for
client after seizure
● Sedation — caution about activities 2. Tardive Dyskinesia
● Photosensitivity — avoid sun exposure; advise client ● late-appearing side effect of antipsychotic medications,
when in the sun to wear protective clothing and is characterized by abnormal, involuntary movements
sunscreen ● newly approved medications to treat TD :
Anticholinergic symptoms valbenazine (Ingrezza)
● Dry mouth — offer ice chips/hard candy deutetrabenazine (Austedo, Teva)
● Blurred vision — report to physician if no improvement ● Recommended to use: Clozapine (Clozaril)
● Constipation — Increase fluid and dietary fiber intake; ● Abnormal Involuntary Movement Scale (AIMS)
client may need a stool softener - is used to screen for symptoms of movement disorder
● Urinary retention — report any frequency or burning - can be administered every 3 to 6 months
with urination
 3. Seizures ● combines computer-based cognitive training with group
● 1% of people taking antipsychotic medications sessions that allow clients to practice and develop
● clozapine — has an incidence of 5% social skills
● Treatment: is a lowered dosage or a different ● decreasing substance misuse in people with
antipsychotic medication schizophrenia
Family education and therapy
4. Neuroleptic Malignant Syndrome ● diminish the negative effects of schizophrenia and
● serious and frequently fatal condition reduce the relapse rate
● characterized by muscle rigidity, high fever, increased
muscle enzymes (particularly, creatine Unusual Speech Patterns of Clients with Schizophrenia
phosphokinase), and leukocytosis (increased ● Clang associations are ideas that are related to one
leukocyte) another based on sound or rhyming rather than
● Treatment: stopping the medication meaning.
● Neologisms are words invented by the client.
5. Agranulocytosis ● Verbigeration is the stereotyped repetition of words or
● Clozapine has the potentially fatal side effect of phrases that may or may not have meaning to the
agranulocytosis (failure of the bone marrow to produce listener.
adequate white blood cells) ● Echolalia is the client’s imitation or repetition of what
● develops suddenly and is characterized by fever, the nurse says.
malaise, ulcerative sore throat, and leukopenia ● Stilted language is use of words or phrases that are
● can occur as long as 18 to 24 weeks flowery, excessive, and pompous.
● weekly white blood cell counts for the first 6 months of ● Perseveration is the persistent adherence to a single
clozapine therapy and every 2 weeks thereafter idea or topic
● dispensed every 7 or 14 days only, and evidence of a ● Word salad is a combination of jumbled words and
white blood cell count above 3,500 cells/mm3 is phrases that are disconnected or incoherent
required

Psychosocial Treatment Mood and Affect

● masklike
cognitive enhancement therapy (CET) ● silly, characterized by giddy laughter for no apparent
reason
● feeling depressed and having no pleasure or joy
Thought Process and Content ● Visual hallucinations involve seeing images that do
● primary feature of schizophrenia: thought disorder not exist at all, such as lights or a dead person
● (alogia) — describes the lack of any real meaning or ● Olfactory hallucinations involve smells or odors.
substance in what the client says They may be a specific scent such as urine or feces or
a more general scent
Types of Delusions ● Tactile hallucinations refer to sensations such as
● Persecutory/paranoid delusions involve the client’s electricity running through the body or bugs crawling on
belief that “others” are planning to harm him or her the skin
● Grandiose delusions are characterized by the client’s ● Gustatory hallucinations involve a taste lingering in
claim to association with famous people or celebrities the mouth
● Religious delusions often center around the second ● Cenesthetic Hallucinations involve the client’s report
coming of Christ or another significant religious figure that he or she feels bodily functions that are usually
or prophet undetectable
● Somatic delusions are generally vague and ● Kinesthetic hallucinations occur when the client is
unrealistic beliefs about the client’s health or bodily motionless but reports the sensation of bodily
functions movement
● Sexual delusions involve the client’s belief that his or
her sexual behavior is known to others Study Chapter Guide !
● Nihilistic delusions are the client’s belief that his or
her organs aren’t functioning or are rotting away, or
that some body part or feature is horribly disfigured or CHAPTER 17: Mood Disorders and Suicide
misshapen
● Referential delusions or ideas of reference involve Terms
the client’s belief that television broadcasts, music, or ● Anergia — (lack of energy)
newspaper articles have special meaning for him or her ● Euthymic mood — (average affect and activity)
● Mood disorders, — also called affective disorders, are
Types of hallucinations pervasive alterations in emotions that are manifested
● Auditory hallucinations, the most common type, by depression or mania or both
involve hearing sounds, most often voices, talking to or ● Psychomotor agitation — (increased body
about the client movements and thoughts)
Command hallucinations are voices demanding that the ● Ruminate — which is repeatedly going over the same
client take action thoughts
 ● Suicide precautions — (e.g., removal of harmful ● Disruptive mood dysregulation disorder is a
items, increased supervision) persistent angry or irritable mood, punctuated by
severe, recurrent temper outburst
● Cyclothymic disorder is characterized by mild mood
CATEGORIES OF MOOD DISORDERS swings between hypomania and depression
● Substance-induced depressive or bipolar disorder
primary mood disorders is characterized by a significant disturbance in mood
1. major depressive disorder that is a direct physiological consequence of ingested
● lasts at least 2 weeks, during which the person substance
experiences a depressed mood or loss of pleasure in ● Seasonal affective disorder (SAD) has two subtypes.
nearly all activities In one, most commonly called winter depression or fall-
2. bipolar disorder (formerly called manic-depressive onset SAD, people experience increased sleep,
illness) appetite, and carbohydrate cravings. The other
● when a person’s mood fluctuates to extremes of mania subtype, called spring-onset SAD, is less common,
and/or depression, as described previously with symptoms of insomnia, weight loss, and poor
Bipolar I disorder—one or more manic or mixed episodes appetite lasting from late spring or early summer until
usually accompanied by major depressive episodes early fall
Bipolar II disorder—one or more major depressive episodes ● Postpartum or “maternity” blues is a mild,
accompanied by at least one hypomanic episode predictable mood disturbance occurring in the first
Mania is a distinct period during which mood is abnormally several days after delivery of a baby
and persistently elevated ● Postpartum depression is the most common
pressured speech (unrelenting, rapid, often loud talking complication of pregnancy
without pauses) ● Postpartum psychosis is a severe and debilitating
Hypomania is a period of abnormally and persistently psychiatric illness, with acute onset in the days
elevated, expansive,or irritable mood and some other milder following childbirth
symptoms of mania. ● Premenstrual dysphoric disorder is a severe form of
premenstrual syndrome
RELATED DISORDERS ● Nonsuicidal self-injury, sometimes called self-
● Persistent depressive (dysthymic) disorder is a mutilation, involves deliberate, intentional cutting,
chronic, persistent mood disturbance characterized by burning, scraping, hitting, or interference with wound
symptoms such as insomnia, loss of appetite, healing
decreased energy
neurotransmitters affected Treatments
1. Serotonin
● serotonin found in the blood or cerebrospinal fluid Selective Serotonin Reuptake Inhibitors.
occur in people with depression ● SSRIs, the most frequently prescribed category of
2. Norephinephrine antidepressants
● deficient in depression and increased in mania ● Low side effects and relative safety
● energizes the body to mobilize during stress Fluoxetine (Prozac) produces a slightly higher rate of mild
Kindling is the process by which seizure activity in a agitation and weight loss but less somnolence.
specific area of the brain is initially stimulated by reaching a
threshold of the cumulative effects of stress
Anticonvulsants inhibit kindling Fluoxetine (Prozac)
● Administer in AM (if nervous) or PM (if drowsy)
Sertraline (Zoloft)
Psychodynamic Theories ● Encourage use of sugar- free beverages or hard
● Depression is a reaction to a distressing life candy.
experience Citalopram (Celexa)
● Depression is a result of specific cognitive distortions ● Administer dose at 6 PM or later
in susceptible people ● Check orthostatic blood pressure

MAJOR DEPRESSIVE DISORDER Cyclic Antidepressants

● relieve symptoms of hopelessness, helplessness
● involves 2 weeks or more of a sad mood ● 10 to 14 days before reaching a serum level that
● twice as common in women begins to alter symptoms; they take 6 weeks to reach
● episodes clear in about 6 months full effect
● norepinephrine and serotonin, are decreased ● cost less, primarily because they have been around
● acute depression with psychotic features, an longer and generic forms are available
antipsychotic is used in combination with an ● cannot be given concurrently with MAOIs
antidepressant
Amitriptyline (Elavil)
● Monitor cardiac function
Amoxapine (Asendin) meperidine.
● Report rashes Symptoms
Desipramine (Norpramin) ● Change in mental state: confusion and agitation
● Administer in AM if client is having insomnia ● Neuromuscular excitement: muscle rigidity, weakness,
Nortriptyline (Pamelor) sluggish pupils, shivering, tremors, myoclonic jerks,
● Report confusion to physician collapse, and muscle paralysis
● Autonomic abnormalities: hyperthermia, tachycardia,
Atypical Antidepressants tachypnea,hypersalivation, and diaphoresis
● used when the client has an inadequate response to or ● Overdose of MAOI and Cyclic Antidepressants
side effects from SSRIs ● MAOI Drug Interactions
Venlafaxine blocks the reuptake of serotonin, norepinephrine,
and dopamine (weakly).
Duloxetine selectively blocks both serotonin and Other Medical Treatments and Psychotherapy
norepinephrine ● Electroconvulsive therapy (ECT) to treat depression
Bupropion is marketed as Zyban for smoking cessation. in select groups, such as clients who do not respond to
antidepressant
Monoamine Oxidase Inhibitors ● Psychotherapy. A combination of psychotherapy and
● used infrequently because of potentially fatal side medications is considered the most effective treatment
effects and interactions with numerous drugs for depressive disorders
● serious side effect is hypertensive crisis, a life- Interpersonal therapy focuses on difficulties in relationships,
threatening condition that can result when a client such as grief
taking MAOIs ingests tyramine- containing food Behavior therapy seeks to increase the frequency of the
● produces symptoms within 20 to 60 minutes after client’s positively reinforcing interactions
ingestion Cognitive therapy focuses on how the person thinks about
● 2- to 4-week lag period to reach level the self, others

DRUG ALERTS Distortions Addressed by Cognitive Therapy

● Absolute, dichotomous thinking — Tendency to
● Serotonin Syndrome view everything in polar categories
Serotonin syndrome occurs when there is an inadequate ● Arbitrary inference — Drawing a specific conclusion
washout period between taking MAOIs and SSRIs or when without sufficient evidence
MAOIs are combined with
 ● Specific abstraction — Focusing on a single (often
minor) detail while ignoring other, more significant Insomnia early
aspects of the experience 0 — no difficulty sleeping
● Overgeneralization — Forming conclusions based on 1 — occasional sleep
too little or too narrow experience 2 — difficulty sleeping at night
● Magnification and minimization — Overvaluing or
undervaluing the significance of a particular event Depersonalization and derealization
● Personalization Tendency — to self-reference Moderate — unreality feeling
external events without basis Severe — nihilistic ideas

Hamilton Rating Scale for Depression Paranoid

2 — suspiciousness
Depressed mood 3 — ideas of reference
0 — absent 4 — delusions of reference
1 — questioning
2 — feelings state spontaneously, verbally BIPOLAR DISORDER
3 — nonverbal feelings stated
4 — virtually, verbal and nonverbal ● extreme mood swings from episodes of mania to
episodes of depression
Feelings of guilt ● first manic episode generally occurs in a person’s
0 — absent teens, 20s, or 30s
1 — feels he let people down lifetime regimen of medications— either an antimanic agent
2 — ruminates called lithium
3 — think illness as punishment ● salt contained in the human body
4 — hallucinations ● peaks in 30 minutes to 4 hours for regular forms and in
4 to 6 hours for the slow-release form
Suicide ● effective in about 75% of people with bipolar illness
0 — absent Interventions of Lithium Toxicity
1 — not worth living 1.5–2 mEq/L — Withhold next dose
2 — wish being dead 2–3 mEq/L — Withhold future doses
3 — suicide gestures 3 mEq/L or above — Hemodialysis may also be used to
4 — suicide attempt remove lithium from the body
Manic Episode DRUG ALERT
● distinct period of abnormally and persistently elevated, ● Depressed clients who begin taking an antidepressant
expansive, or irritable mood and abnormally and may have a continued or increased risk for suicide in
persistently increased goal-directed activity the first few weeks of therapy

Carbamazepine (Tegretol) Interventions

● used for grand mal and temporal lobe epilepsy as well ● Using an Authoritative Role
as for trigeminal neuralgia ● Providing a Safe Environment
● first anticonvulsant found to have mood-stabilizing ● Creating a Support System List
properties, but the threat of agranulocytosis was of ● Family Response
great concern ● Nurse’s Response
unconditional positive regard
Valproic acid (Depakote) ● Legal and Ethical Considerations
● also known as divalproex sodium or sodium valproate,
is an anticonvulsant used for simple absence and
mixed seizures, migraine prophylaxis, and mania Study Chapter Guide !

Clonazepam (Klonopin) CHAPTER 24: Cognitive Disorders

● used in simple absence and minor motor seizures
Terms
● Cognition is the brain’s ability to process, retain, and
SUICIDE use information.
● Cognitive disorder is a disruption or impairment in the
● intentional act of killing oneself higher level functions of the brain.
● Suicidal ideation means thinking about killing oneself. ● Acute Confusion is the abrupt onset of reversible
● Active suicidal ideation is when a person thinks disturbances of consciousness, attention, cognition,
about and seeks ways to commit suicide and perception that develop over a short period of time
● Passive suicidal ideation is when a person thinks ● Delusions is believing that altered sensory perceptions
about wanting to die are real
● Attempted suicide is a suicidal act that either failed or ● Delirium is a syndrome that involves a disturbance of
was incomplete consciousness accompanied by a change in cognition
● Dementia refers to a disease process marked by ● Time away involves leaving clients for a short period
progressive cognitive impairment with no change in the and then returning to them to reengage in interaction
level of consciousness ● Going along means providing emotional reassurance
● Aphasia is deterioration of language function to clients without correcting their misperception or
● Apraxia is impaired ability to execute motor functions delusion.
despite intact motor abilities
● Agnosia is inability to recognize or name objects Adult Cognitive Disorders
despite intact sensory abilities ● dementia
● Executive functioning is the ability to think abstractly ● delirium
and to plan, initiate, sequence, monitor, and stop ● amnestic disorders
complex behavior
● Mild NCD refers to a mild cognitive decline, and a This is reconceptualized in the DSM-5 as neurocognitive
modest impairment of performance disorders, includes the following:
● Major NCD refers to a significant cognitive decline and ● delirium
a substantial impairment in performance ● major NCD
● Echolalia (echoing what is heard) ● mild NCD
● Palilalia (repeating words or sounds over and over) ● and their subtypes by etiology
● Korsakoff syndrome is a long-term use of alcohol that
results in dementia / previously known as an amnestic
disorder since amnesia and confabulation are Delirium
common
● Confabulation is where clients may make up answers ● Delirium is a syndrome that involves a disturbance of
to fill in memory gaps consciousness accompanied by a change in cognition
● Reframing (offering alternative points of view to ● develops over a short period
explain events) ● difficulty paying attention, are easily distracted and
● Empathetic caring includes being kind, respectful, disoriented, and may have sensory disturbances such
calm, and reassuring and paying attention to the client. as illusions, misinterpretations, or hallucinations
● Reminiscence therapy (thinking about or relating ● Common: Elderly patients
personally significant past experiences) ● Treatment: Treat the casual/underlying medical
● Distraction involves shifting the client’s attention and condition
energy to a more neutral topic.
 ● Pharmacologic: ● medications
Haloperidol (Haldol) - antipsychotic / doses of 0.5 to 1 mg to ● baseline cognitive impairment such as that seen in
decrease agitation and psychotic symptoms, as well as to dementia
facilitate sleep.
Lorazepam (Ativan) - benzodiazepine / reserved for treatment Note: Children may be more susceptible to delirium,
of sedative–hypnotic withdrawal / may worsen delirium, especially that related to a febrile illness or certain medications
especially in the elderly such as anticholinergics.

Drugs Causing Delirium

Examples: ● Anesthesia
Illusion (electrical cord on the floor may appear to them as a ● Anticonvulsants
snake) ● Anticholinergics
Misinterpretation (mistake the banging of a laundry cart in ● Antidepressants
the hallway for a gunshot) ● Antihistamines
Hallucination (see “angels” hovering above when nothing is ● Antihypertensives
there) ● Antineoplastics
● Antipsychotics
Causes of Delirium ● Aspirin
● trauma to the central nervous system (CNS) ● Barbiturates
● drug toxicity or withdrawal ● Benzodiazepines
● metabolic disturbances related to organ failure ● Cardiac glycosides
● Cimetidine (Tagamet)
MOST Common Causes ● Hypoglycemic agents
● Physiological or metabolic ● Insulin
● Infection ● Narcotics
● Drug related ● Propranolol (Inderal)
● Reserpine
Risk Factors of Delirium ● Steroids
● increased severity of physical illness ● Thiazide diuretics
● older age
● hearing impairment General Appearance and Motor Behavior
● decreased food and fluid intake ● restless and hyperactive
 ● may have slowed motor behavior, appearing sluggish Intervention
and lethargic with little movement ● Priority: Safety
● Speech: less coherent and more difficult to understand ● If a client is agitated or pulling at IV lines or catheters,
● pressured speech that is rapid, forced, and usually physical restraints may be necessary.
louder than normal, especially at night ● The nurse approaches these clients calmly and
Mood and Affect speaks in a clear low voice
● rapid and unpredictable mood shifts ● Give realistic reassurance
Thought Process and Content ● Minimizing environmental noises
● Thought processes are often disorganized and make ● When clients experience illusions or misperceptions,
no sense. the nurse corrects them matter-of-factly
● fragmented (disjointed and incomplete) thoughts ● Discourage or limit daytime napping to improve ability
● exhibit delusions, believing that their altered sensory to sleep at night
perceptions are real
Sensorium and Intellectual Processes
● usually oriented to people but frequently disoriented to Dementia
time and place ● progressive cognitive impairment with no change in the
● focus on irrelevant stimuli level of consciousness
● believe their misinterpretations are correct and cannot
be convinced otherwise Cognitive Disturbances in Dementia
Judgment and Insight ● Aphasia
● impaired ● Apraxia
● cannot perceive potentially harmful situations ● Agnosia
Roles and Relationships ● Executive functioning
● unlikely to fulfill their roles during the course of delirium
Self-Concept
● frightened or feel threatened
● feel guilt, shame, and humiliation
Physiological and Self-Care Considerations
● disturbed sleep–wake cycles
● fail to perceive internal body cues such as hunger,
thirst, or the urge to urinate or defecate
Comparison of Delirium and Dementia ● remain in the community
2. Moderate
● Confusion is apparent, along with progressive
memory loss
● no longer can perform complex tasks but remains
oriented to person and place
● remain in the community if adequate caregiver support
is available, but some people move to supervised
living situations
3. Severe
● Personality and emotional changes occur
● delusional
● require assistance with ADLs
● live in nursing facilities when they reach this stage,
unless extraordinary community support is available

Etiology

For dementia, genetic components have been identified such

as Huntington disease.
For Alzheimer, the abnormal APOE gene is known to be linked
with it.

Early sign of dementia: Memory impairment The most common types of dementia and their known or
hypothesized causes follow:
Onset and Clinical Course 1. Alzheimer disease
1. Mild ● It is a progressive brain disorder that has a gradual
● Forgetfulness is the hallmark of beginning, mild onset but causes an increasing decline in functioning
dementia
● Occupational and social settings are less enjoyable
 ● Evidenced by atrophy of cerebral neurons, senile ● It is the most common prion disease affecting humans.
plaque deposits, and enlargement of the third and ● Develops: adults aged 40 to 60 years
fourth ventricles of the brain. ● Encephalopathy due to an infectious particle resistant
to boiling
2. Lewy body dementia Mad cow disease and kuru (seen largely in New Guinea from
● It is a disorder that involves progressive cognitive eating infected brain tissue) are other prion diseases.
impairment and extensive neuropsychiatric symptoms
as well as motor symptoms. 6. HIV infection
● Common Manifestations: Delusions and visual ● This results directly from invasion of nervous tissue by
hallucinations HIV or from other acquired immunodeficiency
syndrome–related illnesses such as toxoplasmosis
3. Vascular dementia and cytomegalovirus.
● The symptoms similar to those of Alzheimer disease, ● severe muscle dysfunction
but onset is typically abrupt, followed by rapid changes
in functioning 7. Parkinson disease
● CT Scan & MRI: multiple vascular lesions of the ● It is a slowly progressive neurological condition
cerebral cortex and subcortical structures characterized by tremor, rigidity, bradykinesia, and
postural instability.
4. Frontotemporal lobar degeneration (originally called ● It results from loss of neurons of the basal ganglia.
Pick disease)
● It is a degenerative brain disease that particularly 8. Huntington disease
affects the frontal and temporal lobes ● It is an inherited, dominant gene disease that primarily
● Clinical picture similar to that of Alzheimer disease involves cerebral atrophy, demyelination, and
● Common: 50 to 60 years / death occurs in 2 to 5 enlargement of the brain ventricles.
years ● begins in the late 30s or early 40s and may last 10 to
20 years or more before death.
5. Prion diseases ● Initial manifestations: Personality changes
● It is caused by a prion (a type of protein) that can
trigger normal proteins in the brain to fold abnormally. Neurotransmitters that decrease in Dementia
● Rare / 300 cases per year in US ● acetylcholine
Note: ● dopamine
Creutzfeldt–Jakob disease ● norepinephrine
 ● serotonin warning of the used of antipsychotics in treating
dementia
Treatment for Dementia ● Benzodiazepines are used cautiously, it may cause
Cholinesterase inhibitors delirum and worsen compromised cognitive abilities.
● Donepezil (Aricept) test stool for GI bleeding ● Pimavanserin (Nuplazid) has been specifically FDA
● Rivastigmine (Exelon) monitor for abdominal pain approved to treat delusions and hallucinations, in
● Galantamine (Reminyl, Razadyne, Nivalin) monitor Parkinson's disease.
for syncope
Note: These drugs have shown modest therapeutic effects.
● Tacrine (Cognex) Assessment
It is also a cholinesterase inhibitor; however, it
elevates liver enzymes in about 50% of clients using it. General Appearance and Motor Behavior
Interventions: ● Impairs the ability to carry on meaningful conversation
- Liver function tests are necessary every 1 to 2 weeks ● Conversation becomes repetitive
● Speech may become slurred
NMDA (N-methyl-D-aspartate) receptor antagonist ● Cannot imitate the task when others demonstrate it for
● Memantine (Namenda) monitor for hypertension, them
headache, constipation, and fatigue ● Severe: gait disturbance
- It slows the progression of Alzheimer in the moderate Mood and Affect
or severe stages. ● Mood: Labile
● Common: Emotional outburst
Note: ● Displays anger and hostility
● Namzaric (memantine and donepezil) is a newer Thought Process and Content
combination of two other medications, thereby having ● Common: delusions of persecution
the actions of both cholinesterase inhibition and NMDA ● loss of the ability to plan, sequence, or stop complex
receptor antagonist. behavior
● Antidepressants cause delirium. Sensorium and Intellectual Processes
● SRRIs are used because it has fewer side effects. ● Initial: Memory deficits
● Antipsychotics are used to manage delusions, Note: Dementia first affects recent and immediate memory
hallucinations, or paranoia, and other behaviors, such and then eventually impairs the ability to recognize close
as agitation or aggression. There is a black box family members and even oneself.
● Confabulation is noted
 ● Hallmark of Dementia: Agnosia
● Frequent Problem: Hallucinations (most common is
visual hallucinations)
Judgment and Insight
● Cannot evaluate situations for risks or danger
● May worry that he or she is “losing my mind”
Self-Concept
● May be angry or frustrated with themselves for losing
objects or forgetting important things
● Some clients express sadness at their bodies for
getting old and at the loss of functioning.
Roles and Relationships
● Roles as spouse, partner, or parent deteriorate
Physiological and Self-Care Considerations
● disturbed sleep–wake cycles; nap during the day and
wander at night
● experience bladder and even bowel incontinence

Interventions
● validating feelings and dignity of clients
● reframing (offering alternative points of view to explain
events)

Others
● Touch can provide reassurance and convey caring
when words may not be understood.
● Reminiscing, also called nostalgia, uses the client’s
remote memory, which is not affected as severely or
quickly as recent or immediate memory.

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