Personality

Sum of all traits that differentiate one individual from another

the environment. It includes perceptions, attitudes and emotions. ( Sheila L. Videbeck) Is a total of a persons internal and external patterns of adjustment to life, determined in part by genetically transmitted organic endowment and life experiences. ( Isaac) Total behaviour pattern of an individual through which the inner interests are express Emergence of personality occurs around 2 years of age.

Personality Disorder

 are diagnosed when personality traits become inflexible and maladaptive and

significantly interfere with how a person functions society or cause the person emotional distress. Defined by DSM-IV-TR (Diagnostic Statistical Manual) an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. It seem to derived from interactions among an individuals temperament, family upbringing and life experiences. CATEGORIES OF PERSONALITY DISORDERS Based on predominant or identifying features. A. CLUSTER A includes people whose behaviour appears odd or eccentric and includes paranoid, schizoid and schizotypal personality disorders.

B. CLUSTER B - people who appear dramatic, emotional or erratic and includes antisocial,

borderline, histrionic and narcissistic personality disorder.

dependent and obsessive- compulsive personality disorder.

ONSET AND CLINICAL COURSE Personality disorders are relatively common occurring in 10% to 13% of the general population.
Incidence is even higher for people in lower socioeconomic groups and unstable or

disadvantaged populations. 15% of all psychiatric in-patients have a primary diagnosis of personality disorder.

 40-45% of those with primary diagnosis of major mental illness also have co-existing personality disorder that significantly complicates treatment.
Clients with personality as a result of suicide; they have also higher rates of suicide

attempts, accidents and emergency department visits and increased rates of separation, divorce and involvement in legal proceedings regarding child custody. 70-85 % criminals have personality disorder, 60-70% of alcoholics have personality disorder, and 70-75% drug abuse have personality disorders. (Cloninger and Svakic)
People

with personality disorder often are described as treatment- resistant ( personality characteristics and behavioural pattern are deeply ingrained.

Many clients with personality disorders do not perceive their dysfunctional or maladaptive behaviours as a problem. In deed some of the behaviours are a source of pride.

 The difficulties associated with personality disorders persist throughout young and

middle adulthood but tend to diminish in the 40s and 50s. Those with antisocial personality disorder are less likely to engage in criminal behaviour, although problems with substance abuse and disregard for the feelings of other persist. Clients with borderline personality disorder tend to demonstrate decreased impulsive behaviour, increased adaptive behaviour and more stable relationship by 50 years of age. This increased stability and improve behaviour even without treatment. Some personality disorders such as schizoid, schizotypal, paranoid, avoidant and obsessive-compulsive, tend to remain consistent throughout life.

FACTORS AND CAUSE

A. Behaviour is a learned response that develops as a result of past experiences and

genetic and psychological factors. It develops through the interaction of hereditary dispositions and environmental influences B. Subconscious: composed of material that has been deliberately pushed out of the conscious but can be recalled with some effort C. Unconscious: contains the largest body of material; greatly influences behaviour. a) This material cannot be deliberately brought back into awareness because it is usually unacceptable and painful to the individual.
b) If recalled, it is usually disguised or distorted, as in dreams or slips of the

tongue; however, it is still capable of producing high levels of anxiety. c) According to Freud the personality consists of three parts; the id, ego and superego.

1) Id is the unconscious instincts, impulses, and urges, it is totally selfcentered

2) Ego is the conscious self, The I that deals with reality; the part of the

personality that is shown to the environment.

3) Superego controls, inhibits and regulates impulses and instincts whose uncontrolled expression would endanger the emotional well-being of the individual and the stability of the society, incorporates parental, religious and societal values.

Temperament- refers to the biologic process of sensation, association and motivation that underlie the integration of skills and habits based on emotion. 50% of genetic differences account in temperament traits. FOUR TEMPERAMENT TRAITS
1. Harm avoidance. People with high harm avoidance exhibit fear of uncertainty, social

inhibition, shyness with strangers, rapid fatigability and pessimistic worry in anticipation of problems. High harm avoidance behaviours may result in maladaptive inhibition and excessive anxiety. Those with low harm avoidance are carefree, energetic, outgoing, and optimistic. Low harm avoidance behaviours may result in unwarranted optimism and unresponsiveness to potential harm or danger. 2. High novelty-seeking temperament Results in someone who is quick-tempered, curious, easily bored, impulsive, extravagant and disorderly. He is she may be easily bored and distracted with daily life, prone to angry outburst, and fickle in relationship.

The person low in novelty seeking is slow tempered, stoical, reflective, frugal, reserved, orderly and tolerant of monotony, he or she may adhere to a routine of activities.
3. Reward dependence defines how a person responds to social cues. People high in

reward dependence are tenderhearted, sensitive, sociable and socially dependent. They may become dependent on approval from others and readily assume the ideas or wishes of others without regard for their own beliefs or desires. People with low reward dependence are practical, tough minded, cold, social insensitive, irresolute, and indifferent to being alone. Social withdrawal detachment, aloofness and disinterest in others can result.
4. Persistent Highly persistent people are hardworking and ambitious overachievers

who respond to fatigue or frustration as a personal challenge. They mere persevere even when situation dictates that they should change or stop. People with low persistence are inactive, indolent, unstable and erratic. They tend to give up easily when frustrated and rarely strive for higher accomplishments.

A. PARANOID PERSONALITY DISORDER Is characterized by pervasive mistrust and suspiciousness of others. Client with this disorder interpret others actions as potentially harmful.

Features

 Aloof, withdrawn, remain a considerably physical distance, guarded or hypervigilant, they may survey the room in its contents, look behind furniture or doors, appear alert to any impending danger. Suspects without sufficient basis, that others are exploiting, harming or deceiving them. Be preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and associates Be reluctant to confide in others because of unwarranted fears that the information will be used maliciously against them. Read hidden or demeaning or threatening meanings into benign remarks or events Persistently bear grudges

 Perceive attacks on their character or reputation that are not apparent to other Have recurrent suspicions without justification regarding fidelity of spouse or sexual partner.
Defense mechanism Projection blaming other people, institutions or events

for their own difficulties.

ETIOLOGY

Psychoananalyst believe that the childhood history of an adult with Paranoid Personality Disorder not infrequently includes a controlling parent who was abusive, cruel, and/or sadistic. From this experiences he child learns to be fearful

and mistrusting. In very harsh upbringing the child learns not to ask help and to remain independent. COMMON NURSING DIAGNOSIS Fear Anxiety

INTERVENTIONS

The nurse must approach the client in a formal, business-like manner and refrain from social chitchat or jokes. Rationale these clients takes everything seriously and are particularly sensitive to the reaction and motivation of others.

Being on time, keeping commitments and being particularly straightforward are essential. It is important to involve them in formulating their plans of care because this client needs to feel in control. The nurse asks what the client would like to accomplish their in concrete terms such as minimizing problems at work getting along with other. One of the most effective interventions is helping clients to learn to validate ideas before taking action. Rationale clients can avoid problems if they can refrain for this helps prevent clients from acting on paranoid ideas and beliefs.om taking actions until they have validated their ideas with another person. This helps client from acting on paranoid beliefs. It also assists them to start basing decisions and actions on reality.

B. SCHIZOID PERSONALITY DISORDER

Is characterized by pervasive pattern of detachment from social relationships and restricted range of emotional expression in interpersonal setting. More common in men than woman.

Features Demonstrate pervasive pattern of detachment from social relationships Exhibits restricted range of emotions Must have four or more of the following: Neither desires nor enjoys close relationships, including being part of a family Chooses solitary activities Has little interest in sexual experiences Takes pleasure in few activities

ETIOLOGY

Lacks close friends Appears indifferent to praise criticism Shows emotional coldness

Benjamin (1993)suggests that the child with Schizoid Personality Disorder would

likely have grown up in a home that was orderly and formal, without much warmth, play or spontaneous social interaction. The person with Schizoid personality Disorder remains unattached to self or to others and probably learned behaviours from a parent who was withdrawn. COMMON NURSING DISORDER Impaired social interaction Risk for loneliness

 Ineffective coping INTERVENTIONS Focus on improved functioning in the community. Referrals that will accommodate the clients desire and need for solitude. Facilities designed to promote socialization through group activities would be less desirable. The client need to established at least working relationship with case manager in the community. The case manager can help the client to obtain services and health care, manages finance Etc.. The client has a greater chance of success if he or she can relate his or her needs to one person instead of neglecting important areas of daily life. Offer time and support to the client unconditionally, the client will be unable to respond in the way others do.

C. SCHIZOTYPAL PERSONALITY DISORDER

Is characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioural eccentricities.

ETIOLOGY
The cause of schizotypal Personality disorder is not known. Some tendency for

personality type to be found in more than one family member, but whether this represents a genetic clustering or the results of common upbringing is unknown. Schizoprenia is also seen more commonly among the relatives of schizotypal individuals.

While most persons with Schizotypal personality disorder maintain their personalities throughout adult type without developing schizophrenia, their deficits in social interactions are similar to those found in individuals with schizophrenia. This is common in men than in woman.

FEATURES Demonstrate pervasive pattern of discomfort with social and interpersonal relationships. Exhibits cognitive or perceptual distortions and eccentricities of behaviour Must exhibits five of the following: Ideas of preference Odd belief or magical thinking

Unusual perceptual experiences Odd thinking and speech Suspiciousness or paranoid ideation Behaviour or appearance that is odd, eccentric or peculiar Lack of close friends Excessive social anxiety

INTERVENTIONS:
The focus of nursing care for clients with schizotypal personality disorder is

development of self care and social skills.

 The nurse encourages clients to establish a daily routine for hygiene and grooming. RATIONALE- important rather than depending on the client to decide when hygiene and grooming task are necessary. It help client function in the community with minimal discomfort. The nurse can then role play interactions that clients would have with each of these people. Rationale- allows client to practice clear and logical request to obtain services or to conduct personal business.
Social skills training may help client to talk clearly with others to reduce bizarre beliefs

such as social worker or family member.

A. ANTISOCIAL DISOREDR

Is characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and manipulation.

ETIOLOGY Family history of adults with Antisocial Personality Disorder shows a pattern of violence, neglect and frequently alcoholism. The child may have been a victim of physical abuse or have watched violent parents in their interactions with each other. Adolelescent Conduct Disorder- a prerequisite to the adult diagnosis includes such behaviour as bullying, cruelty to people and animals, stealing or otherwise damaging property, truancy and running away from home. Adults with Antisocial Personality Disorder often have had inordinate control over their families when they were children and adolescent often because of parental negligence or absence.

FEATURES o Violation of the rights of others o Lack of remorse for behaviour o Shallow emotions o Lying o Rationalization of own behaviours o Poor judgement o Impulsivity o Irritability and aggressiveness

o Lack of insight o Thrill seeking behaviour o Exploitation of people in relationships o Poor work history o Consistent irresponsibility COMMON NURSING DIAGNOSIS
Risk for other other-directed violence

Ineffective denial Impaired social interaction INTERVENTIONS

 Forming a therapeutic relationship and promoting responsible behaviour: The nurse must provide structure in the therapeutic relationship, identify acceptable and expected behaviours, and be consistent in those expectations. LIMIT SETTING is an effective technique that involves three steps: 1. Stating the behavioural limit (describing the unacceptable behaviour) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected or desired behaviour
CONFRONTATION is another technique designed to manage manipulative or

deceptive behaviour. The nurse points out clients problematic behaviour while remaining neutral and matter-of-fact. Avoids accusing the client. Helping clients solve problems and control emotions

Clients with personality disorder have an established pattern of reacting impulsively with confronted with problems. The nurse can teach problem solving skills and help client to practice them. Problem solving includes: a) Identify the problem b) Explore solutions c) Choose and implement alternatives d) Evaluate results

Managing emotions, especially anger and frustration can be a major problem. When clients are calm and not upset, the nurse can encourage them to identify sources of frustration. Taking a time-out or leaving the area and going to a neutral place to regain internal control is often a helpful strategy.

 Enhancing Role performance The nurse helps the client to identify specific problems at work or home that are barriers to success in fulfilling roles. Assessing use of alcohol and other drugs is essential when examining role performance, because many clients use or abuse these substances.These clients tend to blame others for their failures and difficulties, and the nurse must redirect them to examine the source of their problems realistically.

Encourage the client to identify the actions that precipitated hospitalization. R- these clients deny responsibility for consequences to their own actions Give positive feedback for honesty. The client may try to act he or she is sick or helpless or use other techniques to avoid responsibility. R- honest identification of the consequences for the client behaviour is necessary for future behaviour change. Identify behaviours that are unacceptable. These may specific (embarrassing Ms. X by using profane language or telling lewd jokes) or general (stealing others possessions) .

R- you may supply limits when the client is unable or unwilling to do so. Limits must be clear, concrete and not open to misinterpretation. Develop specific consequences for the identified unacceptable behaviours (the client may not go to the gym that day, watching televisions is prohibited and so forth.) To be effective the consequence must involve something the client enjoys. R- unpleasant consequences may help decrease or eliminate unacceptable behaviours. Avoid any decision or debate about why the rules or requirement exist. State the requirement or rules in a matter of fact matter. The client may attempt to get special concessions or bend the rules just this once with numerous reasons, excuses, and justifications. Avoid arguing with the client. R Your refusal to be manipulated or charmed will help to decrease manipulative behaviour.

B. BORDERLINE PERSONALITY DISORDER

Is characterized by a pervasive pattern of unstable interpersonal relationships, self image and affect as well as marked impulsivity. It is three times more common in woman than in men.

FEATURES Frantic efforts to avoid real or imagined abandonment Pattern of unstable interpersonal relationships Unstable self-image or sense of self Impulsivity in at least two areas that are potentially self damaging (spending, sex, substance abuse, reckless driving, binge eating) Recurrent suicidal behaviours, gestures or threats or self-mutilating behaviour

Chronic feeling of emptiness Inappropriate anger or difficulty controlling anger Transient, stress-related paranoid ideation. Labile mood Polarized thinking of self and others- (splitting) Impaired judgement Transient psychotic symptoms such as hallucinations demanding self-harm

ETIOLOGY Although precise cause of BPD remains unknown, it is generally assumed that BPD is an acquired condition deriving from the experience of growing up in a chaotic and often

violent family ( Zenarini, 2000) First degree relatives of individuals with BPD are about five times more likely to have this diagnosis than are less closely related individuals. NURSING DIAGNOSIS Risk for suicide Risk for self mutilation Risk for other directed violence Ineffective coping Social isolation INTERVENTIONS Promoting clients safety

The nurse must always seriously consider suicidal ideation with the presence of a plan, and self harm behaviours and institute appropriate interventions. The nurse can encourage client a no-self harm contract, in which a client promises to not engage in self-harm and to report to the nurse when he or she is losing control.

Promoting the therapeutic relationship The nurse must provide structure and limit-setting in the therapeutic relationship. This may mean seeing the client for scheduled appointments of a predetermined length rather than whatever the client appears and demands the nurses immediate attention.

Establishing boundaries in relationships

The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the clients nor the nurses boundaries are violated.

Teaching effective communication skills

The nurse can help clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm. Keeping a journal often helps clients gain awareness of feelings. Clients can use distraction such as taking a walk or listening to music, to deal with delay or they can think about ways to meet needs themselves.

Reshaping thinking patterns

Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking. Thought-stopping is a technique to alter the process of negative or self critical thought patterns such as Im dumb, Im stupid, I cant do anything right. When the thoughts begin the client may actually say. Stop! In a loud voice to stop the negative thoughts. Positive self-talk- the client reframes negative thoughts into positive ones. Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. The nurse asks: So what is the worst thing that could happen? How do you suppose other people might deal with that?

 Can you think of any expectations to that?

Structuring the clients daily activities Minimizing unstructured time by planning activities can help clients to manage time alone. Clients can make a written schedule that includes appointments, shopping, reading the paper, or going for a walk. R- this can also help clients to plan ahead to spend time with others instead of frantically calling others when in distress.

C. HISTRIONIC PERSONALITY DISORDER

Is characterized by a pervasive pattern excessive emotionality and attentionseeking. It is more common in women than men. The tendency of these clients to exaggerate the closeness of relationships or to dramatize relatively minor occurrences can result in unreliable data.

FEATURES Is uncomfortable in situations in which he or she is not the center of attention Displays inappropriate sexually seductive or provocative behaviour Has rapid shifts of emotion Uses physical appearance to draw attention to self Shows dramatization of exaggerated expression of emotion

Is suggestible Considers relationships to be more intimate than they really are

ETIOLOGY THE ADULT Histrionic Personality Disorder has probably been brought op with the sense that his or her value is based on good looks and ability to entertain others.

NURSING DIAGNOSIS o Impaired social interaction o Ineffective coping

INTERVENTIONS

 Gives clients feedback about their social interactions with others including manner of dress and nonverbal behaviour. Feedback should focus on appropriate alternatives not merely criticism. Discuss social situations to explore the clients perceptions of others reactions and behaviour. Teaching those skills and role playing those skills in a safe, nonthreatening environment can help clients to gain confidence in their ability to interact socially. The nurse must be specific in describing and modelling social skills including establishing eye contact, active listening, and respecting personal space. Encouraging clients to use assertive communication such as I statements, may promote self esteem and help them to get their needs met more appropriately.

NARCISSISTIC PERSONALITY DISORDER

Is characterized by a pervasive pattern of grandiosity (in fantasy behaviour) need of admiration and lack of empathy. It is common in adolescence and do not develop in adulthood.

FEATURES

Has grandiose sense of self-importance Is preoccupied with fantasies or unlimited success, power, brilliance, beauty, or ideal love Believes he or she is unique and special and should only associate with other who are special or high-status people Requires admiration of others

 ETIOLOGY

Is interpersonally exploitive Lack empathy Shows arrogance

The developmental history of persons with Narcissistic personality Disoredr typically shows a pattern of selfless love and adoration from significant adult, such that the child escapes realitybased experiences. At the same time, the child experiences an ever-present threat of criticism for not being perfect. Benjamin (1993) states that the rich and famous are particularly vulnerable to developing Narcissistic Personality Disorder in Adulthood because of the attention, devotion, and nurturance given celebrities by the American public. NURSING DIAGNOSIS o Impaired social interaction

o Ineffective coping o Ineffective denial

INTERVENTIONS Use self awareness skills to avoid anger, frustration that their behaviour and attitude can engender. Teach about comorbid medical or psychiatric conditions medication regimen and any needed self-care skills in a matter-of-fact manner.

A. AVOIDANT PERSONALITY DISORDER

FEATURES

Is characterize by pervasive pattern of social discomfort and reticence, lowself esteem and hypersensitivity to negative evaluation.

Is unwilling to get involved with people unless certain being liked Shows restraint in intimate relationships for fear of being shamed or ridiculed Is inhibited in interpersonal relationships because of feeling of inadequacy Views self as socially inept and inferior to others Is unusually reluctant to take personal risk

ETIOLOGY

A person with avoidant personality disorder often has a childhood of being in a family where the opinion of the child not highly regarded or noticed. As a result,

the child is socialized to believe that public exposure can result in humiliation. The individual has a desire to be sociable but also fear that being close to others may bring rejection and/or humiliation. NURSING DIAGNOSIS o FEAR o Risk for loneliness o Ineffective coping INTERVENTION Explore positive self-aspects, positive responses from others and possible reasond for criticism. Helping clients to practice self-affirmations and positive self-talk may be useful in promoting self-esteem.

 Reframing and catastrophizing, can enhance self worth Teach social skills and help clients to practice them in the safety of the nurse-client relationship. The nurse must be careful and patient with clients and not expect them to implement social skills too rapidly.

B. DEPENDENT PRSONALITY DISOREDR FEATURES

Is characterized by pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviour and fears of separation.

Has difficulty making everyday decisions Needs others to assume responsibility for major areas of his or her life

Has difficulty expressing disagreement Has difficulty initiating projects Goes to excessive lengths to obtain nurturance from others Feels uncomfortable or helpless when alone Urgently seeks relationships as a source of care or support In unrealistically preoccupied with fears of being left to take care of self

ETIOLOGY

The theory of dependent of personality Disorder is that, in early childhood, parents did not stop nurturing the child when it was developmentally appropriate to do so, Instead letting the toddler do things on his own. The caregivers offer too much protectiveness. The child becomes incompetent and begins to believe

that he cannot do anything. There is overwhelming parental control and the only option for the developing child is submission. NURSING DIAGNOSIS o Chronic low self-esteem o Fear

INTERVENTIONS Help client express feelings of grief and loss over the end of a relationship while fostering autonomy and self-reliance

 Helping the clients their strength and needs is more helpful than encouraging the overwhelming belief that I cant do anything alone. Reframing and decatastrophizing Assist client in daily functioning Teach problem solving and decision making and help clients apply them to daily life.

C. OBSESSIVE COMPULSSIVE PERSONALITY DISORDER Is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.

FEATURES Is preoccupied with details, list, rules, organization or schedules Aspires to perfectionism that interferes with task completion Is excessively devoted to work and productivity Is over conscientious, scrupulous and inflexible about matters of morality, ethics or values Is unable to discard worn-out and worthless objects Is reluctant to delegate task Adopts a miserly spending style Is rigid and stubborn

ETIOLOGY

Developmental history of an adult with obsessive compulsive personality disorder often reveals a family in which it was expected that the child be perfect and adheres closely to rules. Adults report little warmth in their childhood homes and describe frequent punishment for failure to be perfect. Under such circumstances praise is rarely received, and the child is strongly motivated to strive for carefully correct performance merely to avoid criticism.

NURSING DIAGNOSIS o Anxiety o Fear o Chronic low self-esteem INTEVENTION

 Help client view decision making and completion of projects from a different from a

different perspective. Rather than striving for the goal of perfection, client can set a goal of completing the project or making the decision by a specified deadline. Helping clients to accept or to tolerate less-than perfect work or decision made on time may alleviate some difficulties at work or home. Encouraging client to take risks such as letting someone else plan a family activity, may improve relationships.

Psychosis

Psychosis is a generic psychiatric term for a mental state involving the loss of contact with reality, causing the detioration of normal social functioning. (Reference: Stedman's Medical Dictionary) The word was first used by Ernst Von Reuchtersleben as an alternative for the terms "insanity" and "mania," and is derived from the Greek psyche (mind) and -osis (diseased or abnormal condition). Today, the difference in uses for the terms "psychosis" and "insanity" is vast, the latter employed primarily in a legal setting to denote that a person cannot be held responsible for his or her actions in a court of law, due to psychological distress. Psychosis, on the other hand, is not a clincial diagnosis in and of itself, but, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a symptom common to several other mental illness categories. The three primary causes of psychosis are "functional" (mental illnesses such as schizophrenia and bipolar disorder), "organic" (stemming from medical, non-psychological conditions, such as brain tumors or sleep deprivation), and psychoactive drugs (eg barbituates, amphetamines, and hallucinogens).

A psychotic episode may involve hallucinations, delusions, paranoia, and/or disordered thinking. Psychosis is not necessarily permanent, and occurs in both the chronically mentally ill and otherwise healthy individuals. It is treated by the prescription of anti-psychotic medications, psychotherapy, and, in extreme cases, periods of hospitalization. Psychosis (from the Greek "psyche", for mind or soul, and - "-osis", for abnormal condition) literally means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are said to be psychotic. People experiencing psychosis may report hallucinations or delusional beliefs, and may exhibit personality changes and thought disorder. This may be accompanied by unusual or bizarre behavior, as well as difficulty with social interaction and impairment in carrying out the daily life activities. A wide variety of central nervous system diseases, from both external poisons and internal physiologic illness, can produce symptoms of psychosis.

However, many people have unusual and unshared (distinct) experiences of what they perceive to be different realities without fitting the clinical definition of psychosis. For example, many people in the general population have experienced hallucinations related to religious or paranormal experience.[1][2] These experiences may or may not meet the clinical definition of psychosis. As a result, it has been argued that psychosis is simply an extreme state of consciousness that falls beyond the norms experienced by most.[3] In this view, people who are clinically found to be psychotic may simply be having particularly intense or distressing experiences (see schizotypy). Psychosis is not the same as psychopathy, which is the propensity to engage in extreme antisocial behavior not typically involving hallucinations or delusions.

Signs and symptoms People with psychosis may have one or more of the following: hallucinations, delusions, or thought disorder, as described below.

Hallucinations A hallucination is defined as sensory perception in the absence of external stimuli. They are different from illusions, or perceptual distortions, which are the misperception of external stimuli.[4] Hallucinations may occur in any of the five senses and take on almost any form, which may include simple sensations (such as lights, colors, tastes, and smells) to more meaningful experiences such as seeing and interacting with fully formed animals and people, hearing voices, and having complex tactile sensations. Auditory hallucinations, particularly experiences of hearing voices, are a common and often prominent feature of psychosis. Hallucinated voices may talk about, or to, the person, and may involve several speakers with distinct personas. Auditory hallucinations tend to be particularly distressing when they are derogatory, commanding or preoccupying. However, the experience of hearing voices need not always be a negative one. Research has shown that the majority of people who hear voices are not in need of psychiatric help.[5] The Hearing Voices Movement has subsequently been created to support voice hearers, regardless of whether they are considered to have a mental illness or not.

Delusions Psychosis may involve delusional beliefs, some of which are paranoid in nature. Karl Jaspers has classified psychotic delusions into primary and secondary types. Primary delusions are defined as arising suddenly and not being comprehensible in terms of normal mental processes, whereas secondary delusions may be understood as being influenced by the person's background or current situation (e.g., ethnic or sexual orientation, religious beliefs, superstitious belief).[6] Thought disorder Thought disorder describes an underlying disturbance to conscious thought and is classified largely by its effects on speech and writing. Affected persons show loosening of associations, that is, a disconnection and disorganization of the semantic content of speech and writing. In the severe form speech becomes incomprehensible and it is known as "word-salad". Clinical Scales The Brief Psychiatric Rating Scale (BPRS) [7] assesses the level of 18 symptom constructs of psychosis such as hostility, suspicion, hallucination, and grandiosity. It is based on the clinician's interview with the patient and observations of the patient's behavior over the previous 23 days. The patient's family can also provide the behavior report.

Causes Causes of symptoms of mental illness were customarily classified as "organic" or "functional". Organic conditions are primarily medical or pathophysiological, whereas, functional conditions are primarily psychiatric or psychological. The DSM-IV-TR no longer classifies psychotic disorders as functional or organic. Rather it lists traditional psychotic illnesses, psychosis due to General Medical conditions, and Substance induced psychosis. Psychiatric Functional causes of psychosis include the following:

brain tumors drug abuse amphetamines, cocaine, alcohol[8] among others brain damage schizophrenia bipolar disorder (manic depression) severe clinical depression severe psychosocial stress sleep deprivation some focal epileptic disorders especially if the temporal lobe is affected

exposure to some traumatic event (violent death, etc.) abrupt or over-rapid withdrawal from certain recreational or prescribed drugs

A psychotic episode can be significantly affected by mood. For example, people experiencing a psychotic episode in the context of depression may experience persecutory or self-blaming delusions or hallucinations, while people experiencing a psychotic episode in the context of mania may form grandiose delusions. Stress is known to contribute to and trigger psychotic states. A history of psychologically traumatic events, and the recent experience of a stressful event, can both contribute to the development of psychosis. Short-lived psychosis triggered by stress is known as brief reactive psychosis, and patients may spontaneously recover normal functioning within two weeks.[9] In some rare cases, individuals may remain in a state of full-blown psychosis for many years, or perhaps have attenuated psychotic symptoms (such as low intensity hallucinations) present at most times. Sleep deprivation has been linked to psychosis. However, this is not a risk for most people, who merely experience hypnagogic or hypnopompic hallucinations, i.e. unusual sensory

experiences or thoughts that appear during waking or drifting off to sleep. These are normal sleep phenomena and are not considered signs of psychosis. Vitamin B12 deficiency can also cause symptoms of mania and psychosis. Vitamin D deficiency can cause altered thinking and psychosis. Genetics may also have a role in psychosis. The Genain quadruplets were identical quadruplets who were all diagnosed with schizophrenia. Positive and Negative Symptoms of Psychosis Psychosis manifests itself in a variety of ways and affects an individual's thoughts, feelings, and behaviours. In addition, the symptoms of psychosis are frequently separated into "positive" or thoughts and feelings that are "added on" to how a person ususally thinks and feels and "negative" categories, or things that are "taken away" such as motivation.

I. Confused Thinking

Thoughts become confused and seem to either speed up or slow down. The individual experiencing psychosis may have difficulties concentrating, following instructions or conversations, and remembering things.

II. Changed Feelings Individuals with psychosis may feel strange and cut-off from the rest of the world. They may experience mood swings and feel unusually excited or depressed. Their emotions frequently appear dampened and it is difficult for other others to tell if they are feeling - or simply showing - less emotion. III. "Positive" Symptoms These symptoms are referred to as "positive" because they are viewed as an excess or distortion of the individual's normal functioning. They include: A. Delusions

Delusions are false beliefs that are firmly held. They are distinguished from strongly held beliefs by the degree of conviction with which the belief is held despite contradictory evidence. They are generally organized around one or more of the following themes: 1. Persecutory. Most common. Belief that one is being followed, tormented, or subjected to ridicule. 2. Referential. Also common. Belief that certain gestures, comments, songs, or other environmental cues are specifically directed toward oneself. Grandiose. Belief that one has special abilities or "powers." 3. Religious. Delusions have religious themes (e.g., receiving orders from God) 4. Somatic. Belief that something unusual is occurring in or on one's body, despite medical evidence to the contrary. 5. Loss of Control over Mind or Body. Belief that one's thoughts or body are being controlled by forces or by other individuals. Belief that thoughts are broadcast so others can hear them. A belief that thoughts are being taken out of one's head or are somehow inserted into one's brain. Delusions are considered "bizarre" if they are clearly implausible and are not derived from ordinary life experiences. For example, believing that one's internal organs have been replaced by someone else's without surgery would

be considered a bizarre delusion while the belief that one is being followed by the police would be considered non-bizarre. B. Hallucinations Hallucinations involve seeing, hearing, feeling, smelling, or tasting something that is not actually there. Auditory hallucinations are the most common. They are usually experienced as voices that are perceived as distinct from the individual's own thoughts. C. Disorganized Speech The speech of individuals with psychosis may be disorganized in a variety of ways: Loose Associations. The person frequently moves from one topic to the next with minimal connection between topics.
1. Tangentiality. The person frequently moves from one topic to the next with no

apparent connection between topics. 2. Incoherence. The person's speech is so disorganized as to not be understandable. Since mildly disorganized speech is common and nonspecific, the symptom must be

severe enough to substantially impair effective communication to be considered indicative of psychosis. D. Disorganized Behaviour The behaviour of individuals with psychosis also may be disorganized, often due to difficulties with goal-oriented behaviour: 1. 2. 3. 4. 5. 6. Difficulties performing activities of daily living (e.g., cooking, maintaining hygiene). Marked dishevelment or unusual or inappropriate dress. Inappropriate sexual behaviour. Unpredictable and untriggered agitation. Inappropriate affect (e.g., laughing while describing a personal tragedy). Catatonic behaviour.

I. "Negative" Symptoms. Negative symptoms appear to reflect a decrease in or loss of normal functions. They are difficult to evaluate because they occur on a continuum with normality, are nonspecific, and

may be due to a variety of other factors (e.g., medication side-effects, mood disorder). They include: 1. Restrictions in the range and intensity of emotional expression. 2. Restrictions in the fluency and productivity of thought and speech. 3. Restrictions in the initiation of goal-directed behaviour.

Neurosis Neurosis is a general term referring to mental distress that, unlike psychosis, does not prevent rational thought or daily functioning. This term, coined by William Cullen in the 18th century, has fallen out of favor along with the psychological school of thought called psychoanalysis, founded by Sigmund Freud.

The DSM no longer lists "neurosis" as a category of mental illness, but disorders associated with the term have included obsessive-compulsive, chronic anxiety, phobias, and pyromania. While the Greek roots (neuron, meaning "nerve," and -osis, meaning "disease") implies disorder, neurosis affects most of us in some mild form or other. The problem lies in neurotic thoughts or behaviors that significantly impair, but do not altogether prevent, normal daily living. Neurosis is commonly treated, rather controversially, by psychoanalysis or other psychotherapy, despite the debate over whether or not counselors of this sort are qualified to accurately diagnosis and treat what is defined as a disorder of the nervous system Neurosis is a class of functional mental disorders involving distress but neither delusions nor hallucinations, where behavior is not outside socially acceptable norms.[1] It is also known as psychoneurosis or neurotic disorder, and thus those suffering from it are said to be neurotic. Once a common psychiatric diagnosis, the term is no longer part of mainstream

psychiatric terminology in the United States, though it continues to be employed in psychoanalytic theory and practice, and in various other theoretical disciplines.

PSYCHOSOMATIC began to be used to convey the connection between the mind (psyche) and the body (soma) in states of health and illness. Essentially the mind can cause the body to create physical symptoms or to worsen physical illness. HYSTERIA refers to multiple physical complaints with no organic basis. Sigmund Freud, working with Charcot, observed that people with hysteria improved with hypnosis and experienced relief from their physical symptoms when they recalled memories and expressed emotions. This developmental led Freud to propose that people can convert unexpressed emotions into physical symptoms (Guggenheim 2000), a process now referred to as somatisation.

SOMATIZATION is defined as the transference of mental experiences and states into bodily symptoms. SOMATOFORM DISORDER can be characterized as the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them. THREE CENTRAL FEATURES Physical complaints suggest major medical illness but have no demonstrable organic basis. Psychological factors and conflicts seem important in initiating, exacerbating and maintaining the symptoms Symptoms or magnified health concerns are not under the client conscious control.

A. SOMATIZATION DISORDER
-

Is characterized by multiple physical symptoms without an apparent physiological cause. It begins by 30 years of age, extends over several years, and includes combination of pain and gastrointestinal, sexual and pseudoneurologic symptoms.

SYMPTOMS Pain symptoms- complaints of headache, pain in the abdomen, head, joints, back, chest, rectum; pain during urination, menstruation, or sexual intercourse. Gastrointestinal symptoms nausea, bloating, vomiting (other than during pregnancy), diarrhea or intolerance of several foods.

 Sexual symptoms sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy.
Pseudoneurologic

symptoms conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucination, loss of touch or pain sensation, double vision, blindness, deafness, seizures, dissociative symptoms such as amnesia or loss of consciousness other than fainting.

B. CONVRESION DISORDER Sometimes called conversion reaction, involves unexplained, usually sudden deficits in sensory motor function ( e.g. blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. An attitude of la belle indifference, a seeming lack of concern or distress, is a key feature.

DIAGNOSTIC CRITERIA One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors The symptom or deficit is not intentionally produced or foreigned The symptom or deficit cannot, after appropriate investigation, be fully explained by general medical condition the direct effects of a substance or a culturally sanctioned behaviour or experienced
The symptom or deficit cannot causes clinically significant distress or impairment or

warrants medical evaluation

 The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder and is not better accounted for by another mental disorder.

C. PAIN DISORDER
Has the primary physical symptom of pain, which generally is unrelieved by analgesics

and greatly affected by psychological factors in terms of onset, severity, exacerbation and maintenance.

D. HYPOCHONDRIASIS
-

Is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serous disease 9 disease phobia). It is thought that clients with this disorder misinterpret bodily sensation or functions.

DIAGNOSTIC CRITERIA
Preoccupation with fears of having or the idea that one has, a serious disease based on

the persons misinterpretation of bodily symptoms The preoccupation persist despite appropriate medical evaluation and reassurance The belief in the first criterion is not of delusional intensity The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning The duration of the disturbance is at least 6 months The preoccupation is not better accounted for by another psychological disorder.

E. Body Dysmorphic Disorder

Is preoccupation with an imagined or exaggerated defect in physical appearance such as thinking ones nose is too large or teeth are crooked and unattractive.

RELATED DISORDERS

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms. It is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. People with malingering can stop the physical symptoms as soon as they have gained what they wanted. Factitious Disorder (Munchausens syndrome) - occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. People with this disorder may even inflict injury to themselves to receive attention.

 Muchausens by proxy occurs when a person inflicts

illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero fro saving the victim. ETIOLOGY
Psychosocial theorist believe that people with somatoform disorders keep stress,

anxiety or frustration inside rather than expressing them outwardly. This is called internalization. Clients express these internalized feelings and stress through physical symptoms.
The worsening of physical symptoms helps them to meet psychological needs for

security, attention, and affection through primary and secondary gain.

Primary gain are the direct external benefits that being sick provides such as relief of anxiety, conflict or distress. Secondary gain are the internal or personal benefits received from others because one is sick such as attention from family members and comfort measures. Servan Schreiber (2002) identify this as need to be sick to have emotional needs met.

TREATMENT Treatment focuses on managing symptoms and improving quality life. The health acre provider must show empathy and sensitivity to be the clients physical complaints ( Margo and Margo, 2000). A trusting relationship will help to ensure that clients stay with and receive care from one provider instead of doctor shopping. For many clients depression may accompany or result from somatoform disorders. Thus antidepressants help in some cases.

DRUG Fluoxetine (Prozac)

USAUL DOSE (mg/day) 20-60

NURSING CONSIDERATION Monitor for rash, hives, headache, anxiety, drowsiness, nausea, loss of appetite, avoid alcohol Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolence or insomnia, sweating, sexual dysfunction, avoid alcohol Monitor for nausea, loss of appetite, diarrhea, headache, insomnia, sexual dysfunction, avoid alcohol

Paroxetine (paxil) Sertraline (Zoloft)

20-60 50-200

ASSESSMENT General Appearance and Motor Behaviour

Often clients walk slowly or with an unusual gait because of the pain or disability caused by the symptoms. They may exhibit a facial expression of discomfort or physical distress.

Mood Affect o Labile mood shifting from seeming depressed and sad when describing physical problems to looking bright and excited when talking about how they had to go to the hospital in the middle of the night by ambulance. o Exaggerated emotions Thought process and content o The content of their thinking is primarily about often exaggerated physical concerns. Sensorium and intellectual Processes

o Clients are alert and oriented Judgement and Insight o Exaggerated response to their physical health may affect clients judgement. They have little or no insight into their behaviour Self concept
o

Clients focus only on the physical part of themselves. They are unlikely to think about personal characteristics or strengths and are uncomfortable when asked to do so.

o Low self esteem, lack confidence and have little success in work situations and have difficulty managing life issues. Roles and Relationships o Unlikely to be employed

o o

Lose jobs because of excessive absenteeism or inability to perform work. Decline to see friends and spend little time in social activities for fear they would become desperately ill away from home.

o Lack of family support and understanding. NURSING DIAGNOSIS Ineffective coping Ineffective denial Impaired social interaction Anxiety Disturbed sleep pattern

 Fatigue Pain INTERVENTION Providing Health Teaching Establish daily health routine including adequate rest, exercise and nutrition Teach about relationship of stress and physical symptoms and mind/body relationship Educate about proper nutrition, rest and exercise Educate client in relaxation techniques: progressive relaxation, deep breathing, guided imagery and distraction such as music or other activities. Educate client by role-playing social situation and interaction

Encourage family to provide attention and encouragement when client has fewer complaints Encourage family to decrease special attention when is in sick role.

Assisting the client to express emotions Client may keep a detailed journal of their physical symptoms. The journal may help client to see when physical symptoms seemed worse or better and what other factors may have affected that perception. Teaching coping strategies
a) Emotion focused strategies which help client relax and reduce feelings

of stress. Include progressive relaxation, deep breathing, guided imagery and distractions such as music or other activities.

b) Problem-focused coping strategies which help to resolve or change a clients behaviour or situation or mange life stressors. Include learning problem-solving methods, applying the process to identified problems and role playing interactions with others

Dissociation a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociative Disorder have the essential feature of a disruption in the usually integrated function of consciousness, memory, identify or environmental perception. TYPES OF DISSOCIATIVE DISORDERS

a. Dissociative Amnesia the client cannot remember important personal information

usually of a traumatic or stressful nature

of work without any explanation, travelling to another city, and being unable to remember his or her past or identity. He or she may assume a new identity. c. Dissociative identity disorder (formerly multiple personality disorder) the client displays two or more distinct identities or personality states that recurrently take control of his or her behaviour. This is accompanied by the inability to recall important personal information.
d. Depersonalization disorder the client has a persistent or recurrent feeling of being

detached from his or her mental processes or body. This is accompanied by intact reality testing; that is, the client is not psychotic or out of touch with reality.

ASSESSMENT General appearance and motor behaviour Hyper alert and reacts to even small environmental noises with a startle response. May be very uncomfortable if the nurse is too close physically and may require greater distance or personal space than most people. Appear agitated and may have difficulty sitting still, often needing to pace or move around the room.

Mood affect Look frightened or scared, or agitated and hostile depending on his or her experience

If the client experiences a flashback, he or she appears terrified and may cry, scream or attempt to hide or run away. When the client is dissociating, he or she may speak in a different tone of voice or appear numb with vacant stare

Thought process and Content Clients who have been abused or traumatized report reliving the trauma, often through night mares or flashbacks. Some clients report hallucinations or buzzing voices in their head. Self-destructive thoughts and impulses as well as intermittent suicidal ideation are also common.

Sensorium and intellectual processes

The client is oriented to reality except if the client experiencing flashbacks or dissociative episode. He nurse may also find clients who have been abused or traumatized have memory gaps, which are periods for which they have no clear memories.

Self concept The nurse is likely to find that these clients will have low-self esteem. They may believe they are bad people who somehow deserve or provoke the abuse They think they are unworthy or damaged by their abusive experiences to the point that they will never be worthwhile or valued.

Roles and Relationships

Close relationships are difficult or impossible because the client ability to trust others is severely compromised Problem with authority figures often lead to problems at work.

NURDSING DIAGNOSIS: Risk for self-mutilation Ineffective coping Post trauma response Chronic low self-esteem Powerlessness In addition, the following nursing diagnoses may be pertinent for clients over long periods, although not all diagnoses will apply to each client:

 Disturbed sleep pattern Sexual dysfunction Rape- trauma syndrome Spiritual distress Social isolation NURSING INTERVENTIONS PROMOTING THE CLIENTS SAFETY The nurse can talk with the client about the difference between having self harm thoughts and taking action on those thoughts: having the thought does not mean the client must act on those thoughts.

 Helping the client cope with stress and emotions Grounding techniques are helpful to use with the client who is dissociating or experiencing the flashbacks Helping to promote the clients self-esteem View the client as a survivor of trauma or abuses rather than a victim. It helps refocus their view of themselves from being a victim to being a survivor. Establishing social support