Review Notes Psyche

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REVIEW NOTES

Psychiatric and Mental Health Nursing


MENTAL HEALTH
State of wellbeing in which the individual REALIZES HIS OR HER OWN ABILITIES can cope with the normal stresses of life, can work
productively and fruitfully and able to make contribution to his community (World Health Organization).

MENTAL STATUS EXAMINATION


A. Appearance 3. Thought disturbance
1. Personal Identification – NT description 4. Perceptual disturbance
2. Behavior and Psychomotor Activity - GMT 5. Dreams and fantasies
3. General Description - E. Sensorium
B. Speech 1. Alertness
C. Mood and affect 2. Orientation
4. Mood – a pervasive and sustained emotion that 3. Concentration and Calculation
colors the persons perception 4. Memory
5. Affect – the outward expression 5. Fund of knowledge
D. Thinking 6. Abstract thinking
1. Form of thinking 7. Insight
2. Content of thinking 8. Judgment

SIGMUND FREUD
Components of Personality
1. ID- part of a person that reflects BASIC or innate DESIRES, INSTINCT and SURVIVAL impulses
2. EGO- represents the REALITY aspect
3. SUPER-EGO- part that reflects MORALITY and ethical concepts, and values

FREUD: Personality Stages and Functional Awareness


1. Conscious – perceptions, thoughts and emotion that exist in the person’s awareness
2. Pre-conscious/Subconscious- Thoughts and emotions not currently in awareness but can be recalled with effort
3. Unconscious- thoughts, drives and emotions totally a person is Unaware

FREUD: Psychosexual Stages of Development


• ORAL (birth-18months)
• ANAL (18months-36months)
• PHALLIC/OEDIPAL (3 years-5years)
• LATENT (5years-11years)
• GENITAL (11years-13years)

ERIK ERIKSON
EPIGENETIC PRINCIPLE - STAGES OF DEVELOPMENT
Trust vs Mistrust birth, HOPE view world as safe and secure Psychosis, Addiction, Depression

Autonomy vs Shame & doubt 18mos Achieves sense of control & Paranoia, Obsession, Compulsion,
WILL well-being Impulsive
Initiative vs Guilt 3yrs Development of conscience & Phobia
PURPOSE manage conflict Psychosomatic
Inhibition
Conversion d/o
Industry vs Inferiority 5yrs Confidence in own abilities Creative inhibition
COMPETENCE
Identity vs Role confusion 13 yrs Formulating a sense of self and Borderline, Delinquency
FIDELITY well-being Gender-identity
Intimacy vs isolation 20’s Forming adult, being creative & Schizoid, Distantiation
LOVE productive
Generativity vs stagnation 40’s Establishing the next generation Midlife crisis
CARE Premature invalidism
Integrity vs despair 60’s Accepting one’s responsibilities Extreme alienation & despair
WISDOM for self & life

THERAPEUTIC NURSING PROCESS


Characteristics: Goal-Directed; Understanding: Empathic; Concreteness; Honest: Open Communication; Acceptance: Non-
Judgmental
ORIENTATION (teach them) WORKING (provide therapeutic experience) TERMINATION (take pride)
Trust/rapport Promote positive self-concept Promote self-care
Environment Realistic goal-setting Recognize increasing anxiety
Assessment of strength & Organized support system Increase independence
weaknesses Verbalize feelings (encourage) Demonstrate emotional stability
Contrast (verbal) Implement plan of action Environmental support
(therapeutic) Develop (+) coping behaviors
Help communicate Evaluate the results of plan of action

FOCUS OF THERAPEUTIC RELATIONSHIP


• Reinforced self-worth
• Enhanced self-concept & confidence
• Learn coping strategies
• Examine relationships
• Achieve self-growth
• Solve problems
• Extinguish unwanted behavior

SPEECH PATTERNS ASSOCIATED WITH PSYCHIATRIC PROBLEMS


• Blocking: looses train of thoughts, stops talking • Neologism: coining new term
• Circumstantiality: describing too much detail • Perseveration: answering new question w/ previous
• Echolalia: repeating last word heard question’s answer
• Flight of ideas: shifting to unrelated topic • Pressured speech: speak rapidly w/ urgency
• Loose associations: speaks constantly loosely-related • Verbigeration: repeat words, phrases, sentences
topics several
• Mutism: inability to speak

THERAPEUTIC COMMUNICATION TECHNIQUES


• Offering self – I’ll sit with you • Description of perception – what do you think? What
• Active listening – direct eye contact, distance is your opinion?
• Silence • Voicing doubt – expressing uncertainty / what other
• Empathy – I can hear how painful it is to you conclusions could there be?
• General leads – go on • Placing an event in time or sequence – when did you
• Clarification – what do you mean? Example nga. do this? Then…
• Restating – repeating the exact words of the client • Comparison – how do you compare this from last
• Verbalizing the implied – rephrasing the patients time?
words • Focusing – pursuing a topic until meaning is clear/
• Questioning – who? What? explain more about…
• Making observations – commenting what is seen • Interpreting – provide a view of the meaning / it
• Presenting reality – I know that the voices are real to sound as if….
you but I don’t hear them • Encouraging evaluation – so what does this all mean
to you?
PSYCHOTHERAPY
• basic concept INVOLVES UNDERSTANDING
• focus is on ISSUES OF IMPORTANCE to the client, purpose of the interaction, identification of the roles of the therapist
and client, and the use of primarily verbal means of communication.
• Nonverbal techniques include silence, body language, facial expression, and respect for personal space.

DESENSITIZATION
• Desensitization is the reduction of intense reactions to a stimulus by repeated exposure to the stimulus in a weaker and
milder form.
• Gradually over a period of time, exposure is increased until the fear of the object or situation has ceased.

ELECTROCONVULSIVE THERAPY
An effective treatment for depression that consists of inducing a grand mal (tonic-clonic) seizure by passing an electrical current
through electrodes that are attached to the temples
• Usual course is 6 - 12 treatments given 2-3 times per week
• Maintenance ECT once a month may help to decrease the relapse rate for the client with recurrent depression

At-risk clients include:


• with recent myocardial infarction
• cerebral vascular accident
• cerebral vascular malformation
• clients with intracranial mass lesions

Contraindications:
1. Angina pectoris
2. Congestive heart failure
3. Severe pulmonary disease
4. Fractures
5. Glaucoma
6. PREGNANCY
7. Use of MAOIs and clozapine

Uses
• Manic clients whose conditions are resistant to lithium and antipsychotic medications and clients who are rapid cyclers (a
client with a bipolar disorder who has many episodes of mood swings close together)
• Clients with schizophrenia (especially catatonia), those with schizoaffective syndromes, and psychotic clients.

Indications for use


• When antidepressant medications have no effect
• When there is a need for a rapid definitive response, such as when a client is suicidal or homicidal
• The client is in extreme agitation or stupor

Notes in conducting
• Oxygen is given by mask
• Tongue guard may be placed on the mouth
• 110-150 volts of electricity is delivered for 0.5 to 2 seconds to initiate a tonic clonic seizure, usually lasting for 1-minute

POST procedure
• Continue monitoring of VITAL SIGNS • The patient is returned to the room after all vitals are
• Patient is usually brought to the recovery room where stable
emergency drugs and equipments are available • Mental status examination
• RE-ORIENT the client when he is awake • NPO temporarily and introduce foods once GAG
• Provide reassurance that the amnesia is ONLY reflex will return
temporary

ANXIETY FEAR
State of mental uneasiness Emotion of apprehension

Source may not be identifiable Source is identifiable

Related to the future Related to the present

Vague Definite

Result of psychological or emotional conflict Result of discrete physical or psychological entity,


definite and concrete events

MILD
• Mild anxiety is associated with the tension of everyday • The perceptual field is increased.
life. • Mild anxiety can be motivating, produce growth and
• The individual is ALERT. creativity, and increase learning.

MODERATE
• The focus is on IMMEDIATE CONCERNS. • SELECTIVE INATTENTIVENESS occurs.
• Moderate anxiety narrows the perceptual field. • Learning and problem-solving still take place.

SEVERE
• Severe anxiety is a feeling that something bad is about to • All behaviors is directed at relieving the anxiety.
happen. • Learning and problem-solving are not possible.
• A significant occurs reduction in perceptual field occurs. • The individual needs direction to focus.
• Focus is on specific details or scattered details.

PANIC
• associated with dread and terror and a sense of impending • Increased motor activity occurs.
doom. • Loss of rational thoughts with distorted perception occurs.
• The personality is disorganized. • Inability to concentrate occurs.
• The individual is unable to communicate or function • If prolonged, can lead to exhaustion and death.
effectively.

COPING MECHANISMS
• Compensation - extra effort in one area to offset real or • Denial - treating obvious reality factors as though they do
imagined lack in another area not exist because they are consciously intolerable
• Conversion - A mental conflict is expressed through
physical symptoms
• Displacement - transferring unacceptable feelings • Projection - unconsciously projecting one's own
aroused by one object to another, more acceptable unacceptable qualities or feelings onto others
substitute • Rationalization - JUSTIFYING BEHAVIORS, emotions,
• Dissociation - WALLING OFF specific areas of the motives, considered intolerable through acceptable
personality from consciousness excuses
• Fantasy - a conscious distortion of unconscious wishes • Reaction Formation - expressing unacceptable wishes or
and need to obtain satisfaction behavior by opposite overt behavior
• Fixation - becoming stagnated in a level of emotional • Regression - retreating to an earlier and more
development in which one is comfortable comfortable emotional level of development
• Identification - subconsciously attributing to oneself • Repression - unconscious, deliberate forgetting of
qualities of others unacceptable or painful thoughts, impulses, feelings or
• Intellectualization - use of thinking, ideas, or intellect to acts
avoid emotions • Sublimation - diversion of unacceptable instinctual drives
• Introjection - incorporating the traits of others. into personally and socially acceptable areas.

CRISIS
• Crisis is a temporary state of severe emotional disorganization caused by failure of coping mechanisms and lack of support.
• Decision making and problem solving are inadequate.
• Treatment is immediate, supportive, and directly responsive to the immediate crisis to assist the client and the family through
the stressful situation.

TYPES OF CRISES
• Maturational—relates to developmental stages and associated role changes
• Situational—arises from an external source and is associated with a life event that upsets an individual or a group’s
psychological equilibrium.
• Adventitious—relates to a crisis of disaster or an event that is not a part of everyday life and is unplanned and accidental.

PSYCHOSIS NEUROSIS
• POOR contact with reality • any long term mental or behavioral d/o in which
• PRESENCE of delusions, hallucinations, severe thought contact with reality is retained the condition is
disturbances, alteration of mood, poverty of thought recognized by the patient as abnormal.
and abnormal behavior • features anxiety or behavior exaggerated designed to
• (schizophrenia , major disorder of affect (mania – avoid anxiety
depression), major paranoid states and organic mental • (anxiety d/o ; hysteria to conversion d/o, amnesia,
disorder fugue, multiple personality and depersonalization-
• Benefits fr: PSYCHOANALYSIS and Antipsychotics dissociative d/o ; oc d/o)
• Benefits from Behavior Therapy

DSM V - MENTAL DISORDERS


NEURODEVELOPMENTAL DISORDERS
Assessment STARS
Intellectual Disability • Age requirement
• Delays in oral language development • Deficits in the following areas
• Deficits in memory skills - I
• Difficulty learning social rules - A
• Difficulty with problem solving skills * C
• Delays in the development of adaptive behaviors such * S
as self-help or self-care skills * P
• Lack of social inhibitors

Communication Disorders • reduced


• include speech sound disorder (a new name for phono- • limited
logical disorder), and childhood-onset fluency disorder • impairment in
(a new name for stuttering)
Autism Spectrum Disorder (ASD) • FAILURE – pay close attention to details
• 1) deficits in social communication and social interaction
• 2) restricted repetitive behaviors, interests, and
activities (RRBs)

Attention-Deficit/Hyperactivity Disorder • Onset of Sx before age 12


• The same 18 symptoms are used as in DSM-IV, and •
continue to be divided into two symptom domains

Specific Learning Disorder • inaccurate/slow/effortful word reading


• reading disorder, mathematics disorder, disorder of • spelling
written expression • written expression
• mastering number
• specify if:
- Dys
- Dys

Motor Disorders • TIC


• Tourette’s disorder, persistent (chronic) motor or vocal
tic disorder, provisional tic disorder

Severity Levels for ID (IDD)


LEVEL CONCEPTUAL DOMAIN SOCIAL DOMAIN PRACTICAL DOMAIN
Language, reading, writing, math, Empathy, social judgment, Self management, personal care,
reasoning, knowledge and memory interpersonal communication, job management, money
friendships management, recreation,
organizing school and work
Mild • Difficulty in learning • Immature in • Need support with completion
IQ - of daily tasks in comparison to
peers
Moderate • Conceptual skills • May not interpret social • Reminders needed
IQ - • Social judgment • Extended teaching

Severe • Little understanding of written • Spoken language is quite • Requires support and
IQ - expression limited supervision

Profound • Physical world rather than • Limited understanding • Dependent on others for all
IQ - symbolic process aspects

SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS


ASSESSMENT IMPLEMENTATION STARS
Withdrawal from relationships and world Maintain safety—protect from erratic behavior Emil Kraeplin (1800s): dementia
• Inappropriate display of feelings • With hallucination—do not argue, validate praecox “precoci madness w/ 2
• Hypochondriasis reality, hallmark sx (delusion & hallucination)
respond to feeling tone, never further discuss
• Suspiciousness preceded by dereism (separation of self
voices (don’t ask to tell more about voices)
• Inability to test reality, regression from reality)”
• With delusions—do not argue, point out
• Hallucinations—false sensory feeling Eugene Bleuler: coined schizophrenia
perceptions tone, provide diversional activities (split mind)
• Delusions—persistent false beliefs; • Meet physical needs
grandeur (feel higher rank); persecutory • Establish therapeutic relationship
(beliefs to be a victim); ideas of • Institute measures to promote trust
reference (see people talking think • Engage in individual, group, or family therapy
talking about them) • Encourage client’s affect
• Accept nonverbal behavior
• Loose associations
• Accept regression
• Short attention span • Provide simple activities or tasks
• Inability to meet basic
needs: nutrition, hygiene
• Regression

▪ Associative Looseness – lack of logical thought leading to chaotic and disorganized thinking
▪ Affective Disturbances – flat, blunted, and socially inappropriate affect of feeling tone
▪ Ambivalence – presence of strong conflicting feelings leading to psychic immobility and confusion
▪ Autism – extreme retreat from reality, preoccupation with self, leading to psychotic thought processes

Postitive Symptoms Negative Symptoms


Also called symptoms reflect an excess or distortion of Also called deficit reflect a loss of normal functioning
npsychotic or active ormal functioning and include:
• Delusions • Withdrawal
• Hallucinations • Ambivalence
• Disorganized thinking and behavior • Loss of motivation (avolition)
• Catatonic behavior • Loss of pleasure (anhedonia)
• Loose associations • Poverty of speech (alogia)
• Suspiciousness • Blunted or flat affect
• Bizaare behavior

BIPOLAR AND RELATED DISORDERS


ASSESSMENT IMPLEMENTATION STARS
Disoriented, flight of ideas Meet physical needs first
• Lacks inhibitions, agitated • Simplify environment
• Easily stimulated by environment • Distract and redirect energy
• Sexually indiscreet • Provide external controls
• Affective disorder • Set limits: escalating hyperactivity
• Maintain contact with reality • Use consistent approach
• Elation is defense against underlying • Administer Lithium (help Manic Phase of
depression Bipolar, keep
• Manipulative behavior results from hydrated)
poor • Increase awareness of feelings through
self-esteem reflection

CYCLOTHEMIA BIPOLAR 1 BIPOLAR 2


• Mild depression+ hypomanic; MANIC-DEPRESSIVE • Hypomanic+one or more major
walang major dep, mania or • manic episode (lasts at least 1 wk, depression
mixed= at least 2 years. at least 3 of these sx) • Has or has HX of One or more major
• Numerous periods w/ hypomanic • no past MD EPISODES depressive episodes, at least 1
sx as well as numerous peroids with hypomanic episode
depressive sx that don’t meet the Excessive talking, less sleep, • Never had a manic or mixed episode
criteria for MD inflated self-esteem/ Higher incidence in women
grandiosity, subj feeling that thoughts 5-15%= full manic episode
Sx don’t result from direct physiologic are racing, inc goal-directed activity,
effects of a substance or gen.med distractibility, excessive involvement in
condition pleasurable activities

1 or more manic + major depression

DEPRESSIVE DISORDERS
Characterized by disturbances in feelings, thinking and behavior that tend to occur in a continuum, ranging from severe depression
to severe mania.

MAJOR DEPRESSION DYSTHYMIA


Unipolar, persistent sad mood lasting 2wks or longer CHRONICALLY DEPRESSED mood most of the day, more days
Melancholic feat, Atypical feat, (mood reactivity) than not for at least 2 yrs. Never had a manic d/o, hypomanic
Psychotic feat, or mixed episodes
Postpartum onset, Seasonal
s/sx: at least 2
SX:AT LEAST 5 poor appetite/overeating
Low Interest/ pleasure insomnia/hypersomnia
Wt loss or gain low energy/fatigue
Appetite low self-esteem
Insomnia/hypersomnia indecisiveness
Psychomotor agitation or retardation feeling hopeless
Fatigue/loss of energy
Feels worthless if major dep occurred : full remission
Inapp/ excessive guilt
Indecisiveness
Suicidal

SAD PERSONS SCALE SUICIDE PRECAUTIONS


SEX: males are more successful; ideation is more in females Secure room: lock windows, break proof glass, plastic flatware;
AGE: <17>45 = prone to suicide no cords (phones, extensions), belts, matches/cigars,
DEPRESSION: keep suicidal precautions = preoccupied about sharps/razors
dying
PREVIOUS ATTEMPT: likely to repeat Patient care: 1:1 freq observation, staff communication,
ETHANOL ABUSE: alcoholics restraints & meds as ordered, monitor/restrict visitors
RATIONAL THINKING: impaired
SOCIAL SUPPORT: impaired
ORGANIZED PLAN: gives away things
NO SPOUSE or nagging spouse
SICKNESS: chronic or terminal

FIVE STAGES OF GRIEF


1. Denial • Unconscious avoidance, which varies from a brief
period to the remainder of life
• Allows one to mobilize defenses to cope • An attempt to change reality of loss; person bargains
• Positive adaptive responses - verbal denial; crying for treatment control, expresses wish to be alive for
• Maladaptive responses - no crying, no specific events in near future
acknowledgement of loss • Maladaptive responses - bargains for unrealistic
2. Anger activities or events in distant future
• Expresses the realization of loss 4. Depressions and Withdrawal
• May be overt or covert • Sadness resulting from actual and/or anticipated loss
• Positive adaptive responses - verbal expressions of • Positive adaptive response - crying, social withdrawal
anger • Maladaptive responses - self-destructive actions,
• Maladaptive responses - persistent guilt or low self despair
esteem, aggression, self destructive ideation or 5. Acceptance
behavior • Resolution of feelings about death or other loss,
resulting in peaceful feelings
3. Bargaining • Positive adaptive behaviors - may wish to be alone,
limit social contacts, complete personal business

ANXIETY DISORDERS
no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or
posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders)

ASSESSMENT STARS
Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social deletion of the requirement that individuals over age 18
Phobia) years recognize that their anxiety is excessive or
unreasonable.
Panic Attack
essential features of panic attacks remain unchanged
Panic Disorder and Agoraphobia Panic disorder – RECURRENT UNEXPECTED PANIC
Panic disorder and agoraphobia are unlinked in DSM-5 ATTACKS

Specific Phobia
core features of specific phobia remain the same

Social Anxiety Disorder (Social Phobia)


essential features of social anxiety disorder (social phobia) (formerly
called social phobia) remain the same

Separation Anxiety Disorder • Recurrent excessive distress when anticipating


The core features remain mostly unchanged

Selective Mutism
diagnostic criteria are largely unchanged from DSM-IV

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS


ASSESSMENT STARS
Body Dysmorphic Disorder
• repetitive behaviors or mental acts in response to preoccupations
with perceived defects or flaws in physical appearance

Hoarding Disorder
• new diagnosis in DSM-5. DSM-IV
• as one of the possible symptoms of obsessive-compulsive
personality disorder

Trichotillomania (Hair-Pulling Disorder)


• may occur from any region of the body in which hair grows
• the most common sites are the scalp, eyebrows, and eyelids
• less common sites are axillary, facial, pubic, and peri-rectal
regions
Excoriation (Skin-Picking) Disorder
• essential feature of is recurrent picking at one's own
• most commonly picked sites are the face, arms, and hands,
• many individuals pick from multiple body sites.
• may pick at healthy skin, at minor skin irregularities, at lesions
such as pimples or calluses, or at scabs from previous picking

PERSONALITY DISORDERS
2 or more present: cognition, affectivity, interpersonal functioning, impulse control
CLUSTER A (THE MAD) CLUSTER B (THE BAD) CLUSTER C (THE SAD)
ODD, ECCENTRIC DRAMATIC, EMOTIONAL, ERRATIC ANXIOUS, FEARFUL
Ego Syntonic - comfortable for the Histrionic: center of attention, self-dramatization, poses Obsessive-complusive:
indiv. but not to others (maintain consistent rlxp; inc self-worth, adaptive preoccupied w/ perfectionism,
coping) control of situation (accept the
Schizoid: lacks personal & social r; rituals, enc. Diversion, decrease
detached from others & withdraws Narcissistic: sense of grandiose + importance, excessive anxiety, distractive behavior)
from interactions (maintain comfy self-admiration, lacks empathy, arrogant, fantasies of
distance; initiate structured social unlimited power, beauty, brilliance (set clear realistic Dependent: submissive &
interaxn) expectations, assist in building self-esteem) clinging behavior associated
with an excessive need to be
Schizotypal: almost similar to schiz Borderline: disturbed rlxp, impulsive & unpredictable, cared for by others (facilitate
but psycho episodes are infreq chronic sense of boredom, expected to be alone w/ expression of assistance when
(comfy distance, structured social unstable moods (decrease self-destructive behavior, enc. needed)
interaxn) Verb.)
Avoidant: feeling of
Paranoid - distrust (interprets other Antisocial: exploitation of others, violation of laws/rights inadequacy, social inhibition,
motives as threat), suspicious, of others, impulsive + risky behaviors, lacks honesty, sensitivity to potential
secretive loyalty (use firm & consistent limit setting, facilitate tx rejection or criticism (establish
(establish rapport, risk for rlxp in a structured environment) a trusting relationship)
aggression, support adaptation)

TRAUMA- AND STRESSOR-RELATED DISORDERS


ASSESSMENT IMPLEMENTATION
Acute Stress Disorder The criterion requires being explicit as to whether qualifying traumatic events were
experienced directly, witnessed, or experienced indirectly
Adjustment Disorders

Posttraumatic Stress Disorder reexperiencing, avoidance/numbing, and arousal—there are now four symptom clusters in
DSM-5, because the avoidance/numbing cluster is divided into two distinct clusters

DISSOCIATIVE DISORDERS
ASSESSMENT IMPLEMENTATION
1) derealization is included in the name and symptom structure of
what previously was called depersonalization disorder and is now called
depersonalization/derealization disorder,
2) dissociative fugue is now a specifier of dissociative amnesia
rather than a separate diagnosis, and
3) the criteria for dissociative identity disorder have been changed to
indicate that symptoms of disruption of identity may be reported as well
as observed, and that gaps in the recall of events may occur for everyday
and not just traumatic events
Dissociative Identity Disorder
expanded to include certain possession-form phenomena and
functional neurological symptoms to account for more diverse
presentations of the disorder

SOMATIC SYMPTOM AND RELATED DISORDERS


ASSESSMENT IMPLEMENTATION
Somatic Symptom Disorder
Individuals with somatic symptoms plus abnormal thoughts,
feelings, and behaviors may or may not have a diagnosed medical
condition
Hypochondriasis and Illness Anxiety Disorder
Hypochondriasis has been eliminated as a disorder, in part
because the name was perceived as pejorative and not conducive
to an effective therapeutic relationship
Conversion Disorder (Functional Neurological Symptom
Disorder)

FEEDING AND EATING DISORDERS


ASSESSMENT IMPLEMENTATION
Pica and Rumination Disorder

avoidant/restrictive food intake disorder

Anorexia Nervosa The core diagnostic criteria for anorexia nervosa are
conceptually unchanged from DSM-IV with one exception: the
requirement for amenorrhea has been eliminated
Bulimia Nervosa The only change to the DSM-IV criteria for bulimia nervosa is a
reduction in the required minimum average frequency of binge
eating and inappropriate compensatory behavior frequency
from twice to once weekly
Elimination Disorders
No significant changes have been made to the elimination
disorders diagnostic class from DSM-IV to DSM-5

FACTORS ANOREXIA NERVOSA BULIMIA NERVOSA


PSYCHOLOGICAL *Relentless pursuit of thinness (Hilde Bruch) *Presence of cyclic behavioral pattern
1.dec. self-esteem *Rigidity and over-control 1.Skipping meals
2.distorted body image *Many are hyperactive 2.Binge eating
3.irrational thoughts &beliefs *Desperate need to please others 3.Purging
4.Cycle begins all over again
Cognitive Distortions Selective abstraction
Overgeneralization
Magnification
Superstitious thinking
Dichotomous thinking
PHYSICAL S/Sx *Restricting Type *Purging type
*Binge-eating/purging *Non-purging type

WEIGHT Less than 85% of normal weight for age and Normal or near-normal weight for age and
height height
CARDIO Bradycardia, hypotension, arrhythmias Bradycardia, hypotension, arrhythmias
(d/t FVD, low muscle tone)

FLUID & ELECTROLYTES Hypokalemia, hypocalcemia, dehydration Hypokalemia, hyponatremia, dehydration

ENDO Amenorrhea Irregular menses, hypoglycemia

GASTRO Constipation r/t laxative abuse Constipation


Esophagitis

SLEEP-WAKE DISORDERS
SLEEP: described as neurobiologic window into the pathophysiology of psychiatric disorders
Sleep switch: located in the hypothalamus
Front: regulates sleep
Back: wakefulness center
Varity of structure: ranging from the brain stem to the cerebral hemispheres

Circadian Clock: regulated by a specific group of brain cells in the hypothalamus; Works in sync with the external environment to
coordinate sleep and wakefulness.

MELATONIN: secreted by the pineal gland = promotes sleep in the lower light; excretion occurs when it is dark; daylight suppresses
melatonin

STAGES OF SLEEP:
REM: increased level of brain activity
NREM: composed of 4 stages
Stage 1 NREM: occurs right after the awake stage; 4-5% of total sleep time = considered light sleep
Stage 2 NREM: also considered light 40-50% accounts for total sleep time
Stage 3 NREM: deep sleep; comprises 4-6% of total sleep time and s known as slow wave sleep or delta sleep
Stage 4 NREM: comprises 12-15% of total sleep time; during this stage that sleep terror d/o or sleepwalking d/o occurs

DYSSOMNIAS: d/o of quantity or timing; difficulty initiating or maintaining sleep or excessive sleepiness
• Insomnia: (1 month) diff maintaining or initiating sleep; non restorative
• Primary Hypersomnia: (1 month) excessive sleepiness; prolonged sleep episodes or daytime sleep episodes that occur
almost daily
• Breathing Related D/O:
o Common form is sleep apnea; common type: obstructive
• Narcolepsy: almost irresistible urge to sleep followed by brief episodes of deep sleep followed by sense or refreshment
o Associated with: CATAPLEXY (sudden collapse of muscle tone), SLEEP PARALYSIS (total inability to move for a brief
period), HYPNAGOGIC HALLUCINATIONS (vivid dreamlike images)
• Circadian Rhythm Sleep Disorders: sleep-wake disturbance through internal cues
Delayed sleep phase type
Jet lag type
Shift-work type: normal endogenous sleep-wake cycle

PARASOMNIAS: unusual or sudden phenomenon that appears suddenly during sleep


• Nightmare d/o: frightening dreams (often in women)
• Sleep terror d/o: night terrors/pavor nocturnes: screaming, fear and panic = clinical distress = potential for injury (may last
1 -10 mins), common in children 5-7yrs
• Sleep walking d/o: arousal disorder: “somnambulism”: mild (confusional arousal) = sitting and mumbling on bed;
complex: getting out of bed

Parasomnia NOS
• Bruxism (teeth-grinding = dental bite plate)
• Somniloquy (sleep talking)
• Jactatio capitis nocturna (head-banging)
• Sleep paralysis (inability to execute voluntary movements)

SEXUAL DYSFUNCTIONS
characterized by a disturbance in the sexual response cycle or by pain associated with sexual intercourse/ inhibition of sexual
appetite that compromise sexual response cycle

Sexual desire disorder Little or no sexual desire or an aversion


causes of aversion:
1. Protection: unconscious fear of having sex
2. inhibition of phallic psychosexual phase and unresolved oedipal
conflict = freud
3. fear of the vagina = castration (fear of) = vagina dentata

Sexual arousal disorder Can’t maintain the physiologic requirements:


female = without lubrication = FeSAD (estrogen)
male = without erection = impotence (citrale)
*Viagra (sildinafil citrate)
**one type of impotence accdg to feud: Inability to reconcile feelings of affection
towards a woman with feeling of desire = conflicting for her = can only function to
women he doesn’t desire = MADONNA-PUTANA COMPLEX

Orgasmic disorder Can’t compete response d/t inability to achieve orgasm (anorgasm; retired)
Female orgasmic disorder: Male orgasmic disorder:
fear of impregnation; Rigid/puritanical background
rejection by partner Sex: “sinful”
damage to the vagina Vagina: “dirty”
hostility to men

Sexual pain disorder Genital pain (dyspareunia)


*vaginismus “vag lock”: involuntary spasms of the outer 3rd of the vagina, where the
contractions cause an interference of penile insertion
Causes: 1. strict religious upbringing
2. anticipation at first sexual experience
3. sexual trauma = rape = “weapon”
4. lust murder
5. problematic dyadic relationship
“nonverbal fashion = sign of protest”

PARAPHILIC DISORDERS
PARAPHILIA: condition in which the sexual instinct is expressed in ways that are socially prohibited or unacceptable/biologically
undesirable/ individual doesn’t consider sexual activities as disorder/ activities last over a period of 6 months/ excitement happens
during anticipation
may be coercive or non-coercive (Coercive paraphilia: bandage, sensory deprivation, intense stimulation, discipline)
Exhibitionism Posing one’s genitalia
Fetishism Non-living objects
Frotteurism Non-consenting person
Pedophilia 13 or lower = VICTIM; 16 or 5 older = PERPETRATOR
Incest: relationships by blood or marriage
Masochism Coined after Leopold von Sucher Masoch
Act of being humiliated, beaten, suffer
Hypoxyphilia: act of strangulation or O2-depleting activity
Coercive paraphilia; 6 months

Sadism Inflicting suffering ; Coercive paraphilia; 6 months


Causes:
1. Genetic predispositioning
2. Hormonal malfunctioning
3. Pathological relationship
4. History of sexual abuse
5. Presence of other mental disorder
Voyeurism “voso; peeping tom”; scophelia; 6months
Transvestic fetishism

GENDER DYSPHORIA
Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by
emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se, as was the case in DSM-IV
gender identity disorder.

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS


ASSESSMENT IMPLEMENTATION
Oppositional Defiant Disorder
Four refinements have been made to the criteria for
oppositional defiant disorder

Conduct Disorder
The criteria for conduct disorder are largely unchanged from
DSM-IV

Intermittent Explosive Disorder


The primary change is the type of aggressive outbursts that
should be considered: physical aggression was required in
DSM-IV, whereas verbal aggression and non-
destructive/noninjurious physical aggression also meet
criteria in DSM-5

SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

SUBSTANCE DEPENDENCE: maladaptive pattern of use leading to a clinically significant impairment.


Manifested by 3 or more
With duration of 12 months

Hallmarks of this pattern:


• tolerance = needing an increased amount
• withdrawal = uncomfortable and maladaptive physiologic
• compulsive use = despite persistent desire to cut-down
• taken in larger amounts or longer period than was intended
• great deal of time = spent in activities to obtain the substance
• gives up or reduced = important social or occupational or recreational activities
• continued use despite = knowledge of having a problem

SUBSTANCE ABUSE:
Pattern of repeated abuse of substance that is maladaptive in that significant adverse consequence
occurring within a 12-month period manifested by one more
• recurrent substance abuse =
• recurrent substance use in situations =
• recurrent substance-related legal problems
• continued use despite =

SUBSTANCE INTOXICATION: reversible syndrome of maladaptive physiologic and behavioral changes that are d/t the
effects of substance to person’s CNS
• syndrome includes -

SUBSTANCE WITHDRAWAL: the development of maladaptive physiologic, behavioral and cognitive changes that are the
result of reducing or stopping the heavy and regular use of substance
• syndrome includes clinically significant DISTRESS or IMPAIRMENT in social

ALCOHOLISM
ALCOHOL: one of the most widely used substances n the world; sedative anesthetic = absorbed in the mouth, stomach and SI
= 95% broken down by liver
= generally a person can metabolize 10 ml of alcohol/90mins
= intoxication occurs when a person’s BAL (blood alcohol level) is 0.10% or more

0.05- Initial euphoria; mood lability and


0.15g/dl cognitive disturbance:

0.15- Mood lability with outburst,


0.25g/dl slurred speech; staggered gait or
ataxia, diplopia, drowsiness
0.3g/dl Aggressive behavior, incoherent
speech, labored breathing,
vomiting, stupor
0.4g/dl Coma
0.5g/dl Severe respiratory depression;
death

Patterns of use: regular daily intake

ALCOHOL WITHDRAWAL SYNDROME


Hang-over: unpleasant sx of mild alcohol withdrawal occurring approx 4-6hrs p ingestion
Alcoholic hallucinations: auditory
Generalized seizures: “rum fits”
Delirium tremens: most common sx = condition of severe memory disturbance, agitation, anorexia and hallucinations
MINOR WITHDRAWAL: can occur in 6-12hrs after the alcoholic’s last drink
Early sx include = (last 48-72hrs)
As the sx progresses = (last 48-72hrs)
Onset of hallucinations = marks the onset of major withdrawal
MAJOR WITHDRAWAL: most advanced, life-threatening stage; appears within 2-3 days following the last drink and may last 3-
5 days; sx associated w/ DT usually p 72hrs after the last drink
BLACKOUTS: freq confused w/ “passing out” = unconscious; anterograde amnesia: loss of short-term memories with retention
of remote memories

Gambling Disorder
An important departure from past diagnostic manuals is that the substance-related disorders chapter has been expanded
to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as
gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder
symptoms resemble substance use disorders to a certain extent.
NEUROCOGNITIVE DISORDERS
Key concepts
• Cognition: based on a system of interrelated abilities such as perception, reasoning, judgment, intuition and
memory that allow one to be aware of one’s self.
• Memory: facet of cognition concerned w/ retaining and recalling past experiences
• Delirium: condition of acute cognitive impairment and is caused by a medical condition, substance abuse or
multiple etiologies
• 3 disrupted components of cognition: perception (decreased ability to distinguish and integrate sensory info),
thinking (process is fragmented and disorganized), memory (impaired in 3 aspects: register, retain, recall)
• Dementia: chronic cognitive impairments and is diff by underlying cause not symptoms patterns
May be cortical/subcortical

DELIRIUM CHARACTERISTICS DEMENTIA


Sudden ONSET Gradual
Fluctuating 24-HR COURSE Stable
Disoriented ATTENTION Normal
Disoriented COGNITION Impaired: aphasia, apraxia, agnosia
Visual, auditory HALLUCINATIONS Possible
Usually impaired ORIENTATION Often impaired,
Incoherent, slow, rapid SPEECH PATTERN Normal, aphasia later

Asterixis/coarse tremor INVOLUNTARY MOVEMENT rare


Anxious. Fearful MOOD Depressed anxious = early labile
Short-time and usually reversible if CLINICAL COURSE DAT cortical (early and late)
the underlying cause is identified Huntington’s, Parkinson’s (subcortical)
Substance intoxication ETIOLOGIES Have yet to identify the course AD
Substance withdrawal
Multiple
10-50% of patients EPIDEMIOLOGY Affects all groups
Common in elderly, post op Run in families
Pre-existing cognitive impairment= Low educ level
GREATEST RISK FACTOR May inc risk for AD
Prior head injury = late AD

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