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Clinical Pocket Guide

2nd Edition

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TOOLS/

INDEX

GERICRISISDRUGS

A-Z

DRUGS/

LABS

DISORDERS/

INTERV

ASSESSBASICS

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Mental Health and Mental Illness: Basics

Autonomic Nervous System 13

Biological Aspects of Mental Illness 9

Brain 11

Central and Peripheral Nervous System 10

Confidentiality 15

Confidentiality, Do’s and Don’ts 15

Diathesis-Stress Model 4

Erikson’s Psychosocial Theory 7

Fight-or-Flight Response 4

Freud’s Psychosexual Development 6

General Adaptation Syndrome 4

Health Insurance Portability and Accountability Act (HIPAA) (1996) 16

Informed Consent 18

Key Defense Mechanisms 5

Legal Definition of Mental Illness 2

Legal-Ethical Issues 15

Limbic System 12

Mahler’s Theory of Object Relations 8

Maslow’s Hierarchy of Needs 3

Mental Health 2

Mental Illness/Disorder 2

Mind-Body Dualism to Brain and Behavior 9

Neurotransmitter Functions and Effects 15

Neurotransmitters 15

Patient’s Bill of Rights 18

Peplau’s Interpersonal Theory 9

Positive Mental Health: Jahoda’s Six Major Categories 3

Psychoanalytic Theory 5

Restraints and Seclusion – Behavioral Health Care 17

Right to Refuse Treatment/Medication 18

Stages of Personality Development 6

Sullivan’s Interpersonal Theory 7

Sympathetic and Parasympathetic Effects 13

Synapse Transmission 14

Theories of Personality Development 5

Topographic Model of the Mind 5

Types of Commitment 16

When Confidentiality Must Be Breached 16

BASICS

01Pederson (F)-01 6/25/07 7:46 PM Page 1

Mental Health and Mental Illness: Basics

Mental health and mental illness have been defined in many ways but

should always be viewed in the context of ethnocultural factors and

influence.

Mental Illness/Disorder

The DSM-IV-TR defines mental illness/disorder (paraphrased) as: a clini-

cally significant behavioral or psychological syndrome or pattern asso-

ciated with distress or disability…with increased risk of death, pain,

disability and is not a reasonable (expectable) response to a particular

situation. (APA 2000)

Mental Health

Mental health is defined as: a state of successful performance of mental

function, resulting in productive activities, fulfilling relationships with other

people, and the ability to adapt to change and cope with adversity. (US

Surgeon General Report, Dec 1999)

Wellness-illness continuum – Dunn’s 1961 text, High Level Wellness,

altered our concept of health and illness, viewing both as on a continuum

that was dynamic and changing, focusing on levels of wellness. Concepts

include: totality, uniqueness, energy, self-integration, energy use, and

inner/outer worlds.

Legal Definition of Mental Illness

The legal definition of insanity/mental illness applies the M’Naghten Rule,

formulated in 1843 and derived from English law. It says that: a person is

innocent by reason of insanity if at the time of committing the act, [the

person] was laboring under a defect of reason from disease of the mind

as not to know the nature and quality of the act being done, or if he did

know it, he did not know that what he was doing was wrong.There are

variations of this legal definition by state, and some states have abolished

the insanity defense.

BASICS

01Pederson (F)-01 6/25/07 7:46 PM Page 2

Positive Mental Health: Jahoda’s Six Major Categories

In 1958, Marie Jahoda developed six major categories of positive mental

health:

■ Attitudes of individual toward self

■ Presence of growth and development, or actualization

■ Personality integration

■ Autonomy and independence

■ Perception of reality, and

■ Environmental mastery

The mentally healthy person accepts the self, is self-reliant, and is self-

confident.

Maslow’s Hierarchy of Needs

Maslow developed a hierarchy of needs based on attainment of self-

actualization, where one becomes highly evolved and attains his or

her full potential.

The basic belief is that lower-level needs must be met first in order to

advance to the next level of needs. Therefore, physiological and safety

needs must be met before issues related to love and belonging can be

addressed, through to self-actualization.

Maslow’s Hierarchy of Needs

Self-Actualization

Self-Esteem

Love/Belonging

Safety and Security

Physiological

BASICS

Self-fulfillment/reach highest potential

Seek self-respect, achieve recognition

Giving/receiving affection,

companionship

Avoiding harm; order, structure,

protection

Air, water, food, shelter, sleep,

elimination

01Pederson (F)-01 6/25/07 7:46 PM Page 3

General Adaptation Syndrome (Stress-Adaptation Syndrome)

Hans Selye (1976) divided his stress syndrome into three stages and, in

doing so, pointed out the seriousness of prolonged stress on the body

and the need for identification and intervention.

1. Alarm stage – This is the immediate physiological (fight or flight)

response to a threat or perceived threat.

2. Resistance – If the stress continues, the body adapts to the levels

of stress and attempts to return to homeostasis.

3. Exhaustion – With prolonged exposure and adaptation, the body

eventually becomes depleted. There are no more reserves to draw

upon, and serious illness may now develop (e.g., hypertension,

mental disorders, cancer). Selye teaches us that without intervention,

even death is a possibility at this stage.

CLINICAL PEARL: Identification and treatment of chronic, post-traumatic

stress disorder (PTSD) and unresolved grief, including multiple (compound-

ing) losses, are critical in an attempt to prevent serious illness and improve

quality of life.

Fight-or-Flight Response

In the fight-or-flight response, if a person is presented with a stressful

situation (danger), a physiological response (sympathetic nervous system)

activates the adrenal glands and cardiovascular system, allowing a person

to rapidly adjust to the need to fight or flee a situation.

■ Such physiological response is beneficial in the short term: for instance,

in an emergency situation.

■ However, with ongoing, chronic psychological stressors, a person

continues to experience the same physiological response as if there

were a real danger, which eventually physically and emotionally

depletes the body.

Diathesis-Stress Model

The diathesis-stress model views behavior as the result of genetic and

biological factors. A genetic predisposition results in a mental disorder

(e.g., mood disorder or schizophrenia) when precipitated by environ-

mental factors.

BASICS

01Pederson (F)-01 6/25/07 7:46 PM Page 4

Theories of Personality Development

Psychoanalytic Theory

Sigmund Freud, who introduced us to the Oedipus complex, hysteria, free

association, and dream interpretation, is considered the “Father of

Psychiatry.” He was concerned with both the dynamics and structure of the

psyche. He divided the personality into three parts:

■ Id – The id developed out of Freud’s concept of the pleasure principle. The

id comprises primitive, instinctual drives (hunger, sex, aggression). The id

says, “I want.”

■ Ego – It is the ego, or rational mind, that is called upon to control the

instinctual impulses of the self-indulgent id. The ego says, “I think/I

evaluate.”

■ Superego – The superego is the conscience of the psyche and monitors

the ego. The superego says “I should/I ought.” (Hunt 1994)

Topographic Model of the Mind

Freud’s topographic model deals with levels of awareness and is divided

into three categories:

■ Unconscious mind – All mental content and memories outside of

conscious awareness; becomes conscious through the preconscious

mind.

■ Preconscious mind – Not within the conscious mind but can more

easily be brought to conscious awareness (repressive function of

instinctual desires or undesirable memories). Reaches consciousness

through word linkage.

■ Conscious mind – All content and memories immediately available

and within conscious awareness. Of lesser importance to psychoanalysts.

Key Defense Mechanisms

Defense Mechanism Example

Denial – Refuses to accept a painful

reality, pretending as if it doesn’t exist.

Displacement – Directing anger toward

someone or onto another, less threat-

ening (safer) substitute.

BASICS

A man who snorts cocaine daily,

is fired for attendance

problems, yet insists he

doesn’t have a problem.

An older employee is publicly

embarrassed by a younger

boss at work and angrily cuts

a driver off on the way home.

(Continued on following page)

01Pederson (F)-01 6/25/07 7:46 PM Page 5

Key Defense Mechanisms (Continued)

Defense Mechanism Example

Identification – Taking on

attributes and characteristics

of someone admired.

Intellectualization – Excessive

focus on logic and reason to

avoid the feelings associated

with a situation.

Projection – Attributing to others

feelings unacceptable to self.

Reaction Formation – Expressing

an opposite feeling from what is

actually felt and is considered

undesirable.

Sublimation – Redirecting unac-

ceptable feelings or drives into

an acceptable channel.

Undoing – Ritualistically negating

or undoing intolerable feelings/

thoughts.

Stages of Personality Development

Freud’s Psychosexual Development

Age Stage Task

0 – 18 mo

18 mo – 3 yr

3 – 6 yr

BASICS

Oral

Anal

Phallic

Oral gratification

Independence and control

(voluntary sphincter control)

Genital focus

A young man joins the police academy

to become a policeman like his

father, whom he respects.

An executive who has cancer requests

all studies and blood work and

discusses in detail with her doctor,

as if she were speaking about

someone else.

A group therapy client strongly dis-

likes another member but claims

that it is the member who “dislikes

her.”

John, who despises Jeremy, greets

him warmly and offers him food and

beverages and special attention.

A mother of a child killed in a drive-by

shooting becomes involved in

legislative change for gun laws and

gun violence.

A man who has thoughts that his

father will die must step on sidewalk

cracks to prevent this and cannot

miss a crack.

01Pederson (F)-01 6/25/07 7:46 PM Page 6

Freud’s Psychosexual Development (Continued)

Age Stage Task

6 – 12 yr

13 – 20 yr

Sullivan’s Interpersonal Theory

Age Stage Task

0 – 18 mo

18 mo – 6 yr

6 – 9 yr

9 – 12 yr

12 – 14 yr

14 – 21 yr

Erikson’s Psychosocial Theory

Age Stage Task

0 – 18 mo

18 mo – 3 yr

3 – 6 yr

BASICS

(Continued on following page)

Latency

Genital

Repressed sexuality; channeled

sexual drives (sports)

Puberty with sexual interest in

opposite sex

Infancy

Childhood

Juvenile

Preadolescence

Early adolescence

Late adolescence

Anxiety reduction via oral

gratification

Delay in gratification

Satisfying peer

relationships

Satisfying same-sex

relationships

Satisfying opposite-sex

relationships

Lasting intimate opposite-

sex relationship

Trust vs. mistrust

Autonomy vs.

shame/doubt

Initiative vs. guilt

Basic trust in mother figure

& generalizes

Self-control/independence

Initiate and direct own

activities

01Pederson (F)-01 6/25/07 7:46 PM Page 7

Erikson’s Psychosocial Theory (Continued)

Age Stage Task

6 – 12 yr

12 – 20 yr

20 – 30 yr

30 – 65 yr

65 yr – death

Mahler’s Theory of Object Relations

Age Phase (subphase) Task

0 – 1 mo

1 – 5 mo

5 – 10 mo

10 – 16 mo

16 – 24 mo

24 – 36 mo

BASICS

Industry vs.

inferiority

Identity vs. role

confusion

Intimacy vs.

isolation

Generativity vs.

stagnation

Ego integrity vs.

despair

Self-confidence through suc-

cessful performance and

recognition

Task integration from pre-

vious stages; secure sense

of self

Form a lasting relationship

or commitment

Achieve life’s goals; consider

future generations

Life review with meaning

from both positives and

negatives; positive self-

worth

1. Normal autism

2. Symbiosis

3. Separation –

individuation

– Differentiation

– Practicing

– Rapprochement

– Consolidation

Basic needs fulfillment (for

survival)

Awareness of external fulfillment

source

Commencement of separateness

from mother figure

Locomotor independence; aware-

ness of separateness of self

Acute separateness awareness;

seeks emotional refueling from

mother figure

Established sense of separate-

ness; internalizes sustained

image of loved person/object

when out of sight; separation

anxiety resolution

01Pederson (F)-01 6/25/07 7:46 PM Page 8

Peplau’s Interpersonal Theory

Age Stage Task

Infant

Toddler

Early Childhood

Late Childhood

Stages of Personality Development tables modified from Townsend MC. Psychiatric

Mental Health Nursing, 5/e. Philadelphia: FA Davis, 2006, used with permission

Biological Aspects of Mental Illness

Mind-Body Dualism to Brain and Behavior

■ René Descartes (17th C) espoused the theory of the mind-body dualism

(Cartesian dualism), wherein the mind (soul) was said to be completely

separate from the body.

■ Current research and approaches show the connection between mind and

body and that newer treatments will develop from a better understanding

of both the biological and psychological. (Hunt 1994)

■ The US Congress stated that the 1990s would be “The Decade of the

Brain,” with increased focus and research in the areas of neurobiology,

genetics, and biological markers.

■ The Decade of Behavior (2000–2010) is a “multidisciplinary” initiative

launched by the American Psychological Association (APA), focusing on

the behavioral and social sciences, trying to address major challenges

facing the US today in health, safety, education, prosperity, and

democracy (www.decadeofbehavior.org).

BASICS

Depending on

others

Delaying

satisfaction

Self-identification

Participation

skills

Learning ways to communicate

with primary caregiver for

meeting comfort needs

Some delay in self-gratification to

please others

Acquisition of appropriate roles and

behaviors through perception

of others’ expectations of self

Competition, compromise, coop-

eration skills acquisition; sense

of one’s place in the world

01Pederson (F)-01 6/25/07 7:46 PM Page 9

Central and Peripheral Nervous System

Central Nervous System

■ Brain

■ Forebrain

• Cerebrum (frontal, parietal, temporal, and occipital lobes)

• Diencephalon (thalamus, hypothalamus, and limbic system)

■ Midbrain

• Mesencephalon

■ Hindbrain

• Pons, medulla, and cerebellum

■ Nerve Tissue

■ Neurons

■ Synapses

■ Neurotransmitters

■ Spinal Cord

■ Fiber tracts

■ Spinal nerves

Peripheral Nervous System

■ Afferent System

■ Sensory neurons (somatic and visceral)

■ Efferent System

■ Somatic nervous system (somatic motor neurons)

■ Autonomic nervous system

• Sympathetic Nervous System

Visceral motor neurons

• Parasympathetic Nervous System

Visceral motor neurons

BASICS

01Pederson (F)-01 6/25/07 7:46 PM Page 10

The Brain

Left cerebral hemisphere showing some of the functional areas that have

been mapped. (From Scanlon VC, Sanders T: Essentials of Anatomy and

Physiology, ed. 5. FA Davis, Philadelphia 2007, with permission)

BASICS

Frontal lobe

Premotor area

Motor area

General sensory area

Sensory association

area

Parietal lobe

Occipital lobe

Visual area

Auditory

area

Temporal lobe

Auditory

association

area

Visual

association

area

Motor speech

area

01Pederson (F)-01 6/25/07 7:46 PM Page 11

Limbic System

The limbic system and its structures. (Adapted from Scanlon VC, Sanders

T: Essentials of Anatomy and Physiology, ed. 5. FA Davis, Philadelphia 2007,

with permission)

BASICS

Amygdala

Mammillary Body

Olfactory

Tra ct

Septum

pellucidum

Cingulate

gyrus

Thalamus

Fornix

Hypothalamus

Hippocampus

01Pederson (F)-01 6/25/07 7:46 PM Page 12

Autonomic Nervous System

Sympathetic and Parasympathetic Effects

Structure Sympathetic Parasympathetic

Eye (pupil)

Nasal Mucosa

Salivary Gland

Heart

Arteries

Lung

Gastrointestinal

Tract

Liver

Kidney

Bladder

Sweat Glands

BASICS

Dilation

Mucus reduction

Saliva reduction

Rate increased

Constriction

Bronchial muscle

relaxation

Decreased motility

Conversion of

glycogen to

glucose

increased

Decreased urine

Contraction of

sphincter

↑Sweating

Constriction

Mucus increased

Saliva increased

Rate decreased

Dilation

Bronchial muscle contraction

Increased motility

Glycogen synthesis

Increased urine

Relaxation of sphincter

No change

01Pederson (F)-01 6/25/07 7:46 PM Page 13

Synapse Transmission

Impulse transmission at a synapse. Arrows indicate direction of electrical

impulse. (From Scanlon VC, Sanders T: Essentials of Anatomy and

Physiology, ed. 5. FA Davis, Philadelphia 2007, with permission)

BASICS

Axon of presynaptic

neuron

Vesicles of neurotransmitter

Dendrite of

postsynaptic

neuron

Inactivator

(cholinesterase)

Receptor site

Neurotransmitter

(acetylcholine)

Mitochondrion

01Pederson (F)-01 6/25/07 7:46 PM Page 14

Neurotransmitters

Neurotransmitter Functions and Effects

Neurotransmitter Function Effect

Dopamine

Serotonin

Norepinephrine

Gamma-aminobutyric

acid (GABA)

Acetylcholine

Legal-Ethical Issues

Confidentiality

Confidentiality in all of health care is important but notably so in psychiatry

because of possible discriminatory treatment of those with mental illness.

All individuals have a right to privacy, and all client records and communi-

cations should be kept confidential.

Do’s and Don’ts of Confidentiality

■ Do not discuss clients by using their actual names or any identifier that

could be linked to a particular client (e.g., name/date of birth on an x-ray/

assessment form).

■ Do not discuss client particulars outside of a private, professional

environment. Do not discuss with family members or friends.

■ Be particularly careful in elevators of hospitals or community centers. You

never know who might be on the elevator with you.

■ Even in educational presentations, protect client identity by changing

names (John Doe) and obtaining all (informed consent) permissions.

■ Every client has the right to confidential and respectful treatment.

BASICS

Inhibitory

Excitatory

Inhibitory

Excitatory

Fine movement, emotional behavior.

Implicated in schizophrenia and

Parkinson’s.

Sleep, mood, eating behavior.

Implicated in mood disorders,

anxiety, and violence.

Arousal, wakefulness, learning.

Implicated in anxiety and addiction.

Anxiety states.

Arousal, attention, movement.

Increase ⫽ spasms and decrease ⫽

paralysis.

(Text continued on following page)

01Pederson (F)-01 6/25/07 7:46 PM Page 15

■ Accurate, objective record keeping is important, and documentation is

significant legally in demonstrating what was actually done for client care.

If not documented, treatments are not considered done.

When Confidentiality Must Be Breached

■ Confidentiality and Child Abuse – If it is suspected or clear that a child

is being abused or in danger of abuse (physical/sexual/emotional) or

neglect, the health professional must report such abuse as mandated by

the Child Abuse Prevention Treatment Act, originally enacted in 1974 (PL

93–247).

■ Confidentiality and Elder Abuse – If suspected or clear that an elder is

being abused or in danger of abuse or neglect, then the health

professional must also report this abuse.

■ Tarasoff Principle/Duty to Warn (Tarasoff v. Regents of the University

of California 1976) – Refers to the responsibility of a therapist, health

professional, or nurse to warn a potential victim of imminent danger (a

threat to harm person) and breach confidentiality. The person in danger

and others (able to protect person) must be notified of the intended harm.

The Health Insurance Portability and

Accountability Act (HIPAA) (1996)

Enacted on August 21, 1996, HIPAA was established with the goal of assuring

that an individual’s health information is properly protected while allowing

the flow of health information. (US Department of Health and Human

Services, 2006, HIPAA, 2006)

Types of Commitment

■ Voluntary – An individual decides treatment is needed and admits

him/herself to a hospital, leaving of own volition – unless a professional

(psychiatrist/other professional) decides that the person is a danger to

him/herself or others.

■ Involuntary – Involuntary commitments include: 1) emergency

commitments, including those unable to care for self (basic personal

needs) and 2) involuntary outpatient commitment (IOC).

■ Emergency – Involves imminent danger to self or others; has

demonstrated a clear and present danger to self or others.

Usually initiated by health professionals, authorities, and sometimes

friends or family. Person is threatening to harm self or others. Or

evidence that the person is unable to care for her- or himself

(nourishment, personal, medical, safety) with reasonable probability

that death will result within a month.

■ 302 Emergency Involuntary Commitment – If a person is an

immediate danger to self or others or is in danger due to a lack of

ability to care for self, then an emergency psychiatric evaluation may

be filed (section 302). This person must then be evaluated by a

BASICS

01Pederson (F)-01 6/25/07 7:46 PM Page 16

psychiatrist and released, or psychiatrist may uphold petition (patient

admitted for up to five days). (Laben & Crofts Yorker 1998; emergency

commitments 2004)

Restraints and Seclusion for an Adult — Behavioral

Health Care

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

wants to reduce the use of behavioral restraints but has set forth guidelines

for safety in the event they are used.

■ In an emergency situation, restraints may be applied by an authorized and

qualified staff member, but an order must be obtained from a Licensed

Independent Practitioner (LIP) within 1 hour of initiation of restraints/

seclusion.

■ Following application of restraints, the following time frames must be

adhered to for reevaluation/reordering:

■ Within first hour, physician or LIP must evaluate the patient face to

face, after initiation of restraint/seclusion, if hospital uses accreditation

for Medicare deemed status purposes. If not for deemed status, LIP

performs face-to-face evaluation within 4 hours of initiation of

restraint/seclusion.

■ If adult is released prior to expiration of original order, LIP must

perform a face-to-face evaluation within 24 hours of initiation of

restraint/seclusion.

■ LIP reorders restraint every 4 hours until adult is released from

restaint/seclusion. A qualified RN or other authorized staff person

reevaluates individual and need to continue restraint/seclusion.

■ LIP face-to-face evaluation every 8 hours until patient is released from

restraint/seclusion.

■ 4-hour RN or other qualified staff reassessment and 8-hour face-to-face

evaluation repeated, as long as restraint /seclusion clinically necessary.

(JCAHO revised 2005)

■ The American Psychiatric Nurses Association and International Society of

Psychiatric-Mental Health Nurses are committed to the reduction of seclu-

sion and restraint and have developed position statements, with a vision

of eventually eliminating seclusion and restraint. (APNA 2001; ISPN 1999)

■ Learn your institutional policies on restaints and seclusion and take

advantage of any training available, contacting supervisors/managers if

any questions about protocols.

ALERT: The decision to initiate seclusion or restraint is made only after all

other less restrictive, nonphysical methods have failed to resolve the

behavioral emergency (APNA 2001). Restraint of a patient may be both

physical and pharmacological (chemical) and infringes on a patient’s

BASICS

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01Pederson (F)-01 6/25/07 7:46 PM Page 17

freedom of movement and may result in injury (physical or psychological)

and/or death. There must be an evaluation based on benefit: risk con-

sideration and a leaning toward alternative solutions. Restraints may

be used when there is dangerous behavior and to protect the patient and

others. You need to become familiar with the standards as set forth by

JCAHO and any state regulations and hospital policies. The least restrictive

method should be used and considered first, before using more restrictive

interventions.

A Patient’s Bill of Rights

■ First adopted in 1973 by the American Hospital Association, A Patient’s

Bill of Rights was revised on October 21, 1992

■ Sets forth an expectation of treatment and care that will allow for

improved collaboration between patients, health care providers,

and institutions resulting in better patient care. (American Hospital

Association [revised] 1992)

Informed Consent

■ Every adult person has the right to decide what can and cannot be done

to his or her own body (Schloendorff v. Society of New York Hospital,

105 NE 92 [NY 1914]).

■ Assumes a person is capable of making an informed decision about own

health care.

■ State regulations vary, but mental illness does not mean that a person is

or should be assumed incapable of making decisions related to his or her

own care.

■ Patients have a right to:

■ Information about their treatment and any procedures to be performed.

■ Know the inherent risks and benefits.

■ Without this information (specific information, risks, and benefits) a

person cannot make an informed decision. The above also holds true for

those who might participate in research. (Laben & Crofts Yorker 1998)

Right to Refuse Treatment/Medication

■ Just as a person has the right to accept treatment, he or she also has

the right to refuse treatment to the extent permitted by the law and to

be informed of the medical consequences of his/her actions.

■ In some emergency situations, a patient can be medicated or treated

against his/her will, but state laws vary, and so it is imperative to be-

come knowledgeable about applicable state laws. (American Hospital

Association [revised] 1992; Laben & Crofts Yorker 1998)

BASICS

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Psychiatric Assessment

Abnormal Involuntary Movement Scale (AIMS) 41

AIMS Rating Form 42

CAGE Screening Questionnaire 33

Clock-Drawing Test 50

Culturally Mediated Beliefs and Practices 51

Depression-Arkansas Scale (D-ARK Scale) 46

Documentation 57

DSM-IV-TR Multiaxial Classification and Tool 38

Edinburgh Postnatal Depression Scale (EPDS) 44

Ethnocultural Assessment Tool 55

Ethnocultural Considerations 50

Focus Charting (DAR) 57

Geriatric Depression Rating Scale (GDS) 49

Global Assessment of Functioning (GAF) Scale 40

Medical History 25

Mental Status Assessment and Tool 34

Mini-Mental State Examination (MMSE) 50

Perception of Mental Health Services: Ethnocultural Differences 54

PIE Charting (APIE) (Example) 58

PIE Method (APIE) 58

Problem-Oriented Record (POR) 57

Psychiatric History and Assessment Tool 20

Short Michigan Alcohol Screening Test (SMAST) 33

Substance History and Assessment Tool 31

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Psychiatric History and Assessment Tool

Identifying/Demographic Information

Name Room No.

Primary Care Provider:

DOB Age Sex

Race: Ethnicity:

Marital Status: No. Marriages:

If married/divorced/separated/widowed, how long?

Occupation/School (grade):

Highest Education Level:

Religious Affiliation:

City of Residence:

Name/Phone # of Significant Other:

Primary Language Spoken:

Accompanied by:

Admitted from:

Previous Psychiatric Hospitalizations (#):

Chief Complaint (in patient’s own words):

DSM-IV Diagnosis (previous/current):

Nursing Diagnosis:

Notes:

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Family Members/Significant Others Living in Home

Name Relationship Age Occupation/Grade

Family Members/Significant Others Not in Home

Name Relationship Age Occupation/Grade

Children

Name Age Living at Home?

CLINICAL PEARL: Compare what the client says with what other family

members, friends, or significant others say about situations or previous

treatments. It is usually helpful to gather information from those who

have observed/lived with the client and can provide another valuable

source/side of information. The reliability of the client in recounting the

past must be considered and should be noted.

Genogram – See Disorders/Intervention Tab for sample genogram and

common genogram symbols.

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Past Psychiatric Treatments/Medications

It is important to obtain a history of any previous psychiatric hospitalizations, the number of hospi-

talizations and dates, and to record all current/past psychotropic medications, as well as other medi-

cations the client may be taking. Ask the client what has worked in the past, and also what has not

worked, for both treatments and medications.

Inpatient Treatment

Facility/Location Dates From/To Diagnosis Treatments Response(s)

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Outpatient Treatments/Services

Psychiatrist/Therapist Location Diagnosis Treatment Response(s)

Psychotropic Medications (Previous Treatments)

Name Dose/Dosages Treatment Length Response Comments

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Current Psychotropic Medications

Name Dose/Dosages Date Started Response(s) Serum Levels

Other Current Medications, Herbals, and OTC Medications

Name Dose/Dosages Date Started Response(s) Comments

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CLINICAL PEARL: It is important to ask about any herbals, OTC medica-

tions (e.g., pseudoephedrine), or nontraditional treatments as client may

not think to mention these when questioned about current medications.

Important herbals include, but are not limited to: St. John’s wort, ephedra

(ma huang), ginseng, kava kava, and yohimbe. These can interact with

psychotropics or other medications or cause anxiety and/or drowsiness,

as well as other adverse physiological reactions. Be sure to record and

then report any additional or herbal medications to the psychiatrist,

advanced practice nurse, psychiatric nurse, and professional team staff.

Medical History (See Clinical Pearls for Italics)

TPR: BP:

Height: Weight:

Cardiovascular (CV)

Does client have or ever had the following disorders/symptoms (include

date):

Hypertension Murmurs Chest Pain (Angina)

Palpitations/

Tachycardia

Fainting/

Syncope

Leg Pain

(Claudication)

Heart Bypass

CLINICAL PEARL: Heterocyclic antidepressants must be used with caution

with cardiovascular disease. Tricyclic antidepressants (TCAs) may produce

life-threatening arrhythmias and ECG changes.

Shortness of

Breath

Myocardial

Infarction

Arrhythmias

Angioplasty

Ankle Edema/Congestive Heart

Failure

High Cholesterol

Other CV Disease

Other CV surgery

02Pederson (F)-02 6/25/07 7:46 PM Page 25

Central Nervous System (CNS)

Does client have or ever had the following disorders/symptoms (include

date):

Headache

Dizziness/Vertigo

Myasthenia Gravis

Brain Tumor

TIAs

CLINICAL PEARL: Remember that myasthenia gravis is a contraindica-

tion to the use of antipsychotics; tremors could be due to a disease

such as Parkinson’s or could be a side effect of a psychotropic (lithium/

antipsychotic). Sometimes the elderly may be diagnosed as having

dementia when in fact they are depressed (pseudodementia). Use TCAs

cautiously with seizure disorders; bupropion use contraindicated in

seizure disorder.

Dermatological/Skin

Does client have or ever had the following disorders/symptoms (include

date):

Psoriasis Hair Loss Itching

Rashes Acne Other/Surgeries

CLINICAL PEARL: Lithium can precipitate psoriasis or psoriatic arthritis

in patients with a history of psoriasis, or the psoriasis may be new onset.

Acne is also a possible reaction to lithium (new onset or exacerbation),

and lithium may result in, although rarely, hair loss (alopecia). Rashes

in patients on carbamazepine or lamotrigine may be a sign of a life-

threatening mucocutaneous reaction, such as Stevens-Johnson syndrome

(SJS). Discontinue medication/immediate medical attention needed.

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Head Injury

Loss of Consciousness

(LOC); how long?

Parkinson’s Disease

Seizure Disorder

Other

Tremors

Stroke

Dementia

Multiple Sclerosis

Surgery

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Endocrinology/Metabolic

Does client have or ever had the following disorders/symptoms (include

date):

Polydipsia

Hyperthyroidism

Polycystic

Ovarian

Syndrome

CLINICAL PEARL: Clients on lithium should be observed and tested for

hypothyroidism. Atypical and older antipsychotics are associated with

treatment-emergent diabetes (need periodic testing: FBS, HgbA1c, lipids;

BMI, etc).

Eye, Ears, Nose,Throat

Does client have or ever had the following disorders/symptoms (include

date):

Eye Pain

Red Eye

Glaucoma

Hoarseness

CLINICAL PEARL: Eye pain and halo around a light source are possible

symptoms of glaucoma. Closed-angle glaucoma is a true emergency and

requires immediate medical attention to prevent blindness. Anticholiner-

gics (low-potency antipsychotics [chlorpromazine] or tricyclics) can cause

blurred vision. Check for history of glaucoma as antipsychotics are

contraindicated.

Halo around

Light Source

Double vision

Tinnitus

Other

Blurring

Flashing Lights/Floaters

Ear Pain/Otitis Media

Other/Surgery

Polyuria

Hypothyroidism

Other

Diabetes Type 1 or 2

Hirsutism

Surgery

02Pederson (F)-02 6/25/07 7:46 PM Page 27

Gastrointestinal

Does client have or ever had the following disorders/symptoms (include

date):

Nausea & Vomiting

GERD

Colon Cancer

CLINICAL PEARL: Nausea is a common side effect of many medications;

tricyclic antidepressants can cause constipation. Nausea seems to be

more common with paroxetine. Over time clients may adjust to these side

effects, therefore no decision should be made about effectiveness/side

effects or changing medications without a reasonable trial.

Genitourinary/Reproductive

Does client have or ever had the following disorders/symptoms (include

date):

Miscarriages? Y/N Abortions? Y/N

# When? # When?

Nipple Discharge

Lactation

Pregnancy Problems

Prostate Problems (BPH)

Penile Discharge

Renal Disease

Other/Surgery

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Diarrhea

Crohn’s Disease

Irritable Bowel Syndrome

Constipation

Colitis

Other/Surgery

Amenorrhea

Dysuria

Postpartum

Depression

Menopause

UTI

Urinary Cancer

Other Gyneco-

logical Cancer

Gynecomastia

Urinary Incontinence

Sexual Dysfunction

Fibrocystic Breast

Disease

Pelvic Pain

Breast Cancer

Other

02Pederson (F)-02 6/25/07 7:46 PM Page 28

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CLINICAL PEARL: Antipsychotics have an effect on the endocrinological

system by affecting the tuberoinfundibular system. Those on antipsy-

chotics may experience gynecomastia and lactation (men also). Women

may experience amenorrhea. Some drugs (TCAs), such as amitriptyline,

must be used with caution with BPH. Postpartum depression requires

evaluation and treatment (see Postpartum Major Depressive Episode in

Disorders-Interventions Tab).

Respiratory

Does client have or ever had (include date):

Chronic Cough

Asthma

Cancer (Lung/Throat)

Other Questions:

Allergies (food/environmental/pet/contact)

Diet

Drug Allergies

Accidents

High Prolonged Fever

Tobacco Use

Childhood Illnesses

Sore Throat

COPD

Sleep Apnea

Bronchitis

Pneumonia

Other/Surgery

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Fractures

Menses Began

Birth Control

Disabilities (hearing/speech/movement)

Pain (describe/location/length of time [over or under 3 months]/severity

between 1 [least] and 10 [worst])/Treatment

Family History

Mental Illness

Medical Disorders

Substance Abuse

Please note who in the family has the problem/disorder.

Substance Use

Prescribed Drugs

Name Dosage Reason

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Street Drugs

Name Amount/Day Reason

Alcohol

Name Amount/Day/Week Reason

Substance History and Assessment Tool

1. When you were growing up, did anyone in your family use substances

(alcohol or drugs)? If yes, how did the substance use affect the family?

2. When (how old) did you use your first substance (e.g., alcohol,

cannabis) and what was it?

3. How long have you been using a substance(s) regularly? Weeks,

months, years?

4. Pattern of abuse

a. When do you use substances?

b. How much and how often do you use?

c. Where are you when you use substances and with whom?

5. When did you last use; what was it and how much did you use?

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 31

6. Has substance use caused you any problems with family, friends, job,

school, the legal system, other? If yes, describe:

7. Have you ever had an injury or accident because of substance abuse?

If yes, describe:

8. Have you ever been arrested for a DUI because of your drinking or

other substance use?

9. Have you ever been arrested or placed in jail because of drugs or

alcohol?

10. Have you ever experienced memory loss the morning after substance

use (can’t remember what you did the night before)? Describe the

event and feelings about the situation:

11. Have you ever tried to stop your substance use? If yes, why were you

not able to stop? Did you have any physical symptoms such as

shakiness, sweating, nausea, headaches, insomnia, or seizures?

12. Describe a typical day in your life.

13. Are there any changes you would like to make in your life? If so,

describe:

14. What plans or ideas do you have for making these changes?

15. History of withdrawal:

Other comments:

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Modified from Townsend 5th ed., 2006, with permission

02Pederson (F)-02 6/25/07 7:46 PM Page 32

CAGE Screening Questionnaire

drugs? Y__ N__

(A) Have you been Annoyed

by the criticism of others about your

drinking/drug use? Y__ N__

(G) Have you felt Guilty

about the amount of drinking you do? Y__ N__

(E) Have you ever had an Eye Opener

(drink) first thing in the morning to

steady your nerves? Y__ N__

A positive (yes) response to two or more questions suggests that there is

an alcohol/substance abuse problem.

(Ewing JA: Detecting alcoholism: The CAGE questionnaire. JAMA

252:1905–1907, 1984. Copyright

1984 American Medical Association.

Note: The need to cut down

is related to tolerance (needing more

substance for same effect) and the eye opener

is related to withdrawal

syndrome (reduction/cessation of substance).

Short Michigan Alcohol Screening Test (SMAST)

■ Do you feel you are a normal drinker? [no] Y__ N__

■ Does someone close to you worry about your drinking? [yes] Y__ N__

■ Do you feel guilty about your drinking? [yes] Y__ N__

■ Do friends/relatives think you’re a normal drinker? [no] Y__ N__

■ Can you stop drinking when you want to? [no] Y__ N__

■ Have you ever attended an AA meeting? [yes] Y__ N__

■ Has drinking created problems between you and a loved one/relative?

[yes] Y__ N__

■ Gotten in trouble at work because of drinking? [yes] Y__ N__

■ Neglected obligations/family/work 2 days in a row because

of drinking? [yes] Y__ N__

■ Gone to anyone for help for your drinking? [yes] Y__ N__

■ Ever been in a hospital because of drinking? [yes] Y__ N__

■ Arrested for drunk driving or DUI? [yes] Y__ N__

■ Arrested for other drunken behavior? [yes] Y__ N__

■ Total ⫽

Five or more positive items suggests alcohol problem.

(Positive answers are in brackets above) (Selzer 1975)

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(Reprinted with permission from Journal of Studies on Alcohol, vol. 36, pp. 117–126,

1975. Copyright by Journal of Studies on Alcohol, Inc., Rutgers Center of Alcohol

Studies, Piscataway, NJ 08854 and Melvin L. Selzer, MD)

02Pederson (F)-02 6/25/07 7:46 PM Page 33

Age

Race/Ethnicity

Educational Level

Occupation

Mental Status Assessment and Tool

The components of the mental status assessment are:

■ General Appearance

■ Behavior/Activity

■ Speech and Language

■ Mood and Affect

■ Thought Process and Content

■ Perceptual Disturbances

■ Memory/Cognitive

■ Judgment and Insight

Each component must be approached in a methodical manner so that a

thorough evaluation of the client can be done from a mood, thought,

appearance, insight, judgment, and overall perspective.

It is important to document all these findings even though this record

represents one point in time. It is helpful over time to see any patterns

(regressions/improvement) and to gain an understanding of any changes

that would trigger a need to reevaluate the client or suggest a decline in

functioning.

Mental Status Assessment Tool

Identifying Information

Name

Sex

Significant Other

Religion

Presenting problem:

Appearance

Grooming/dress

Hygiene

Eye contact

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Posture

Identifying features (marks/scars/tattoos)

Appearance versus stated age

Overall appearance

CLINICAL PEARL: It is helpful to ask the client to talk about him/herself

and to ask open-ended questions to help the client express thoughts and

feelings; e.g., “Tell me why you are here?” Encourage further discussion

with: “Tell me more.” A less direct and more conversational tone at the

beginning of the interview may help reduce the client’s anxiety and set

the stage for the trust needed in a therapeutic relationship.

Behavior/Activity (check if present)

Hyperactive

Agitated

Psychomotor retardation

Calm

Tremors

Tics

Unusual movements/gestures

Catatonia

Akathisia

Rigidity

Facial movements (jaw/lip smacking)

Other

Speech

Slow/rapid

Pressured

Tone

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 35

Volume (loud/soft)

Fluency (mute/hesitation/latency of response)

Attitude

Is client:

Cooperative Uncooperative

Warm/friendly Distant

Suspicious Combative

Guarded Aggressive

Hostile Aloof

Apathetic Other

Mood and Affect

Is client:

Elated Sad Depressed

Irritable Anxious

Fearful Guilty

Worried Angry

Hopeless Labile

Mixed (anxious and depressed)

Is client’s affect:

Flat

Blunted or diminished

Appropriate

Inappropriate/incongruent (sad and smiling/laughing)

Other

Thought Process

Concrete thinking

Circumstantiality

Tangentiality

Loose association

Echolalia

Flight of ideas

Perseveration

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Clang associations

Blocking

Word salad

Derailment

Other

Thought Content

Does client have:

Delusions (grandiose/persecution/reference/somatic):

Suicidal/homicidal thoughts

If homicidal, toward whom?

Obsessions

Paranoia

Phobias

Magical thinking

Poverty of speech

Other

CLINICAL PEARL: Questions around suicide and homicide need to be

direct. For instance, Are you thinking of harming yourself/another per-

son right now? (If another, who?) Clients will usually admit to suicidal

thoughts if asked directly but will not always volunteer this information.

Any threat to harm someone else requires informing the potential victim

and the authorities. (See When Confidentiality Must be Breached, Tarasoff

Principle/Duty to Warn, in Basics Tab.)

Perceptual Disturbances

Is client experiencing:

Visual Hallucinations

Auditory Hallucinations

Commenting

Discussing

Commanding

Loud

Soft

Other

Other Hallucination (olfactory/tactile)

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 37

Illusions

Depersonalization

Other

Memory/Cognitive

Orientation (time/place/person)

Memory (recent/remote/confabulation)

Level of alertness

Insight and Judgment

Insight (awareness of the nature of the illness)

Judgment

For example: “What would you do if you saw a fire in a movie theater?”

“How will you manage financially once you leave the hospital?”

Other

Impulse control

Other

DSM-IV-TR Multiaxial Classification and Tool

Allows for assessment on various axes, which provides information on

different domains and assists in planning interventions and identifying

outcomes. Includes GAF (axis V) (explained later).

Components

Axis I: Clinical Disorder (or focus of clinical attention)

Axis II: Personality Disorders/Mental Retardation

Axis III: General Medical Conditions

Axis IV: Psychosocial/Environmental

Axis V: Global Assessment of Functioning (GAF)

Current:

Past Year, highest level:

Admission:

Discharge:

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02Pederson (F)-02 6/25/07 7:46 PM Page 38

Sample DSM-IV-TR Multiaxial Classifications

Axis I: V61.10 Partner Relational Problem

Axis II: 301.6 Dependent Personality Disorder

Axis III: 564.1 Irritable Bowel Syndrome

Axis IV: Two small daughters at home

Axis V: GAF (current) 65

Past year, highest level: 80

Axis I: 296.44 Bipolar I Disorder, most recent episode manic, severe with

psychotic features

Axis II: 301.83 Borderline Personality Disorder

Axis III: 704.00 Alopecia

Axis IV: Unemployed

Axis V: GAF Admission: 28

Discharge: 62

DSM-IV-TR Multiaxial Evaluation Tool*

Axis I:

Clinical Disorder/Clinical Focus

Include diagnostic code/

DSM-IV name

Axis II:

Personality Disorders/Mental Retardation; include

Diagnostic code/DSM-IV name

Axis III:

Any General Medical Conditions

Include ICD-9-CM codes/names

Axis IV:

Psychosocial/Environmental Problems:

(family/primary support group/social/occupational/

educational/health care/legal/crime/other)

Axis V (GAF):

Current/hospital:

Highest level past year/discharge:

Multiaxial form reprinted with permission from the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

ASSESS

*See Tools Tab for DSM-IV-TR Classification/Codes

02Pederson (F)-02 6/25/07 7:46 PM Page 39

Text/image rights not available.

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CLINICAL PEARL: It is often an Axis I disorder (depression/anxiety) that

brings a client into therapy but an Axis II disorder (dependent/borderline

personality) that keeps the client in therapy. Problems/crises continue in

spite of treatment.

Global Assessment of Functioning (GAF)/Scale

The GAF provides an overall rating of assessment of function. It is

concerned with psychosocial/occupational aspects and divided into ten

ranges of functioning, covering both symptom severity and functioning.

The GAF is recorded as a numerical value on Axis V of the Multiaxial

System (see above).

Global Assessment of Functioning (GAF) Scale

Note: Use intermediate codes when appropriate

Code (e.g., 45, 68, 72).

100

Superior functioning in a wide range of activities, life’s problems

never seem to get out of hand, sought out by others because

of his or her many positive qualities. No symptoms.

Absent or minimal symptoms (e.g., mild anxiety before an

exam), good functioning in all areas, interested and involved

in a wide range of activities, socially effective; generally

satisfied with life; no more than general problems or concerns

(e.g., an occasional argument with family members).

If symptoms are present, they are transient and expectable

reactions to psychosocial stressors (e.g., difficulty

concentrating after family argument); slight impairment in

social, work, or school functioning (e.g., temporarily falling

behind in schoolwork).

Some mild symptoms (e.g., depressed mood and mild insomnia)

OR some difficulty in social, occupational, or school

functioning (e.g., occasional truancy, or theft within the

household), but generally functioning pretty well, has some

meaningful interpersonal relationships.

Moderate symptoms (e.g., flat affect and circumstantial speech,

occasional panic attacks) OR moderate difficulty in social,

occupational, or school functioning (e.g., few friends, conflicts

with peers or co-workers).

02Pederson (F)-02 6/25/07 7:46 PM Page 40

Global Assessment of Functioning (GAF) Scale

Note: Use intermediate codes when appropriate

Code (e.g., 45, 68, 72).

0 ⫽ Inadequate information

GAF scale reprinted with permission from the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright

2000). American Psychiatric Association.

Abnormal Involuntary Movement Scale (AIMS)

■ AIMS is a 5- to 10-minute clinician/other-trained rater (psychiatric nurse)

scale to assess for tardive dyskinesia. AIMS is not a scored scale but

rather a comparative scale documenting changes over time (Guy 1976).

■ Baseline should be done before instituting pharmacotherapy and then

every 3 to 6 months thereafter. Check with federal and hospital

regulations for time frames. Long-term care facilities are required

to perform the AIMS at initiation of antipsychotic therapy and every

6 months thereafter.

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Serious symptoms (e.g., suicidal ideation, severe obsessional

rituals, frequent shoplifting) OR serious impairment in social,

occupational, or school functioning (e.g., no friends, unable to

keep a job).

Some impairment in reality testing or communication (e.g., speech

is at times illogical, obscure, or irrelevant) OR major impairment

in several areas, such as work, school, family relations, judg-

ment, thinking, or mood (e.g., depressed man avoids friends,

neglects family, and is unable to work; child frequently beats up

younger children, is defiant at home, and is failing at school).

Behavior is considerably influenced by delusions or hallucinations

OR serious impairment in communication or judgment (e.g.,

sometimes incoherent, acts grossly inappropriately, suicidal

preoccupation) OR inability to function in almost all areas (e.g.,

stays in bed all day; no job, home, or friends).

Some danger of hurting self or others (e.g., suicide attempts

without clear expectation of death; frequently violent; manic

excitement) OR occasionally fails to maintain minimal personal

hygiene (e.g., smears feces) OR gross impairment in

communication (e.g., largely incoherent or mute).

Persistent danger of severely hurting self or others (e.g., recurrent

violence) OR persistent inability to maintain minimal personal

hygiene OR serious suicidal act with clear expectation of death.

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 41

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Code:

0: None

1: Minimal, may be

extreme normal

2: Mild

3: Moderate

4: Severe

AIMS Examination Procedure

Either before or after completing the examination procedure, observe the

client unobtrusively, at rest (e.g., in waiting room). The chair to be used in this

examination should be hard and firm without arms.

■ Ask client to remove shoes and socks.

■ Ask client if there is anything in his/her mouth (e.g., gum, candy); if there

is, to remove it.

■ Ask client about the current condition of his/her teeth. Ask client if he/she

wears dentures. Do teeth or dentures bother the client now?

■ Ask client whether he/she notices any movements in mouth, face, hands,

or feet. If yes, ask to describe and to what extent they currently bother

client or interfere with his/her activities.

■ Have client sit in chair with hands on knees, legs slightly apart and feet flat

on floor. (Look at entire body for movements while client is in this position.)

■ Ask client to sit with hands hanging unsupported: if male, between legs; if

female and wearing a dress, hanging over knees. (Observe hands and

other body areas.)

■ Ask client to open mouth. (Observe tongue at rest in mouth.) Do this twice.

■ Ask client to protrude tongue. (Observe abnormalities of tongue

movement.) Do this twice.

■ Ask client to tap thumb, with each finger, as rapidly as possible for 10 to

15 seconds; separately with right hand, then with left hand. (Observe facial

and leg movements.)

■ Flex and extend client’s left and right arms (one at a time). (Note any

rigidity.)

■ Ask client to stand up. (Observe in profile. Observe all body areas again,

hips included.)

■ Ask client to extend both arms outstretched in front with palms down.

(Observe trunk, legs, and mouth.)

■ Have client walk a few paces, turn, and walk back to chair. (Observe hands

and gait.) Do this twice.

AIMS Rating Form

Name Rater Name

Date ID #

Instructions:

Complete the above examination procedure

before making ratings. For movement

ratings, circle the highest severity observed.

02Pederson (F)-02 6/25/07 7:46 PM Page 42

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Facial and

Oral Move-

ments

Extremity

Movements

Trunk

Movements

Global Judg-

ments

1. Muscles of Facial Expression

■ e.g., movements of forehead,

eyebrows, periorbital area,

cheeks.

■ Include frowning, blinking,

smiling, and grimacing.

2. Lips and Perioral Area

e.g., puckering, pouting, smacking

3. Jaw

e.g., biting, clenching, chewing,

mouth opening, lateral movement

4. Tongue

Rate only increase in movements

both in and out of mouth, NOT the

inability to sustain movement.

5. Upper (arms, wrists, hands, fingers)

■ Include choreic movements (i.e.,

rapid, objectively purposeless,

irregular, spontaneous), athetoid

movements (i.e., slow, irregular,

complex, serpentine).

■ Do NOT include tremor (i.e.,

repetitive, regular, rhythmic).

6. Lower (legs, knees, ankles, toes)

e.g., lateral knee movement, foot

tapping, heel dropping, foot

squirming, inversion and eversion

of the foot

7. Neck, shoulders, hips

e.g., rocking, twisting, squirming,

pelvic gyrations

8. Severity of Abnormal

Movements

9. Incapacitation Due to

Abnormal Movements

10. Client’s Awareness of

Abnormal Movements

Rate only client’s report.

0 1 2 3 4

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 43

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11. Current Problems With

Teeth and/or Dentures

12. Does Client Usually Wear

Dentures?

0: No 1: Yes

2. I have looked forward with

enjoyment to things.

■ As much as I ever did

■ Rather less than I used to

■ Definitely less than I used to

■ Hardly at all

(Continued)

Dental Status

The Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is a valid screening tool for detecting postpartum depression. It

is important to differentiate postpartum blues from postpartal depression

and to observe for psychosis. Bipolar disorder and previous postpartum

psychosis increase risk for suicide or infanticide. (See Postpartum Major

Depressive Episode in the Disorders-Interventions Tab for signs and

symptoms, evaluation, and treatment of postpartum depression.)

The Edinburgh Postnatal Depression Scale (EPDS)

Name:

Your date of birth:

Baby’s Age:

As you have recently had a baby, we would like to know how you are

feeling now. Please underline

the answer that comes closest to how

you have felt IN THE PAST 7 DAYS, not just how you feel today.

Sample question:

Here is an example already completed:

I have felt happy

■ Yes, most of the time

■ Y

es, some of the time

■ No, not very often

■ No, not at all

This would mean “I have felt happy some of the time during the past week.”

Please complete the following questions in the same way:

1. I have been able to laugh and

see the funny side of things.

■ As much as I always could

■ Not quite so much now

■ Definitely not so much now

■ Not at all

02Pederson (F)-02 6/25/07 7:46 PM Page 44

Text/image rights not available.

3. I have blamed myself

unnecessarily when things

went wrong.*

■ Yes, most of the time

■ Yes, some of the time

■ Not very often

■ No, never

5. I have felt scared or panicky

for no very good reason.*

■ Yes, quite a lot

■ Yes, sometimes

■ No, not much

■ No, not at all

7. I have been so unhappy

that I have had difficulty

sleeping.*

■ Yes, most of the time

■ Yes, sometimes

■ Not very often

■ No, not at all

9. I have been so unhappy

that I have been crying.*

■ Yes, most of the time

■ Yes, quite often

■ Only occasionally

■ No, never

Total score ⫽ (See scoring p. 46)

Instructions for users:

1. The mother is asked to underline the response that comes closest to

how she has been feeling in the previous 7 days.

2. All ten items must be completed.

3. Care should be taken to avoid the possibility of the mother

discussing her answers with others.

4. The mother should complete the scale herself, unless she has

limited English or has difficulty with reading.

ASSESS

4. I have been anxious or worried

for no good reason.

■ No, not at all

■ Hardly ever

■ Yes, sometimes

■ Yes, very often

6. Things have been getting on top

of me.*

■ Yes, most of the time I haven’t

been able to cope at all

■ Yes, sometimes I haven’t been

coping as well as usual

■ No, most of the time I have

coped quite well

■ No, I have been coping as

well as ever

8. I have felt sad or miserable.*

■ Yes, most of the time

■ Yes, quite often

■ Not very often

■ No, not at all

10. The thought of harming myself

has occurred to me.*

■ Yes, quite often

■ Sometimes

■ Hardly ever

■ Never

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 45

Text/image rights not available.

5. The EPDS may be used at 6–8 weeks to screen postnatal women.

The child health clinic, postnatal check-up, or a home visit may

provide suitable opportunities for its completion.

Scoring:

Questions 1, 2, and 4 are scored 0, 1, 2, and 3 according to increased

severity of the symptoms. The top response (e.g., As much as I always

could, question 1) would be scored a 0 and the bottom response (e.g.,

Not at all, question 1) scored a 3. Items marked with an asterisk *

(questions 3, 5–10) are reverse scored (i.e., 3, 2, 1, and 0). The total

score is calculated by adding together the scores for each of the ten

items. Maximum score is 30. Patients scoring 13 or more should be

assessed for possible depression. A cut-off of 10 or more may be used

if greater sensitivity is required. Any score above 0 on item 10 should

always prompt further assessment.

natal Depression Scale may be photocopied by individual researchers

or clinicians for their own use without seeking permission from the

publishers. The scale must be copied in full and all copies must

acknowledge the following source: Cox, J.L., Holden, J.M., & Sagovsky,

R. (1987). Detection of postnatal depression. Development of the 10-

item Edinburgh Postnatal Depression Scale. British Journal of Psychi-

atry, 150, 782–786. Written permission must be obtained from the Royal

College of Psychiatrists for copying and distribution to others or for

republication (in print, online or by any other medium).

Translations of the scale, and guidance as to its use, may be found in

Cox, J.L. & Holden, J. (2003) Perinatal Mental Health: A Guide to the

Edinburgh Postnatal Depression Scale. London: Gaskell.

Depression-Arkansas Scale (D-ARK Scale)

The D-ARK scale is a practical, self-report assessment scale for measuring

major depressive disorder in clinical settings. It is scientifically sound and

simple to use (Smith, Kramer, Hollenberg et al 2002).

Depression-Arkansas (D-ARK) Scale

Underline or circle your response to each of 11 questions that follow; note

that each question relates to the past 4 weeks:

1. How often in the past 4 weeks have you felt depressed, blue, or in low

spirits for most of the day?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week (4) Nearly

every day for at least two weeks

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02Pederson (F)-02 6/25/07 7:46 PM Page 46

Text/image rights not available.

2. How often in the past 4 weeks did you have days in which you

experienced little or no pleasure in most of your activities?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week (4) Nearly

every day for at least two weeks

3. How often in the past 4 weeks has your appetite been either less than

usual or greater than usual?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week (4) Nearly

every day for at least two weeks

4. In the past 4 weeks, have you gained or lost weight without trying to?

(1) No (2) Yes, a little weight (3) Yes, some weight (4) Yes, a lot of

weight

5. How often in the past 4 weeks have you had difficulty sleeping or

trouble with sleeping too much?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week (4) Nearly

every day for at least two weeks

6. In the past 4 weeks, has your physical activity been slowed down or

speeded up so much people who know you could notice?

(1) No (2) Yes, a little slowed or speeded up (3) Yes, somewhat slowed

or speeded up (4) Yes, very slowed or speeded up

7. In the past 4 weeks, have you often felt more tired out or less

energetic than usual?

(1) No (2) Yes, a little tired (3) Yes, somewhat tired out (4) Yes, very

tired out

8. How often in the past 4 weeks have you felt worthless or been

bothered by feelings of guilt?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week

(4) Nearly every day for at least two weeks

9. In the past 4 weeks, have you often had trouble thinking,

concentrating, or making decisions?

(1) No (2) Yes, a little trouble thinking (3) Yes, some trouble thinking

(4) Yes, a lot of trouble thinking

10. How often have you thought about death or suicide in the past

4 weeks?

(1) Not at all (2) 1 to 3 days a week (3) Most days a week

(4) Nearly every day for at least two weeks

11. In the past 4 weeks, have you thought a lot about a specific way to

commit suicide?

(1) No (2) Yes

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(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 47

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Diagnostic Score (see scoring below)

Part A

Part B

Total Score (A ⫹ B) ⫽

D-ARK Diagnostic Scoring

Part A: If respondent scores Questions 1 or 2 greater than or equal to 2;

then Part A ⫽ 1

Part B: Score individual items as follows:

If question 1 is greater than or equal to 2, Criterion 1 ⫽ 1;

Score

If question 2 is greater than or equal to 2, Criterion 2 ⫽ 1;

Score

If question 3 is greater than or equal to 2, or Question

4 is greater than or equal to 2, Criterion 3 ⫽ 1;

Score

If questions 5–9 are greater than or equal to 3, Criteria 4–8 ⫽ 1 each;

Score

If Question 10 is greater than or equal to 3, or Question 11 ⫽ 2, Criterion

9 ⫽ 1; Score

Part B: Add scores for Criterion 1 through 9, and Total: ; if the

total of Criteria 1–9 is greater than or equal to 5, then Part B ⫽ 1

If Part A

⫽

1 and Part B

⫽

1, then the respondent meets the criteria for

depression.

Note: The D-ARK Scale includes all 9 DSM-IV Criteria symptoms for

diagnosing Major Depressive Disorder. (See DSM-IV-TR, Mood

Episodes, Criteria for Major Depressive Episode and also Major

Depressive Episode in the Disorders-Interventions Tab.)

D-ARK Severity Scoring

Recode Questions 1–10 as 0 to 3; if Question 11 ⫽ 1, then Question

11 ⫽ 0; if Question 11 ⫽ 2, then Question 11 ⫽ 3. Calculate the mean

of questions 1–11; multiply by 33.33. This product is the severity score.

If Question 10 is missing (not answered) or two or more questions are

missing, do not score severity.

University of Arkansas for Medical Sciences

4301 West Markham Street

Little Rock, AR 72205

Used with permission.

02Pederson (F)-02 6/25/07 7:46 PM Page 48

Geriatric Depression Rating Scale (GDS)

Short Version

Choose the best answer for how you have felt over the past week (circle

yes or no):

1. Are you basically satisfied with your life? YES/NO

2. Have you dropped many of your activities and interests? YES/NO

3. Do you feel that your life is empty? YES/NO

4. Do you often get bored? YES/NO

5. Are you in good spirits most of the time? YES/NO

6. Are you afraid that something bad is going to happen to you?

YES/NO

7. Do you feel happy most of the time? YES/NO

8. Do you often feel helpless? YES/NO

9. Do you prefer to stay at home, rather than going out and doing new

things? YES/NO

10. Do you feel you have more problems with memory than most?

YES/NO

11. Do you think it is wonderful to be alive now? YES/NO

12. Do you feel pretty worthless the way you are now? YES/NO

13. Do you feel full of energy? YES/NO

14. Do you feel that your situation is hopeless? YES/NO

15. Do you think that most people are better off than you are? YES/NO

Total Score ⫽

Bold answers ⫽ depression

GDS Scoring:

12–15 Severe depression

8–11 Moderate depression

5–7 Mild depression

0–4 Normal

(Yesavage et al. 1983; Sheikh 1986; GDS Web site:

http://www.stanford.edu/~yesavage/)

ALERT: As with all rating scales, further evaluation and monitoring are

often needed. Be sure to perform a Mini-Mental State Examination

(MMSE) first to screen for/rule out dementia (cognitive deficits).

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02Pederson (F)-02 6/25/07 7:46 PM Page 49

Mini-Mental State Examination (MMSE)

The Mini-Mental State Examination is a brief (10-minute) standardized,

reliable screening instrument used to assess for cognitive impairment

and commonly used to screen for dementia. It evaluates orientation,

registration, concentration, language, short-term memory, and visual-

spatial aspects and can be scored quickly (24–30 ⫽ normal; 18–23 ⫽

mild/moderate cognitive impairment; 0–17 ⫽ severe cognitive

impairment). (Folstein et al. 1975; Psychological Assessment

Resources, Inc.)

The Clock-Drawing Test

Another test that is said to be possibly more sensitive to early dementia

is the clock-drawing test. There are many variations and clock is first

drawn (by clinician) and divided into tenths or quadrants. Client is asked

to put the numbers in the appropriate places and then indicate the time

as “ten minutes after eleven.” Scoring is based on test used and

completion of the tasks. (Manos 2004)

Ethnocultural Considerations

With over 400 ethnocultural groups, it is impossible to cover every group

within North America. It is important, however, to become familiar with

the characteristics and customs of most ethnocultural groups you will be

working with and sensitive to any differences.

Ethnicity refers to a common ancestry through which individuals have

evolved shared values and customs. This sense of commonality is trans-

mitted over generations by family and reinforced by the surrounding

community (McGoldrick, 2005).

Suggested References for Further Reading Include:

Lipson J, and Dibble S: Culture and Clinical Care, 2/e. University of

California, School of Nursing, San Francisco 2005.

McGoldrick M, Giordano J, and Garcia-Preto N: Ethnicity and Family

Therapy, 3/e. The Guilford Press, New York 2005.

Purnell LD, and Paulanka BJ: Guide to Culturally Competent Health

Care. FA Davis, Philadelphia 2005.

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02Pederson (F)-02 6/25/07 7:46 PM Page 50

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Culturally Mediated Beliefs and Practices

Dying/birth Role differences Religion Communication

African

American

Arab

American

Reluctant to donate

organs

Ask about advance

directives/durable

power of attorney

(may not have any)

– usually family

makes decisions as

a whole. Burials

may take up to 5–7

d after death. Varied

responses to death.

Colostrum is believed

harmful to the

infant

Death is God’s will;

turn patient’s bed to

face Mecca and

read the Koran. No

cremation, no

autopsy (except

forensic) and organ

donation accept-

able.

Baptist/Methodist/

other Protes-

tant/Muslim

(Nation of

Islam/other sects)

Determine affiliation

during interview/

determine impor-

tance of church/

religion.

Muslim (usually

Sunni)/Protestant/

Greek orthodox/

other Christian

Duties of Islam:

Declaration of

faith, prayer 5

times/d, alms-

giving, fasting

during Ramadan,

and pilgrimage to

Mecca.

Varies by educa-

tional level/socio-

economic level.

High percentage of

families is

matriarchal.

Extended family

important in

health education;

include women in

decision mak-

ing/health

information.

Men make most

decisions

(patrilineal) and

women respon-

sible for daily

needs (wield a lot

of influence over

family and home);

family loyalty

more important

than individual

needs.

Eye Contact:

Demonstrates

respect/trust, but

direct contact may

be interpreted as

aggressive.

Other: Silence may

indicate distrust.

Prefer use of last

name (upon

greeting) unless

referred to

otherwise.

Eye Contact: Females

may avoid eye con-

tact with males/

strangers.

Other: Supportive

family members

may need a break

from caregiving;

obtain an interpre-

ter if necessary.

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 51

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Culturally Mediated Beliefs and Practices (Continued)

Dying/birth Role differences Religion Communication

Asian

American

Native

Americans

May use incense/

spiritual. Need

extra time with

deceased mem-

bers; natural

cycle of life.

Full family

involvement

throughout life

cycle; do not

practice birth

control or limit

size of family.

Primarily Buddhism

and Catholicism;

Taoism and Islam

Traditional Native

American or

Christian;

spirituality based

on harmony with

nature.

Father/eldest son

primary decision

maker;

recognized head

has great

authority.

Varies tribe to

tribe; most

tribes matrilineal

and be sure to

identify the gate-

keeper of the

tribe.

Eye Contact: Direct

eye contact may

be viewed as

disrespectful.

Other: Use inter-

preters whenever

possible (be

careful about tone

of voice). Often a

formal distance.

Eye Contact: Eye

contact sustained.

Other: American

Indian may be

term preferred by

older adults; use

an interpreter to

avoid misunder-

standings. Do not

point with finger.

02Pederson (F)-02 6/25/07 7:46 PM Page 52

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Culturally Mediated Beliefs and Practices

Dying/birth Role differences Religion Communication

Mexican

Americans

Russian

Americans

Adapted from Purnell & Paulanka 2005 and Myers 2006, with permission

Family support

during labor; very

expressive during

bereavement (find

a place where

family can grieve

together quietly).

Fertility practices

follow Catholic

teachings. Abor-

tion considered

wrong.

Father may not

attend birth;

usually closest

family female

does; family

wants to be

informed of

impending death

before patient.

Roman Catholic

primarily

Eastern Orthodox

and Judaism;

remember recent

oppression; also

Molokans, Tartar

Muslims, Pene-

costals, Baptists.

About 60% not

religious.

Equal decision

making with all

family

members; men

expected to

provide

financial

support.

Men and women

share decision

making; family,

women,

children highly

valued.

Eye Contact: Eye

contact may be

avoided with

authority figures.

Other: Silence may

indicate disagree-

ment with proposed

plan of care; greet

adults formally

(sen˜ or, se˜nora, etc,

unless told

otherwise).

Eye Contact: Direct

eye contact

acceptable/nodding

means approval.

Other: Use inter-

preters whenever

possible; Russians

are distant until

trust is established.

02Pederson (F)-02 6/25/07 7:46 PM Page 53

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Perception of Mental Health Services: Ethnocultural Differences

African Americans

■ Often distrustful of therapy and mental health services. May seek

therapy because of child-focused concerns.

■ Seek help and support through “the church,” which provides a sense of

belonging and community (social activities/choir). Therapy is for “crazy

people” (McGoldrick 2005).

Mexican Americans

■ Understanding the migration of the family is important, including who

has been left behind. The church in the barrio often provides commu-

nity support.

■ Curanderos (folk healers) may be consulted for problems such as: mal

de ojo (evil eye) and susto (fright) (McGoldrick 2005).

Puerto Ricans

■ Nominally Catholic, most value the spirit and soul. Many believe in

spirits that protect or harm and the value of incense and candles to

ward off the “evil eye.”

■ Often underutilize mental health services, and therapist needs to

understand that expectations about outcome may differ (McGoldrick

2005).

Asian American

■ Many Asian-American families are transitioning from the extended

family to the nuclear unit and struggling to hold on to old ways while

developing new skills.

■ Six predictors of mental health problems are: 1) employment/financial

status, 2) gender (women more vulnerable), 3) old age, 4) social isola-

tion, 5) recent immigration, and 6) refugee premigration experiences

and postmigration adjustment (McGoldrick 2005).

Above are just a few examples of many ethnocultural groups and the

differences in the understanding and perception of mental health/therapy.

Please refer to suggested references (p. 50) for additional and more

comprehensive information.

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Ethnocultural Assessment Tool

Client’s name Ethnic origin

City/State Birth date

Significant other Relationship

Primary language spoken Second language

Interpreter required? Available?

Highest level of education Occupation

Presenting problem/chief complaint:

Has problem occurred before? If so how was it handled?

Client’s usual manner of coping with stress?

Who is (are) client’s main support system?

Family living arrangements (describe):

Major decision maker in family:

Client’s/family members’ roles in the family:

Religious beliefs and practices:

Are there religious restrictions or requirements?

Who takes responsibility for health concerns in family?

Any special health concerns or beliefs?

(Continued on following page)

02Pederson (F)-02 6/25/07 7:46 PM Page 55

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Who does family usually approach for medical assistance?

Usual emotional/behavioral response to:

Anger

Anxiety

Pain

Fear

Loss/change/failure

What are sensitive topics client is unwilling to discuss because of

ethnocultural taboos?

Client’s feelings about touch and touching?

Client’s feelings regarding eye contact?

Client’s orientation to time (past/present/future)?

Illnesses/diseases common to client’s ethnicity?

Client’s favorite foods:

Foods that client requests or refuses because of ethnocultural reasons:

Client’s perception of the problem and expectations of care and outcome:

Other:

Modified from Townsend 5th ed., 2006, with permission

02Pederson (F)-02 6/25/07 7:46 PM Page 56

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Documentation

Problem-Oriented Record (POR)

POR Data Nursing Process

S (Subjective)

O (Objective)

A (Assessment)

P (Plan)

I (Intervention)

E (Evaluation)

Focus Charting (DAR)

Charting Data Nursing Process

D (Data)

Focus

A (Action)

R (Response)

Client’s verbal reports (e.g.,

“I feel nervous”)

Observation (e.g., client is

pacing)

Evaluation/interpretation of

S and O

Actions to resolve problem

Descriptions of actions

completed

Reassessment to determine

results and necessity of

new plan of action

Assessment

Diagnosis/outcome

identification

Planning

Implementation

Evaluation

Describes observations

about client/supports the

stated focus

Current client concern/

behavior/significant

change in client status

Immediate/future actions

Client’s response to care

or therapy

Assessment

Diagnosis/outcome

identification

Plan and implementation

Evaluation

02Pederson (F)-02 6/25/07 7:46 PM Page 57

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PIE Method (APIE)

Charting Data Nursing Process

A (Assessment)

P (Problem)

I (intervention)

E (Evaluation)

POR, DAR, and APIE modified from Townsend 5th ed., 2006, with

permission

CLINICAL PEARL: It is important to systematically assess and evaluate

all clients and to develop a plan of action, reevaluating all outcomes. It

is equally important to document all assessments, plans, treatments,

and outcomes. You may “know” you provided competent treatment,

but without documentation there is no record from a legal perspective.

Do not ever become complacent about documentation.

Example of APIE Charting

DATE/TIME PROBLEM: PROGRESS NOTE:

5–22–07

1000

Example modified from Townsend 5th ed., 2006, with permission

Subjective and objective data

collected at each shift

Problems being addressed from

written problem list and

identified outcomes

Actions performed directed at

problem resolution

Response appraisal to determine

intervention effectiveness

Assessment

Diagnosis/out-

come identi-

fication

Plan and imple-

mentation

Evaluation

Social

Isolation

A: States he does not want to sit with or talk

to others; they “frighten him.” Stays in room;

no social involvement.

P: Social isolation due to inability to trust.

I: Spent time alone with client to initiate trust;

accompanied client to group activities;

praised participation.

E: Cooperative although still uncomfortable

in presence of group; accepted positive

feedback.

02Pederson (F)-02 6/25/07 7:46 PM Page 58

DISORDERS/

INTERV

Psychiatric Disorders/Interventions

Psychiatric Disorders

Addiction, Withdrawal, and Tolerance/Internet Addiction 65

ADHD Treatments, Nonpharmacological 96

Anorexia Nervosa/Bulimia Nervosa 90

Anxiety Disorders 78

Anxiety Disorder, Generalized (GAD) (table) 80

Anxiety Disorders: Client/Family Education 83

Anxiety, Four Levels 79

Attention Deficit/Hyperactivity Disorder (ADHD) 96

Bipolar Disorders 73

Borderline Personality Disorder (BPD) (table) 93

Bulimia Nervosa (BN) (table) 91

Childhood and Adolescence, disorders of 95

Conduct Disorder/Oppositional Defiant Disorder 97

Delirium, Dementia, and Amnestic Disorders 61

Delusions, common 71

Dementia of Alzheimer’s Type (AD) (table) 62

Dementia of the Alzheimer’s Type, Medications for 63

Dementia With Lewy Bodies 63

Dementia: Client/Family Education 63

Depressive Disorders 73

Depressive Episode, Major (table) 75

Eating Disorders 89

Eating Disorders: Client/Family Education 90

Gender Identity Disorder 87

Hypoactive Sexual Desire Disorder (table) 88

Manic Episode (table) 76

Mental Retardation 95

Mood Disorders 72

Mood Disorders: Client/Family Education 78

Obsessive-Compulsive Disorder (OCD) (table) 81

Paraphilias 87

Personality Disorders 92

Personality Disorders: Client/Family Education 94

Postpartum Major Depressive Episode (table) 77

Posttraumatic Stress Disorder (PTSD) (table) 82

Schizophrenia (table) 69

Schizophrenia and Other Psychotic Disorders 67

Schizophrenia: Client/Family Education 72

03Pederson (F)-03 6/25/07 7:47 PM Page 59

Schizophrenia, Four A’s 70

Schizophrenia, Positive and Negative Symptoms 70

Sexual and Gender Identity Disorders 86

Sexual Dysfunctions 86

Sexual Dysfunctions/Paraphilias/Gender Identity Disorders:

Client/ Family Education 89

SIGECAPS – Mnemonic for Depression 74

Somatoform Disorders 84

Somatization Disorder (SD) (table) 85

Substance Dependence (table) 66

Substance Use Disorders 64

Substance-Induced Disorders 65

Substance-Related Disorders 64

Substance-Related Disorders: Client/Family Education 67

Thought Disorders – Content of Thought (Definitions) 71

Thought Disorders – Form of Thought (Definitions) 71

Psychiatric Interventions

Cognitive Behavioral Therapy 109

Cognitive Behavioral Therapy, Distortions in Thinking 110

Communication Techniques 101

Complementary Therapies 111

Emerging/New Treatments for Depression, Nonpharmacological 110

Family Therapy 107

Family Therapy Models/Theories 107

Genogram 107

Genogram, Sample 109

Genogram Symbols, Common 108

Group Development, Stages of 103

Group: Individual Roles/Difficult Group Members 104

Group Interventions 103

Leadership Styles 104

Nonverbal Communication 100

Phases of Relationship Development 99

Therapeutic Milieu 103

Therapeutic Relationship/Alliance 98

Therapeutic Relationship, Core Elements 98

Therapeutic Use of Self 98

Yalom’s Therapeutic Factors 106

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Delirium, Dementia, and Amnestic Disorders

These disorders are characterized by clinically significant cognitive

deficits and notable changes from previous levels of functioning. The

changes may be due to a medical condition or substance abuse or

both (APA 2000).

■ Dementia – Characterized by intellectual decline and usually pro-

gressive deficits not only in memory but also in language, perception,

learning, and other areas. Dementia of the Alzheimer’s type (AD) is

the most common dementia, followed by vascular dementia (ischemic

vascular dementia). Other causes: Infections: HIV, encephalitis,

Creutzfeldt-Jakob disease; drugs and alcohol (Wernicke-Korsakoff’s

syndrome [thiamine deficiency]); inherited such as Parkinson’s disease

and Huntington’s disease. Some dementias (AD) are essentially

irreversible and others potentially reversible (drug toxicities, folate

deficiency).

■ Delirium – Organic brain syndrome resulting in a disturbance in

consciousness and cognition that happens within a short period

with a variable course.

■ Amnestic Disorder – Disturbance in memory and impaired ability

to learn new information or recall previously learned information.

■ Pseudodementia – Cognitive difficulty that is caused by depression

but may be mistaken for dementia. Need to consider and rule out in

the elderly who may appear to have dementia when actually suffering

from depression, which is a treatable disease. Could be depressed with

cognitive deficits as well.

CLINICAL PEARL – AD is a progressive and irreversible dementia with

a gradually declining course, whereas ischemic vascular dementia

(ministrokes and transient ischemic attacks) often presents in a stepwise

fashion with an acute decline in cognitive function.

It is important to

distinguish between dementia and delirium because delirium can

be life-threatening and should be viewed as an emergency.

Delirium

can be differentiated from dementia by its rapid onset, fluctuating in

and out of a confusional state, and difficulty in attending to surround-

ings. Delirium is usually caused by a physical condition, such as infec-

tion; therefore, the underlying cause needs to be treated. Keep in mind

that a person with dementia may also become delirious.

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Dementia of Alzheimer’s Type (AD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Memory

impairment

■ Inability to learn

new material

■ Language deter-

ioration (naming

objects)

■ Inability to execute

typical tasks (cook/

dress self)

■ Executive func-

tioning distur-

bances (planning/

abstract thinking/

new tasks)

■ Paranoia

■ Progressive from

mild forgetfulness

to middle and late

dementia (requir-

ing total ADL care/

bedridden)

■ Course: 18 mo -

27 y [avg. 10 - 12 y]

■ Idiopathic

■ Many theo-

ries (viral/

trauma)

■ Pathology

shows

neuritic

plaques and

neurofib-

rillary

tangles; also

amyloid

protein

■ Familial AD

(presenilin

1 gene)

■ Apolipo-

protein E

genotype

(Kukull 2002)

■ Ischemic

vascular

dementia

■ Dementia with

Lewy bodies

■ Alcoholic

dementia

(Wernicke-

Korsakoff

[thiamine

deficiency];

pellagra [niacin

deficiency];

hepatic

encephalitis)

■ Delirium

■ Depression

■ Medical disor-

der (HIV,

syphilis)

■ Other

substance

abuse

■ Psychosis

■ Mental status

exam

■ Folstein Mini-

Mental State Exam

■ Neuropsycho-

logical testing

(Boston naming;

Wisconsin card

sorting test)

■ Depression-

Arkansas (D-ARK)

Scale; Beck

Depression

Inventory (BDI)

(R/O depression)

■ Geriatric

Depression Scale

(R/O depression)

■ CBC, blood

chemistry (renal,

metabolic/hepatic),

sed rate, T4/TSH,

, folate, UA,

FTA-Abs, CT

scan/MRI; HIV titer

■ Early diagnosis

■ Symptom treat-

ment (aggres-

sion/agitation)

■ Behavioral

management

■ Communication

techniques

■ Environmental

safety checks

■ Antipsychotics

■ Antidepressants

■ Sedatives

■ Antianxiety

agents

■ Nutritional

supplements

■ Anti-Alzheimer’s

agents (e.g.,

donepezil

[Aricept]);

memantine

(Namenda)

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Dementia With Lewy Bodies

Clients with dementia with Lewy bodies usually present with pronounced

changes in attention (drowsiness, staring), parkinsonian symptoms, and

visual hallucinations; unlike AD, the course is usually rapid. Donepezil,

rivastigmine, and levodopa may benefit cognitive/motor symptoms.

ALERT: Important to differentiate AD from dementia with Lewy bodies.

Clients with Lewy bodies dementia are very sensitive to antipsychotics

and, because of their psychosis (visual hallucinations), they are often

treated with an antipsychotic. Such treatment often results in extra-

pyramidal symptoms (EPS) (Goroll 2006).

Medications to Treat Dementia of the Alzheimer’s Type

■ Medications used to treat mild to moderate AD include tacrine

[Cognex], donepezil [Aricept], and galantamine [Reminyl].

■ Memantine (Namenda), which is an NMDA receptor antagonist,

is the first drug approved for moderate to severe AD.

Client/Family Education: Dementia

■ Educate family on how to communicate with loved ones with

dementia, especially if paranoid. Family members should not argue

with someone who is agitated or paranoid.

■ Focus on positive behaviors, avoiding negative behaviors that do

not pose a safety concern.

■ Avoid arguments by talking about how the dementia client is

feeling rather than arguing the validity of a statement. For

instance, if the client says that people are coming into the house

and stealing, family members can be taught to discuss the feelings

around the statement rather than the reality of it (“That must be

hard for you, and we will do all we can to keep you safe.”).

■ Educate family about environmental safety, as dementia clients may

forget they have turned on a stove, or they may have problems with

balance. Throw rugs may need to be removed and stove disconnected,

with family members providing meals.

■ Family members need to understand that this is a long-term

management issue requiring the support of multiple health

professionals and family and friends. Management may require

medication (control of hostility or for hallucinations/delusions).

Medications need to be started at low doses and titrated slowly.

(Continued on following page)

03Pederson (F)-03 6/25/07 7:47 PM Page 63

■ Keep in mind that a spouse or family caregiver is also dealing with

his/her own feelings of loss, helplessness, and memories of the person

who once was and no longer exists.

■ Teach the family caregiver how to manage difficult behaviors and

situations in a calm manner, which will help both the family member

and the client.

■ Caregiver stress. Remember that the caregiver also needs a break

from the day-to-day stress of caring for someone with dementia. This

could involve respite provided by other family members and friends

(Chenitz et al. 1991).

Substance-Related Disorders

■ Substances include prescribed medications, alcohol, over-the-counter

medications, caffeine, nicotine, steroids, illegal drugs, and others;

substances serve as central nervous system (CNS) stimulants, CNS

depressants, and pain relievers; and may alter both mood and

behaviors.

■ Many substances are accepted by society when used in moderation

(alcohol, caffeine), and others are effective in chronic pain

management (opioids) but can be abused in some instances and illegal

when sold on the street.

■ Substance use becomes a problem when there is recurrent and

persistent use despite social, work, and/or legal consequences and

despite a potential danger to self or others.

Substance Use Disorders

Substance Dependence

■ Repeated use of drug despite substance-related cognitive, behavioral,

and physiological problems.

■ Tolerance, withdrawal, and compulsive drug-taking may result. There is

a craving for the substance.

■ Substance dependence does not apply to caffeine.

Substance Abuse

■ Recurrent and persistent maladaptive pattern of substance use with

significant adverse consequences occurring repeatedly or persistently

during the same 12-month period.

■ Repeated work absences, DUIs, spousal arguments, fights (APA 2000).

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Substance-Induced Disorders

Substance Intoxication

■ Recent overuse of a substance, such as an acute alcohol intoxication,

that results in a reversible, substance-specific syndrome.

■ Important behavioral and psychological changes (alcohol: slurring

of speech, poor coordination, impaired memory, stupor, or coma).

■ Can happen with one-time use of substance.

Substance Withdrawal

■ Symptoms differ and are specific to each substance (cocaine,

alcohol).

■ Symptoms develop when a substance is discontinued after frequent

substance use (anxiety, irritability, restlessness, insomnia, fatigue)

(APA 2000).

Addiction, Withdrawal, and Tolerance/Internet Addiction

■ Addiction – The repeated, compulsive use of a substance that

continues in spite of negative consequences (physical, social,

legal, etc.).

■ Physical Withdrawal/Withdrawal Syndrome – Physiological

response to the abrupt cessation or drastic reduction in a substance

used (usually) for a prolonged period. The symptoms of withdrawal

are specific to the substance used.

■ Tolerance – Increased amounts of a substance over time are needed

to achieve the same effect as obtained previously with smaller

doses/amounts.

See Assessment Tab for CAGE Screening Questionnaire, Short Michigan

Alcohol Screening Test, and Substance History and Assessment.

■ Internet Addiction – Even though there is no evidence or research

suggesting Internet addiction exists as a disorder, behaviors can be

compulsive, and the Internet offers many opportunities for sexual

addicts. More research is needed (DeAngelis 2000; Ng & Weimer-

Hastings 2005).

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DISORDERS/

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Substance Dependence

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Maladaptive coping

mechanism

■ Clinically signif-

icant impairment/

distress, same

12-mo period

■ Tolerance develops:

increasingly

larger amounts

needed for

same effect

■ Intense cravings

and compulsive

use; unsuccessful

efforts to cut down

■ Inordinate time

spent obtaining

substance

(protecting supply)

■ Important activities

given up

■ Continue despite

physical/psycho-

logical problems

■ Genetics

(hereditary,

esp. alcohol)

■ Biochemical

■ Psychosocial

■ Ethnocultural

■ Need to

approach as

biopsychoso-

cial disorder

■ Response to

substances

can be very

individual-

istic

■ Consider

comorbidities:

mood dis-

orders, such

as bipolar/

depression.

ECA study:

(Reiger et al.

1990) 60.7%

diagnosed

with bipolar I

had lifetime

diagnosis of

substance use

disorders

■ Untreated

chronic pain

■ Undiagnosed

depression in

elderly

(isolation a

problem)

■ CAGE

questionnaire

■ SMAST, AUDIT,

others

■ Toxicology screens

(emergencies)

■ Arkansas-

Depression

(D-ARK) Scale;

Beck Depression

Inventory (BDI)

(R/O depression)

■ GDS

■ Labs: Liver

function tests

(LFTs) – ␥-

glutamyltransfer-

ase (GGT) and

mean corpuscular

volume (MCV); %

CDT

(carbohydrate-

deficient

transferrin) (Anton

2001)

■ Early

identification

and education

■ Confidential and

nonjudgmental

approach

■ Evaluate for

comorbidities

and treat other

disorders

■ Evaluate own

attitudes about

substance use/

dependence

■ Psychotherapy

■ Behavior therapy

■ 12-step

programs

■ Medications:

mood stabilizers,

antidepressants,

naltrexone

■ Detoxification

■ Hospitalization

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Client/Family Education: Substance-Related Disorders

■ Keep in mind that most clients underestimate their substance use

(especially alcohol consumption) and that denial is the usual defense

mechanism.

■ When substance dependence/abuse is suspected, it is important to

approach the client in a supportive and nonjudgmental manner. Focus

on the consequences of continued substance use and abuse

(physically/emotionally/family/employment), and discuss the need for

complete abstinence. Even with a desire to stop, there can be relapses.

■ If a substance user/abuser will not seek help, then family members

should be encouraged to seek help through organizations such as

AlAnon (families of alcoholics) or NarAnon (families of narcotic

addicts). AlaTeen is for adolescent children of alcoholics, and Adult

Children of Alcoholics (ACOA) is for adults who grew up with alcoholic

parents.

■ For substance abusers, there is Alcoholics Anonymous, Narcotics

Anonymous, Overeaters Anonymous, Smokers Anonymous, Women

for Sobriety, etc. There is usually a support group available to deal with

the unique issues of each addiction.

■ In some instances, medication may be required to manage the

withdrawal phase (physical dependence) of a substance.

Benzodiazepines may be needed, including inpatient detoxification.

■ Naltrexone, an opioid antagonist, reduces cravings by blocking opioid

receptors in the brain and is used in heroin addiction and alcohol

addiction (reduces cravings and number of drinking days) (Tai 2004;

Maxman & Ward 2002).

■ Educate clients and families about the possibility of comorbidities

(bipolar disease) and the need to treat these disorders as well.

ALERT: Be aware of the increase in methamphetamine addiction in

North America, its highly addictive nature, and the devastating social

and physical (neurotoxic) consequences of use (Barr et al. 2006).

Schizophrenia and Other Psychotic Disorders

In 1908, Eugen Bleuler, a Swiss psychiatrist, introduced the term schizo-

phrenia, which replaced the term dementia praecox, used by Emil

Kraepelin (1896). Kraepelin viewed this disorder as a deteriorating

(Continued on following page)

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DISORDERS/

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organic disease; Bleuler viewed it as a serious disruption of the mind,

a “splitting of the mind.” In 1948, Fromm-Reichman coined the term

schizophrenogenic mother, described as cold and domineering,

although appearing self-sacrificing. Bateson (1973, 1979) introduced the

double bind theory, wherein the child could never win and was always

wrong (invalidation disguised as acceptance; illusion of choice;

paradoxical communication).

■ Schizophrenia is a complex disorder, and it is now accepted that

schizophrenia is the result of neurobiological factors rather than due

to some early psychological trauma.

■ The lifetime prevalence rate (US/worldwide) is about 1%.

■ Onset in the late teens to early 20s, equally affecting men and

women.

■ Devastating disease for both the client and the family.

■ Schizophrenia affects thoughts and emotions to the point that social

and occupational functioning is impaired (Kessler 1994; Bromet

1995).

■ About 9% to 13% of schizophrenics commit suicide (Meltzer 2003).

■ Early diagnosis and treatment are critical to slowing the

deterioration and decline, which will result without treatment.

■ Earlier typical antipsychotic drugs effective against most of the

positive symptoms; less effective against negative symptoms.

■ Atypical antipsychotic drugs work on both negative and positive

symptoms.

■ Family/community support is key factor in improvement.

■ Subtypes of schizophrenia include paranoid, disorganized,

catatonic, undifferentiated, and residual types.

■ National Association for the Mentally Ill (www.nami.org) is an

important national organization that has done much to educate society

and communities about mental illness and to advocate for the

seriously mentally ill.

■ Other psychotic disorders include schizophreniform disorder,

schizoaffective disorder, delusional disorder, brief psychotic disorder,

shared psychotic disorder (folie à deux), psychotic disorder due to a

medical condition, substance-induced, and not otherwise specified

(NOS).

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DISORDERS/

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Schizophrenia

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ At least for 1 mo,

two or more from

the following:

■ Delusions

■ Hallucinations

■ Disorganized

speech

■ Disorganized

behavior

■ Negative symp-

toms (alogia,

affective flatten-

ing, avolition)

■ Functional distur-

bances at school,

work, self care,

personal relations

■ Disturbance contin-

ues for 6 mo

■ Dopamine

hypothesis

(excess)

■ Brain abnor-

malities (third

ventricle

sometimes

larger)

■ Frontal lobe –

decreased

glucose

use/smaller

frontal lobe

■ Genetic –

familial;

monozygotic

twin (47% risk

vs 12%

dizygotic)

■ Virus

■ No specific

cause

■ Schizophreni-

form disorder

■ Schizoaffective

■ Mood disorder

with psychotic

symptoms

■ Medical

disorder/

substance

abuse with

psychotic

episode

■ Delusional

disorder

■ Note: with

schizophrenia,

the condition

persists for at

least 6 mo

and is chronic

and

deteriorating

■ Psychiatric

evaluation and

mental status

exam

■ No test can

diagnose

schizophrenia

■ Positive and

Negative

Syndrome Scale

(PANSS)

■ Abnormal

Involuntary

Movement Scale

(AIMS)

■ Need to R/O other

possible medical/

substance use

disorders: LFTs,

toxicology

screens, CBC,

thyroid function

test (TFT), CT

scan, etc.

■ Antipsychotic –

usually atypi-

cals for new

onset: olanza-

pine, aripipra-

zole, etc.

■ New: paliperi-

done (Invega)

■ Acute psychotic

episode may

need high

potency

(haloperidol)

■ Hospitalization

until positive

symptoms

under control

■ Patient/family

education

■ NAMI for

patient/family

education,

patient

advocate

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Positive and Negative Symptoms of Schizophrenia

■ Positive Symptoms

Positive symptoms are excesses in behavior (excessive

function/distortions)

■ Delusions

■ Hallucinations (auditory/visual)

■ Hostility

■ Disorganized thinking/behaviors

■ Negative Symptoms

Negative symptoms are deficits in behavior (reduced function; self-care

deficits)

■ Alogia

■ Affective blunting

■ Anhedonia

■ Asociality

■ Avolition

■ Apathy

Four A’s of Schizophrenia

■ Eugen Bleuler in 1911 proposed four basic diagnostic areas for

characterizing schizophrenia. These became the 4 A’s:

A: Inappropriate Affect

A: Loosening of Associations

A: Autistic Thoughts

A: Ambivalence

■ These four A’s provide a memory tool for recalling how schizophrenia

affects thinking, mood (flat), thought processes, and decision-making

ability (Shader 2003).

CLINICAL PEARL – When auditory hallucinations first begin, they usually

sound soft and far away and eventually become louder. When the sounds

become soft and distant again, the auditory hallucinations are usually

abating. The majority of hallucinations in North America are auditory

(versus visual), and it is unlikely that a client will experience both auditory

and visual hallucinations at the same time.

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Thought Disorders – Content of Thought (Definitions)

Common Delusions

Delusion of Grandeur – Exaggerated/unrealistic sense of importance,

power, identity. Thinks he/she is the President or Jesus Christ.

Delusion of Persecution – Others are out to harm or persecute in some

way. May believe his/her food is being poisoned or he/she is being

watched.

Delusion of Reference – Everything in the environment is somehow

related to the person. A television news broadcast has a special message

for this person solely.

Somatic Delusion – An unrealistic belief about the body, such as the

brain is rotting away.

Control Delusion – Someone or something is controlling the person.

Radio towers are transmitting thoughts and telling person what to do.

Thought Disorders – Form of Thought (Definitions)

Circumstantiality – Excessive and irrelevant detail in descriptions with

the person eventually making his/her point. We went to a new restaurant.

The waiter wore several earrings and seemed to walk with a limp…yes,

we loved the restaurant.

Concrete Thinking – Unable to abstract and speaks in concrete, literal

terms. For instance, a rolling stone gathers no moss would be interpreted

literally.

Clang Association – Association of words by sound rather than

meaning. She cried till she died but could not hide from the ride.

Loose Association – A loose connection between thoughts that are

often unrelated. The bed was unmade. She went down the hill and

rolled over to her good side. And the flowers were planted there.

Tangentiality – Digressions in conversation from topic to topic and

the person never makes his/her point. Went to see Joe the other day.

By the way, bought a new car. Mary hasn’t been around lately.

Neologism – Creation of a new word meaningful only to that person.

The hiphopmobilly is on its way.

Word Salad – Combination of words that have no meaning or

connection. Inside outside blue market calling.

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Client/Family Education: Schizophrenia

■ Client and family education is critical to improve chances of relapse

prevention and to slow or prevent regression and associated long-term

disability.

■ Refer client/family to the National Association for the Mentally Ill

(NAMI) (www.nami.org) (1-800-950-NAMI [6264]) and National

Schizophrenia Foundation (www.NSFoundation.org) (800-482-9534).

■ Client needs both medication and family/community support.

■ Studies have shown that clients taking medication can still relapse if

living with high expressed emotion family members (spouse/parent).

These family members are critical, intense, hostile, and overly involved

versus low expressed emotion family members (Davies 1994).

■ Once stabilized on medication, clients often stop taking their

medication because they feel they no longer need their medication

(denying the illness or believing they have recovered). It is important

to stress the need for medication indefinitely and that maintenance

medication is needed to prevent relapse.

■ Clients also stop their medication because of untoward side effects.

Engage the client in a discussion about medications so that he/she has

some control about options. The newer atypical drugs have a better

side-effect profile, but it is important to listen to the client’s concerns

(weight gain/EPS) as adjustments are possible or a switch to another

medication. Educate client/family that periodic lab tests will be needed.

ALERT: For those on antipsychotic therapy, there is also a concern with

treatment-emergent diabetes, especially for those with risk factors for

diabetes, such as family history, obesity, and glucose intolerance (Buse

et al. 2002).

■ Early diagnosis, early treatment, and ongoing antipsychotic mainte-

nance therapy with family support are critical factors in slowing the

progression of this disease and in keeping those with schizophrenia

functional and useful members of society.

Mood Disorders

A mood disorder is related to a person’s emotional tone or affective state

and can have an effect on behavior and can influence a person’s

personality and worldview.

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■ Extremes of mood (mania or depression) can have devastating

consequences on client, family, and society alike.

■ These consequences include financial, legal, marital, relationship,

employment, and spiritual losses as well as despair that results in

potential suicide and death.

■ Correct diagnosis is needed, and effective treatments are available.

The mood disorders are divided into depressive disorders and bipolar

disorders.

■ The depressive disorders include major depressive disorder,

dysthymic disorder, and depressive disorder NOS.

■ The bipolar disorders include bipolar I disorder, bipolar II disorder,

cyclothymic disorder, and bipolar disorder NOS.

Depressive Disorders

■ Major depressive disorder (unipolar depression) requires at least

2 weeks of depression/loss of interest and four additional depressive

symptoms, with one or more major depressive episodes.

■ Dysthymic disorder is an ongoing low-grade depression of at least

2 years’ duration for more days than not and does not meet the criteria

for major depression.

■ Depression NOS does not meet the criteria for major depression and

other disorders (APA 2000).

Bipolar Disorders

■ Bipolar I disorder includes one or more manic or mixed episodes,

usually with a major depressive episode.

■ Bipolar II disorder includes one or two major depressive episodes

and at least one hypomanic (less than full mania) episode.

■ Cyclothymic disorder includes at least 2 years of hypomanic periods

that do not meet the criteria for the other disorders.

■ Bipolar NOS does not meet any of the other bipolar criteria.

■ Others: Mood disorders due to a general medical condition, substance-

induced mood disorders, and mood disorder NOS (APA 2000).

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SIGECAPS – Mnemonic for Depression

Following is a mnemonic for easy recall and review of the DSM-IV criteria

for major depression or dysthymia:

Sleep (increase/decrease)

Interest (diminished)

Guilt/low self-esteem

Energy (poor/low)

Concentration (poor)

Appetite (increase/decrease)

Psychomotor (agitation/retardation)

Suicidal ideation

A depressed mood for 2 or more weeks, plus four SIGECAPS ⫽ major

depressive disorder

A depressed mood, plus three SIGECAPS for 2 years, most days ⫽

dysthymia (Brigham and Women’s Hospital 2001).

CLINICAL PEARL – Important to determine that a depressive episode is a

unipolar depression versus a bipolar disorder with a depressive episode.

A first-episode bipolar I or II may begin with major depression. The

presentation is a “clinical snapshot in time” rather than the complete

picture. Further evaluation and monitoring are needed. Bipolar clients are

often misdiagnosed for years.

■ One study (Ghaemi et al. 2003) showed 37% of patients were misdi-

agnosed (depression vs bipolar), resulting in new or worsening rapid

cycling (mania) in 23% because antidepressants were prescribed

(Keck 2003).

■ Although the tricyclic antidepressants (TCAs) are more likely to trigger

a manic episode, the selective serotonin reuptake inhibitors (SSRIs)

have also been implicated.

ALERT: If a client who is recently prescribed antidepressants begins

showing manic symptoms, consider that this client may be bipolar.

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Major Depressive Episode

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Depressed

mood or loss

of interest

for at least

2 weeks and

five or more of:

■ Significant

weight loss/

gain

■ Insomnia or

hypersomnia

■ Psychomotor

agitation or

retardation

■ Fatigue

■ Worthless

feelings or

inappropriate

guilt

■ Problem

concentrating

■ Recurrent

thoughts of

death

■ Familial

predisposi-

tion (female

to male,

3:1)

■ Deficiency

of norepin-

ephrine

(NE) and

serotonin

■ Hypotha-

lamic

dysfunction

■ Psychoso-

cial factors

■ Unknown

■ Bipolar I or II

disorder

■ Schizoaffective

■ Grief (major

loss) (acute

distress → 3

mo)

■ Postpartum

depression

■ Thyroid/adrenal

dysfunction;

hypothyroidism

■ Neoplasms

■ CNS (stroke)

■ Vitamin

deficiencies

(folic acid)

■ Medication

(reserpine,

prednisone)

■ Pseudodementia

(older adult)

■ Substance

abuse disorder

(cocaine)

■ Psychiatric

evaluation and

mental status

exam

■ D-ARK Scale

(see Assess-

ment Tab); BDI;

Zung Self-

Rating Depres-

sion Scale;

Geriatric

Depression

Scale

■ MMSE

■ Physical exam

■ R/O other

possible

medical/sub-

stance use

disorders: LFTs,

toxicology

screens, CBC,

TFT, CT scan,

etc.

■ Antidepressants:

usually SSRIs (fluoxe-

tine, sertraline); selec-

tive norepinephrine

reuptake inhibitors

(SNRIs) (venlafaxine)

■ TCAs: side effects

include sedation, dry

mouth, blurred vision;

TCAs not good for

elderly (falls)

■ MAOIs

■ New: selegiline patch

(Emsam)

■ Others: bupropion

■ Cognitive behavioral

therapy (CBT)

■ Psychotherapy

■ Electroconvulsive

theraphy (ECT)

Emerging:

■ Vagal nerve

stimulation

■ Transcranial magnetic

stimulation

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DISORDERS/

INTERV

Manic Episode

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Persistent elevated,

irritable mood

≥1 wk, plus three

or more (irritable,

four or more):

■ ↑ Self-esteem

■ ↓ Sleep

■ ↑Talk/pressured

speech

■ Racing thoughts/

flight of ideas

■ Distractibility

■ Extreme goal-

directed activity

■ Excessive

buying/sex/

business

investments

(painful conse-

quences)

■ Genetic: familial

predisposition

(female to male,

1.2:1)

■ Bipolar onset

18 – 20 yr

■ Catecholamines:

NE, dopamine

■ Many hypothe-

ses: serotonin,

acetylcholine;

neuroanatomi-

cal (frontotem-

poral lesions)

■ Complex

disorder

■ Hypomanic

episode

(bipolar II)

■ Mixed episode

(major

depressive

and manic

episode ≥1

wk)

■ Cyclothymia

■ Substance-

induced

(cocaine)

■ ADHD

■ Dual

diagnosis

■ Brain lesion

■ General

medical

condition

■ Psychiatric

evaluation and

mental status

exam

■ Young Mania

Rating Scale

(YMRS)

(bipolar I)

■ Need to R/O

other possible

medical/

substance

use/induced

disorders: LFTs,

toxicology

screens, CBC,

TFT, CT scan,

etc.

■ Mood stabiliz-

ers: lithium

(standard);

anticonvulsants

(carbamazepine,

valproic acid,

lamotrigine,

topiramate)

■ Combined

treatments:

lithium and

anticonvulsant

■ Antipsychotics:

e.g., aripipra-

zole, olanzapine

■ Lithium: ⫹ for

mania/not for

mixed

■ Therapy and

medication

compliance

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DISORDERS/

INTERV

Postpartum Major Depressive Episode

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Symptoms similar

to major depressive

episode

■ Acute onset to

slowly over first

3 postpartum

(PP) months

■ Persistent/

debilitating

vs blues

■ Depressed

mood, tearful-

ness, insomnia,

suicidal thoughts

■ Anxiety, obsession

about well-being

of infant

■ Affects functioning

■ Occurs in 10% –

15% of women

■ Highest risk: hx

of depression,

previous PP

depression,

depression

during pregnancy

■ Previous PP

depression with

psychosis: ↑30%

– 50% risk of

recurrence at

subsequent

delivery

■ PP blues:

(fluctuating

mood; peaks

4th d post

delivery; ends

2 weeks;

functioning

intact)

■ PP psychosis:

1 – 2/1000

women; ↑ risk:

bipolar/

previous PP

psychosis;

infanticide/

suicide risk

high

■ Medical cause

■ Edinburgh

Postnatal

Depression

Scale (EPDS):

self-rated

questionnaire

(see Assess-

ment Tab)

■ Screen during

PP period

■ Psychiatric

evaluation

■ Physical exam

■ Routine lab

tests: CBC, TFT

(thyroid/

anemia)

■ Pharmacologi-

cal: SSRIs,

SNRIs, TCAs

(insomnia);

consider

weight gain,

dry mouth,

sedation with

TCAs

■ CBT, individ-

ual, group

psychotherapy

■ Anxiolytics

■ ECT

■ Psychosis:

hospitalization;

mood stabi-

lizers, antipsy-

chotics, ECT

03Pederson (F)-03 6/25/07 7:47 PM Page 77

DISORDERS/

INTERV

Client/Family Education: Mood Disorders

Mood disorders can range from subthreshold to mild (dysthymic) to

extreme (manic/psychotic) fluctuations in emotion and behaviors.

Family and client need educating about the specific disorder, whether

major depression, bipolar I or II, postpartum depression, or unresolved

grief. Without treatment, support, and education, the results can be

devastating emotionally, interpersonally, legally, and financially.

■ The mood disorders need to be explained in terms of their biochemical

basis – “depression is an illness, not a weakness,” although often

recurrent, chronic illness.

■ Families and clients need to understand that early diagnosis and

treatment are essential for effective management and improved

outcome.

■ It may be helpful to compare with other chronic illnesses, such as

diabetes and asthma, as a model and to reinforce the biological

basis of the illness to reduce stigma. As with any chronic illness

(diabetes, asthma), ongoing management, including pharmacological

treatment, is required, realizing there may be exacerbations and

remissions.

■ Reinforce the need to adhere to the dosing schedule as prescribed

and not to make any unilateral decisions, including stopping, without

conferring with health professional.

■ Work with client and family on side-effect management. If client can

be part of the decision making when there are options, client will be

more willing to become involved in own recovery and continue

treatment.

■ Address weight gain possibilities (lithium, anticonvulsants, anti-

psychotics); monitor weight, BMI, exercise, and food plans to prevent

weight gain.

Anxiety Disorders

■ The anxiety disorders include a wide range of disorders from the very

specific, such as phobias, to generalized anxiety disorder, which is

pervasive and experienced as dread or apprehension.

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DISORDERS/

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■ Other anxiety disorders include panic disorder, agoraphobia (avoidance

of places that may result in panic), social phobia, obsessive-compulsive

disorder, post-traumatic stress disorder, acute stress disorder, anxiety

due to a medical disorder, substance-induced anxiety disorder, and

anxiety disorder NOS.

■ Some anxiety is good, motivating people to perform at their best.

Excessive anxiety can be crippling and may result in the “fight or

flight” reaction. The fighter is ever ready for some perceived aggres-

sion and is unable to relax, and the escaper (flight) freezes with anxiety

and may avoid upsetting situations or actually dissociate (leave his/her

body/fragment).

■ Either extreme is not good and can result in physical and emotional

exhaustion. (See Fight-or-Flight Response and Stress-Adaptation

Syndrome in Basics Tab.)

Four Levels of Anxiety

■ Mild Anxiety – This is the anxiety that can motivate someone positively

to perform at a high level. It helps a person to focus on the situation at

hand. For instance, this kind of anxiety is often experienced by

performers before entering the stage.

■ Moderate Anxiety – Anxiety moves up a notch with narrowing of the

perceptual field. The person has trouble attending to his/her

surroundings, although he/she can follow commands/direction.

■ Severe Anxiety – Increasing anxiety brings the person to another level,

resulting in an inability to attend to his/her surroundings, except for

maybe a detail. Physical symptoms may develop, such as sweating and

palpitations (pounding heart). Anxiety relief is the goal.

■ Panic Anxiety – The level reached is now terror, where the only concern

is to escape. Communication impossible at this point (Peplau 1963).

CLINICAL PEARL – Recognizing level of anxiety is important in determin-

ing intervention. Important to manage anxiety before it escalates. At the

moderate level, firm, short, direct commands are needed: You need to sit

down, Mr. Jones.

03Pederson (F)-03 6/25/07 7:47 PM Page 79

DISORDERS/

INTERV

Generalized Anxiety Disorder (GAD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Excessive anxiety;

at least 6 mo; diffi-

cult to control worry/

hypervigilant

■ Associated with

three or more:

■ Restless/on edge

■ Easily fatigued

■ Concentration

problems

■ Irritability

■ Muscle tension

■ Sleep

disturbance

■ Causes significant

distress

■ Often physical

complaints: dizzi-

ness, tachycardia,

tightness of chest,

sweating, tremor

■ Neurotrans-

mitter dysregu-

lation: NE,

5-HT, GABA

■ Autonomic

nervous system

activation:

locus ceruleus/

NE release/

limbic system

■ 1-year

prevalence

rate: 1%;

lifetime

prevalence, 5%

■ Familial

association

■ Over half:

onset in

childhood

■ Anxiety disor-

der due to a

medical condi-

tion (hyperthy-

roidism;

pheochro-

mocytoma)

■ Substance-

induced

anxiety or

caffeine-

induced

anxiety

disorder

■ Other anxiety

disorders:

panic disorder,

OCD, etc.;

DSM-IV

criteria help

rule out

■ Self-rated

scales: Beck

Anxiety

Inventory

(BAI); State

Trait Anxiety

Inventory

■ Observer-rated

scale:

Hamilton

Anxiety Rating

Scale (HAM-A)

■ Psychiatric

evaluation

■ Physical exam

■ Routine lab

tests; TFTs

■ Pharmacolog-

ical: benzodi-

azepines very

effective

(diazepam,

lorazepam);

nonbenzodi-

azepines:

buspirone

■ Antidepres-

sants, (SSRIs):

escitalopram

and paroxetine

■ Beta blockers:

propranolol

■ CBT

■ Deep muscle

relaxation

■ Individual and

family therapy

■ Education

03Pederson (F)-03 6/25/07 7:47 PM Page 80

DISORDERS/

INTERV

Obsessive Compulsive Disorder (OCD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Obsessions –

recurrent, intru-

sive thoughts that

cause anxiety OR

Compulsions –

repetitive behav-

iors (hand washing,

checking) that

reduce distress/

anxiety and must

be adhered to

rigidly

■ Driven to perform

compulsions

■ Time-consuming

(⬎1 hr/d), interfere

with normal routine

■ Recognizes

thoughts/

behaviors are

unreasonable

■ Genetic evidence

■ Neurobiological

basis: orbitofrontal

cortex, cingulate,

and caudate

nucleus

■ Neurochemical:

serotonergic and

possibly

dopaminergic

■ Association

between OCD and

Tourette’s, and

others

■ Lifetime preva-

lence of 2.5%

■ Women ⬎ men

■ Avg onset: 20 y

■ Childhood:

7 – 10 y

■ Other anxiety

disorders:

phobias

■ Impulse

control

disorders

■ Obsessive-

compulsive

personality

disorder

■ Body

dysmorphic

disorder

■ Depression

■ Neurological

disorders

■ Yale-Brown

Obsessive

Compulsive

Scale (Y-

BOCS)

■ Psychiatric

evaluation

■ Mental

status exam

■ Neurologi-

cal exam

■ Pharmacolog-

ical: SSRIs:

fluoxetine:

(higher doses);

fluvoxamine;

clomipramine

■ Beta blockers:

propranolol

■ Behavior

therapy:

exposure and

response

prevention

■ Deep muscle

relaxation

■ Individual and

family therapy

■ Education

03Pederson (F)-03 6/25/07 7:47 PM Page 81

DISORDERS/

INTERV

Posttraumatic Stress Disorder (PTSD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Traumatic event

(self/family/witness

others); threat of

harm or death or

actual death and

helplessness

■ Reexperiencing

event “flashbacks”

(triggers: sounds/

smell)

■ Hypervigilance/

recurrent

nightmares/

numbing

■ Anniversary reac-

tions (unaware

reenactment related

to trauma)

■ Persistent anxiety/

outbursts

■ Acute (⬍3 mo);

chronic (≥3 mo);

delayed (⬎6 mo)

■ Rape, torture,

child abuse,

natural disaster,

murder, war,

terrorism, etc.

■ Physiological/

neurochemical/

endocrinological

alterations

■ Sympathetic

hyperarousal

■ Limbic system

(amygdala

dysfunction)

■ “Kindling”: ↑

neuronal

excitability

■ Risk factor:

trauma

■ Lifetime preva-

lence ~8% (US)

■ Acute stress

disorder

■ Obsessive-

compulsive

disorder

■ Adjustment

disorder

■ Depression

■ Panic

disorder

■ Psychotic

disorders

■ Substance-

induced

disorder

■ Psychotic

disorder

due to a

general

medical

condition

■ Delirium

■ PTSD scale

(clinician-

administered)

■ Psychiatric

evaluation

■ Mental status

exam

■ Neurological

exam

■ CAGE, SMAST

■ Physical

exam, routine

blood studies

■ No laboratory

test can

diagnose

■ Debriefing

(rescuers, etc.)

■ Individual or group

psychotherapy

■ CBT

■ Eye Movement

Desensitization and

Reprocessing

(EMDR) (Shapiro

2001)

■ Pharmacotherapy:

Antidepressants –

SSRIs, SNRIs,

MAOIs, TCAs;

antipsychotics;

anxiolytics; mood

stabilizers

■ Family and com-

munity support/

art therapy/

psychodrama

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DISORDERS/

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Client/Family Education: Anxiety Disorders

Anxiety, the most common disorder in the United States, exists along

a continuum and may be in response to a specific stressor (taking a

test), or it may present as a generalized “free-floating” anxiety (GAD)

or a panic disorder (PD) (feeling of terror). A 1-year prevalence rate

for all anxieties has been said to be in the 5% – 15% range

(Shader 2003).

■ Most people have experienced some degree of anxiety, so it might be

helpful for family members to understand the four stages of anxiety

and how one stage builds on the other – especially in trying to explain

panic disorder.

■ It is important for families to understand the importance of early

diagnosis and treatment of anxiety disorders, as these are chronic

illnesses and will become worse and more difficult to treat over

time.

■ Explain to client and family the need for ongoing management

(pharmacological/education/psychotherapeutic/CBT), just as diabetes,

asthma, and heart disease must be managed.

■ Many of these disorders are frustrating to family members. It is hard to

understand the repetitive hand washing or checking that can be done

by someone with OCD. Family members are also affected, and the

client’s illness becomes a family issue as well.

■ The client may also need to be educated about the needs of other

family members (maybe time away from client [respite]). Family

therapy may be needed to negotiate and agree on living arrange-

ments in a way that respects the needs of the client and all family

members.

■ As in all chronic disorders, remissions and exacerbations will be

experienced. At times reinforcement sessions (CBT) are needed,

especially with CBT and exposure/response prevention for OCD.

■ Remind families that patience, persistence, and a

multimodal/multiteam approach to treatment are needed.

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DISORDERS/

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Somatoform Disorders

Somatoform disorders are characterized by physical symptoms that

suggest a physical disorder, but are not fully explained by a

general medical condition. Following is a listing of somatoform

disorders:

■ Somatization Disorder (see table that follows) begins before age 30

with multiple symptoms (pain, GI, sexual, and pseudoneurological),

lasting a long time (years).

■ Undifferentiated Somatoform Disorder is similar to somatization

disorder but does not qualify for somatization disorder (less intense/

not as pronounced/less impairment), and symptoms last at least 6

months.

■ Conversion Disorder affects voluntary motor/sensory functions,

which causes significant distress or impairment socially or in other

areas of functioning, but cannot be explained by a medical/neurological

condition.

■ Pain Disorder – the focus of attention is pain itself of sufficient

severity to warrant clinical attention, with psychological factors playing

a key role.

■ Hypochondriasis involves fear of disease and idea that one has a

serious disease, despite medical evidence to the contrary, and a focus

on the body’s symptoms/functions for at least 6 months.

■ Body Dysmorphic Disorder is an obsession/preoccupation with

an (perceived) exaggerated “defect” (nose, lips, eyes) in physical

appearance, with frequent checking in the mirror. Preoccupation

causes significant distress or social, occupational, or other functional

impairment.

■ Somatoform Disorder NOS – Does not meet criteria for any of the

somatoform disorders (APA 2000).

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DISORDERS/

INTERV

Somatization Disorder (SD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Hx of physical com-

plaints before age 30

over several years;

seeking Rx or affects

important areas of

functioning

Each must be met:

■ Four pain symptoms

in four different areas

(head/back/stomach/

joint pain)

■ Two GI symptoms (N, V)

■ One sexual symptom

(ED, pain)

■ One pseudoneuro-

logical symptom

(paralysis/balance)

■ Cannot be fully ex-

plained by a medical

condition or a sub-

stance OR physical

symptoms are in

excess of history/lab

findings

■ Symptoms are not

feigned

■ Prevalence

rates of

0.2% – 2% for

women and

less than

0.2% for men

■ Observed in

10% – 20% of

female first

degree rela-

tives with SD

■ Male

relatives of

women with

SD have

increased risk

of antisocial

personality

disorder and

substance-

disorders

■ May be

underlying

mood

disorder

■ Somato-

form disor-

der NOS

(symptoms

⬍6 mo)

■ General

medical

condition

■ Schizo-

phrenia

■ Panic

disorder

■ Depressive

disorder

■ Anxiety

disorder

■ Factitious

disorder

■ Malinger-

ing

■ Pain disor-

der associ-

ated

with….

■ Psychiatric

evaluation

■ Mental status

exam

■ Neurological

exam

■ Physical

exam, routine

blood studies

■ No lab test is

remarkable

for these

subjective

complaints

■ Must R/O

medical

condition

■ Antidepressants

■ Stress management

■ Lifestyle changes

(exercise)

■ Collaboration be-

tween primary care

physician and

mental health

provider (MHP)

■ Psychotherapy

■ CBT

■ Psychoeducation

■ Family support

■ Support/

understanding –

client often believes

symptoms are

physical/ refuses

psychological help

■ Avoid unnecessary

medical treatments/

tests (often doctor/

hospital shops)

■ Chronic fluctuating

disorder – rarely

remits

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DISORDERS/

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Sexual and Gender Identity Disorders

The Sexual and Gender Identity Disorders are divided into three main

categories by the DSM-IV-TR. In order to understand dysfunction, sexual

health needs to be defined and understood.

■ Sexual health is defined as a state of physical, emotional, mental, and

social well-being related to sexuality; it is not merely the absence of

disease or dysfunction. It requires a respectful and positive approach,

free of coercion, discrimination, and violence. Sexual practices are safe

and have the possibility of pleasure (WHO 1975).

■ A person’s sex refers to biological characteristics that define this

person as a male or a female (some individuals possess both male and

female biological characteristics [hermaphrodite/intersex]) (WHO 2002).

■ Gender refers to the characteristics of men and women that are

socially constructed rather than biologically determined. People are

taught the behaviors and roles that result in their becoming men and

women, also known as gender identity and gender roles.

■ Gender roles are also culturally determined and differ from one

culture to another; they are not static; they are also affected by the

law and religious practice.

■ Gender also relates to power relationships (between men and

women) as well as reproductive rights issues and responsibilities

(APA 2000).

■ Sexual orientation refers to the sexual preference of a person,

whether male to female, female to female, male to male, or bisexual.

Variations in sexual preference are considered to be sexually healthy

(APA 2000).

Sexual Dysfunctions

■ Sexual dysfunction is a disturbance in the sexual response cycle or

is associated with pain during intercourse.

■ Sexual response cycle dysfunctions include the areas of desire,

excitement, orgasm, and resolution. Categories include: hypoactive

sexual desire disorder, sexual aversion disorder, female sexual arousal

disorder, male erectile disorder, female and male orgasmic disorders,

and premature ejaculation.

■ The pain disorders include: dyspareunia, vaginismus, sexual function

due to a medical disorder, substance-induced sexual dysfunction, and

sexual dysfunction NOS.

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DISORDERS/

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Paraphilias

■ The paraphilias are sexually arousing fantasies, urges, or behaviors

triggered by/focused on nonhuman objects, self or partner humiliation,

nonconsenting adults, or children, which are recurrent for a period of at

least 6 months.

■ There are episodic paraphilias that operate only during times of

stress.

■ Paraphilias include pedophilia (sexual activity with a child ≤13 y);

frotteurism (touching/rubbing nonconsenting person); fetishism

(nonhuman object used for/needed for arousal); exhibitionism (genital

exposure to a stranger); voyeurism (observing unsuspecting persons

naked or in sexual activity); sexual masochism (humiliation/suffering),

sadism (excitement from inflicting suffering/humiliation); and others

(APA 2000).

Gender Identity Disorder

■ Gender Identity Disorder requires a cross-gender identification

and a belief and insistence that “one is the other sex.” The desire is

persistent, and the preference is for cross-sex roles. Prefers the

stereotypical roles and games/pastimes/clothing of other sex.

■ There exists an extreme and persistent discomfort with the biological

sex at birth and the sense of oneself as not belonging to the gender

role of the biological sex.

■ Boys will have an aversion to own penis and testicles, and girls resent

growing breasts or female clothing.

■ This is not a physical intersex condition, and there is definite distress

over the biological sex that affects important areas of functioning (APA

2000).

Because sexuality and its dysfunctions involve cultural considerations

and attitudes, moral and ethical concerns, religious beliefs, as well as

legal considerations, it is important to evaluate your own beliefs, values,

possible prejudices, and comfort level in dealing with sexual disorders.

03Pederson (F)-03 6/25/07 7:47 PM Page 87

DISORDERS/

INTERV

Hypoactive Sexual Desire Disorder

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Deficiency or

absence of sexual

fantasies or

desires; persistent/

recurrent

■ Marked distress/

interpersonal

difficulties

■ Not substance-

induced or due

to a general

medical condition

■ Does not usually

initiate sex and

reluctantly engages

in sex with partner

■ Relationship/

marital difficulties

■ Lifelong/acquired/

situational

■ Psycholog-

ical: partner

incompati-

bility, anger,

sexual

identity

issues,

sexual

preference

issues,

negative

parental

views (as a

child)

■ Sexual

aversion

disorder

(intense

fear/disgust

over sex vs

disinterest)

■ Extremes in

sexual

appetite

(sexual addict

as a partner)

■ Major

depression

■ Medical

condition

■ Substance

abuse

■ Medication

■ Sexual abuse

■ Other

■ Complete

physical

exam,

including

medical

history

■ Psychiatric

evaluation

■ Mental status

exam

■ Sexual history

■ Routine lab

work, thyroid

function tests

■ BDI

■ D-ARK Scale

■ Zung

■ CAGE

■ SMAST

■ Refer to sex

therapist

■ Relationship

therapy

■ CBT

■ Assuming no

physical/

medication/

substance use

disorder, deal

with

relationship

issues and

assure sexual

compatibility

and sexual

orientation

03Pederson (F)-03 6/25/07 7:47 PM Page 88

DISORDERS/

INTERV

Client/Family Education: Sexual Dysfunctions/

Paraphilias/Gender Identity Disorders

Sexual Dysfunctions

■ Clients and their partners need to understand where in the sexual

response cycle the problem exists (arousal/orgasm).

■ If the problem is one of desire or aversion, this needs to be explored

further to determine the causes: couple discord, gender identity, sexual

orientation issues, negative views of sexual activity, previous sexual

abuse, body image, or self-esteem issues.

■ The same holds true for other sexual dysfunctions (orgasmic

problems/erectile dysfunction) in that issues around substance

use/abuse; previous sexual experiences; possible psychological,

physical, and other stressors as factors, including medical conditions

and prescribed medications, need to be explored.

■ Referral to a sex therapist may be needed to find ways to reconnect

intimately. Sometimes partner education is needed on how to satisfy

the other partner (mutual satisfaction).

Paraphilias and Gender Identity Disorders

The Paraphilias and Gender Identity Disorders require help from

professionals especially trained in dealing with these disorders. Clients

and families need to receive support and education from these

professionals.

Eating Disorders

■ Eating disorders are influenced by many factors, including family

rituals and values around food and eating, ethnic and cultural

influences, societal influences, and individual biology.

■ American society currently stresses physical beauty and fitness and

favors the thin and slim female as the ideal.

■ There has been a dramatic increase in the number of obese people in

the United States – at an alarming rate among children.

■ With society’s emphasis on fast and convenient foods, high in calories,

a reduction in exercise (computers/TV), and the ongoing value of “thin

as beautiful,” eating disorders remain a concern.

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DISORDERS/

INTERV

Anorexia Nervosa/Bulimia Nervosa

■ Two specific eating disorders are anorexia nervosa (AN) and bulimia

nervosa (BN). (For BN see table that follows.) Both use/manipulate

eating behaviors in an effort to control weight. Each has its dangers

and consequences if maintained over time.

■ Anorexia Nervosa – The AN client is terrified of gaining weight and

does not maintain a minimally acceptable body weight.

■ There is a definite disturbance in the perception of the size or shape

of the body.

■ AN is more common in the industrialized societies and can begin as

early as age 13 y.

■ Body weight in the anorexic client is less than 85% of what would be

expected for that age and height.

■ Even though underweight, client still fears becoming overweight.

■ Self-esteem and self-evaluation based on weight and body shape.

■ Amenorrhea develops, as defined by absence of three consecutive

menstrual cycles (APA 2000).

Client/Family Education: Eating Disorders

■ Client and family need to understand the serious nature of both

disorders; mortality rate for AN clients is 2% – 8% (30% – 40% recover;

25% – 30% improve; 15% – 20% do not improve). About 50% of BN

clients recover with treatment (Rakel 2000).

■ Team approach important – client and family need to be involved with

the team, which should or may include a nutritionist, psychiatrist,

therapist, physician, psychiatric nurse, nurse, eating disorder specialist,

and others.

■ Teach client coping strategies, allow for expression of feelings, teach

relaxation techniques, and help with ways (other than food) to feel in

control.

■ Family therapy important to work out parent-child issues, especially

around control (should have experience with eating disorders).

■ Focus on the fact that clients do recover and improve, and encourage

patience when there is a behavioral setback.

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Bulimia Nervosa (BN)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Recurrent binge

eating of large

amount of food

over short period

■ Lack of control

and cannot stop

■ Self-induced

vomiting, laxatives

(purging), fasting,

exercise (nonpurg-

ing) to compensate

■ At least 2 ⫻/w for

3 mo

■ Normal weight;

some underweight/

overweight

■ Tooth enamel

erosion/finger or

pharynx bruising

■ Fluid & electrolyte

disturbances

■ Genetic

predisposition

■ Hypothalamic

dysfunction

implication

■ Family hx of

mood

disorders and

obesity

■ Issues of

power and

control

■ Societal

emphasis on

thin

■ Affects 1% –

3% women

■ Develops late

adolescence

through

adulthood

■ Anorexia

nervosa,

binge-eating,

purging type

■ Major

depressive

disorder

(MDD) with

atypical

features

■ BPD

■ General

medical

conditions:

Kleine-Levin

syndrome

■ Endocrine

disorders

■ Complete

physical exam

■ Psychiatric

evaluation

■ Mental status

exam

■ Routine lab

work,

including TFT,

CBC,

electrolytes,

■ D-ARK Scale;

BDI

■ ECG

■ SMAST

■ CAGE

■ Individual,

group,

marital, family

therapy

■ Behavior

modification

■ Nutritional

support

■ Medical

support

■ Client-family

education

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Personality Disorders

■ When a pattern of relating to and perceiving the world is inflexible and

maladaptive, it is described as a personality disorder.

■ The pattern is enduring and crosses a broad range of social,

occupational, and personal areas.

■ The pattern can be traced back to adolescence or early adulthood and

may affect cognition, affect, interpersonal functioning, or impulse

control.

Cluster A Personality Disorders

■ Cluster A disorders include the paranoid personality, schizoid

personality, and schizotypal personality disorders.

■ This cluster includes the distrustful, emotionally detached, eccentric

personalities.

Cluster B Personality Disorders

■ Cluster B disorders include the antisocial, borderline, histrionic, and

narcissistic personality disorders.

■ This cluster includes those who have disregard for others, with

unstable and intense interpersonal relationships, excessive attention

seeking, and entitlement issues with a lack of empathy for others.

Cluster C Personality Disorders

■ Cluster C personality disorders include the avoidant personality,

dependent personality, and the obsessive-compulsive personality

disorders.

■ This cluster includes the avoider of social situations; the clinging,

submissive personality; and the person preoccupied with details, rules,

and order (APA 2000).

CLINICAL PEARL – Obsessive-compulsive personality disorder (OCPD) is

often confused with obsessive-compulsive disorder (OCD). OCD is an

anxiety disorder that is ego-dystonic (uncomfortable to person), whereas

OCPD is a rigid way of functioning in the world. OCD clients want to

change and dislike their disorder, whereas OCPD clients do not see that

there is any problem with their excessive detail or controlling ways. They

do not see that they need to change.

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Borderline Personality Disorder (BPD)

Signs & Symptoms Causes Rule Outs Labs/Tests/Exams Interventions

■ Pattern of unstable

interpersonal

relationships

■ Fear of abandon-

ment

■ Splitting: idealize

and devalue

(love/hate)

■ Impulsive (four

areas: sex,

substance abuse,

binge eating,

reckless driving)

■ Suicidal gestures/

self-mutilation

■ Intense mood

changes lasting

a few hours

■ Chronic emptiness

■ Intense anger

■ Transient paranoid

ideation

■ Mood

disorders

(often co-

occur)

■ Histrionic,

schizotypal,

paranoid,

antisocial,

dependent,

and

narcissistic

PDs

■ Personality

change due

to a general

medical

condition

■ Millon Clinical

Multiaxial

Inventory-III

(MCMI-III)

■ Psychiatric

evaluation

■ Mental status

exam

■ D-ARK Scale;

BDI

■ CAGE

■ SMAST

■ Physical exam,

routine lab

work, TFT

■ Linehan (1993)

dialectical behavior

therapy (DBT)

■ CBT

■ Group, individual,

family therapy (long-

term therapy)

■ Special strategies

■ Boundary setting

■ Be aware that these

can be difficult

clients even for

experienced MH

professionals

■ Pharmacotherapy:

antidepressants,

mood stabilizers,

antipsychotics;

caution with

benzodiazepines

(dependence)

■ Genetic

predisposition

■ Family hx of

mood

disorders; may

be a variant

of/related to

bipolar

disorder

■ Physical/

sexual abuse

■ About 2% of

general

population

■ Predominantly

female (75%)

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DISORDERS/

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Client/Family Education: Personality Disorders

■ Share personality disorder with client and family and educate about

the disorder. In this way the client has a basis/framework to understand

his/her recurrent patterns of behavior.

■ Work with client and family in identifying most troublesome behaviors

(temper tantrums), and work with client on alternative responses and

to anticipate triggers.

■ For clients who act out using suicidal gestures, an agreement may

have to be prepared that helps client work on impulse control.

Agreement might set an amount of time that client will not mutilate

and what client will do instead (call a friend/therapist/listen to music).

Need to teach alternative behaviors.

■ It is better to lead clients to a conclusion (“Can you see why your friend

was angry when you did such and such?”) rather than tell the client

what he or she did, especially those clients with a BPD.

■ Because these are long-standing, fixed views of the world, they require

time and patience and can be frustrating to treat. Usually require an

experienced therapist.

■ Although BPD receives much attention, all clients with personality

disorders (narcissist, dependent, avoidant personalities) suffer in

relationships, occupations, social situations.

■ Client needs to be willing to change, and a therapeutic (trusting)

relationship is a prerequisite for anyone with a personality disorder to

accept criticisms/frustrations. Some clients believe the problems rest

with everyone but themselves.

■ Helpful books for BPD clients and families to read in order to

understand the borderline personality include: Kreisman JJ, Straus H: I

Hate You – Don’t Leave Me. New York, Avon Books, 1991, and Kreisman

JJ, Straus H: Sometimes I Act Crazy: Living with Borderline Personality

Disorder. Hoboken, NJ, John Wiley & Sons, 2004.

■ For professionals: Linehan MM: Skills Training Manual for Treating

Borderline Personality Disorder. New York: Guilford Press, 1993, and

Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality

Disorder. New York: Guilford Press, 1993.

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Disorders of Childhood and Adolescence

Disorders diagnosed in childhood or adolescence include:

■ Mental retardation – onset before age 18 and IQ ⬍70.

■ Learning disorders – include mathematics, reading disorder; disorder

of written expression, with academic functioning below age, education

level, intelligence.

■ Communication disorders – speech or language difficulties, including

expressive language, mixed receptive-expressive language,

phonological disorder, and stuttering.

■ Motor skills – developmental coordination disorder, with poor motor

coordination for age and intelligence.

■ Pervasive developmental disorders – deficits in multiple developmental

areas, including autism, Asperger’s, Rett’s, and childhood disintegrative

disorder.

■ Feeding/eating disorders – disturbances of infancy and childhood,

including pica, rumination, and feeding disorder of infancy and early

childhood.

■ Tic disorders – vocal and motor tics such as Tourette’s, transient tic, and

chronic motor or vocal tic disorder.

■ Elimination disorders – include encopresis and enuresis.

■ Attention deficit/disruptive behavior – includes ADHD, predominantly

inattentive, predominantly hyperactive-impulsive, or combined type;

conduct disorder, oppositional defiant disorder, and others.

■ Others – separation anxiety, selective mutism, reactive attachment

disorder, and so forth (APA 2000).

Mental Retardation

50 – 70 IQ MILD

35 – 49 IQ MODERATE

20 – 34 IQ SEVERE

⬍20 IQ PROFOUND

Modified from Townsend 5e, 2006, with permission

Able to live independently with some assistance;

some social skills; does well in structured

environment

Some independent functioning; needs to be

supervised; some unskilled vocational abilities

(workshop)

Total supervision; some basic skills (simple

repetitive tasks)

Total care and supervision; care is constant and

continual; little to no speech/no social skills

ability

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Attention Deficit/Hyperactivity Disorder (ADHD)

■ ADHD is characterized either by persistent inattention or by

hyperactivity/impulsivity for at least 6 months.

■ Inattention includes:

■ Carelessness and inattention to detail

■ Cannot sustain attention and does not appear to be listening

■ Does not follow through on instructions and unable to finish tasks,

chores, homework

■ Difficulty with organization and dislikes activities that require

concentration and sustained effort

■ Loses things; distracted by extraneous stimuli; forgetful

■ Hyperactivity-impulsivity includes:

■ Hyperactivity

■ Fidgeting, moving feet, squirming

■ Leaves seat before excused

■ Runs about/climbs excessively

■ Difficulty playing quietly

■ “On the go” and “driven by motor”

■ Excessive talking

■ Impulsivity

■ Blurts out answers, speaks before thinking

■ Problem waiting his/her turn

■ Interrupts or intrudes

■ Impairment is present before age 7 y, and impairment is present in at

least two settings (or more).

■ Significant impairment in functioning in social, occupational, or

academic setting. Symptoms are not caused by another disorder.

Prevalence rate, school-aged children: 3% – 7% (APA 2000).

■ Many possible causes: genetics; biochemical (possible neurochemical

deficits [dopamine, NE]); intrauterine exposure to substances such as

alcohol or smoking; exposure to lead, dyes, and additives in food;

stressful home environments.

■ Adult ADHD – Study presented at American Psychiatric Association

(May 2004) estimates about 2.9% of the US general adult population

suffers from ADHD (Faraone 2004).

Nonpharmacological ADHD Treatments

■ Individual/family therapy

■ Behavior modification: clear expectations and limits

■ Break commands up into clear steps

■ Support desired behaviors and immediately respond to undesired

behaviors with consequences

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■ Natural consequences helpful (loses bicycle; do not replace; has to

save own money to replace)

■ Time outs may be needed for cooling down/reflecting

■ Role playing: helpful in teaching friend-friend interactions; helps child

prepare for interactions and understand how intrusive behaviors annoy

and drive friends away

■ Inform school: important that school knows about ADHD diagnosis, as

this is a disability (Americans With Disabilities Act)

■ Seek out special education services

■ Classroom: sit near teacher, one assignment at a time, written

instructions, untimed tests, tutoring (need to work closely with teacher

and explain child’s condition [ADHD])

■ Nutritional: many theories remain controversial but include food

sensitivities (Feingold diet, allergen elimination, leaky gut syndrome,

Nambudripad’s allergy elimination technique), supplementation

(thiamine), minerals (magnesium, iron), essential fatty acids, amino

acids; evaluate for lead poisoning

For Pharmacological ADHD Treatments – See Drugs/Labs Tab.

ADHD/Learning Disability Web Sites:

Internet Mental Health: ADHD: http://www.mentalhealth.com/dis/

p20-ch01.html

National Institute of Mental Health: ADHD:

http://gopher.nimh.nih.gov/healthinformation/adhdmenu.cfm

Children and Adults With ADHD (CHADD): http://www.chadd.org/

National Center for Learning Disabilities: http://www.ld.org/

Conduct Disorder/Oppositional Defiant Disorder

■ Conduct disorder (CD) (serious rule violation, aggression, destruction)

and oppositional defiant disorder (ODD) (negative, hostile, defiant) are

other important disorders of childhood and adolescence.

■ Serious comorbidities include CD/ADHD, ODD/ADHD, and

CD/ADHD/GAD/MDD.

■ A position paper by the International Society of Psychiatric-Mental

Health Nurses, entitled Prevention of Youth Violence, can be found at:

http://ispn-psych.org/docs/3-01-youth-violence.pdf

Because of size limitations, PsychNotes can provide only limited and basic

information related to the unique and comprehensive specialty of child

and adolescent psychiatry. For more complete coverage, refer to any of

the standard psychiatric textbooks and references.

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Psychiatric Interventions

Therapeutic Relationship/Alliance

■ The therapeutic relationship is not concerned with the skills of the

mental health professional (MHP) but rather with the attitudes and the

relationship between the MHP and the client. This relationship comes

out of the creation of a safe environment, conducive to communication

and trust.

■ An alliance is formed when the professional and the client are working

together cooperatively in the best interest of the client. The therapeutic

relationship begins the moment the MHP and client first meet (Shea

1999).

Core Elements of a Therapeutic Relationship

■ Communication/rapport – It is important to establish a connection

before a relationship can develop. Encouraging the client to speak,

using open-ended questions, is helpful. Asking general (not personal)

questions can relax the client in an initial session. It is important to

project a caring, nonjudgmental attitude.

■ Trust – A core element of a therapeutic relationship. Many clients have

experienced disappointment and unstable, even abusive, relationships.

Trust develops over time and remains part of the process. Without

trust, a therapeutic relationship is not possible. Other important

elements are confidentiality, setting boundaries, and consistency.

■ Dignity/Respect – Many clients have been abused and humiliated and

have low self-esteem. If treated with dignity through the therapeutic

relationship, clients can learn to regain their dignity.

■ Empathy – Empathy is not sympathy (caught up in client’s feelings) but

is, rather, open to understanding the “client’s perceptions” and helps

the client understand these better through therapeutic exploration.

■ Genuineness – Genuineness relates to trust because it says to the

client: I am honest, and I am a real person. Again, it will allow the client

to get in touch with her/his “real” feelings and to learn from and grow

from the relationship.

Therapeutic Use of Self

Abilty to use one’s own personality consciously and in full awareness to

establish relatedness and to structure interventions (Travelbee 1971).

Requires self-awareness and self-understanding.

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Phases of Relationship Development

■ Orientation phase – This is the phase when the MHP and client first

meet and initial impressions are formed.

■ Rapport is established, and trust begins.

■ The relationship and the connection are most important.

■ Client is encouraged to identify the problem(s) and become a

collaborative partner in helping self.

■ Once rapport and a connection are established, the relationship is

ready for the next phase.

■ Identification phase – In this phase the MHP and client are:

■ Clarifying perceptions and setting expectations in and for the

relationship.

■ Getting to know and understand each other.

■ Exploitation (working) phase – The client is committed to the process

and to the relationship and is involved in own self-help; takes

responsibility and shows some independence.

■ This is known as the working phase because this is when the hard

work begins.

■ Client must believe and know that the MHP is caring and on his/her

side when dealing with the more difficult issues during therapeutic

exploration.

■ If this phase is entered too early, before trust is developed, clients

may suddenly terminate if presented with painful information.

■ Resolution phase – The client has gained all that he/she needs from the

relationship and is ready to leave.

■ This may involve having met stated goals or resolution of a crisis.

■ Be aware of fear of abandonment and need for closure.

■ Both the MHP and client may experience sadness, which is normal.

■ Dependent personalities may need help with termination, reflecting

upon the positives and the growth that has taken place through the

relationship (Peplau 1992).

■ If a situation brings a client back for therapy, the relationship has

already been established (trust); therefore, there is not a return to the

orientation phase. Both will identify new issues and re-establish

expectations of proposed outcomes. It will now be easier to move into

the working phase of the relationship, and this will be done more

quickly.

CLINICAL PEARL – Trust and safety are core elements of a therapeutic

alliance, as many clients have experienced abuse, inconsistency, broken

promises, and “walking on eggs.”

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DISORDERS/

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Nonverbal Communication

Nonverbal communication may be a better indication of what is going on

with a client than verbal explanations.

■ Although verbal communication is important, it is only one component

of an evaluation.

■ Equally important to develop your skills of observation.

■ Some clients are not in touch with their feelings, and only their

behaviors (clenched fist, head down, arms crossed) will offer clues to

feelings.

■ Nonverbal communication may offer the client clues as to how the

MHP is feeling as well.

■ Physical appearance – A neat appearance is suggestive of someone

who cares for him/herself and feels positive about self. Clients with

schizophrenia or depression may appear disheveled and unkempt.

■ Body movement/posture – Slow or rapid movements can suggest

depression or mania; a slumped posture, depression. Medication-

induced body movements and postures include: pseudoparkinsonism

(antipsychotic); akathisia (restlessness/moving legs [antipsychotic]).

Warmth (smiling) and coldness (crossed arms) are also nonverbally

communicated.

■ Touch – Touch forms a bridge or connection to another. Touch has

different meanings based on culture, and some cultures touch more

than others. Touch can have a very positive effect, but touching

requires permission to do so. Many psychiatric clients have had

“boundary violations,” so an innocent touch may be misinterpreted.

■ Eyes – The ability to maintain eye contact during conversation offers

clues as to social skills and self-esteem. Without eye contact, there is a

“break in the connection” between two people. A lack of eye contact

can suggest suspiciousness, something to hide. Remember cultural

interpretations of eye contact (see Basics Tab).

■ Voice – Voice can be a clue to the mood of a client. Pitch, loudness, and

rate of speech are important clues. Manic clients speak loudly, rapidly,

and with pressured speech. Anxious clients may speak with a high

pitch and rapidly. Depressed clients speak slowly, and obtaining

information may feel like “pulling teeth.”

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DISORDERS/

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Communication Techniques

Technique Rationale Example

Reflecting

Silence

Paraphrasing

Making

observations

Open-ended/

broad

questions

Encouragement

Reframing

Reflects back to clients

their emotions, using

their own words

Allows client to explore

all thoughts/feelings;

prevents cutting

conversation at a

critical point or missing

something important

Restating, using different

words to ensure you

have understood the

client; helps clarify

Helps client recognize

feelings he/she may

not be aware of and

connect with behaviors

Encourages client to take

responsibility for

direction of session;

avoids yes/no

responses

Encourages client to

continue

Presenting same

information from

another perspective

(more positive)

C: John never helps with the

housework.

MHP: You’re angry that John

doesn’t help.

MHP nods with some vocal

cues from time to time so

C knows MHP is listening

but does not interject.

C: My grandkids are coming

over today and I don’t feel

well.

MHP: Your grandkids are

coming over, but you wish

they weren’t, because you

are not well. Is that what

you are saying?

MHP: Every time we talk

about your father you

become very sad.

MHP: What would you like

to deal with in this

session?

MHP: Tell me more…uh

huh…and then?

C: I lost my keys, couldn’t

find the report, and barely

made it in time to turn my

report in.

MHP: In spite of all that, you

did turn your report in.

(Text continued on following page)

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DISORDERS/

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Communication Techniques (Continued)

Technique Rationale Example

Challenging

idea/ belief

system

Recognizing

change/

recognition

Clarification

Exploring in

detail

Focusing

Metaphors/

symbols

Acceptance

Break through denial or

fixed belief; always

done with a question

Reinforces interest in

client and positive

reinforcement (this is

not a compliment)

Assures that MHP did

not misunderstand;

encourages further

exploration

If it appears a particular

topic is important, then

the MHP asks for more

detail; MHP takes the

lead from the client

(client may resist

exploring further)

Use when a client is

covering multiple

topics rapidly

(bipolar/anxious) and

needs help focusing

Sometimes clients speak

in symbolic ways and

need translation

Positive regard and open

to communication

MHP: Who told you that you

were incompetent? Where

did you get the idea that

you can’t say no?

MHP: I noticed that you were

able to start our session

today rather than just sit

there.

MHP: This is what I thought

you said...; is that correct?

MHP: This is the first time

I’ve heard you talk about

your sister; would you like

to tell me more about her?

MHP: A lot is going on, but

let’s discuss the issue of

your job loss, as I would

like to hear more about

that.

C: The sky is just so gray

today and night comes so

early now.

MHP: Sounds like you are

feeling somber.

MHP: I hear what you are

saying. Yes, uh-huh. (full

attention).

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Therapeutic Milieu*

■ In the therapeutic milieu (milieu is French for surroundings or

environment), the entire environment of the hospital is set up so that

every action, function, and encounter is therapeutic.

■ The therapeutic community is a smaller representation of the larger

community/society outside.

■ The coping skills and learned behaviors within the community will also

translate to the larger outside community.

Seven Basic Assumptions:

1. The health in each individual is to be realized and encouraged to grow.

2. Every interaction is an opportunity for therapeutic intervention.

3. The client owns his or her own environment.

4. Each client owns his or her own behavior.

5. Peer pressure is a useful and powerful tool.

6. Inappropriate behaviors are dealt with as they occur.

7. Restrictions and punishment are to be avoided. (Skinner 1979)

*Difficult in era of managed care (short stays).

Group Interventions

Stages of Group Development

I. Initial Stage (in/out)

■ Leader orients the group and sets the ground rules, including

confidentiality.

■ There may be confusion and questions about the purpose of the group.

■ Members question themselves in relation to others and how they will

fit in the group.

II. Conflict Stage (top/bottom)

■ Group is concerned with pecking order, role, and place in group.

■ There can be criticism and judgment.

■ Therapist may be criticized as group finds its way.

III. Cohesiveness (Working) Stage (near/far)

■ After conflict comes a group spirit, and a bond and trust develop

among the members.

■ Concern is now with closeness, and an “us versus them” attitude

develops: those in the group versus those outside the group.

■ Eventually becomes a mature working group.

(Continued on following page)

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DISORDERS/

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IV. Termination

■ Difficult for long-term groups; discuss well before termination.

■ There will be grieving and loss (Yalom 2005).

Leadership Styles

■ Autocratic – The autocratic leader essentially “rules the roost.” He or

she is the most important person of the team and has very strong

opinions of how and when things should be done. Members of a group

are not allowed to make independent decisions, as the autocrat trusts

only his/her opinions. The autocrat is concerned with power and

control and is very good at persuasion. High productivity/low morale.

■ Democratic – The democratic leader focuses on the group and

empowers the group to take responsibility and make decisions.

Problem solving and taking action are important, along with offering

alternative solutions to problems (by group members). Lower

productivity/high morale.

■ Laissez-Faire – This leaderless style results in confusion because of

the lack of direction and noninvolvement; it also results in low

productivity and morale (Lippitt & White 1958).

Individual Roles/Difficult Group Members

■ Monopolizer – Involved in some way in every conversation, offering

extensive detail or always presents with a “crisis of the week”

(minimizing anyone else’s concerns/issues).

■ Has always experienced a similar situation: I know what you mean;

my dog died several years ago, and it was so painful I am still not

over it.

■ Will eventually cause anger and resentment in the group if leader

does not control the situation; dropouts result.

■ Help-rejecting complainer – Requests help from the group and then

rejects each and every possible solution so as to demonstrate the

hopelessness of the situation.

■ No one else’s situation is as bad as that of the help-rejecting

complainer. (You think you have it bad; wait until you hear my

story!)

■ Often looks to the group leader for advice and help and competes

with others for this help, and because he/she is not happy, no one

else can be happy either.

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■ Silent client – Does not participate but observes.

■ Could be fear of self-disclosure, exposing weaknesses. Possibly feels

unsafe in leaderless group.

■ Does not respond well to pressure or being put on the spot, but

must somehow be respectfully included and addressed.

■ The long-term silent client does not benefit from being in a group,

nor does the group, and should possibly withdraw from the group.

■ Boring client – No spontaneity, no fun, no opinions, and a need to

present to the world what the client believes the world wants to see

and hear.

■ If you are bored by the client, likely the client is boring.

■ Requires the gradual removal of barriers that have kept the

individual buried inside for years.

■ Often tolerated by others but seldom missed if leaves the group.

■ Narcissist – Lack of awareness of others in the group; seeing others

as mere appendages and existing for one’s own end; feels special and

not part of the group (masses).

■ Expects from others but gives nothing.

■ Can gain from some groups and leaders.

■ Psychotic client – Should not be included in early formative stages of

a group.

■ If a client who is a member of an established group decompensates,

then the group can be supportive because of an earlier connection

and knowledge of the nonpsychotic state of the person.

■ Borderline client – Can be challenging in a group because of

emotional volatility, unstable interpersonal relationships, fears of

abandonment, anger control issues, to name a few.

■ Borderline clients idealize or devalue (splitting) – the leader is at first

great and then awful.

■ Some borderline group members who connect with a group may be

helped as trust develops and borderline client is able to accept some

frustrations and mild criticisms (Yalom 2005).

CLINICAL PEARL – It is important to understand that subgroups (splitting

off of smaller group/unit) can and do develop within the larger group.

Loyalty transferred to a subgroup undermines overall goals of larger

group (some clients are in and some out). May be indirect hostility to

leader. Some subgroups and extragroup activities are positive as long as

there is not a splintering from/hostility toward larger group. Group needs

to openly address feelings about subgroups and outside activities – if

splintering or secretiveness continues, will be a detriment to group’s

cohesiveness and therapeutic benefit.

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106

Yalom’s Therapeutic Factors

The factors involved in and derived from the group experience that

help and are of value to group members and therapeutic success are:

■ Instillation of hope – Hope that this group experience will be

therapeutic and effective.

■ Universality – Despite individual uniqueness, there are common

denominators that allow for a connection and reduce feelings of being

alone in one’s plight.

■ Didactic interaction – In some instances, instruction and education can

help people understand their circumstances, and such information

relieves anxiety and offers power, such as understanding cancer,

bipolar disorder, or HIV.

■ Direct advice – In some groups, advice giving can be helpful when one

has more experience and can truly help another (cancer survivor

helping newly diagnosed cancer patient). Too much advice giving can

impede. Advice giving/talking/refusing tells much about the group

members and stage of group.

■ Altruism – Although altruism suggests a concern for others that is

unselfish, it is learning that through giving to others, one truly

receives. One can find meaning through giving.

■ Corrective recapitulation of the primary family group – Many clients

develop dysfunctions related to the primary group – the family of

origin. There are often unresolved relationships, strong emotions,

and unfinished business. The group often serves as an opportunity

to work out some of these issues as leaders and group members

remind each other of primary family members, even if not

consciously.

■ Socializing techniques – Direct or indirect learning of social skills.

Helpful to those whose interpersonal relationships have fallen short

because of poor social skills. Often provided by group feedback,

such as You always turn your body away from me when I talk and

you seem bored. In many instances, individuals are unaware of

the behaviors that are disconcerting or annoying to others.

■ Imitative behavior – Members may model other group members, which

may help in exploring new behaviors.

DISORDERS/

INTERV

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107

DISORDERS/

INTERV

Family Therapy

Family Therapy Models/Theories

■ Intergenerational – The theory of Murray Bowen (1994) that states

problems are multigenerational and pass down from generation to

generation until addressed. Requires direct discussion and clarification

with previous generation members if possible. Concerned with level of

individual differentiation and anxiety, triangles, nuclear family

emotional system, and multigenerational emotional process. Therapist

must remain a neutral third party.

■ Contextual – The therapy of Boszormenyi-Nagy that focuses on give

and take between family members, entitlement and fulfillment,

fairness, and the family ledger (an accounting of debits and merits).

■ Structural – Developed by Salvador Minuchin and views the family as a

social organization with a structure and distinct patterns. Therapist

takes an active role and challenges the existing order.

■ Strategic – Associated with Jay Haley and focuses on problem

definition and resolution, using active intervention.

■ Communications – Focuses on communications in the family and

emphasizes reciprocal affection and love; the Satir model.

■ Systemic – Involves multidimensional thinking and use of paradox

(tactics that appear opposite to therapy goals but designed to achieve

goals); also called the Milan model.

CLINICAL PEARL – In dealing with families, it is important to have an

understanding of how families operate, whatever model is used. A model

offers a framework for viewing the family. A family is a subsystem within

a larger system (community/society) and will reflect the values and

culture of that society. Unlike working with individuals, it is the family that

is the client.

Genogram

A genogram is a visual diagram of a family over two or three generations.

It provides an overview of the family and any significant emotional and

medical issues and discord among members. It offers insight into patterns

and unresolved issues/conflicts throughout the generations.

(Continued on following page)

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108

DISORDERS/

INTERV

Common Genogram Symbols

From Townsend 5e 2006, with permission.

Male

Female

Separated(s)

Offspring

Conflictual

relationship

Miscarriage

or abortion

Adopted (boy)

Pregnant

Unmarried

relationship

Overclose

relationship

Married (m)

Divorced (d)

Twins (boys)

Death

KEY

NOTE: Include ages and

dates of significant

events when known.

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109

Sample Genogram

From Townsend 5e 2006, with permission.

Cognitive Behavioral Therapy

■ Cognitive behavioral therapy (CBT) deals with the relationship between

cognition, emotion, and behavior.

■ Cognitive aspects are: automatic thoughts, assumptions, and

distortions.

■ Individuals are often unaware of the automatic thoughts that may

affect beliefs and behaviors, such as I never do well in school or I

am stupid.

■ Deep-seated beliefs, or schemas, affect perceptions of the world.

■ Individuals are also influenced by distortions in their thinking.

■ Important aspects of CBT include agenda setting, review, feedback,

and homework.

■ Some techniques may involve treating the behaviors rather than the

cognitive aspects.

DISORDERS/

INTERV

1956

1976 MI

1968

1985 MI

1983

1982

1984

CVA

Abortion

1989

(m) 1958

(d) 1960

( Patient )

100

(s) 1961

(m) 1961

1945

(Continued on following page)

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110

■ Fearful, dysfunctional clients respond better to behavioral versus

cognitive interventions. This may involve task or activity

assignments.

■ Other behavioral interventions are: social skills training,

assertiveness training, deep-muscle relaxation, exposure and

systematic desensitization techniques, and in vivo interventions

(phobias/agoraphobia). (Freeman et al. 2004)

Distortions in Thinking

■ Catastrophizing – an uncomfortable event is turned into a catastrophe.

■ Dichotomous thinking – either/or thinking, such as I am good or I am

evil.

■ Mind reading – believes that the person knows what the other is

thinking without clarifying.

■ Selective abstraction – focusing on one aspect rather than all aspects.

Individual hears only the one negative comment during a critique and

does not hear the five positive comments.

■ Fortune telling – anticipates a negative future event without facts or

outcome. I know I am going to fail that test.

■ Overgeneralization – one event is now representative of the entire

situation. A forgotten anniversary is interpreted as: the marriage is over

and will never be the same.

CLINICAL PEARL – CBT has been shown to be quite effective in treating

depression and anxiety disorders (panic/phobia/OCD) and is very helpful

when used in conjunction with medication. Through CBT, clients learn to

change their thinking and to “reframe” their views/thoughts as well as

learn tools/techniques to deal with future episodes. CBT provides the

client with a sense of control over his/her fears, depression, and anxiety,

as there is an active participation in treatment and outcome.

Emerging/New Nonpharmacological Treatments for Depression

■ Novel treatments are emerging in the treatment of depression, some

showing clinical benefit and needing further study (Holtzheimer &

Nemeroff 2006).

■ Vagal nerve stimulation – uses a small implantable device and is

indicated for the adjunctive long-term treatment of chronic or

recurrent depression for patients 18 years of age or older who are

experiencing a major depressive episode and have not had an

adequate response to four or more adequate antidepressant

treatments. (Cyberonics Inc 2005; Nemeroff et al. 2006)

■ Transcranial magnetic stimulation – noninvasive, relatively

painless novel technique to alter brain physiology (Rachid &

Bertschy 2006).

DISORDERS/

INTERV

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111

Complementary Therapies

■ Art therapy – the use of art media, images, and the creative process

to reflect human personality, interests, concerns, and conflicts. Very

helpful with children and traumatic memories.

■ Biofeedback – learned control of the body’s physiological responses

either voluntarily (muscles) or involuntarily (autonomic nervous

system), such as the control of blood pressure or heart rate.

■ Dance therapy – as the mind/body is connected, dance therapy focuses

on direct expression of emotion through the body, affecting feelings,

thoughts, and the physical and behavioral responses.

■ Guided imagery – imagination is used to visualize improved health;

has positive effect on physiological responses.

■ Meditation – self-directed relaxation of body and mind; health-

producing benefits through stress reduction.

■ Others: humor therapy, deep-muscle relaxation, prayer, acupressure,

Rolfing, pet therapy, massage therapy, and so forth.

CLINICAL PEARL – Never underestimate the benefit of the complementary

therapies. Complementary is often referred to as alternative therapy. In

some ways, alternative is a misnomer because these are not alternatives

but should be complements to traditional treatments. Both go hand in

hand in a comprehensive approach to healing and treatment of the body,

mind, and spiritual self.

DISORDERS/

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112

Psychotropic Drugs/Labs

Psychotropic Drugs

Antiparkinsonian Agents 115

Antipsychotic-Induced Movement Disorders 116

Antipsychotic Use Contraindications 116

Attention Deficit Hyperactivity Disorder (ADHD) Agents 114

Childhood and Adolescence, Antidepressants in 115

Drug-Herbal Interactions 116

Elderly and Medications 117

Extrapyramidal Symptoms (EPS) 116

MAOI Diet (Tyramine) Restrictions 117

Neuroleptic Malignant Syndrome (NMS) 118

Pharmacokinetics 114

Serotonin Syndrome 119

Tardive Dyskinesia 116

Therapeutic Drug Classes 112

Antianxiety Agents 112

Antidepressants 113

Antipsychotic (Neuroleptic) Agents 113

Mood Stabilizers 113

Labs/Plasma Levels

Clozaril Protocol 121

Disorders and Labs/Tests 120

General Chemistry 122

Hematology 124

Plasma Level/Lab Test Monitoring 120

Plasma Levels (Therapeutic) – Mood Stabilizers 120

Renal/Kidney 125

Thyroid Panel 124

Urinalysis (UA) 125

Psychotropic Drugs

Therapeutic Drug Classes

Antianxiety (Anxiolytic) Agents

Used in the treatment of generalized anxiety, obsessive-compulsive disorder

(OCD), post-traumatic stress disorder (PTSD), phobic disorders, insomnia,

and others and include:

DRUGS/LABS

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113

■ Benzodiazepines (alprazolam, clonazepam, lorazepam, oxazepam)

■ Azaspirone (buspirone)

■ Alpha-2 adrenergics (clonidine)

■ Antihistamines (hydroxyzine)

■ Beta blockers (propranolol)

■ Antidepressants (doxepin, escitalopram)

■ Hypnosedatives for insomnia, such as barbiturates (phenobarbital) and

imidazopyridine (zolpidem).

Antidepressant Agents

Used in the treatment of depression, bipolar (depressed), OCD, and others,

and include:

■ Tricyclics (amitriptyline, desipramine, doxepin, imipramine)

■ Monoamine oxidase inhibitors (MAOIs) (phenelzine, tranylcypromine)

■ Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, paroxetine,

sertraline)

■ Serotonin norepinephrine reuptake inhibitors (SNRIs) (venlafaxine,

duloxetine)

■ Others (aminoketone/triazolopyridine) (bupropion [Wellbutrin], trazodone

[Desyrel])

Mood-Stabilizing Agents

Used in the treatment of bipolar disorder (mania/depression), aggression,

schizoaffective, and others, and include:

■ Lithium

■ Anticonvulsants (valproic acid, carbamazepine, lamotrigine, topiramate)

■ Calcium channel blockers (verapamil)

■ Alpha-2 adrenergics (clonidine) and beta adrenergics (propranolol)

Antipsychotic (Neuroleptic) Agents

Used in the treatment of schizophrenia, psychotic episodes

(depression/organic [dementia]/substance-induced), bipolar disorder,

agitation, delusional disorder, and others, and include:

■ Phenothiazines (chlorpromazine, thioridazine)

■ Butyrophenones (haloperidol)

■ Thioxanthenes (thiothixene)

■ Diphenylbutyl piperidines (pimozide)

■ Dibenzoxazepine (loxapine)

■ Dihydroindolone (molindone)

DRUGS/LABS

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■ Dibenzodiazepine (clozapine)

■ Benzisoxazole (risperidone)

■ Thienobenzodiazepine (olanzapine)

■ Benzothiazolyl piperazine (ziprasidone)

■ Dihydrocarbostyril (aripiprazole)

Although other agents (e.g., stimulants) may be used in the treatment of

psychiatric disorders, the most common therapeutic classes and agents are

listed above.

Pharmacokinetics

■ The Cytochrome P-450 Enzyme Sytem is involved in drug

biotransformation and metabolism. It is important to develop a knowledge

of this system to understand drug metabolism and especially drug

interactions. Over 30 P-450 isoenzymes have been identified. The major

isoenzymes include

CYP1A2/2A6/2B6/2C8/2C9/2C18/2C19/2D6/2E1/3A4/3A5-7.

■ Half-Life is the time (hours) that it takes for 50% of a drug to be eliminated

from the body. Time to total elimination involves halving the remaining

50%, and so forth, until total elimination. Half-life is considered in

determining dosing frequency and time to steady state. The rule of thumb

for steady state (stable concentration/manufacture effect) attainment is

4-5 half-lives. Because of fluoxetine’s long half-life, a 5-week washout is

recommended after stopping fluoxetine and before starting an MAOI to

avoid a serious and possibly fatal reaction.

■ Protein Binding is the amount of drug that binds to the blood’s plasma

proteins; the remainder circulates unbound. It is important to understand

this concept when prescribing two or more highly protein-bound drugs as

one drug may be displaced, causing increased blood levels and adverse

effects.

Attention Deficit Hyperactivity Disorder (ADHD) Agents

Chemical Class Generic/Trade Dosage Range/Day

Amphetamines

Amphetamine

mixtures

DRUGS/LABS

Dextroamphetamine sulfate

(Dexadrine)

Methamphetamine (Desoxyn)

Dextroamphetamine/ampheta-

mine (Adderall)

5–60 mg

5–25 mg

5–60 mg

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115

Attention Deficit Hyperactivity Disorder (ADHD) Agents (Continued)

Chemical Class Generic/Trade Dosage Range/Day

Miscellaneous

From Townsend 2006. Used with permission.

Antidepressants in Childhood and Adolescence

ALERT: Childhood depression has been on the rise in the United States,

coupled with an increase in the prescribing of antidepressants for

adolescents and also for children under age 5. In 2003, in the UK, suicidality

in children was linked to Seroxat (Paxil), and now all antidepressants are

linked to the possibility of increased suicidality in children and adolescents

as well as young adults. Clearly, all children treated with antidepressants, as

well as adults, need to be closely monitored (face to face), especially early

in treatment, and assessed for suicidal ideation and risk (Johnson 2003;

Seroxat 2004; Health Canada 2004).

Antiparkinsonian Agents

These are anticholinergics used to treat drug-induced parkinsonism,

Parkinson’s disease, and extrapyramidal symptoms (EPS). These include:

■ Benztropine (Cogentin)

■ Biperiden (Akineton)

■ Trihexyphenidyl (Artane)

■ Amantadine (dopaminergic) and diphenhydramine (antihistaminic) and

others

Anticholinergic side effects include:

■ Blurred vision, dry mouth, constipation

■ Sedation, urinary retention, tachycardia

ALERT: Use cautiously in the elderly and in cardiac arrhythmias.

DRUGS/LABS

Methylphenidate (Ritalin;

Methylin; Concerta; Metadate)

Dexmethylphenidate (Focalin)

Pemoline (Cylert)

Atomoxetine (Strattera)

Bupropion (Wellbutrin)

10–60 mg

5–20 mg

37.5–112.5 mg

70 kg: 40–100 mg;

≤70 kg: 0.5–1.4 mg/kg

3 mg/kg

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Antipsychotic Use Contraindications

■ Addison’s disease

■ Bone marrow depression

■ Glaucoma (narrow angle)

■ Myasthenia gravis

Antipsychotic-Induced Movement Disorders

Extrapyramidal Symptoms (EPS)

EPS are caused by antipsychotic treatment and need to be monitored/

evaluated for early intervention.

■ Akinesia – rigidity and bradykinesia

■ Akathisia – restlessness; movement of body; unable to keep still;

movement of feet (do not confuse with anxiety)

■ Dystonia – spasmodic and painful spasm of muscle (torticollis [head

pulled to one side])

■ Oculogyric crisis – eyes roll back toward the head. This is an emergency

situation.

■ Pseudoparkinsonism – simulates Parkinson’s disease with shuffling gait,

drooling, muscular rigidity, and tremor

■ Rabbit syndrome – rapid movement of the lips that simulate a rabbit’s

mouth movements

Tardive Dyskinesia

Permanent dysfunction of voluntary muscles. Affects the mouth – tongue

protrudes, smacking of lips, mouth movements.

ALERT: Evaluate clients on antipsychotics for possible tardive dyskinesia by

using the Abnormal Involuntary Movement Scale (AIMS) (see AIMS form in

Assessment Tab).

Drug-Herbal Interactions

Antidepressants should not be used concurrently with: St. John’s wort or

SAMe (serotonin syndrome and/or altered antidepressant metabolism).

Benzodiazepines/sedative/hypnotics should not be used concurrently with

chamomile, skullcap, valerian, or kava. St. John’s wort may reduce the

effectiveness of benzodiazepines metabolized by CYP P450 3A4.

Conventional antipsychotics (haloperidol, chlorpromazine) that are sedating

should not be used in conjunction with chamomile, skullcap, valerian, or

kava. Carbamazepine, clozapine, and olanzapine should not be used

concurrently with St. John’s wort (altered drug metabolism/effectiveness).

DRUGS/LABS

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ALERT: Ask all clients specifically what, if any, herbal or OTC medications

they are using to treat symptoms.

Elderly and Medications (Start Low, Go Slow)

■ Relevant drug guides provide data about dosing for the elderly and

debilitated clients; also see Drugs A-Z Tab.

■ The elderly or debilitated clients are started at lower doses, often half the

recommended adult dose. This is due to:

■ Decreases in GI absorption

■ Decrease in total body water (decreased plasma volume)

■ Decreased lean muscle and increased adipose tissue

■ Reduced first-pass effect in the liver and cardiac output

■ Decreased serum albumin

■ Decreased glomerular filtration and renal tubular secretion

■ Time to steady state is prolonged

Because of decrease in lean muscle mass and increase in fat (retains

lipophilic drugs [fat-storing]), reduced first-pass metabolism, and decreased

renal function, drugs may remain in the body longer and produce an

additive effect.

ALERT: With the elderly, start doses low and titrate slowly. Drugs that result

in postural hypotension, confusion, or sedation should be used cautiously or

not at all.

■ Poor Drug Choices for the Elderly – Drugs that cause postural hypotension

or anticholinergic side effects (sedation).

■ TCAs – anticholinergic (confusion, constipation, visual blurring); cardiac

(conduction delay; tachycardia); alpha-1 adrenergic (orthostatic

hypotension [falls])

■ Benzodiazepines – longer the half-life; greater the risk of falls. Choose a

shorter half-life. Lorazepam (T

12–15 h) is a better choice than

diazepam (T

20–70 h; metabolites up to 200 h).

■ Lithium – use cautiously in elderly, especially if debilitated.

■ Consider age, weight, mental state, and medical disorders and compare

with side-effect profile in selecting medications.

MAOI Diet (Tyramine) Restrictions

Foods: Must Avoid Completely

■ Aged red wines (cabernet sauvignon/merlot/chianti)

■ Aged (smoked, aged, pickled, fermented, marinated, and processed)

meats (pepperoni/bologna/salami, pickled herring, liver, frankfurters,

bacon, ham)

DRUGS/LABS

(Text continued on following page)

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■ Aged/mature cheeses (blue/cheddar/provolone/brie/romano/parmesan/

Swiss)

■ Overripe fruits and vegetables (overripe bananas/sauerkraut/all overripe

fruit)

■ Beans (fava, Italian, Chinese pea pod, fermented bean curd, soya sauce,

tofu, Miso soup)

■ Condiments (bouillon cubes/meat tenderizers/canned soups/gravy/sauces/

soy sauce)

■ Soups (prepared/canned/frozen)

■ Beverages (beer/ales/vermouth/whiskey/liqueurs/nonalcoholic wines and

beers)

Foods: Use With Caution (Moderation)

■ Avocados (not overripe)

■ Raspberries (small amounts)

■ Chocolate (small amount)

■ Caffeine (2 – 8 oz. servings per day or less)

■ Dairy products (limit to buttermilk, yogurt, and sour cream [small

amounts]); cream cheese, cottage cheese, milk OK if fresh.

Medications: Must Avoid

■ Stimulants

■ Decongestants

■ OTC medications (check with PCP/pharmacist)

■ Opioids

■ Meperidine

■ Ephedrine/epinephrine

■ Methyldopa

■ Herbal remedies

Any questions about foods, OTC medications, herbals, medications (newly

prescribed) should be discussed with the psychiatrist, pharmacist, or

advanced practice nurse because of serious nature of any food-drug, drug-

drug combinations.

Neuroleptic Malignant Syndrome (NMS)

A serious and potentially fatal syndrome caused by antipsychotics and other

drugs that block dopamine receptors. Important not to allow client to

become dehydrated (predisposing factor). More common in warm climates,

in summer. Possible genetic predisposition.

Signs and Symptoms

■ Fever: 103–105 F or greater

■ Blood pressure lability (hypertension or hypotension)

DRUGS/LABS

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■ Tachycardia (130 bpm)

■ Tachypnea (25 rpm)

■ Agitation (respiratory distress, tachycardia)

■ Diaphoresis, pallor

■ Muscle rigidity (arm/abdomen like a board)

■ Change in mental status (stupor to coma)

Stop antipsychotic immediately.

ALERT: NMS is a medical emergency (10% mortality rate); hospitalization

needed. Lab test: creatinine kinase (CK) to determine injury to the muscle.

Drugs used to treat NMS include: bromocriptine, dantroline, levodopa,

lorazepam.

Serotonin Syndrome

Can occur if client is taking one or more serotonergic drugs (e.g., SSRIs; also

St. Johns wort), especially higher doses. Do not combine SSRIs/SNRIs/

clomipramine with MAOI; also tryptophan, dextromethorphan combined

with MAOI can produce this syndrome.

If stopping fluoxetine (long half-life) to start an MAOI – must allow a

5-week washout period. At least 2 weeks for other SSRIs before starting

an MAOI. Discontinue MAOI for 2 weeks before starting another antide-

pressant or other interacting drug.

Signs and Symptoms

■ Change in mental status, agitation, confusion, restlessness, flushing

■ Diaphoresis, diarrhea, lethargy

■ Myoclonus (muscle twitching or jerks), tremors

If serotonergic medication is not discontinued, progresses to:

■ Worsening myoclonus, hypertension, rigor

■ Acidosis, respiratory failure, rhabdomyolysis

ALERT: Must discontinue serotonergic drug immediately. Emergency medical

treatment and hospitalization needed to treat myoclonus, hypertension, and

other symptoms.

NOTE: Refer to Physicians’ Desk Reference or product insert for complete

drug information (dosages, warnings, indications, adverse effects,

interactions, etc.) needed to make appropriate choices in the treatment of

clients. Although every effort has been made to provide key information

about medications and classes of drugs, such information is not and cannot

be all-inclusive in a reference of this nature. Professional judgment, training,

supervision, relevant references, and current drug information is critical to

the appropriate selection, evaluation, monitoring, and management of

clients and their medications.

DRUGS/LABS

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Labs/Plasma Levels

Therapeutic Plasma Levels — Mood Stabilizers

■ Lithium: 1.0–1.5 mEq/L (acute mania)

0.6–1.2 mEq/L (maintenance)

Toxic: 2.0 mEq/L

■ Carbamazepine: 4–12 g/mL

Toxic 15 g/mL

■ Valproic acid: 50–100 g/mL

NOTE: Lithium blood level should be drawn in the morning about 12 hours

after last oral dose and before first morning dose.

Plasma Level/Lab Test Monitoring

■ Lithium – Initially check serum level every 1–2 wk (for at leat 2 mo), then

every 3–6 mo; renal function every 6–12 mo; TFTs every year.

■ Carbamazapine – Serum levels every 1–2 wk (at least for 2 mo); CBC and

LFTs every mo, then CBCs/LFTs every 6–12 mo; serum levels every 3–6

mo as appropriate.

■ Valproic acid – Serum level checks every 1–2 wk; CBC/LFTs every mo;

serum level every 3–6 mo; CBC/LFT every 6–12 mo.

Disorders and Labs/Tests

■ Labs and tests should be performed on all clients before arriving at a

diagnosis to rule out a physical cause that may mimic a psychological

disorder and before starting treatments. Tests should be repeated as

appropriate after diagnosis to monitor treatments/reevaluate.

Disorder Labs/Tests

Anxiety

Dementia

DRUGS/LABS

Physical exam, psych eval, mental status exam, TFTs

(hyperthyroidism), CBC, general chemistry, toxicology

screens (substance abuse); anxiety inventories/rating

scales

Physical exam, psych eval, mental status exam, Mini-

Mental State Exam, TFTs, LFTs, CBC, sed rate, general

chemistry, toxicology screens (substance abuse), B

folate, UA, HIV, FTA-ABS (syphilis), depression

inventories/rating scales (Geriatric Rating Scale)

(R/O depression), CT/MRI

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Disorder Labs/Tests (Continued)

Depression

Mania

Postpartum

depression

Schizophrenia

Clozaril Protocol – Clozaril Patient Management System

Indications for use: Patients with a diagnosis of schizophrenia, unresponsive

or intolerant to three different neuroleptics from at least two different

therapeutic groups, when given adequate doses for adequate duration.

■ System for monitoring WBCs of patients on clozapine. Important because

of possible (life-threatening) agranulocytosis and leukopenia.

■ Need to monitor WBCs, absolute neutrophil count (ANC), and differential

before initiating therapy and after.

■ WBC and ANC weekly first 6 mo, then bi-weekly, then weekly for 1 month

after discontinuation.

■ Only available in 1–wk supply (requires WBCs, patient monitoring, and

controlled distribution through pharmacies).

■ If WBC 3000 mm

or granulocyte count 1500 mm

— withhold

clozapine (monitor for signs & symptoms of infection).

■ Monthly monitoring approved under certain situations (FDA approval

2005).

■ Patients must be registered with the Clozaril National Registry (see

www.clozaril.com).

DRUGS/LABS

Physical exam, psych eval, mental status exam, Mini-

Mental State Exam (R/O dementia), TFTs

(hypothyroidism), LFTs, CBC, general chemistry,

toxicology screens (substance abuse); depression

inventories/rating scales (R/O pseudodementia),

CT/MRI

Physical exam, psych eval, mental status exam, Young

Mania Rating Scale (bipolar I), TFTs (hyperthyroidism),

LFTs, toxicology screens (substance abuse), CBC, UA,

ECG (40 y), serum levels (VA, CBZ, Li), BMI, general

chemistry/metabolic panel, pregnancy test, CT/MRI

Physical exam, psych eval (history of previous

depression/psychosis), mental status exam, TFTs, CBC,

general chemistry, Edinburgh Postnatal Depression

Scale, monitor/screen during postpartal period

Physical exam, psych eval, mental status exam, TFTs

(hyperthyroidism), LFTs, toxicology screens (substance

abuse), CBC, UA, serum glucose, BMI, general

chemistry/metabolic panel, pregnancy test, CT/MRI;

Positive and Negative Syndrome Scale, AIMs

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General Chemistry

Note: Reference ranges vary according to brand of laboratory assay

materials used. Check normal reference ranges from your facility’s laboratory

when evaluating results.

Lab Conventional SI Units

Albumin

Aldolase

Alkaline

phosphatase

Ammonia

Amylase

Anion gap

AST, SGOT

Bilirubin, direct

Bilirubin, total

BUN



(calcium)

Calcitonin

Carbon dioxide (CO

)

Chloride (Cl



)

Cholesterol

Cortisol

Creatine

Creatine kinase

(CK)

Creatinine

Ferritin

Folate

Glucose

Ionized calcium

DRUGS/LABS

3.5–5.0 g/100 mL

1.3–8.2 U/L

13–39 U/L, infants and

adolescents up to 104 U/L

12–55 mol/L

4–25 units/mL

8–16 mEq/L

Male: 8–46 U/L

Female: 7–34 U/L

Up to 0.4 mg/100 mL

Up to 1.0 mg/100 mL

8–25 mg/100 mL

8.5–10.5 mg/100 mL

Male: 0–14 pg/mL

Female: 0–28 pg/mL

24–30 mEq/L

100–106 mEq/L

 200 mg/dL

(AM) 5–25 g/100 mL

(PM) 10 g/100 mL

Male: 0.2–0.5 mg/dL

Female: 0.3–0.9 mg/dL

Male: 17–148 U/L

Female: 10–79 U/L

0.6–1.5 mg/100 mL

10–410 ng/dL

2.0–9.0 ng/mL

70–110 mg/100 mL

4.25–5.25 mg/dL

35–50 g/L

22–137 nmol sec

1

217–650 nmol · sec

1

L, up to 1.26 mol/L

12–55 mol/L

4–25 arb. unit

8–16 mmol/L

0.14–0.78 kat/L

0.12–0.58 kat/L

Up to 7 mol/L

Up to 17 mol/L

2.9–8.9 mmol/L

2.1–2.6 mmol/L

0–4.1 pmol/L

0–8.2 pmol/L

24–30 mmol/L

100–106 mmol/L

5.18 mmol/L

0.14–0.69 mol/L

0–0.28 mol/L

15–40 mol/L

25–70 mol/L

283–2467 nmol sec

1

167–1317 nmol sec

1

53–133 mol/L

10–410 g/dL

4.5–0.4 nmol/L

3.9–5.6 mmol/L

1.1–1.3 mmol/L

04Pederson (F)-04 6/25/07 7:48 PM Page 122

123

General Chemistry (Continued)

Lab Conventional SI Units

Iron (Fe)

Iron binding

capacity (IBC)



(potassium)

Lactic acid

LDH (lactic

dehydrogenase)

Lipase

Magnesium



(magnesium)



(sodium)

Osmolality

Phosphorus

Potassium (K



)

Prealbumin

Protein, total

PSA

Pyruvate

Sodium (Na



)

T4, free

T4, total

Thyroglobulin

Triglycerides

TSH

Urea nitrogen

Uric acid

DRUGS/LABS

50–150 g/100 mL

250–410 g/100 mL

3.5–5.0 mEq/L

0.6–1.8 mEq/L

45–90 U/L

2 units/mL or less

1.5–2.0 mEq/L

135–145 mEq/L

280–296 mOsm/kg water

3.0–4.5 mg/100 mL

3.5–5.0 mEq/L

18–32 mg/dL

6.0–8.4 g/100 mL

 4.0 ng/mL

0–0.11 mEq/L

135–145 mEq/L

75–195 ng/100 mL

Male: 0.8–1.8 ng/dL

Female: 0.8–1.8 ng/dL

4–12 g/100 mL

3–42 /mL

40–150 mg/100 mL

0.5–5.0 U/mL

8–25 mg/100 mL

3.0–7.0 mg/100 mL

9.0–26.9 mol/L

44.8–73.4 mol/L

3.5–5.0 mmol/L

0.6–1.8 mmol/L

750–1500 nmol · sec

1

Up to 2 arb. unit

0.8–1.3 mmol/L

135–145 mmol/L

280–296 mmol/kg

1.0–1.5 mmol/L

3.5–5.0 mmol/L

180–320 mg/L

60–84 g/L

 4 g/L

0–0.11 mmol/L

135–145 mmol/L

1.16–3.00 nmol/L

10–23 pmol/L

52–154 nmol/L

3–42 g/L

0.4–1.5 g/L

0.5–5.0 arb. unit

2.9–8.9 mmol/L

0.18–0.42 mmol/L

04Pederson (F)-04 6/25/07 7:48 PM Page 123

124

Hematology

Lab Conventional SI Units

Blood volume

Red Blood

Cell (RBC)

Hemoglobin

(Hgb)

Hematocrit

(Hct)

Leukocytes (WBC)

■ Bands

■ Basophils

■ Eosinophils

■ Lymphocytes

■ B-Lymphocytes

■ T-Lymphocytes

■ Monocytes

■ Neutrophils

Platelets

Erythrocyte

Sedimentation

Rate (ESR)

Thyroid Panel

Total 75–195 ng/100 mL 1.16–3.00 nmol/L

Uptake (RT

U) 25%–35% 0.25–0.35

Uptake Ratio 0.1–1.35 0.1–0.35

Total 4–12 g/100 mL 52–154 nmol/L

Free 0.9–2.3 ng/dL 10–30 nm/L

TSH 0.5–5.0 U/mL 0.5–5.0 arb. unit

DRUGS/LABS

8.5%–9.0% of body weight

in kg

Male: 4.6–6.2 million/mm

Female: 4.2–5.9 million/mm

Male: 13–18 g/100 mL

Female: 12–16 g/100 mL

Male: 45%–52%

Female: 37%–48%

4,300–10,800/mm

80–85 mL/kg

4.6–6.2  10

4.2–5.9  10

Male: 8.1–11.2 mmol/L

Female: 7.4–9.9 mmol/L

Male: 0.45–0.52

Female: 0.37–0.48

4.3–10.8  10

0–5%

0–1%

1%–4%

25%–40%

10%–20%

60%–80%

2%–8%

54%–75%

150,000–350,000/mm

Male: 1–13 mm/hr

Female: 1–20 mm/hr

0.03–0.08  10

0–0.01  10

0.01–0.04  10

0.25–0.40  10

0.10–0.20  10

0.60–0.80  10

0.02–0.08  10

0.54–0.75  10

150–350  10

Male: 1–13 mm/hr

Female: 1–20 mm/hr

04Pederson (F)-04 6/25/07 7:48 PM Page 124

125

Renal/Kidney

Lab Conventional SI Units

BUN 6–23 mg/dL 2.5–7.5 mmol/L

Creatinine 15–25 mg/kg of body 0.13–0.22 mmol

weight/day kg

–1

/day

Uric acid Male: 4.0–9.0 mg/dL 238–535 mol/L

Female: 3.0–6.5 mg/dL 178–387 mol/L

Urinalysis (UA)

Color Yellow-straw

Specific Gravity 1.005–1.030

pH 5.0–8.0

Glucose Negative

Sodium 10–40 mEq/L

Potassium  8 mEq/L

Chloride  8 mEq/L

Protein Negative-trace

Osmolality 500–800 mOsm/L

DRUGS/LABS

04Pederson (F)-04 6/25/07 7:48 PM Page 125

126

Psychotropic Drugs A – Z

The following drugs are listed alphabetically within this tab by generic name

(example trade name in parentheses):

Alprazolam (Xanax) 127

Amitriptyline (Elavil) 128

Aripiprazole (Abilify) 128

Benztropine (Cogentin) 129

Bupropion (Wellbutrin) 129

Buspirone (BuSpar) 130

Carbamazapine (Tegretol) 130

Chlordiazepoxide (Librium) 131

Chlorpromazine (Thorazine) 131

Citalopram (Celexa) 132

Clomipramine (Anafranil) 132

Clonazepam (Klonopin) 133

Clozapine (Clozaril) 133

Desipramine (Norpramin) 134

Diazepam (Valium) 134

Divalproex sodium (Depakote) 135

Doxepin (Sinequan) 135

Duloxetine (Cymbalta) 136

Escitalopram (Lexapro) 136

Eszopiclone (Lunesta) 137

Fluoxetine (Prozac) 137

Fluphenazine (Prolixin) 138

Flurazepam (Dalmane) 138

Fluvoxamine (Luvox) 139

Gabapentin (Neurontin) 139

Haloperidol (Haldol) 140

Hydroxyzine (Atarax) 140

Imipramine (Tofranil) 141

Lamotrigine (Lamictal) 141

Lithium (Eskalith) 142

Lorazepam (Ativan) 143

Loxapine (Loxitane) 143

Mirtazapine (Remeron) 144

Molindone (Moban) 144

MAOIs (Nardil) 145

Nadolol (Corgard) 146

Nefazodone (Serzone) 146

Nortriptyline (Pamelor) 147

Olanzapine (Zyprexa) 147

Olanzapine and Fluoxetine HCl

(Symbax)* 148

Oxazepam (Serax) 148

Paliperidone (Invega)* 149

Paroxetine (Paxil) 149

Phenobarbital (Luminal) 150

Pimozide (Orap) 150

Propranolol (Inderal) 151

Quetiapine (Seroquel) 151

Ramelteon (Rozerem)* 152

Risperidone (Risperdal) 153

Selegiline patch (Emsam)* 154

Sertraline (Zoloft) 155

Thioridazine (Mellaril) 156

Topiramate (Topamax) 157

Trazodone (Desyrel) 158

Trihexyphenidyl (Artane) 159

Venlafaxine (Effexor) 160

Zalephon (Sonata) 161

Ziprasidone (Geodon) 161

Zolpidem (Ambien) 162

* Latest drugs approved/released into the marketplace.

DRUGS A-Z

05Pederson (F)-05 6/25/07 8:45 PM Page 126

DRUGS A-Z

127

Psychotropic Drugs A – Z (Alphabetical Listing)

Psychotropic Drug Tables that follow include each drug’s half life (T

), protein binding, Canadian drug

trade names (in italics), dose ranges and adult doses, most common side effects (CSE), geriatric and

dose considerations, and LIFE-THREATENING (ALL CAPS) side effects, listed alphabetically by generic

name. (See Alert at end of tab as well as FDA Warnings.)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

Alprazolam

(Xanax, Xanax

XR, Apo-

Alpraz,

Novo-Alprazol,

Nu-Alpraz)

Intermediate

 12–15 h

0.25–0.5 mg po

2–3 times

daily (anxiety);

panic: 0.5 mg

3 times daily;

not to exceed

10 mg/d; XR:

0.5–1 mg once

daily in AM;

usual range

3–6 mg/d.

Use: Anxiety,

panic;

unlabeled: PMS

CSE: Dizziness,

drowsiness,

lethargy; some-

times confu-

sion, hangover,

paradoxical

excitation, con-

stipation, diar-

rhea, nausea,

vomiting

↓ Dose required;

begin 0.25 mg

2–3 times/d;

assess CNS

and risk for

falls. Elderly

have ↑ sensi-

tivity to benzo-

diazepines.

Antianxiety agent

Monitor CBC, liver,

renal function in

long-term therapy;

avoid grapefruit

juice; risk for

psychological/

physical depend-

ence; seizures on

abrupt discontinu-

ation. Interacts

with alcohol,

antidepressants,

antihistamines,

other benzos and

opioids.

05Pederson (F)-05 6/25/07 8:45 PM Page 127

128

DRUGS A-Z

Range: 50–300

mg/d; dosage:

75 mg/d po in

divided doses

up to 150 mg/d

or 50–100 mg

hs; increase by

25–50 mg to 150

mg (in hospital:

start 100 mg/d

up to 300 mg).

Schizophrenia: 10-

15 mg/d po (up

to 30 mg/d); ↑

only after 2 wk

at a given dose.

Bipolar: 30 mg/d

(start at 15 mg/d

if larger dose

not tolerated).

Use: Depression;

unlabeled: chronic

pain

CSE: Blurred vision,

dry eyes, dry

mouth, sedation,

hypotension,

constipation,

ARRHYTHMIAS

Use: Schizophrenia,

acute bipolar mania

(manic/mixed)

CSE: Nausea, anxiety,

confusion, con-

stipation, orthosta-

tic hypotension, ↑

salivation, ecchy-

moses, NMS

Use caution:

Orthostatic

hypotension,

sedation,

confusion

(falls); CV

disease;

titrate

slowly.

Orthostatic

hypotension;

caution with

CV disease.

↑ mortality in

elderly with

dementia-

psychosis.

Antidepressant

[TCA]

Hx CV disease or

high doses:

Monitor ECG

prior to and

through Rx.

Antipsychotic

Contraindicated:

Lactation;

caution with CV/

cerebrovascular

diseases; avoid

dehydration;

NEUROLEPTIC

MALIGNANT

SYNDROME.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

Amitriptyline

(Elavil, Apo-

Amitriptyline)

 10–50 h

Protein binding

95%

Aripiprazole

(Abilify)

 75 h;

dehydroari-

piprazole 

94 h

Protein binding

 99%

05Pederson (F)-05 6/25/07 8:45 PM Page 128

DRUGS A-Z

129

Benztropine

(Cogentin, Apo-

Benztropine)

 Unknown

Bupropion

(Wellbutrin,

Wellbutrin SR,

Wellbutrin XL)

 14 h

(metabolites

possibly long

er)

Parkinsonism:

0.5–6 mg/d

EPS: PO/IM/

IV: 1–4 mg qd

or bid or 1–2

mg po 2–3

times daily;

acute dystonia:

IM/IV: 1–2 mg;

then 1–2 mg po

bid.

200–450 mg/d po

IR: 100 mg po

bid; after 3 d ↑

to tid; wk 4 to

450 mg/d in

divided doses,

not to exceed

150 mg/dose.

Use: Parkinson’s,

drug-induced

EPS, and acute

dystonia

CSE: Blurred

vision, dry

mouth, dry eyes,

constipation,

urinary retention

Use: Depression;

adult ADHD

(SR only); ↑

female sexual

desire

CSE: Agitation,

headache, dry

mouth, nausea,

vomiting,

SEIZURES

Use cautiously; ↑

risk of adverse

reactions.

Use cautiously;

increased risk

of drug

accumulation.

Antiparkinson agent

Contraindicated:

Narrow-angle

glaucoma and TD;

assess parkin-

sonian/EPS

symptoms;

bowel function

(constipation)/

urinary retention

IM/IV: Monitor

pulse/BP closely;

advise slow

position changes.

Antidepressant

Contraindicated:

Hx bulimia or

anorexia; seizure

disorder. Seizure

risk ↑ at doses

450 mg; avoid

alcohol.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 129

DRUGS A-Z

130

Buspirone

(BuSpar)

 2–3 h

Protein binding 

95%

Carbamazepine

(Tegretol, Tegre-

tol XR, Equetro,

Epitol, Apo-

Carbamazepine,

Tegretol CR)

 single

dose  25–65 h;

chronic dosing

 8–29 h

15–60 mg/d po

Range: 400–1200

mg/d

Start: 200 mg/d

or 100 mg bid;

increase

weekly by 200

mg/d until

reach

therapeutic

level/mania

improvement

with tolerable

side effects.

(Do not crush

Tegretol XR)

Antianxiety agent

Contrainidicated:

Severe renal/hepatic

impairment; does

not appear to cause

dependence.

Anticonvulsant

Caution: Impaired

liver/cardiac

functions. Monitor

CBC, platelets,

reticulocytes, &

serum iron wkly first

2 mo, then yearly.

D/C if bone marrow

depression.

Therapeutic Range

(4–12 μg/mL).

Sx of SJS: cough,

FUO, mucosal

lesions, rash; stop

CBZ.

Use: Anxiety

management

CSE: Dizziness,

drowsiness,

blurred vision,

palpitations,

chest pain,

nausea, rashes,

myalgia,

sweating

Use: Bipolar: Acute

mania/mixed;

seizures, trigem-

inal pain

CSE: Ataxia,

drowsiness,

blurred vision.

APLASTIC

ANEMIA,

AGRANULOCY-

TOSIS,

THROMBOCYTO-

PENIA, STEVENS-

JOHNSON

SYNDROME

(SJS)

Contraindicated:

Severe

renal/hepatic

disease.

Use cautiously

CV/hepatic

disease; BPH

and increased

intraocular

pressure.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 130

DRUGS A-Z

131

Chlordiazepoxide

(Librium,

Libritabs, Apo-

Chlordiaze-

poxide)

 5–30 h

Chlorpromazine

(Thorazine, Thor-

Prom, Chlorpro-

manyl, Largactil,

Novo-Chlorpro-

mazine)

 initial 2 h;

end 30 h

Protein binding 

≥90%

May cause pro-

longed sedation

in the elderly and

is associated with

increased risk of

falls. Must reduce

dose or consider

short-acting

benzodiazepine.

Caution: Sedating;

decrease initial

dose. Caution:

BPH

Anxiety: 5–25 mg

po 3–4  daily.

Alcohol withdra-

wal: IM: 50–100

mg; may

repeat in 3–4 h

or po 50–100

mg; repeat

until agitation

↓ (to 400

mg/d).

Range: 40–800

mg/d po

Psychoses: 10–25

mg po 2–4

times/d; may

↑ q 3–4 d up to

1 g/d; IM: Start

25–50 mg IM

to max. 400

mg q 3–12 h

(max. 1 g/d).

Antianxiety agent

Contraindicated:

Narrow-angle

glaucoma,

porphyria;

caution with

hepatic/renal

impairment and

history of suicide

attempt/sub-

stance abuse.

Antipsychotic

Contraindicated:

Glaucoma, bone

marrow depres-

sion, severe liver/

CV disease.

Monitor BP,

pulse, and

respirations,

CBCs, LFTs, and

eye exams; EPS,

akathisia, NMS.

Use: Adjunct

anxiety

management;

alcohol

withdrawal

CSE: Dizziness,

drowsiness, pain

at IM site

Use: Psychosis;

combativeness

CSE: Hypotension

(esp IM), dry

eyes, sedation,

blurred vision,

constipation, dry

mouth, photo-

sensitivity,

NMS, AGRAN-

ULOCYTOSIS

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 131

DRUGS A-Z

132

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

Citalopram

(Celexa)

 35 h

Clomipramine

(Anafranil, Apo-

Clomipramine)

 20–30 h

Range: 20–60

mg/d po

Start 20 mg po

daily, increased

weekly, if

needed, by 20

mg/d up to 60

mg/d (usual

dose: 40 mg/d).

Range: 25–250

mg/d po

Start 25 mg/d po;

gradually

increase to 100

mg/d (up to 250

mg/d).

Antidepressant

[SSRI]

Contraindicated:

Use within 14

days of MAOI;

Caution: hx of

mania or seizures;

serotonin

syndrome with

SAMe or St.

John’s wort;

monitor for mood

changes and

assess for suicide.

Antidepressant

[TCA]

Caution: CV disease

including conduc-

tion

abnormalities, hx:

seizures, bipolar,

hypotensive

disorders; avoid

alcohol; fatal with

MAOIs.

Use: Depression

CSE: Apathy,

confusion,

drowsiness,

insomnia,

abdominal

pain, anorexia,

diarrhea,

dyspepsia,

nausea,

sweating,

tremor

Use: OCD

CSE: Dizziness,

drowsiness,

increased

appetite,

weight gain,

constipation,

nausea

20 mg po once

daily; may

increase to 40

mg/d only in

those not

responding.

Lower doses with

hepatic/renal

impairment.

Use with caution in

elderly (sedation,

orthostatic

hypotension; CV

disease; BPH).

05Pederson (F)-05 6/25/07 8:45 PM Page 132

133

DRUGS A-Z

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

Clonazepam

(Klonopin,

Rivotril, Syn-

Clonazepam)

 18–50 h

Clozapine

(Clozaril,

FazaClo)

 8–12 h

Protein binding

 95%

[FazaClo—orally

disintegrating

tablets]

Range: 1.5–4 mg/d

po (panic/anxi-

ety); as high as

6 mg/d; up to

20 mg/d for

seizures.

Range: 300–900

mg/d po

Start 25 mg po

1–2  daily; ↑

25–50 mg/d

over 2 wk up to

300–450 mg/d

(not to exceed

900 mg/d).

FazaClo: start

12.5 mg 1–2 

daily; no water

needed.

Antianxiety agent

Contraindicated: Severe

liver disease; assess

for drowsiness: dose-

related. Monitor:

CBC/LFTs with

prolonged therapy.

Antipsychotic

Must follow Clozaril

protocol: Monitor

BP/pulse; CBC

(WBC/diff 3000/

—withhold

clozapine).

(See Clozaril Protocol in

Drug-Lab Tab.)

Monitor for signs of

myocarditis, akathisia,

EPS, and NMS.

(For FazaClo Protocol,

see www.Fazaclo.

com)

Use: Panic disorder,

seizure disorders;

restless leg

syndrome.

CSE: Behavioral

changes,

drowsiness, ataxia

Use: Refractive

schizophrenia

(unresponsive to

other treatments)

CSE: Dizziness,

sedation,

hypotension,

tachycardia,

constipation,

NMS, SEIZURES,

AGRANULOCYTO-

SIS, LEUKOPENIA,

MYOCARDITIS

(D/C clozapine)

Caution:

Drowsiness;

Contraindi-

cated: Liver

disease

Use cautiously

with CV/

hepatic/renal

disease;

sedating;

↑

mortality in

elderly with

dementia-

psychosis

05Pederson (F)-05 6/27/07 7:09 PM Page 133

DRUGS A-Z

134

Desipramine

(Norpramin,

Pertofrane)

 12–27 h

Protein binding 

90%–92%

Diazepam

(Valium, Apo-

Diazepam,

Vivol )

 20–50 h

(up to 100 h for

metabolites)

Range: 25–300 mg/d

100–200 mg/d po

single or divided

doses (up to 300

mg/d).

Range: 4–40 mg/d

Anxiety: po: 2–10

mg 2–4  daily;

IM/IV: 2–10 mg q

4 h prn.

Alcohol WD: po: 10

mg 3–4  first 24

h; then 5 mg 3–4

 daily; IM/IV: 10

mg, then 5–10 mg

in 3–4 h as

needed.

Use: Depression;

unlabeled: chronic

pain

CSE: Blurred vision,

dry eyes, dry

mouth, sedation,

hypotension,

constipation

ARRHYTHMIAS

Use: Anxiety adjunct;

alcohol withdrawal

CSE: Dizziness,

drowsiness,

lethargy

Reduce dosage:

25–50 mg/d po (in

divided doses (up

to 150 mg/d);

sedation. Caution

with CV disease,

BPH; monitor BP

& pulse.

Dosage reduction

required; caution:

hepatic/renal

disease; assess:

risk for falls;

prolonged

sedation in the

elderly.

Antidepressant

(TCA)

Contraindicated:

Narrow-angle

glaucoma.

Monitor BP/

pulse; ECG prior

to and through Rx

if hx of CV disease

or high doses.

Antianxiety agent

Monitor: BP/pulse/

respirations; CBC,

LFTs; renal tests

periodically with

prolonged ther-

apy; monitor for

dependence. Alco-

holics: ETOH with-

drawal–assess for:

tremors, delir-ium,

agitation,

hallucinations.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 134

135

DRUGS A-Z

Divalproex

sodium

(Depakote,

Depakote ER,

Epival)

[Valproate]

 5–20 h

Doxepin

(Sinequan,

Zonalon,

Triadapin)

 8–25 h

Range: 500–1500

mg/d po [up to

4000 mg/d]

Initially: 750 mg/d

in divided doses,

titrated to clinical

effect/plasma

levels; ER: Single

dose at bedtime.

Range: 25–300 mg/d

25 mg po 3  daily,

up to150 mg

(inpatient up to

300 mg/d).

Use: Bipolar, acute

mania &

prophylaxis

CSE: Nausea,

vomiting,

indigestion,

HEPATOTOXICITY,

PANCREATITIS

Use: Depression/

anxiety

CSE: Blurred vision,

dry eyes, dry

mouth, sedation,

hypotension,

constipation,

ARRHYTHMIAS

Caution with renal

impairment, organic

brain disease,

assess for excessive

somnolence.

Dose reduction:

25–50 mg/d po

initially, increase as

needed; caution

with preexisting CV

disease, BPH; assess

for falls and

anticholinergic

effects.

Anticonvulsant

Contraindicated:

Hepatic

impairment;

Monitor LFTs,

serum ammonia

before and

throughout Rx.

Hyperammonemia:

D/C VA.

Caution: Renal/

bleeding disorders;

bone marrow

depression; terato-

genicity; need VA

levels (50–100

g/mL).

Antidepressant

Monitor blood pres-

sure and pulse;

ECGs with hx of CV

disease; WBC w

diff, LFTs, and

serum glucose

periodically.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 135

DRUGS A-Z

136

Duloxetine

(Cymbalta)

 12 h

Protein

binding 

90%

Escitalopram

(Lexapro)

 increased

in hepatic

impairment

Range: 40–60 mg/d

20–30 mg po twice

daily

Range: 10–20 mg/d;

10 mg po once

daily, may

increase to 20

mg/d after 1 wk.

Use: Major depres-

sive disorder

CSE: fatigue,

drowsiness,

insomnia, ↓

appetite,

constipation, dry

mouth, nausea,

dysuria,

↑sweating,

SEIZURES

Use: Depression,

generalized

anxiety disorder

CSE: Insomnia,

diarrhea, nausea,

sexual dysfunction

Use with caution;

increase slowly.

↓ dose in elderly;

caution with

hepatic/renal

impairment

(10 mg po once

daily); T

increased in the

elderly

Antidepressant

[SNRI]

Contraindicated:

Concurrent

MAOIs, hepatic

impairment/ETOH

use; with renal

impairment: start

with lower dose.

Monitor BP (↑ BP

dose-related) &

LFTs; monitor for

suicidality.

Antidepressant

[SSRI]

Contraindicated:

Concurrent

MAOIs or

citalopram.

Caution: hx

mania/seizures or

risk for suicide;

monitor for

suicidality.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 136

137

DRUGS A-Z

Eszopiclone

(Lunesta)

 6 h

Protein binding 

weakly bound

Fluoxetine

(Prozac, Prozac

Weekly, Serafem

[PMDD])

 1-3 d

(norfluoxetine:

5-7 d)

Protein binding 

94.5%

Range: 1–3 mg po

Start at 2 mg po hs,

may ↑ to 3 mg if

needed.

Range: 20–80 mg po

Depression/OCD:

Start 20 mg/d po,

may ↑ weekly up

to 80 mg; Panic

disorder: Start 10

mg/d po up to 60

mg/d; Prozac

Weekly: 90 mg/wk

Use: Insomnia: Sleep

latency/

maintenance

CSE: Anxiety,

confusion,

depression,

headache,

migraine,

dizziness,

hallucinations

Use: Depression

(also geriatric),

OCD, bulimia

nervosa, panic

disorder

CSE: Anxiety,

drowsiness,

headache,

insomnia,

nervousness,

diarrhea, sexual

dysfunction,

↑ sweating,

pruritus, tremor

Elderly should start

with 1 mg po

dose and take

immediately

before bedtime;

should not

exceed 2 mg/hs.

Starting dose: 10

mg/d (not to

exceed 60 mg);

Caution with

hepatic/renal

impairment and

with multiple

medications (long

). Elderly at

risk for excessive

CNS stimulation,

sleep distur-

bances, and

agitation.

Sedative/hypnotic

Severe hepatic

impairment: Start

1 mg. Caution:

Concomitant

illness, drug/ETOH

abuse, psychiatric

illness, abrupt

withdrawal (See

FDA warning).

Antidepressant

[SSRI]

Serious fatal

reactions with

MAOIs, long

washout needed.

Caution:

Hepatic/renal/

pregnancy/

seizures.

Peds/Adol

(18–24y): May

increase risk of

suicidal thinking

and behavior;

must closely

monitor.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 137

DRUGS A-Z

138

Fluphenazine

hydrochloride

(Prolixin, Apo-

Fluphenazine)

 4.7–15.3 h

Fluphenazine

decanoate

(Prolixin Deca-

noate, Modecate)

 6.8–9.6 d

Fluphenazine

Enanthate

 3.7 d

Protein binding

≥ 90%

Flurazepam

(Dalmane, Apo-

Flurazepam,

Somnol)

 2.3 h

(active

metabolite may

be 30–200 h)

Protein binding 

97%

Range: 1–40 mg/d

Fluphenazine

HCl: Start:

2.5–10 mg/d po

(divided dose

q 6–8 h);

maintenance:

1–5 mg/d; IM:

1.25–2.5 mg q

6–8 h

Decanoate: Start

12.5–25 mg

IM/SC q 1–4 wk

(may ↑ to 100

mg/dose).

Range: 15–30 mg

Usual dose: 15–30

mg po hs.

Use: Psychotic

disorders,

schizophrenia,

chronic

schizophrenia

CSE: EPS,

photosensitivity,

sedation, tardive

dyskinesia,

AGRANULO-

CYTOSIS

Use: Short-term

insomnia

management

(4 wk)

CSE: Drowsiness,

confusion,

dizziness,

paradoxical

excitation, blurred

vision, constipation

Use lower doses:

Fluphenazine HCl:

Start with 1–2.5

mg/d po; caution

with BPH,

respiratory

disease;

Contraindicated:

severe liver/CV

disease.

Initial dose ↓: 15

mg po initially hs;

hepatic disease;

warn patient and

family about ↑

risk for falls and

requires

assessment for

falls and fall

prevention.

Antipsychotic

Contraindicated:

Severe liver/CV

disease, use with

pimozide,

glaucoma, bone

marrow

depression.

Monitor BP, pulse,

respiration, ECG

changes, EPS,

akathisia, TD, NMS

(report

immediately).

Periodic CBCs,

LFTs, eye exams.

Sedative/hypnotic

Contraindicated: CNS

depression,

narrow-angle glau-

coma, pregnancy,

lactation. Caution:

Hepatic disease, hx

suicide attempts.

Avoid alcohol. (See

FDA warning.)

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 138

DRUGS A-Z

139

Fluvoxamine

(Luvox)

 13.6–15.6 h

Gabapentin

(Neurontin,

Gabarone)

 5–7 h

Range: 50–300 mg/d

Start: 50 mg/d po

hs, ↑ 50 mg q

4–7 d (divide

equally, if dose

100 mg)

(do not exceed

300 mg/d)

Range: 900–1800

mg/d

Start: 300 mg po 3 

daily; titrate up to

1800 mg/d in

divided doses

(doses up to 3600

mg/d have been

used)

Use: OCD. Unla-

beled: depression.

CSE: Headache,

dizziness,

drowsiness,

nervousness,

insomnia, nausea,

diarrhea,

constipation

Use: Partial seizures.

Unlabeled: Bipolar

disorder and

chronic pain

CSE: Drowsiness,

ataxia, confusion,

depression; may

also cause dizzi-

ness, hostility,

vertigo, hyperten-

sion, anorexia

Reduce dose, titrate

slowly; caution

with impaired

hepatic function

Use cautiously;

especially with

renal impairment

(↓ dose and/or ↑

dosing interval).

Antidepressant

[SSRI]

Serious fatal

reactions with

MAOIs. Peds/Adol

(18–24y): Weigh

risk vs benefit.

Monitor closely

for suicidality.

Anticonvulsant

Caution: Renal

impairment

(↓ dose).

Discontinuation

requires at least a

wk; should be

done gradually;

dosages no more

than 12 h apart.

Risk of CNS

depression with

alcohol, opioids,

other CNS

depressants.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 139

DRUGS A-Z

140

Haloperidol

(Haldol, Apo-

Haloperidol)

Haloperidol

decanoate

 21–24 h

Protein Binding 

90%

Hydroxyzine

(Atarax, Vistaril,

Apo-Hydroxy-

zine, Novohy-

droxyzin)

 3 h

Range: 1–100 mg/d

Haloperidol: 0.5–5

mg po 2–3  d (to

100 mg/d).

Decanoate: 10–15

times the oral

dose.

Range: 100–400

mg/d

25–100 mg po 4 

daily (do not

exceed 600

mg/d).

Use: Psychotic

disorders,

aggressive states,

schizophrenia

CSE: EPS, blurred

vision,

constipation, dry

mouth/eyes,

NMS, SEIZURES

Use: Anxiety,

pruritis, preop

sedation

CSE: Drowsiness,

dry mouth, pain

at IM site

Dosage reduction

required: 0.5–2 mg

po two  daily;

increasing

gradually; caution:

CV/diabetes, BPH.

Dosage reduction;

severe hepatic

disease; at ↑ risk

for falls and CNS

effects. Monitor

for drowsiness,

agitation,

sedation.

Antipsychotic

Monitor BP, pulse,

respiration,

akathisia, EPS,

tardive dyskine-

sia, NMS (report

immediately).

Perform CBC w

diff, LFTs, eye

exams

periodically. Avoid

alcohol/CNS

depressants.

Caution: Tox ic

encephalopathy w

haloperidol 

lithium.

Antianxiety/sedative/

hypnotic

Contraindicated

in pregnancy. Use

cautiously severe

hepatic dysfunc-

tion. Avoid

alcohol/CNS

depressants.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 140

DRUGS A-Z

141

Imipramine

(Tofranil, Apo-

Imipramine)

 8–16 h

Protein binding

 89–95%

Lamotrigine

(Lamictal)

 25.4 h (on

lamotrigine

alone)

Range: 30–300 mg/d

25–50 mg po 3–4 

daily (not to

exceed 300

mg/d).

Range: 75–250 mg/d

Bipolar pt not on

CBZ/VA: Start 25

mg/d po 

2 wk, then 50

mg/d  2 wk,

then 100 mg/d 

1 wk, then 200

mg/d.

Use: Depression

CSE: Blurred vision,

dry eyes, dry

mouth, sedation,

constipation,

hypotension,

ARRHYTHMIAS

Use: Partial seizures,

bipolar disorder

maintenance

CSE: Nausea,

vomiting, dizzi-

ness, headache,

ataxia photo-

sensitivity, rash,

STEVENS

JOHNSON

SYNDROME (SJS)

25 mg po hs

initially, up to

100 mg/d, divided

doses. Use

cautiously in

elderly, preex-

isting CV disease

(monitor ECGs),

BPH.

May cause

dizziness/

drowsiness.

Caution with

impaired

renal/CV/

hepatic disease.

Antidepressant

[tricyclic]

Monitor ECGs in

heart disease; also

BP and pulse.

Contraindicated:

Concurrent MAOIs;

avoid use with

SSRIs, or

clonidine.

Anticonvulsant

Contrainidicated:

Lactation. Caution:

lmpaired renal/

cardiac/hepatic

function, hx rash

on lamotrigine.

Avoid abrupt

discontinuation.

Assess for skin

rash. Sx of SJS:

Cough, FUO,

mucosal lesions,

rash; stop

lamotrigine.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 141

DRUGS A-Z

142

Lithium

(Eskalith, Eskalith

CR, Lithobid,

Lithonate,

Lithotabs,

Carbolith,

Duralith)

 20-27 h

Acute mania:

1800-2400 mg/d;

Maintenance:

300-1200 mg/d.

Start: 300-600 mg

po 3  daily;

usual main-

tenance: 300 mg

3-4  daily. Slow

release: 200-300

mg po 3  daily

to start, up to

1800 mg/d

(divided doses);

Extended release:

300-600 mg po

3  daily to start.

Use: Bipolar

disorder: Acute

manic episodes;

prophylaxis

against recurrence

CSE: Fatigue,

headache,

impaired memory,

ECG changes,

bloating, diarrhea,

nausea, abdominal

pain, leukocytosis,

polyuria, acne,

hypothyroidism,

tremors, weight

gain, SEIZURES,

ARRHYTHMIAS

Initial dose

reduction recom-

mended; caution

w CV/renal/

thyroid disease,

diabetes mellitus.

Antimanic

Serum lithium levels:

Acute mania: 1.0-1.5

mEq/L; Mainte-

nance: 0.6-1.2

mEq/L. Narrow

therapeutic range;

Signs of toxicity:

vomiting, diarrhea,

slurred speech,

drowsiness, ↓

coordination. Li

↓ thyroid function

(hypothyroidism)/

renal changes.

Monitor thyroid/

kidney function,

WBC w diff,

electrolytes,

glucose, ECG,

weight (also BMI).

Caution: Tox ic

encephalopathy w

haloperidol 

lithium.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 142

DRUGS A-Z

143

Lorazepam

(Ativan, Apo-

Lorazepam)

 10–16 h

Loxapine

(Loxitane,

Loxapac)

 5 h/

12–19 h

Range: 2–6 mg/d

(up to 10 mg/d);

1–3 mg po 2-3 x

daily; Insomnia:

2-4 mg po hs.

Range: 20–250 mg/d

Start: 10 mg po 2 

daily, ↑ until

psychotic

symptom

improvement.

Use: Anxiety,

insomnia

CSE: Dizziness,

drowsiness,

lethargy; rapid IV:

APNEA, CARDIAC

ARREST

Use: Psychotic

disorders,

schizophrenia

CSE: Drowsiness,

orthostatic

hypotension,

ataxia,

constipation,

nausea, blurred

vision

Dosage reduction;

caution

hepatic/renal/

pulmonary

impairment; more

susceptible to

CNS effects and

increased risk for

falls.

Evaluate/monitor

for confusion,

orthostatic

hypotension,

sedation, ↓ dose;

at risk for falls.

Antianxiety/sedative/

hypnotic.

Contraindicated:

Comatose or CNS

depression, preg-

nancy, lactation,

glaucoma. Caution:

In hepatic/renal/

pulmonary

impairment/

drug abuse.

Antipsychotic

Contraindicated:

Severe CNS

depression/coma.

Caution:

Parkinson’s, bone

marrow

suppression,

cardiac, renal,

respiratory

disease; sedating,

Monitor for EPS,

NMS, TD.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 143

DRUGS A-Z

144

Mirtazapine

(Remeron,

Remeron

Soltabs)

 20–40 h

Protein binding

 85%

Molindone

(Moban)

 1.5 h

Range: 15–45 mg/d

Start: 15 mg/d po

hs, increase q

1–2 wk up to

45 mg/d.

Range: 15–225 mg/d

Start: 50–75 mg/d

po, increase at

4 d intervals

(up to 225 mg).

Use: Depression

CSE: Drowsiness,

constipation, dry

mouth, increased

appetite, weight

gain

Use: Psychotic

disorders,

schizophrenia

CSE: Sedation,

drowsiness,

constipation,

weight gain,

blurred vision

Lower dose; use

cautiously w

hepatic/renal

disease.

Initial ↓ dose;

caution w

diabetes, BPH,

respiratory

disease; increased

risk for falls

(sedation/

orthostatic

hypotension).

Antidepressant

[tetracyclic]

Contraindicated:

Concurrent MAOI

therapy; caution

w hx seizures,

suicide attempt.

Closely monitor

for suicidality/

safety not deter-

mined in children,

lactation, preg-

nancy. Periodic

CBCs, LFTs.

Antipsychotic

Contraindicated w

CNS depression.

Monitor for EPS,

NMS, and TD.

Caution with

cardiac, renal,

hepatic,

respiratory

disease.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 144

DRUGS A-Z

145

MAOIs:

Phenelzine

(Nardil)

Tranylcypromine

(Parnate)

Isocarboxazid

(Marplan)

 Unknown

[See selegiline

patch]

Phenelzine:

Range: 45–90 mg/d

Start: 15 mg po 3 

daily and increase

to 60–90 mg/d.

Tranylcypromine:

Range: 30–60 mg/d

Start: 30 mg/d po

divided dose

(AM/PM) up to

60 mg/d.

Isocarboxazid:

Range: 20–60 mg/d

Start: 10 mg/d po,

increasing every

few days (up to

60 mg/d in 2–4

divided doses).

Use: Atypical

depression, panic

disorder; other Rx

ineffective or not

tolerated

CSE: Dizziness,

headaches,

insomnia,

restlessness,

blurred vision,

arrythmias,

orthostatic

hypotension,

diarrhea,

SEIZURES,

HYPERTENSIVE

CRISIS

Use cautiously,

titrate slowly,

↑ risk of adverse

reactions.

Antidepressant

Potentially fatal

reactions with

other antide-

pressants (SSRIs,

TCAs, etc). Five

wk washout w

fluoxetine. Must

follow MAOI diet

(foods high in

tyramine) to avoid

hypertensive crisis

(emergency) [See

MAOI diet in Drug-

Lab Tab]; hyperten-

sive crisis from

caffeine; also

amphetamines,

levadopa,

dopamine,

epinephrine,

reserpine, and

others. Avoid

opioids

(meperidine).

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 145

DRUGS A-Z

146

Nadolol

(Corgard;

Syn-Nadolol)

 10–24 h

Nefazodone

(Serzone*)

40 mg/d po

(up to 240 mg)

200-600 mg/d po

Use: Tremors,

akathisia

CSE: Fatigue,

impotence,

ARRYTHMIAS,

CHF, BRADY-

CARDIA,

PULMONARY

EDEMA

Use: Depression

CSE: Insomnia,

dizziness,

drowsiness,

HEPATIC FAILURE;

HEPATIC TOXICITY

Initial dose

reduction

recommended;

increased

sensitivity to beta

blockers.

Initiate lower dose.

HEPATIC FAILURE;

HEPATIC

TOXICITY.

Antianginal; beta

blocker

Contraindicated:

CV diseases (CHF,

bradycardia,

heart block, etc.);

renal impairment:

↑ dosing

intervals.

Antidepressant

Serzone has been

withdrawn from

the North

American market

for rare but

serious liver

failure; generic

is still available.

*Withdrawn from North American market

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 146

DRUGS A-Z

147

Nortriptyline

(Pamelor, Aventyl)

 18–28 h

Protein binding 

92%

Olanzapine

(Zyprexa, Zyprexa

Zydis, Zyprexa

Intramuscular)

 21–54 h

Protein binding 

93%

Range: 75–150 mg/d

Start: 25 mg

po 3–4  daily up

to 150 mg/d.

Range: 5–20 mg/d

Schizophrenia:

Start: 5–10 mg po/d

(not to exceed 20

mg/d).

Bipolar:

Start: 10–15 mg/d po

(not to exceed 20

mg/d); IM (acute

agitation): 5–10

mg, may repeat in

2 h/4 h.

Use: Depression

CSE: Drowsiness,

fatigue, blurred

vision, dry

eyes/mouth,

hypotension,

constipation,

ARRYTHMIAS

Use: Schizophre-

nia, psychotic

disorders; bipolar:

Acute mania;

mixed episodes;

long-term

maintenance

CSE: Agitation,

dizziness, seda-

tion, orthostatic

hypotension,

constipation,

weight gain. NMS,

SEIZURES

Susceptible to side

effects: ↓ dose:

30–50 mg/d po in

divided doses;

caution w BPH, CV

disease; monitor

ECGs in elderly.

Dosage reduction

may be needed;

reduce dosage for

debilitated or

nonsmoking

females ≥65: start

at 5 mg/d po.

Caution w CV,

CVA, BPH, hepatic

disease.

↑

mortality in elderly

with dementia-

related psychosis.

Antidepressant

[TCA]

Contraindicated in

narrow-angle

glaucoma.

Potential fatal

reaction with

MAOIs. Monitor

ECGs w heart

disease.

Antipsychotic

Monitor for

treatment-

emergent

diabetes (serum

glucose, BMI),

akathisia, EPS,

NMS; perform

CBCs, LFTs, eye

exams. Monitor

BP, pulse,

respiratory

rate, ECG.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 147

DRUGS A-Z

148

Olanzapine and

fluoxetine HCl

(Symbax)

Olanzapine

 21–54 h

Protein binding

93%

Fluoxetine

 1–3 d

(norfluoxetine:

5–7 d)

Protein binding

 94.5%

Oxazepam

(Serax, Apo-

Oxazepam)

 5–15 h

Protein binding

 97%

Dosing options:

6/25, 6/50, 12/25,

12/50 mg/d

Efficacy: fluoxetine

6–12 mg and olan-

zapine 25–50 mg.

Start 6/25 mg once

daily po in

evening.

Range: 30–120 mg/d

Anxiety: 10–30 mg

po 3–4  daily.

Sedative/alcohol

withdrawal: 15–30

mg po 3–4 

daily.

Use: Bipolar

depressive

disorder

CSE: Drowsiness,

weight gain, dry

mouth, diarrhea,

increased appetite,

tremor, sore

throat, weakness,

NMS, TD

Use: Anxiety, alcohol

withdrawal

CSE: Dizziness,

drowsiness,

hangover,

impaired memory,

blurred vision,

constipation,

nausea

Start with 6/25

mg/d, especially if

hypotensive or

hepatic

impairment or

slow metabolism.

↓ dose: Start 5 mg

po 1–2  daily,

may increase as

needed; caution

w hepatic, severe

COPD disease; ↑

risk for falls.

Antipsychotic/

Antidepressant

Same as olanzapine

and fluoxetine

Antianxiety/Seda-

tive/Hypnotic

Contraindicated:

CNS depression,

coma, narrow-

angle glaucoma,

pregnancy,

lactation.

Caution: Hepatic

dysfunction;

monitor CBCs,

LFTs, avoid

alcohol.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 148

DRUGS A-Z

149

Paliperidone

(Invega)

Major active

metabolite of

risperidone

Protein binding

 74%

Paroxetine

(Paxil,

Paxil CR)

 24 h

Protein

binding

 95%

Range: 3–12 mg/d

Usual dose: 6 mg/d

po extended-

release tab in AM

(once daily

dosing).

Range: 10–60 mg/d;

CR: 12.5–75 mg/d.

Depression: Start

20 mg po q AM,

(may increase by

10 mg/d at weekly

intervals)

CR: Start 25 mg po

once daily, may

increase weekly

by 1.25 mg, up to

62.5 mg/d.

Use: Schizophrenia

CSE: Somnolence,

orthostatic

hypotension,

akathisia, EPS,

parkinsonism

Use: Depression,

panic disorder,

OCD, GAD, PTSD,

PMDD

CSE: Anxiety, dizzi-

ness, drowsiness,

dry mouth,

headache,

insomnia, nausea,

constipation,

diarrhea, weak-

ness, ejaculatory

disturbance,

sweating, tremor

Caution w decreased

renal function;

moderate to severe

renal impairment

(dose: 3 mg/d);

↑

mortality with

dementia-related

psychosis.

↓ dose: start

10 mg/d po, up to

40 mg/d; CR: Start

12.5 mg po daily,

up to 50 mg/d.

Caution w hepatic,

renal Impairment.

Antipsychotic

Causes ↑ in QT

interval; avoid

drugs that

prolong QT int.

(e.g., quinidine)

Antidepressant/

Antianxiety [SSRI]

Caution: Hepatic,

renal, seizure

disorders/

pregnancy/

lactation.

Withdrawal

syndrome: Do not

stop abruptly.

Peds/Adol (18–24y):

↑ risk for suicide;

weigh risks vs

benefits; closely

monitor for

suicidality. (See

FDA warning.)

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 149

DRUGS A-Z

150

Phenobarbi-

tal

(Luminal,

Ancalixir)

 2–6 d

Pimozide

(Orap)

 50 h

Protein binding

 99%

Range: 30–320 mg/d

Sedation: 30–120

mg/d po/IM

(divided doses)

Hypnotic: 120–320

mg hs (PO, SC, IV,

IM)

Range: 2–10 mg/d

Start 1–2 mg/d po,

increase as

needed every

other day.

Use: Sedative/

hypnotic (short

term)

CSE: Hangover,

drowsiness,

excitation

Use: Tourette’s,

psychosis

CSE: Orthostatic

hypotension,

palpitations, QT

prolongation,

drowsiness,

dizziness, blurred

vision

Use cautiously; ↓

dose; hepatic/

renal disease.

Moderately sedating;

caution in

Parkinson’s,

arrhythmias,

cerebrovascular,

cardiovascular

disease; may cause

orthostatic

hypotension.

Sedative/Hypnotic

Life-threatening side

effects:

ANGIOEDEMA,

SERUM SICKNESS,

LARYNGOSPASM

(IV). IV: Monitor BP,

pulse, respiratory

status.

Resuscitation

equipment

available.

Antipsychotic

Contraindicated: CNS

depression,

prolonged QT

syndrome,

dysrhythmias.

Caution in

respiratory, CV,

hepatic, renal

disease. Assess for

EPS, TD, akathisia,

NMS.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 150

DRUGS A-Z

151

Propranolol

(Inderal, Apo-

propranolol)

 3.4–6 h

Protein binding

 93%

Quetiapine

(Seroquel)

 6 h

[Seroquel XR—

once daily

dosing

available

late 2007]

Tremors: 80–

120 mg/d po (up

to 320 mg/d)

Akathisia: 30–

120 mg/d po

Range: 150–800

mg/d

Schizophrenia: Start

25 mg po 2 

daily, gradually

increase to 300-

400/800 mg/d.

Bipolar mania:

Start 100 mg/d po

2 divided doses,

up to 800 mg/d

Use: Essential tremor,

anxiety, akathisia

CSE: Fatigue,

weakness,

impotence,

ARRHYTHMIAS,

BRADYCARDIA,

CHF, PULMONARY

EDEMA

Use: Schizophrenia,

bipolar mania

CSE: Dizziness,

headache,

somnolence,

weight gain, NMS,

SEIZURES

↓ dose (elderly have

increased

sensitivity to beta

blockers); renal,

hepatic, pulmo-

nary disease,

diabetes.

May require dose

reduction; use

cautiously in

Alzheimer’s, pts

≥65 y, & hx

seizures.

Warn-

ing: ↑ mortality in

elderly with

dementia-related

psychosis.

Also

caution w CV/

hepatic disease.

Antianginal/beta

blocker

Contraindicated:

Heart block, CHF,

bradycardia.

Monitor BP, pulse,

& for orthostatic

hypotension.

Abrupt withdrawal:

life-threatening

arrhythmias.

Antipsychotic

Contraindicated:

Lactation. Caution

in CV disease;

cerebrovascular

disease,

dehydration.

Monitor for EPS,

NMS. Monitor BP

(hypotension),

pulse during dose

titration.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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152

DRUGS A-Z

Ramelteon

(Rozerem)

[melatonin

receptor

agonist]

 1–2.6 h; M-II

metabolite 2–5 h

Protein binding 

82%

Adult dose: 8 mg po

within 30 min of

sleep.

Do not administer

with high-fat

meal.

Use: Insomnia

(difficulty with

sleep onset)

CSE: Somnolence,

dizziness, nausea,

fatigue, headache

FDA warning: Risk of

severe allergic

reaction and

complex sleep-

related behaviors

(e.g., sleep-

driving).

As with any drug

that causes

somnolence and

dizziness, use

with caution.

Hypnotic

Contraindicated:

Severe liver

disease and

fluvoxamine (CYP

1A2 inhibitor).

Interactions with

rifampin and

azole antifungals

(ketoconazole).

Effect on

reproductive

hormones in

adults (↓ testos-

terone, ↑

prolactin). Avoid

alcohol. In

pregnancy,

benefit must

outweigh risk.

Report: ↓ menses,

galactorrhea, ↓

libido, ↓ fertility.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 152

DRUGS A-Z

153

Risperidone

(Risperdal,

Risperdal M-

Tab, Risperdal

Consta)

 Metabo-

lizers: 3 h

(9-hydroxy-

risperidone,

21 h)

Poor metabo-

lizers: 20 h

(9-hydroxy-

risperidone,

30 h)

Range: 4–12 mg/d

Dosing may be

once/d

(↑ risk of EPS w

dose  6 mg).

Schizophrenia:

Start 1 mg po

2  daily, ↑ to 3

mg 2  daily (up

to 16 mg/d). IM:

25 mg q 2 wk,

may ↑ 37.5/50 mg.

Bipolar Mania:

2–3 mg/d po

(range:

1–5 mg/d).

Use: Schizophrenia;

bipolar: mania,

acute or mixed;

new indication:

irritability asso-

ciated with autism

CSE: EPS (akathisia),

dizziness, aggres-

sion, insomnia,

sedation, dry

mouth, pharyn-

gitis, cough, visual

disturbances,

itching, skin rash,

constipation,

diarrhea, libido,

weight gain/loss,

NMS

Warning: ↑

mortality in

elderly with

dementia-related

psychosis.

Caution: Renal/

hepatic

disease/CV

disease. Bipolar

mania: Start 0.5

mg po 2  daily,

up to 1.5 mg 2 

daily (gradually

increase weekly if

necessary at

small incre-

ments).

Antipsychotic

Caution:

Renal/hepatic

impairment.

Dosing may be

once daily or bid

and increments

should be small

(1 mg). Maximal

effect seen with

4-8 mg/d, and

doses above 6

mg/d not more

efficacious, and

with ↑ risk of EPS.

Monitor BP, pulse

during titration:

may cause

tachycardia,

hypotension, QT

prolongation.

Establish oral

dosing tolerance

before using IM.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 153

DRUGS A-Z

154

Selegiline Patch

(Emsam) [MAOI]

First transdermal

patch delivering

medication

systemically over

24 h period.

Protein binding 

90% over a 2-

500 ng/mL

concentration

range.

Range: 6 mg/24 h

to 12 mg/24 h

Recommended

starting and

target dose:

6 mg/24 h.

Use: Major

depressive

disorder

CSE: Mild skin

reaction/

redness at patch

site. D/C if redness

continues for

several hours after

patch removal;

hypotension.

HYPERTENSION

Patients 50 yr and

older at higher

risk for rash.

Antidepressant

With doses above

6 mg/24 h, must

follow MAOI diet

(foods high in

tyramine).

Hypertensive crisis

is an emergency.

Contraindicated:

Amphetamines,

pseudoephedrine,

etc; other selegiline

products (Eldepryl).

Monitor BP, also for

headache, nausea,

stiff neck, palpi-

tations. Close

monitoring of

children for

suicidality. Read

full prescribing

information.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 154

DRUGS A-Z

155

Sertraline

(Zoloft)

 24 h

Protein binding

 98%

Range: 50–200 mg/d

Depression/OCD:

Start: 50 mg/d po

AM or PM, may ↑

slowly/weekly to

200 mg/d.

Panic disorder: Start:

25 mg/d po, up to

50 mg/d.

PTSD/SAD: Start: 25

mg/d po (to 200

mg/d).

Use: Depression,

panic disorder,

OCD, PTSD, social

anxiety disorder

(SAD), PMDD.

CSE: Drowsiness,

dizziness,

headache, fatigue,

insomnia, nausea,

diarrhea, dry

mouth, sexual

dysfunction,

sweating, tremor.

Caution with

drowsiness,

hepatic/renal

impairment.

Start with

lower dose.

Antidepressant

[SSRI]

Contraindicated:

Concurrent

Pimozide or

MAOIs (serious

fatal reactions),

need 14 d

washout period.

Do not use with

St. John’s wort or

SAMe. Caution:

Hepatic/renal/

pregnancy/

lactation/seizures/

hx mania.

Peds/Adol: May

increase the risk

of suicidal

thinking and

behavior and

must be closely

monitored.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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156

DRUGS A-Z

Thioridazine

(Mellaril, Mellaril-S,

Apo-thioridazine,

Novo-Ridazine)

 21–24 h

Protein binding 

90%

Range: 150–800

mg/d

Start: 50–100 mg po

tid, increase

gradually up to

800 mg/d.

Use: Schizophrenia

CSE: Sedation,

blurred vision,

dry eyes,

hypotension,

constipation,

dry mouth,

photosensitivity.

NMS,

ARRYTHMIAS

QTC PROLON-

GATION, AGRAN-

ULOCYTOSIS.

Use cautiously, at

risk for EPS/CNS

adverse effects.↑

risk for falls

(sedation/

dehydration/

hypotension).

Caution with CV

disease, BPH. Be

especially careful

with debilitated

patients.

Antipsychotic

Contraindicated: QTc

interval 450

msec; agents that

prolong QTc

interval; also,

narrow-angle

glaucoma, bone

marrow depres-

sion, severe liver or

cardiovascular

disease. Monitor

BP, pulse, resp, and

ECGs, CBCs, eye

exams. Monitor for

agranulocytosis;

occurs between

4–10 wk of Rx.

Assess for NMS,

TD, akathisia.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 156

DRUGS A-Z

157

Topiramate

(Topamax)

 21 h

Range: 50–400 mg/d

(maximum dose:

1600 mg/d)

Start: 50 mg/d po,

increase 50

mg/wk up to

200 mg bid.

Use: Seizures,

migraines

(unlabeled: bipolar,

treatment-resistant)

CSE: Dizziness,

drowsiness,

impaired memory/

concentration,

nervousness,

diplopia,

nystagmus, nausea,

weight loss, ataxia,

paresthesias,

INCREASED

SEIZURES, SUICIDE

ATTEMPT

Adjust dose ↓ for

renal/hepatic

impairment.

Dosage reduction

recommended if

CCr 70 mL/min/

1.73 m

for adults

and geriatric

population.

Anticonvulsant

Contraindicated:

Lactation.

Topiramate has not

been shown to be

as effective as

monotherapy in

bipolar disorder,

may be efficacious

as adjunctive

treatment.

Concomitant use

with valproic acid

associated with

hyperammonemia

(with or without

encephalopathy).

Monitor for

alterations in LOC,

cognitive function,

lethargy, vomiting.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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158

DRUGS A-Z

Trazodone

(Desyrel, Trialo-

dine, Trazon)

 5–9 h

Protein binding

 89%–95%

Range: 150–400

mg/d

(hospitalized up

to 600 mg/d)

Depression: 50 mg

po tid (150 mg/d),

up to 400 mg/d

(titrate 50 mg

every 4 d).

Insomnia: 25–100

mg hs.

Use: Major

depression.

Unlabeled: Insomnia

CSE: Drowsiness,

hypotension, dry

mouth, PRIAPISM;

may also experience

confusion, dizziness,

insomnia, night-

mares, palpitations,

impotence, myalgia

Reduce dose

initially.

Start:

75 mg/d po in

divided doses,

increase every

4 d; titrate slowly;

caution w CV,

hepatic, renal

disease.

Observe elderly for

drowsiness &

hypotension;

caution about

slow positional

changes.

Antidepressant/

sedative

PRIAPISM

(prolonged

erection): Medical

emergency; avoid

alcohol, concomi-

tant use with

fluoxetine,

opioids, and

drugs that inhibit

and induce the

CYP3A4 enzyme

system; also kava,

valerian (↑ CNS

depression), St.

John’s wort and

SAMe (serotonin

syndrome).

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 158

DRUGS A-Z

159

Trihexiphenidyl

(Artane, Artane

Sequels, Apo-

Trihex)

 3.7 h

Antiparkinson

Contraindicated:

Glaucoma,

thyrotoxicosis,

tachycardia (due

to cardiac

insufficiency),

acute hemor-

rhage.

Alcohol intoler-

ance (Elixir

only).

Additive effects

with anticholin-

ergic drugs and

CNS depres-

sants.

Caution w

elderly: Causes

drowsiness/

dizziness (↑

risk-adverse

reactions); BPH,

chronic renal,

hepatic, CV,

pulmonary

disease.

Use: Parkinson’s, drug-

induced

parkinsonism

CSE: Dizziness,

nervousness,

drowsiness, blurred

vision, mydriasis,

dry mouth, nausea;

may also experience

orthostatic

hypotension,

tachycardia, and

urinary hesitancy

Range: 6–10 mg/d

(up to 15 mg/d)

Start: 1–2 mg/d po;

↑ by 2 mg every

3–5 d.

Sequels (ER): q 12 h

after dose is

determined w

tabs/elixir.

Monitor for

decreased signs

& symptoms of

parkinsonian

syndrome: ↓

tremors/rigidity.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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160

DRUGS A-Z

Venlafaxine

(Effexor,

Effexor XR)

 venlafax-

ine: 3–5 h; O-

desmethylvenla

faxine (ODV)

9–11 h

Range: 75–225

mg/d; do not

exceed 375 mg/d.

Start: 75 mg/d po

(2–3 divided

doses), up to 225

mg/d (divided

doses) (do not

exceed 375 mg/d).

XR: 37.5–75 mg po

once daily; in-

crease q 4 d up

to 225 mg.

Use: Major

depression,

generalized anxiety

disorder (XR) and

social anxiety

disorder (XR)

CSE: Anxiety,

abnormal dreams,

dizziness, insomnia,

nervousness, visual

disturbances,

anorexia, dry

mouth, weight loss,

sexual dysfunction,

ecchymoses

(bruising),

SEIZURES.

Use cautiously

with CV disease

(hypertension);

reduce dose in

renal/hepatic

impairment.

Antidepressant

Caution with pre-

existing

hypertension.

Monitor blood

pressure (risk of

sustained

hypertension

[treatment

emergent]); may

be dose-related.

Concurrent MAOI

therapy

contraindicated.

Avoid alcohol/CNS

depressants.

Possible serotonin

syndrome with

SAMe, St. John’s

wort. Hepatic

impairment: ↓

dose by 50%.

Renal impairment:

↓ dose by

25%–50%.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

05Pederson (F)-05 6/25/07 8:45 PM Page 160

DRUGS A-Z

161

Zalephon

(Sonata)

 Unknown

Ziprasidone

(Geodon)

 po 7h;

IM 2–5 h

Range: 5–20 mg

Usual: 10 mg po hs.

Use no longer

than 7–10 d.

Range: 40–160 mg/d

Schizophrenia:

Start: 20 mg po

bid, up to 80 mg

bid.

Mania: Start: 40 mg

po bid, up to 80

mg bid; IM: 10–20

mg prn (up to

40 mg/d).

Use: Short-term

insomnia, unable to

initiate sleep

CSE: Drowsiness,

dizziness, anxiety,

amnesia

(See FDA Warning)

Use: Schizophrenia,

bipolar (manic and

mixed), IM: acute

agitation

CSE: Dizziness,

drowsiness,

restlessness,

nausea,

constipation,

diarrhea,

PROLONGED QT

INTERVAL, NMS

Lower dose: Start at

5 mg hs, to maxi-

mum of 10 mg po

hs. Caution: Mild/

moderate hepatic

impairment.

↓ Dose in elderly.

Contraindicated: QT

prolongation,

caution w CV/

hepatic disease

and CV drugs;

65 y;

Alzheimer’s

dementia. Risk of

falls.

Warning: ↑mortality

in elderly with

dementia-related

psychosis.

Sedative/hypnotic

Contraindicated:

Severe hepatic

impairment.

Avoid other CNS

depressants

(alcohol, opioids,

kava).

Antipsychotic

Persistent QTc

measurements

500: D/C

ziprasidone.

Evaluate

palpitations,

syncope. Agents

(pimozide) that

prolong QT

interval are

contrainidicated.

Avoid CNS

depressants.

Monitor BP,

pulse, ECG, and

for EPS, NMS,

and TD.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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162

DRUGS A-Z

Zolpidem

(Ambien,

Ambien CR)

 2.5–2.6 h

ALERT: Refer to the Physicians Desk Reference or product insert (prescribing information)

for complete and current drug information (dosages, warnings, indications, adverse effects, interactions,

etc.) needed to make appropriate choices in the treatment of clients before administering any

medications. Although every effort has been made to provide key information about medications and

classes of drugs, such information is not and cannot be all-inclusive in a reference of this nature and

should not be used for prescribing or administering of medications. Professional judgment, training,

supervision, relevant references, and “current” drug information are critical to the appropriate selection,

evaluation, and use of drugs, as well as the monitoring and management of clients and their

medications.

FDA WARNINGS (2007): The US Food and Drug Administration wants all makers of antidepressants to

include warnings about increased risk for suicidality in young adults ages 18-24 during initial treatment.

The FDA also wants all manufacturers of sedatives-hypnotics to warn about possible severe allergic

reactions as well as complex-sleep related behaviors, such as sleep-driving.

Range: 5–10 mg hs

Usual: 10 mg po hs;

CR: 12.5 mg

po hs.

Use: Insomnia

CSE: Amnesia,

daytime drowsiness,

“drugged” feeling,

diarrhea, physical/

psychological

dependence (See

FDA warning 2007)

Initial ↓ dose;

geriatric or

hepatic disease:

Start: 5 mg po hs,

may increase to

10 mg; CR: 6.25

mg po hs.

Sedative/hypnotic

Caution in alcohol

abuse and avoid

use with CNS

depressants. For

short-term

treatment of

insomnia; after 2

wk avoid abrupt

withdrawal.

Psychotropic Drugs A – Z (Alphabetical Listing)

Dose Range/ Use/Common Geriatric Classification

Generic Adult Daily Side Effects & Dose

Assessment

(Trade) Dose (CSE) Considerations Cautions

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163

Crisis/Suicide/Grief/Abuse

Abuse, Child (Physical/Sexual), Signs of 169

Abuse, Other Kinds 170

Abuse, Victims of 168

Anger Escalation, Signs of 164

Anger, Early Signs 163

Assaultive Behaviors, Prevention/Management 163

Crisis Intervention 163

Death and Dying/Grief 167

Incest 170

Safety Plan (to Escape Abuser) 168

Suicide 164

Suicide Assessment 165

Suicide Interventions 166

Suicide, Groups at Risk 165

Terrorism/Disasters 166

Crisis Intervention

Phases

I. Assessment – What caused the crisis, and what are the individual’s

responses to it?

II. Planning intervention – Explore individual’s strengths, weaknesses,

support systems, and coping skills in dealing with the crisis.

III. Intervention – Establish relationship, help understand event and explore

feelings, and explore alternative coping strategies.

IV. Evaluation/reaffirmation – Evaluate outcomes/Plan for future/Evaluate

need for follow-up (Aguilera, 1998).

Prevention/Management of Assaultive Behaviors

Assessment of signs of anger is very important in prevention and in

intervening before anger escalates to assault/violence.

Early Signs of Anger

■ Muscular tension: clenched fist

■ Face: furled brow, glaring eyes, tense mouth, clenched teeth, flushed face

■ Voice: raised or lowered

If anger is not identified and recognized at the preassaultive tension state,

it can progress to aggressive behavior.

CRISIS

(Continued on following page)

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164

Anger Management Techniques

■ Remain calm

■ Help client recognize anger

■ Find an outlet: verbal (talking) or physical (exercise)

■ Help client accept angry feelings; not acceptable to act on them

■ Do not touch an angry client

■ Medication may be needed

Signs of Anger Escalation

■ Verbal/physical threats

■ Pacing/appears agitated

■ Throwing objects

■ Appears suspicious/disproportionate anger

■ Acts of violence/hitting

Anger Management Techniques

■ Speak in short command sentences: Joe, calm down.

■ Never allow yourself to be cornered with an angry client; always have

an escape route (open door behind you)

■ Request assistance of other staff

■ Medication may be needed; offer voluntarily first

■ Restraints and/or seclusion may be needed (see Use of Restraints

in Basics tab)

■ Continue to assess/reassess (ongoing)

■ When stabilized, help client identify early signs/triggers of anger

and alternatives to prevent future anger/escalation

Suicide

Risk Factors Include:

■ Mood disorders such as depression and bipolar disorder

■ Substance abuse (dual diagnosis)

■ Previous suicide attempt

■ Loss – marital partner, partner, close relationship, job, health

■ Expressed hopelessness or helplessness (does not see a future)

■ Impulsivity/aggressiveness

■ Family suicides, significant other or friend/peer suicide

■ Isolation (lives alone/few friends, support relationships)

■ Stressful life event

■ Previous or current abuse (emotional/physical/sexual)

■ Sexual identity crisis/conflict

■ Available lethal method, such as a gun

■ Legal issues/incarceration (USPHS, HHS 1999)

CRISIS

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165

Suicide Assessment

■ Hopelessness – a key element; client is unable to see a future or self in

that future.

■ Speaks of suicide (suicidal ideation) – important to ask client if he/she has

thoughts of suicide; if so, should be considered suicidal.

■ Plan – client is able to provide an exact method for ending life; must take

seriously and consider immediacy of act.

■ Giving away possessions – any actions such as giving away possessions,

putting affairs in order (recent will), connecting anew with old

friends/family members as a final goodbye.

■ Auditory hallucinations – commanding client to kill self.

■ Lack of support network – isolation, few friends or withdrawing from

friends/support network.

■ Alcohol/other substance abuse – drinking alone.

■ Previous suicide attempt or family history of suicide.

■ Precipitating event – death of a loved one; loss of a job, especially long-

term job; holidays; tragedy; disaster.

■ Media – suicide of a famous personality or local teenager (Rakel 2000).

CLINICAL PEARL – Do not confuse self-injurious behavior (cutting) with

suicide attempts, although those who repeatedly cut themselves to relieve

emotional pain could also attempt suicide. “Cutters” may want to stop

cutting self but find stopping difficult, as this has become a pattern of

stress reduction.

Groups at Risk for Suicide

■ Elderly – especially those who are isolated, widowed; multiple losses,

including friends/peers.

■ Males – especially widowed and without close friends; sole emotional

support came from marriage partner who is now deceased.

■ Adolescents and young adults.

■ Serious/terminal illness – not all terminally ill clients are suicidal, but

should be considered in those who become depressed or hopeless.

■ Mood disorders – depression and especially bipolar; always observe and

assess those receiving treatment for depression, as suicide attempt may

take place with improvement of depressive symptoms (client has the

energy to commit suicide).

■ Schizophrenia – newly diagnosed schizophrenics and those with

command hallucinations.

■ Substance abusers – especially with a mental disorder.

■ Stress and loss – stressful situations and loss can trigger a suicide

attempt, especially multiple stressors and losses or a significant loss.

CRISIS

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166

Suicide Interventions

■ Effective assessment and knowledge of risk factors

■ Observation and safe environment (no “sharps”)

■ Psychopharmacology, especially the selected serotonin reuptake inhibitors

(SSRIs) (children, adolescents, and young adults on SSRIs need to be

closely monitored)

■ Identification of triggers; educating client as to triggers to seek help

early on

■ Substance abuse treatment; treatment of pain disorders

■ Psychotherapy/cognitive behavioral therapy/electroconvulsive therapy

■ Treatment of medical disorders (thyroid/cancer)

■ Increased activity if able

■ Support network/family involvement

■ Involvement in outside activities/avoid isolation – join outside groups,

bereavement groups, organizations, care for a pet

■ Client and family education

Elder Suicide (see Geriatric tab)

Terrorism/Disasters

With the increase in worldwide terrorism and natural disasters, health-care

professionals need to increase their knowledge and awareness of the effects

of psychological damage on individuals and communities affected by these

disasters. In large-scale disasters, loss can involve individual homes/lives as

well as whole communities (neighborhoods). Neighbors and friends may be

lost as well as reliable and familiar places and supports (neighborhoods,

towns, rescue services).

With terrorism and war, loss may involve body parts (self-image) and a

sense of trust and safety. Previous beliefs may be challenged. Individuals

may experience shock, disorientation, anger, withdrawal, to name a few

feelings/responses. People’s ability to experience these disasters almost

immediately through the media can result in vicarious traumatization. The

long-term effects on both individuals and future generations cannot be

underestimated, and all health-care professionals need to familiarize

themselves with disaster and terrorism preparedness. The psychological

effects cannot be minimized, and mental health (and all health-care)

professionals need to recognize the signs of post-traumatic stress disorder,

acute stress disorder, substance abuse, suicide, and grief. (See Posttraumatic

Stress Disorder and Substance Use Disorders in the Disorders-Interventions

tab; see also Suicide Assessment, Stages of Death and Dying, and

Complicated Versus Uncomplicated Grief below)

CRISIS

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167

Death and Dying/Grief

Stages of Death and Dying (Kübler-Ross)

1. Denial and isolation – usually temporary state of being unable to accept

the possibility of one’s death or that of a loved one.

2. Anger – replacement of temporary “stage one” with the reality that death

is possible/going to happen. This is the realization that the future

(plans/hopes) will have an end; a realization of the finality of the self. May

fight/argue with health-care workers/push family/friends away.

3. Bargaining – seeks one last hope or possibility; enters an agreement or

pact with God for “one last time or event” to take place before death. (Let

me live to see my grandchild born or my child graduate from college.)

4. Depression – after time, loss, pain, the person realizes that the situation and

course of illness will not improve; necessary stage to reach acceptance.

5. Acceptance – after working/passing through the previous stages, the

person finally accepts what is going to happen; this is not resignation

(giving up) or denying and fighting to the very end: it is a stage that

allows for peace and dignity (Kübler-Ross 1997).

Complicated Versus Uncomplicated Grief

Complicated Grief Uncomplicated Grief

■ Excessive in duration (may be

delayed reaction or compounded

by losses [multiple losses]); usually

longer than 3 – 6 mo

■ Disabling symptoms, morbid preoc-

cupation with deceased/physical

symptoms

■ Substance abuse, increased

alcohol intake

■ Risk factors: limbo states (missing

person), ambivalent relationship,

multiple losses; long-term partner

(sole dependency); no social

network; history of depression

■ Suicidal thoughts – may want to

join the deceased

CRISIS

■ Follows a major loss

■ Depression perceived as normal

■ Self-esteem intact

■ Guilt specific to lost one (should

have telephoned more)

■ Distress usually resolves within

12 wk (though mourning can

continue for 1 or more years)

■ Suicidal thoughts transient or

unusual (Shader 2003)

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168

Victims of Abuse

Cycle of Battering

Phase I. Tension Building – Anger with little provocation; minor battering and

excuses. Tension mounts and victim tries to placate. (Victim assumes

guilt: I deserve to be abused.)

Phase II. Acute Battering – Most violent, up to 24 hours. Beating may be

severe, and victim may provoke to get it over. Minimized by abuser. Help

sought by victim if life-threatening or fear for children.

Phase III. Calm, Loving, Respite – Batterer is loving, kind, contrite. Fear of

victim leaving. Lesson taught, and now batterer believes victim

“understands.”

■ Victim believes batterer can change, and batterer uses guilt. Victim

believes this (calm/loving in phase III) is what batterer is really like. Victim

hopes the previous phases will not repeat themselves.

■ Victim stays because of fear for life (batterer threatens more, and self-

esteem lowers), society values marriage, divorce is viewed negatively,

financial dependence.

Starts all over again – dangerous, and victim often killed (Walker 1979).

Be aware that victims (of batterers) can be wives, husbands, intimate

partners (female/female, male/male, male/female), and pregnant women.

Safety Plan (to Escape Abuser)

■ Doors, windows, elevators – rehearse exit plan.

■ Have a place to go – friends, relatives, motel – where you will be and feel

safe.

■ Survival kit – pack and include money (cab); change of clothes; identifying

info (passports, birth certificate); legal documents, including protection

orders; address books; jewelry; important papers.

■ Start an individual checking/savings account.

■ Always have a safe exit – do not argue in areas with no exit.

■ Legal rights/domestic hotlines – know how to contact abuse/legal/

domestic hotlines (see Web sites).

■ Review safety plan consistently (monthly) (Reno 2004).

CRISIS

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169

Signs of Child Abuse (Physical/Sexual)

Physical Abuse Sexual Abuse

■ Pattern of bruises/welts

■ Burns (e.g., from cigarettes,

scalds)

■ Lesions resembling bites or

fingernail marks

■ Unexplained fractures or

dislocations, especially in child

younger than 3 y

■ Areas of baldness from hair

pulling

■ Injuries in various stages of

healing

■ Other injuries or untreated illness,

unrelated to present injury

■ X-rays revealing old fractures

Signs Common to Both

■ Signs of “failure to thrive”

syndrome

■ Details of injury changing

from person to person

■ History inconsistent with

developmental stages

■ Parent blaming child or

sibling for injury

■ Parental anger toward

child for injury

■ Parental hostility toward

health-care workers

Adapted from Myers RNotes 2e, 2006, page 156, with permission.

Child Abuser Characteristics

Characteristics associated with those who may be child abusers:

■ In a stressful situation, such as unemployed

■ Poor coping strategies; may be suspicious or lose temper easily

CRISIS

■ Signs of genital irritation, such as

pain or itching

■ Bruised or bleeding genitalia

■ Enlarged vaginal or rectal orifice

■ Stains and/or blood on underwear

■ Unusual sexual behavior

■ Exaggeration or absence of

emotional response from parent

regarding child’s injury

■ Parent not providing child with

comfort

■ Toddler or preschooler not

protesting parent’s leaving

■ Child showing preference for

health-care worker over parent

(Continued on following page)

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170

■ Isolated; few support systems or none

■ Do not understand needs of children, basic care, or child development

■ Expect child perfection, and child behavior blown out of proportion

(Murray & Zentner 1997)

Incest

Often a father-daughter relationship (biological/stepfather) but can be father-

son as well as mother-son.

■ Child is made to feel special (It is our special secret); gifts given.

■ Favoritism (becomes intimate friend/sex partner replacing mother/other

parent).

■ Serious boundary violations and no safe place for child (child’s bedroom

usually used).

■ May be threats if child tells about the sexual activities (Christianson &

Blake 1990).

Signs of Incest

■ Low self-esteem, sexual acting out, mood changes, sudden poor

performance in school

■ Parent spends inordinate amount of time with child, especially in room

or late at night; very attentive to child

■ Child is apprehensive (fearing sexual act/retaliation)

■ Alcohol and drugs may be used (Christianson & Blake 1990)

ALERT: All child abuse (physical/sexual/emotional) or child neglect must be

reported.

Elder Abuse (see Geriatric Tab)

Other Kinds of Abuse

■ Emotional Neglect – parental/caretaker behaviors include:

■ Ignoring child

■ Ignoring needs (social, educational, developmental)

■ Rebuffing child’s attempts at establishing interactions that are

meaningful

■ Little to no positive reinforcement (KCAPC 1992)

■ Emotional Injury – results in serious impairment in child’s functioning on

all levels.

■ Treatment of child is harsh, with cruel and negative comments,

belittling child

■ Child may behave immaturely, with inappropriate behaviors for age

■ Child demonstrates anxiety, fearfulness, sleep disturbances

CRISIS

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171

■ Child shows inappropriate affect, self-destructive behaviors

■ Child may isolate, steal, cheat, as indication of emotional injury (KCAPC

1992)

■ Male Sexual Abuse – Males are also sexually abused by mothers, fathers,

uncles, pedophiles, and others in authority (coach, teacher, minister,

priest)

■ Suffer from depression, shame, blame, guilt, and other effects of child

sexual abuse

■ Issues related to masculinity, isolation, and struggles with seeking or

receiving help

CRISIS

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172

Geriatric/Elderly

Age-Related Changes and Their Implications 172

Disorders of Late Life 173

Elder Abuse – Behavioral Signs 175

Elder Abuse – Medical and Psychiatric History 175

Elder Abuse – Physical Signs 175

Elder Abuse 175

Elder Suicide 176

Elder Suicide – Warning Signs 176

Geriatric Assessment 172

Pharmacokinetics in the Elderly 174

Geriatric Assessment

Key Points

■ Be mindful that the elderly client may be hard of hearing, but do not

assume that all elderly are hard of hearing.

■ Approach and speak to elderly clients as you would any other adult client.

It is insulting to speak to the elderly client as if he/she were a child.

■ Eye contact helps instill confidence and, in the presence of impaired

hearing, will help the client to better understand you.

■ Be aware that both decreased tactile sensation and ROM are normal

changes with aging. Care should be taken to avoid unnecessary

discomfort or even injury during a physical exam/assessment.

■ Be aware of generational differences, especially gender differences

(i.e., modesty for women, independence for men).

■ Assess for altered mental states.

■ Dementia: Cognitive deficits (memory, reasoning, judgment, etc.)

■ Delirium: Confusion/excitement marked by disorientation to time and

place, usually accompanied by illusions and/or hallucinations

■ Depression: Diminished interest or pleasure in most/all activities

Age-Related Changes and Their Implications

Decreased skin thickness

Decreased skin vascularity

Loss of subcutaneous tissue

Elderly clients are more prone to skin

breakdown

Altered thermoregulation response can

put elderly at risk for heatstroke

Decreased insulation can put elderly at

risk for hypothermia

GERI

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GERI

173

Age-Related Changes and Their Implications (Continued)

Decreased aortic elasticity

Calcification of thoracic wall

Loss of nerve fibers/neurons

Decreased nerve conduction

Reduced tactile sensation

From Myers, RNotes, 2e, 2006, p.96, with permission

Disorders of Late Life

■ Dementia – Dementia of the Alzheimer’s type (AD), dementia with Lewy

bodies, vascular and other dementias, delirium, and amnestic disorder

(see Delirium, Dementia, and Amnestic Disorders in the Disorders-

Interventions tab).

■ Geriatric depression – Depression in old age is often assumed to be

normal; however, depression at any age is not normal and needs to be

diagnosed and treated. Factors can include:

■ Physical and cognitive decline

■ Loss of function/self-sufficiency

■ Loss of marriage partner, friends (narrowing support group), isolation

■ The elderly may have many somatic complaints (head hurts, stomach

upsets) that mask the depression (Chenitz 1991) (see Geriatric

Depression Scale in Assessment tab).

■ Pseudodementia – Cognitive difficulty that is actually caused by

depression but may be mistaken for dementia.

■ Need to consider and rule out dementia (Mini-Mental State

Examination) and actually differentiate from depression (Geriatric

Depression Scale)

■ Can be depressed with cognitive deficits as well

■ Late-onset schizophrenia – Presents later in life, after age 60 y.

■ Psychotic episodes (delusions or hallucinations) may be overlooked

(schizophrenia is considered to be a young-adult disease)

■ Organic brain disease should be considered as part of the differential

diagnosis

Produces increased diastolic blood pressure

Obscures heart and lung sounds and

displaces apical pulse

The elderly client needs extra time to learn

and comprehend and to perform certain

tasks

Response to pain is altered

Puts client at risk for accidental self-injury

(Continued on following page)

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GERI

174

■ Decreased intestinal motility

■ Diminished blood flow to

the gut

■ Decreased body water

■ Increased percentage of

body fat

■ Decreased amount of

plasma proteins

■ Decreased lean body mass

■ Decreased blood flow to

liver

■ Diminished liver function

■ Delayed peak effect

■ Delayed signs/symptoms

of toxic effects

■ Increased serum

concentration of water-

soluble drugs

■ Increased half-life of fat-

soluble drugs

■ Increased amount of

active drug

■ Increased drug

concentration

■ Decreased rate of drug

clearance by liver

■ Increased accumulation

of some drugs

Characteristics of Late-Onset Schizophrenia

■ Delusions of persecution common, hallucinations prominent; “partition”

delusion (people/objects pass through barriers and enter home) common;

rare in early onset.

■ Sensory deficits – often auditory/visual impairments

■ May have been previously paranoid, reclusive, yet functioned otherwise

■ Lives alone/isolated/unmarried

■ Negative symptoms/thought disorder rare

■ More common in women (early onset: equally common) (Lubman &

Castle 2002)

Psychotropic Drugs – Geriatric Considerations

(See Drugs A–Z tab for geriatric considerations; and the Elderly and

Medications [Drugs/Labs tab].)

Pharmacokinetics in the Elderly

Pharmacokinetics is the way that a drug is absorbed, distributed and used,

metabolized, and excreted by the body. Age-related physiological changes

affect body systems, altering pharmacokinetics and increasing or altering a

drug’s effect.

Physiological Effect on Change Pharmacokinetics

Absorption

Distribution

Metabolism

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GERI

175

Physiological Effect on Change Pharmacokinetics

Excretion

From Myers, RNotes, 2e, 2006, p. 97, with permission

Elder Abuse

There are many types of elder abuse, which include:

■ Elder neglect (lack of care by omission or commission)

■ Psychological or emotional abuse (verbal assaults, insults, threats)

■ Physical (physical injury, pain, drugs, restraints)

■ Sexual abuse (nonconsensual sex: rape, sodomy)

■ Financial abuse (misuse of resources: social security, property)

■ Self-neglect (elder cannot provide appropriate self care)

Elder Abuse – Physical Signs

■ Hematomas, welts, bites, burns, bruises, and pressure sores

■ Fractures (various stages of healing), contractures

■ Rashes, fecal impaction

■ Weight loss, dehydration, substandard personal hygiene

■ Broken dentures, hearing aids, other devices; poor oral hygiene; traumatic

alopecia; subconjunctival hemorrhage

Elder Abuse – Behavioral Signs

Caregiver

■ Caregiver insistence on being present during entire appointment

■ Answers for client

■ Caregiver expresses indifference or anger, not offering assistance

■ Caregiver does not visit hospitalized client

Elder

■ Hesitation to be open, appearing fearful, poor eye contact, ashamed,

baby talk

■ Paranoia, anxiety, anger, low self-esteem

■ Physical signs: contractures, inconsistent medication regimen

(subtherapeutic levels), malnutrition, poor hygiene, dehydration

■ Financial: signed over power of attorney (unwillingly), possessions gone,

lack of money

Elder Abuse – Medical and Psychiatric History

■ Mental health/psychiatric interview

■ Assess for depression, anxiety, alcohol (substance) abuse, insomnia

■ Functional independence/dependence

■ Cognitive impairment (Stiles et al. 2002)

ALERT: All elder abuse must be reported.

■ Diminished kidney function

■ Decreased creatinine

clearance

■ Increased accumulation of

drugs excreted by kidney

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GERI

176

Elder Suicide

Warning Signs

■ Failed suicide attempt

■ Indirect clues – stockpiling medications; purchasing a gun; putting affairs

in order; making/changing a will; donating body to science; giving

possessions/money away; relationship, social downturns; recent

appointment with a physician

■ Situational clues – recent move, death of spouse/friend/child

■ Symptoms – depression, insomnia, agitation, others

Elder Profile for Potential Suicide

■ Male gender

■ White

■ Divorced or widowed

■ Lives alone, isolated, moved recently

■ Unemployed, retired

■ Poor health, pain, multiple illnesses, terminal

■ Depressed, substance abuser, hopeless

■ Family history of suicide, depression, substance abuse; harsh parenting,

early trauma in childhood

■ Wish to end hopeless, intolerable situation

■ Lethal means: guns, stockpiled sedatives/hypnotics

■ Previous attempt

■ Not inclined to reach out; often somatic complaints

Suspected Elder Suicidality

Ask direct questions:

■ Are you so down you see no point in going on? (If answer is yes, explore

further: Tell me more)

■ Have you (ever) thought of killing yourself? ( When? What stopped you?)

■ How often do you have these thoughts?

■ How would you kill yourself? (Lethality plan) (Holkup 2002)

Gather information – keep communication open in a nonjudgmental way;

do not minimize or offer advice in this situation

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TOOLS/

INDEX

177

Tools/References/Index

Abbreviations 179

Assessment Tools 180

Community Resources/Phone Numbers 177

DSM-IV-TR Classification: Axes I and II Categories and Codes 180

Nursing Diagnoses (NANDA): Accepted for Use and Research

(2007–2008) 196

Nursing Diagnoses (NANDA), Assigning to Client Behaviors 194

Psychiatric Terminology (Glossary) 201

References 215

Index 223

Community Resources/Phone Numbers

Name/Program Phone Number

Sexual and Physical Abuse

Substance Abuse

Communicable Disease (AIDs/Hepatitis)

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TOOLS/

INDEX

178

Homeless Shelters

Child/Adolescent Hotlines

Suicide Hotlines

Hospitals (Medical/Psychiatric)

Other

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TOOLS/

INDEX

179

Abbreviations

AD Dementia of Alzheimer’s

type

ADHD Attention deficit

hyperactivity disorder

AE Adverse event

AIMS Abnormal Involuntary

Movement Scale

BAI Beck Anxiety Inventory

BDI Beck Depression Inventory

BP Blood pressure

BPD Borderline personality

disorder

BPH Benign prostatic

hypertrophy

CBC Complete blood count

CBT Cognitive behavioral

therapy

CHF Congestive heart failure

CK Creatine kinase

CNS Central nervous system

COPD Chronic obstructive

pulmonary disease

CT scan Computed tomography

scan

CV Cardiovascular

DBT Dialectical behavioral

therapy

d/c Discontinue

ECA Epidemiologic Catchment

Area Survey

ECG Electrocardiogram

ECT Electroconvulsive therapy

EMDR Eye movement desen-

sitization and reprocessing

EPS Extrapyramidal symptoms

FBS Fasting blood sugar

GABA Gamma-aminobutyric acid

GAD Generalized anxiety disorder

GDS Geriatric Depression Scale

Hx History

LFTs Liver function tests

IM Intramuscular

IV Intravenous

kg Kilogram

L Liter

MAOI Monoamine oxidase inhibitor

MCV Mean corpuscular volume

MDD Major depressive disorder

␮g Microgram

mEq Milliequivalent

MH Mental health

mL Milliliter

MMSE Mini-Mental State Exam

MRI Magnetic resonance imaging

MSE Mental Status Exam

NAMI National Association for the

Mentally Ill

NE Norepinephrine

NMS Neuroleptic malignant

syndrome

OCD Obsessive-compulsive

disorder

OCPD Obsessive-compulsive

personality disorder

OTC Over the counter

PANSS Positive and Negative

Syndrome Scale

(Continued on following page)

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TOOLS/

INDEX

180

SSRI Selective serotonin reuptake

inhibitor

1/2

Drug’s half-life

TCA Tricyclic antidepressant

TFT Thyroid function test

TIA Transient ischemic attack

TPR Temperature, pulse,

respiration

UA Urinalysis

UTI Urinary tract infection

PCOS Polycystic Ovarian

Syndrome

PMDD Premenstrual

dysphoric disorder

PTSD Posttraumatic stress

disorder

SMAST Short Michigan

Alcohol Screening Test

SNRI Serotonin-norepinephrine

reuptake inhibitor

Assessment Tools

See Assessment Tab for the following tools/rating scales:

■ Abnormal Involuntary Movement Scale (AIMS)

■ CAGE Screening Questionnaire

■ Depression-Arkansas Scale (D-ARK scale)

■ DSM-IV Multiaxial Assessment Tool

■ Edinburgh Postnatal Depression Scale (EPDS)

■ Geriatric Depression Scale (GDS)

■ Global Assessment of Functioning (GAF) Scale

■ Ethnocultural Assessment Tool

■ Mental Status Assessment Tool

■ Psychiatric History and Assessment Tool

■ Short Michigan Alcohol Screening Test (SMAST)

■ Substance History and Assessment

DSM-IV-TR Classification: Axes I and II Categories and Codes

DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR

ADOLESCENCE

Mental Retardation

NOTE: These are coded on Axis II.

317 Mild Mental Retardation

318.0 Moderate Retardation

318.1 Severe Retardation

318.2 Profound Mental Retardation

319 Mental Retardation, Severity Unspecified

Learning Disorders

315.00 Reading Disorder

315.1 Mathematics Disorder

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315.2 Disorder of Written Expression

315.9 Learning Disorder Not Otherwise Specified (NOS)

Motor Skills Disorder

315.4 Developmental Coordination Disorder

Communication Disorders

315.31 Expressive Language Disorder

315.32 Mixed Receptive-Expressive Language Disorder

315.39 Phonological Disorder

307.0 Stuttering

307.9 Communication Disorder NOS

Pervasive Developmental Disorders

299.00 Autistic Disorder

299.80 Rett’s Disorder

299.10 Childhood Disintegrative Disorder

299.80 Asperger’s Disorder

299.80 Pervasive Developmental Disorder NOS

Attention-Deficit and Disruptive Behavior Disorders

314.xx Attention-Deficit/Hyperactivity Disorder

314.01 Combined Type

314.00 Predominantly Inattentive Type

314.01 Predominantly Hyperactive-Impulsive Type

314.9 Attention-Deficit/Hyperactivity Disorder NOS

312.xx Conduct Disorder

.81 Childhood-Onset Type

.82 Adolescent-Onset Type

.89 Unspecified Onset

313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder NOS

Feeding and Eating Disorders of Infancy or Early Childhood

307.52 Pica

307.53 Rumination Disorder

307.59 Feeding Disorder of Infancy or Early Childhood

Tic Disorders

307.23 Tourette’s Disorder

307.22 Chronic Motor or Vocal Tic Disorder

307.21 Transient Tic Disorder

307.20 Tic Disorder NOS

Elimination Disorders

–––.— Encopresis

787.6 With Constipation and Overflow Incontinence

307.7 Without Constipation and Overflow Incontinence

307.6 Enuresis (Not Due to a General Medical Condition)

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Other Disorders of Infancy, Childhood, or Adolescence

309.21 Separation Anxiety Disorder

313.23 Selective Mutism

313.89 Reactive Attachment Disorder of Infancy or Early Childhood

307.3 Stereotypic Movement Disorder

313.9 Disorder of Infancy, Childhood, or Adolescence NOS

DELIRIUM, DEMENTIA, AND AMNESTIC AND OTHER COGNITIVE DISORDERS

Delirium

293.0 Delirium Due to…(Indicate the general medical condition)

–––.— Substance Intoxication Delirium (refer to Substance-Related Disorders

for substance-specific codes)

–––.— Substance Withdrawal Delirium (refer to Substance-Related Disorders

for substance-specific codes)

–––.— Delirium Due to Multiple Etiologies (code each of the specific

etiologies)

780.09 Delirium NOS

Dementia

294.xx* Dementia of the Alzheimer’s Type, With Early Onset

.10 Without Behavioral Disturbance

.11 With Behavioral Disturbance

294.xx* Dementia of the Alzheimer’s Type, With Late Onset

.10 Without Behavioral Disturbance

.11 With Behavioral Disturbance

290.xx Vascular Dementia

.40 Uncomplicated

.41 With Delirium

.42 With Delusions

.43 With Depressed Mood

294.1x* Dementia Due to HIV Disease

294.1x* Dementia Due to Head Trauma

294.1x* Dementia Due to Parkinson’s Disease

294.1x* Dementia Due to Huntington’s Disease

294.1x* Dementia Due to Pick’s Disease

294.1x* Dementia Due to Creutzfeldt-Jakob Disease

294.1x* Dementia Due to (indicate the general medical condition not listed

above)

––– .— Substance-Induced Persisting Dementia (refer to Substance-Related

Disorders for substance-specific codes)

––– .— Dementia Due to Multiple Etiologies (code each of the specific

etiologies)

294.8 Dementia NOS

*Also add ICD–9–CM codes valid after October 1, 2000 on Axis Ill for these

disorders.

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Amnestic Disorders

294.0 Amnestic Disorder Due to (indicate the general medical condition)

–––.— Substance-Induced Persisting Amnestic Disorder (refer to Substance-

Related Disorders for substance-specific codes)

294.8 Amnestic Disorder NOS

Other Cognitive Disorders

294.9 Cognitive Disorder NOS

MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION NOT

ELSEWHERE CLASSIFIED

293.89 Catatonic Disorder Due to (indicate the general medical condition)

310.1 Personality Change Due to (indicate the general medical condition)

293.9 Mental Disorder NOS Due to (indicate the general medical condition)

SUBSTANCE-RELATED DISORDERS

Alcohol-Related Disorders

Alcohol Use Disorders

303.90 Alcohol Dependence

305.00 Alcohol Abuse

Alcohol-Induced Disorders

303.00 Alcohol Intoxication

291.81 Alcohol Withdrawal

291.0 Alcohol Intoxication Delirium

291.0 Alcohol Withdrawal Delirium

291.2 Alcohol-Induced Persisting Dementia

291.1 Alcohol-Induced Persisting Amnestic Disorder

291.x Alcohol-Induced Psychotic Disorder

.5 With Delusions

.3 With Hallucinations

291.89 Alcohol-Induced Mood Disorder

291.89 Alcohol-Induced Anxiety Disorder

291.89 Alcohol-Induced Sexual Dysfunction

291.89 Alcohol-Induced Sleep Disorder

291.9 Alcohol-Related Disorder NOS

Amphetamine (or Amphetamine-like)-Related Disorders

Amphetamine Use Disorders

304.40 Amphetamine Dependence

305.70 Amphetamine Abuse

Amphetamine-Induced Disorders

292.89 Amphetamine Intoxication

292.0 Amphetamine Withdrawal

292.81 Amphetamine Intoxication Delirium

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292.xx Amphetamine-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Amphetamine-Induced Mood Disorder

292.89 Amphetamine-Induced Anxiety Disorder

292.89 Amphetamine-Induced Sexual Dysfunction

292.89 Amphetamine-Induced Sleep Disorder

292.9 Amphetamine-Related Disorder NOS

Caffeine-Related Disorders

Caffeine-Induced Disorders

305.90 Caffeine Intoxication

292.89 Caffeine-Induced Anxiety Disorder

292.89 Caffeine-Induced Sleep Disorder

292.9 Caffeine-Related Disorder NOS

Cannabis-Related Disorders

Cannabis Use Disorders

304.30 Cannabis Dependence

305.20 Cannabis Abuse

Cannabis-Induced Disorders

292.89 Cannabis Intoxication

292.81 Cannabis Intoxication Delirium

292.xx Cannabis-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.89 Cannabis-Induced Anxiety Disorder

292.9 Cannabis-Related Disorder NOS

Cocaine-Related Disorders

Cocaine Use Disorders

304.20 Cocaine Dependence

305.60 Cocaine Abuse

Cocaine-Induced Disorders

292.89 Cocaine Intoxication

292.0 Cocaine Withdrawal

292.81 Cocaine Intoxication Delirium

292.xx Cocaine-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Cocaine-Induced Mood Disorder

292.89 Cocaine-Induced Anxiety Disorder

292.89 Cocaine-Induced Sexual Dysfunction

292.89 Cocaine-Induced Sleep Disorder

292.9 Cocaine-Related Disorder NOS

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Hallucinogen-Related Disorders

Hallucinogen Use Disorders

304.50 Hallucinogen Dependence

305.30 Hallucinogen Abuse

Hallucinogen-Induced Disorders

292.89 Hallucinogen Intoxication

292.89 Hallucinogen Persisting Perception Disorder (Flashbacks)

292.81 Hallucinogen Intoxication Delirium

292.xx Hallucinogen-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Hallucinogen-Induced Mood Disorder

292.89 Hallucinogen-Induced Anxiety Disorder

292.9 Hallucinogen-Related Disorder NOS

Inhalant-Related Disorders

Inhalant Use Disorders

304.60 Inhalant Dependence

305.90 Inhalant Abuse

Inhalant-Induced Disorders

292.89 Inhalant Intoxication

292.81 Inhalant Intoxication Delirium

292.82 Inhalant-Induced Persisting Dementia

292.xx Inhalant-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Inhalant-Induced Mood Disorder

292.89 Inhalant-Induced Anxiety Disorder

292.9 Inhalant-Related Disorder NOS

Nicotine-Related Disorders

Nicotine Use Disorders

305.1 Nicotine Dependence

Nicotine-Induced Disorders

292.0 Nicotine Withdrawal

292.9 Nicotine-Related Disorder NOS

Opioid-Related Disorders

Opioid Use Disorders

304.00 Opioid Dependence

305.50 Opioid Abuse

Opioid-Induced Disorders

292.89 Opioid Intoxication

292.0 Opioid Withdrawal

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292.81 Opioid Intoxication Delirium

292.xx Opioid-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Opioid-Induced Mood Disorder

292.89 Opioid-Induced Sexual Dysfunction

292.89 Opioid-Induced Sleep Disorder

292.9 Opioid-Related Disorder NOS

Phencyclidine (or Phencyclidine-like)-Related Disorders

Phencyclidine Use Disorders

304.60 Phencyclidine Dependence

305.90 Phencyclidine Abuse

Phencyclidine-Induced Disorders

292.89 Phencyclidine Intoxication

292.81 Phencyclidine Intoxication Delirium

292.xx Phencyclidine-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Phencyclidine-Induced Mood Disorder

292.89 Phencyclidine-Induced Anxiety Disorder

292.9 Phencyclidine-Related Disorder NOS

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Sedative, Hypnotic, or Anxiolytic Use Disorders

304.10 Sedative, Hypnotic, or Anxiolytic Dependence

305.40 Sedative, Hypnotic, or Anxiolytic Abuse

Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders

292.89 Sedative, Hypnotic, or Anxiolytic Intoxication

292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal

292.81 Sedative, Hypnotic, or Anxiolytic Intoxication Delirium

292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium

292.82 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia

292.83 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic

Disorder

292.xx Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder

292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder

292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual Dysfunction

292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep Disorder

292.9 Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS

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Polysubstance-Related Disorder

304.80 Polysubstance Dependence

Other (or Unknown) Substance-Related Disorders

Other (or Unknown) Substance Use Disorders

304.90 Other (or Unknown) Substance Dependence

305.90 Other (or Unknown) Substance Abuse

Other (or Unknown) Substance-Induced Disorders

292.89 Other (or Unknown) Substance Intoxication

292.0 Other (or Unknown) Substance Withdrawal

292.81 Other (or Unknown) Substance-Induced Delirium

292.82 Other (or Unknown) Substance-Induced Persisting Dementia

292.83 Other (or Unknown) Substance-Induced Persisting Amnestic Disorder

292.xx Other (or Unknown) Substance-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84 Other (or Unknown) Substance-Induced Mood Disorder

292.89 Other (or Unknown) Substance-Induced Anxiety Disorder

292.89 Other (or Unknown) Substance-Induced Sexual Dysfunction

292.89 Other (or Unknown) Substance-Induced Sleep Disorder

292.9 Other (or Unknown) Substance-Related Disorder NOS

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

295.xx Schizophrenia

.30 Paranoid type

.10 Disorganized type

.20 Catatonic type

.90 Undifferentiated type

.60 Residual type

295.40 Schizophreniform Disorder

295.70 Schizoaffective Disorder

297.1 Delusional Disorder

298.8 Brief Psychotic Disorder

297.3 Shared Psychotic Disorder

293.xx Psychotic Disorder Due to (indicate the general medical condition)

.81 With Delusions

.82 With Hallucinations

–––.— Substance-Induced Psychotic Disorder (refer to Substance-Related

Disorders for substance-specific codes)

298.9 Psychotic Disorder NOS

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MOOD DISORDERS

(Code current state of Major Depressive Disorder or Bipolar I Disorder in fifth

digit: 0 ⫽ unspecified; 1 ⫽ mild; 2 ⫽ moderate; 3 ⫽ severe, without

psychotic features; 4 ⫽ severe, with psychotic features; 5 ⫽ in partial

remission; 6 ⫽ in full remission.)

Depressive Disorders

296.xx Major Depressive Disorder

.2x Single Episode

.3x Recurrent

300.4 Dysthymic Disorder

311 Depressive Disorder NOS

Bipolar Disorders

296.xx Bipolar I Disorder

.0x Single Manic Episode

.40 Most Recent Episode Hypomanic

.4x Most Recent Episode Manic

.6x Most Recent Episode Mixed

.5x Most Recent Episode Depressed

.7 Most Recent Episode Unspecified

296.89 Bipolar II Disorder (specify current or most recent episode:

Hypomanic or Depressed)

301.13 Cyclothymic Disorder

296.80 Bipolar Disorder NOS

293.83 Mood Disorder Due to (indicate the general medical condition)

–––.— Substance-Induced Mood Disorder (refer to Substance-Related

Disorders for substance-specific codes)

296.90 Mood Disorder NOS

ANXIETY DISORDERS

300.01 Panic Disorder Without Agoraphobia

300.21 Panic Disorder With Agoraphobia

300.22 Agoraphobia Without History of Panic Disorder

300.29 Specific Phobia

300.23 Social Phobia

300.3 Obsessive-Compulsive Disorder

309.81 Post-traumatic Stress Disorder

308.3 Acute Stress Disorder

300.02 Generalized Anxiety Disorder

293.89 Anxiety Disorder Due to (indicate the general medical condition)

–––.— Substance-Induced Anxiety Disorder (refer to Substance-Related

Disorders for substance-specific codes)

300.00 Anxiety Disorder NOS

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SOMATOFORM DISORDERS

300.81 Somatization Disorder

300.82 Undifferentiated Somatoform Disorder

300.11 Conversion Disorder

307.xx Pain Disorder

.80 Associated with Psychological Factors

.89 Associated with Both Psychological Factors and a General Medical

Condition

300.7 Hypochondriasis

300.7 Body Dysmorphic Disorder

300.82 Somatoform Disorder NOS

FACTITIOUS DISORDERS

300.xx Factitious Disorder

.16 With Predominantly Psychological Signs and Symptoms

.19 With Predominantly Physical Signs and Symptoms

.19 With Combined Psychological and Physical Signs and Symptoms

300.19 Factitious Disorder NOS

DISSOCIATIVE DISORDERS

300.12 Dissociative Amnesia

300.13 Dissociative Fugue

300.14 Dissociative Identity Disorder

300.6 Depersonalization Disorder

300.15 Dissociative Disorder NOS

SEXUAL AND GENDER IDENTITY DISORDERS

Sexual Dysfunctions

Sexual Desire Disorders

302.71 Hypoactive Sexual Desire Disorder

302.79 Sexual Aversion Disorder

Sexual Arousal Disorders

302.72 Female Sexual Arousal Disorder

302.72 Male Erectile Disorder

Orgasmic Disorders

302.73 Female Orgasmic Disorder

302.74 Male Orgasmic Disorder

302.75 Premature Ejaculation

Sexual Pain Disorders

302.76 Dyspareunia (Not Due to a General Medical Condition)

306.51 Vaginismus (Not Due to a General Medical Condition)

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Sexual Dysfunction Due to a General Medical Condition

625.8 Female Hypoactive Sexual Desire Disorder Due to (indicate the general

medical condition)

608.89 Male Hypoactive Sexual Desire Disorder Due to (indicate the general

medical condition)

607.84 Male Erectile Disorder Due to (indicate the general medical condition)

625.0 Female Dyspareunia Due to (indicate the general medical condition)

608.89 Male Dyspareunia Due to (indicate the general medical condition)

625.8 Other Female Sexual Dysfunction Due to (indicate the general medical

condition)

608.89 Other Male Sexual Dysfunction Due to (indicate the general medical

condition)

––– .— Substance-Induced Sexual Dysfunction (refer to Substance-Related

Disorders for substance-specific codes)

302.70 Sexual Dysfunction NOS

Paraphilias

302.4 Exhibitionism

302.81 Fetishism

302.89 Frotteurism

302.2 Pedophilia

302.83 Sexual Masochism

302.84 Sexual Sadism

302.3 Transvestic Fetishism

302.82 Voyeurism

302.9 Paraphilia NOS

Gender Identity Disorders

302.xx Gender Identity Disorder

.6 In Children

.85 In Adolescents or Adults

302.6 Gender Identity Disorder NOS

302.9 Sexual Disorder NOS

EATING DISORDERS

307.1 Anorexia Nervosa

307.51 Bulimia Nervosa

307.50 Eating Disorder NOS

SLEEP DISORDERS

Primary Sleep Disorders

Dyssomnias

307.42 Primary Insomnia

307.44 Primary Hypersomnia

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347 Narcolepsy

780.59 Breathing-Related Sleep Disorder

307.45 Circadian Rhythm Sleep Disorder

307.47 Dyssomnia NOS

Parasomnias

307.47 Nightmare Disorder

307.46 Sleep Terror Disorder

307.46 Sleepwalking Disorder

307.47 Parasomnia NOS

Sleep Disorders Related to Another Mental Disorder

307.42 Insomnia Related to (indicate the Axis I or Axis II disorder)

307.44 Hypersomnia Related to (indicate the Axis I or Axis II disorder)

Other Sleep Disorders

780.xx Sleep Disorder Due to (indicate the general medical condition)

.52 Insomnia type

.54 Hypersomnia type

.59 Parasomnia type

.59 Mixed type

Substance-Induced Sleep Disorder (refer to Substance-Related

Disorders for substance-specific codes)

IMPULSE CONTROL DISORDERS NOT ELSEWHERE CLASSIFIED

312.34 Intermittent Explosive Disorder

312.32 Kleptomania

312.33 Pyromania

312.31 Pathological Gambling

312.39 Trichotillomania

312.30 Impulse Control Disorder NOS

ADJUSTMENT DISORDERS

309.xx Adjustment Disorder

.0 With Depressed Mood

.24 With Anxiety

.28 With Mixed Anxiety and Depressed Mood

.3 With Disturbance of Conduct

.4 With Mixed Disturbance of Emotions and Conduct

.9 Unspecified

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PERSONALITY DISORDERS

NOTE: These are coded on Axis II.

301.0 Paranoid Personality Disorder

301.20 Schizoid Personality Disorder

301.22 Schizotypal Personality Disorder

301.7 Antisocial Personality Disorder

301.83 Borderline Personality Disorder

301.50 Histrionic Personality Disorder

301.81 Narcissistic Personality Disorder

301.82 Avoidant Personality Disorder

301.6 Dependent Personality Disorder

301.4 Obsessive-Compulsive Personality Disorder

301.9 Personality Disorder NOS

OTHER CONDITIONS THAT MAY BE A FOCUS OF CLINICAL ATTENTION

Psychological Factors Affecting Medical Condition

316 Choose name based on nature of factors:

Mental Disorder Affecting Medical Condition

Psychological Symptoms Affecting Medical Condition

Personality Traits or Coping Style Affecting Medical Condition

Maladaptive Health Behaviors Affecting Medical Condition

Stress-Related Physiological Response Affecting Medical Condition

Other or Unspecified Psychological Factors Affecting Medical Condition

Medication-Induced Movement Disorders

332.1 Neuroleptic-Induced Parkinsonism

333.92 Neuroleptic Malignant Syndrome

333.7 Neuroleptic-Induced Acute Dystonia

333.99 Neuroleptic-Induced Acute Akathisia

333.82 Neuroleptic-Induced Tardive Dyskinesia

333.1 Medication-Induced Postural Tremor

333.90 Medication-Induced Movement Disorder NOS

Other Medication-Induced Disorder

995.2 Adverse Effects of Medication NOS

Relational Problems

V61.9 Relational Problem Related to a Mental Disorder or General Medical

Condition

V61.20 Parent-Child Relational Problem

V61.10 Partner Relational Problem

V61.8 Sibling Relational Problem

V62.81 Relational Problem NOS

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Problems Related to Abuse or Neglect

V61.21 Physical Abuse of Child

V61.21 Sexual Abuse of Child

V61.21 Neglect of Child

–––.— Physical Abuse of Adult

V61.12 (if by partner)

V62.83 (if by person other than partner)

–––.—Sexual Abuse of Adult

V61.12 (if by partner)

V62.83 (if by person other than partner)

Additional Conditions That May Be a Focus of Clinical Attention

V15.81 Noncompliance with Treatment

V65.2 Malingering

V71.01 Adult Antisocial Behavior

V71.02 Childhood or Adolescent Antisocial Behavior

V62.89 Borderline Intellectual Functioning (coded on Axis II)

780.9 Age-Related Cognitive Decline

V62.82 Bereavement

V62.3 Academic Problem

V62.2 Occupational Problem

313.82 Identity Problem

V62.89 Religious or Spiritual Problem

V62.4 Acculturation Problem

V62.89 Phase of Life Problem

ADDITIONAL CODES

300.9 Unspecified Mental Disorder (nonpsychotic)

V71.09 No Diagnosis or Condition on Axis I

799.9 Diagnosis or Condition Deferred on Axis I

V71.09 No Diagnosis on Axis II

799.9 Diagnosis Deferred on Axis II

DSM-IV-TR criteria in Disorders Tab, Global Assessment of Functioning (GAF) form,

Multiaxial System, and DSM-IV-TR classifications: Axes I and II categories and codes,

reprinted with permission from the Diagnostic and Statistical Manual of Mental

Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association,

2000.

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Risk for injury; Risk for other-directed

violence

Imbalanced nutrition: Less than body

requirements

Anxiety (specify level)

Confusion, acute/chronic; Disturbed

thought processes

Disturbed thought processes

Ineffective denial

Dysfunctional grieving

Risk for injury

Decisional conflict (specify)

Impaired social interaction

Ineffective role performance

Disturbed sensory perception

(kinesthetic)

Disturbed body image

Powerlessness

Post-trauma syndrome

Disturbed sensory perception

(auditory; visual)

Low self-esteem (chronic; situational)

Assigning Nursing Diagnoses (NANDA) to Client Behaviors

Following is a list of client behaviors and the NANDA nursing diagnoses that

correspond to the behaviors and that may be used in planning care for the

client exhibiting the specific behavioral symptoms.

Behaviors NANDA Nursing Diagnoses

Aggression; hostility

Anorexia or refusal to eat

Anxious behavior

Confusion; memory loss

Delusions

Denial of problems

Depressed mood or anger

turned inward

Detoxification; withdrawal

from substances

Difficulty making important

life decision

Difficulty with interpersonal

relationships

Disruption in capability to

perform usual responsibilities

Dissociative behaviors

(depersonalization;

derealization)

Expresses feelings of disgust

about body or body part

Expresses lack of control over

personal situation

Flashbacks, nightmares, obsession

with traumatic experience

Hallucinations

Highly critical of self or others

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Behaviors NANDA Nursing Diagnoses

HIV-positive; altered immunity

Inability to meet basic needs

Insomnia or hypersomnia

Loose associations or flight

of ideas

Manic hyperactivity

Manipulative behavior

Multiple personalities; gender

identity disturbance

Orgasm, problems with; lack

of sexual desire

Overeating, compulsive

Phobias

Physical symptoms as coping

behavior

Projection of blame; rationalization

of failures; denial of personal

responsibility

Ritualistic behaviors

Seductive remarks; inappropriate

sexual behaviors

Self-mutilative behaviors

Sexual behaviors (difficulty,

limitations, or changes in;

reported dissatisfaction)

Stress from caring for chronically

ill person

Stress from locating to new

environment

Substance use as a coping

behavior

Substance use (denies use is a

problem)

Ineffective protection

Self-care deficit (feeding; bathing/

hygiene; dressing/grooming;

toileting)

Disturbed sleep pattern

Impaired verbal communication

Risk for injury

Ineffective coping

Disturbed personal identity

Sexual dysfunction

Risk for imbalanced nutrition: More

than body requirements

Fear

Ineffective coping

Defensive coping

Anxiety (severe); Ineffective coping

Impaired social interaction

Self-mutilation; Risk for self-mutilation

Ineffective sexuality patterns

Caregiver role strain

Relocation stress syndrome

Ineffective coping

Ineffective denial

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Risk for suicide; Risk for self-directed

violence

Disturbed thought processes;

Ineffective coping

Risk for deficient fluid volume

Social isolation

Behaviors NANDA Nursing Diagnoses

Suicidal

Suspiciousness

Vomiting, excessive, self induced

Withdrawn behavior

Used with permission from Townsend, 5e, 2006

Nursing Diagnoses (NANDA): Accepted for Use and Research (2007–2008)

Activity Intolerance [specify level]

Activity Intolerance, risk for

Airway Clearance, ineffective

Allergy Response, latex

Allergy Response, latex, risk for

Anxiety [specify level]

Anxiety, death

Aspiration, risk for

Attachment, risk for impaired parent/infant/child

Autonomic Dysreflexia

Autonomic Dysreflexia, risk for

Blood Sugar, risk for unstable

Body Image, disturbed

Body Temperature, risk for imbalanced

Bowel Incontinence

Breastfeeding, effective

Breastfeeding, ineffective

Breastfeeding, interrupted

Breathing Pattern, ineffective

Cardiac Output, decreased

Caregiver Role Strain

Caregiver Role Strain, risk for

Comfort, readiness for enhanced

Communication, impaired verbal

Communication, readiness for enhanced

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Conflict, parental role

Confusion, acute

Confusion, risk for acute

Confusion, chronic

Constipation

Constipation, perceived

Constipation, risk for

Contamination

Contamination, risk for

Coping, compromised family

Coping, disabled family

Coping, readiness for enhanced family

Coping, defensive

Coping, ineffective

Coping, ineffective community

Coping, readiness for enhanced

Coping, readiness for enhanced community

Death Syndrome, risk for sudden infant

Decisional Conflict (specify)

Decision-Making, readiness for enhanced

Denial, ineffective

Dentition, impaired

Development, risk for delayed

Diarrhea

Disuse Syndrome, risk for

Diversional Activity, deficient

Energy Field, disturbed (revised)

Environmental Interpretation Syndrome, impaired

Failure to Thrive, adult

Falls, risk for

Family Processes: alcoholism, dysfunctional

Family Processes, interrupted

Family Processes, readiness for enhanced

Fatigue

Fear (specify focus)

Fluid Balance, readiness for enhanced

[Fluid Volume, deficient hyper/hypotonic]

Fluid Volume, deficient [isotonic]

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Fluid Volume, excess

Fluid Volume, risk for deficient

Fluid Volume risk for imbalanced

Gas Exchange, impaired

Glucose, risk for unstable level

Grieving

Grieving, complicated

Grieving, risk for complicated

Growth, risk for disproportionate

Growth & Development, delayed

Health Behavior, risk prone

Health Maintenance, ineffective

Health-Seeking Behaviors (specify)

Home Maintenance, impaired

Hope, readiness for enhanced

Hopelessness

Human Dignity, risk for compromised

Hyperthermia

Hypothermia

Identify, disturbed personal

Immunization Status, readiness for enhanced

Infant Behavior, disorganized

Infant Behavior, organized, readiness for enhanced

Infant Behavior, risk for disorganized

Infant Feeding Pattern, ineffective

Infection, risk for

Injury, risk for

Injury, risk for perioperative positioning

Insomnia

Intracranial Adaptive Capacity, decreased

Knowledge, deficient [Learning Need] [specify]

Knowledge [specify], readiness for enhanced

Lifestyle, sedentary

Liver Function, risk for impaired

Loneliness, risk for

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Memory, impaired

Mobility, impaired bed

Mobility, impaired physical

Mobility, impaired wheelchair

Moral Distress

Nausea

Noncompliance, [Adherence, ineffective] [specify]

Nutrition, less than body requirements, imbalanced

Nutrition, more than body requirements, imbalanced

Nutrition, readiness for enhanced

Nutrition, more than body requirements, risk for imbalanced

Oral Mucous Membrane, impaired

Pain, acute

Pain, chronic

Parenting, impaired

Parenting, readiness for enhanced

Parenting, risk for impaired

Perioperative Positioning, risk for

Peripheral Neurovascular Dysfunction, risk for

Poisoning, risk for

Post-Trauma Syndrome [specify stage]

Post-Trauma Syndrome, risk for

Power, readiness for enhanced

Powerlessness [specify level]

Powerlessness, risk for

Protection, ineffective

Rape-Trauma Syndrome

Rape-Trauma Syndrome: compound reaction

Rape-Trauma Syndrome: silent reaction

Religiosity, impaired

Religiosity, risk for impaired

Religiosity, readiness for enhanced

Relocation Stress Syndrome

Relocation Stress Syndrome, risk for

Role Performance, ineffective

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Self-Care, readiness for enhanced

Self-Care Deficit: bathing/hygiene

Self-Care Deficit: dressing/grooming

Self-Care Deficit: feeding

Self-Care Deficit: toileting

Self-Concept, readiness for enhanced

Self-Esteem, chronic low

Self-Esteem, situational low

Self-Esteem, risk for situational low

Self-Mutilation

Self-Mutilation, risk for

Sensory Perception, disturbed: (specify: visual, auditory, kinesthetic,

gustatory, tactile, olfactory)

Sexual Dysfunction

Sexuality Pattern, ineffective

Skin Integrity, impaired

Skin Integrity, risk for impaired

Sleep, readiness for enhanced

Sleep Deprivation

Social Interaction, impaired

Social Isolation

Sorrow, chronic

Spiritual Distress

Spiritual Distress, risk for

Spiritual Well-Being, readiness for enhanced

Stress Overload

Suffocation, risk for

Suicide, risk for

Surgical Recovery, delayed

Swallowing, impaired

Therapeutic Regimen Management, effective

Therapeutic Regimen Management, ineffective

Therapeutic Regimen Management, ineffective community

Therapeutic Regimen Management, ineffective family

Therapeutic Regimen Management, readiness for enhanced

Thermoregulation, ineffective

Thought Processes, disturbed

Tissue Integrity, impaired

Tissue Perfusion, ineffective (specify type: cerebral, cardiopulmonary, renal,

gastrointestinal, peripheral)

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Transfer Ability, impaired

Trauma, risk for

Unilateral Neglect Syndrome

Urinary Elimination, impaired

Urinary Elimination, readiness for enhanced

Urinary Incontinence, functional

Urinary Incontinence, overflow

Urinary Incontinence, reflex

Urinary Incontinence, stress

Urinary Incontinence, total

Urinary Incontinence, urge

Urinary Incontinence, risk for urge

Urinary Retention [acute/chronic]

Ventilation, impaired spontaneous

Ventilatory Weaning Response, dysfunctional

Violence, [actual/] risk for other-directed

Violence, [actual/] risk for self-directed

Walking, impaired

Wandering [specify sporadic or continual]

Used with permission from NANDA International: Definitions and Classification,

2007–2008. NANDA, Philadelphia, PA, 2007

Psychiatric Terminology

abreaction. “Remembering with feeling”; bringing into conscious

awareness painful events that have been repressed and reexperiencing

the emotions that were associated with the events.

adjustment disorder. A maladaptive reaction to an identifiable

psychosocial stressor that occurs within 3 months after onset of the

stressor. The individual shows impairment in social and occupational

functioning or exhibits symptoms that are in excess of a normal and

expectable reaction to the stressor.

affect. The behavioral expression of emotion; may be appropriate

(congruent with the situation); inappropriate (incongruent with the

situation); constricted or blunted (diminished range and intensity); or flat

(absence of emotional expression).

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agoraphobia. The fear of being in places or situations from which escape

might be difficult (or embarrassing) or in which help might not be

available in the event of a panic attack.

akathisia. Restlessness; an urgent need for movement. A type of

extrapyramidal side effect associated with some antipsychotic

medications.

akinesia. Muscular weakness or a loss or partial loss of muscle movement;

a type of extrapyramidal side effect associated with some antipsychotic

medications.

amnesia. An inability to recall important personal information that is too

extensive to be explained by ordinary forgetfulness.

anhedonia. The inability to experience or even imagine any pleasant

emotion.

anorexia. Loss of appetite.

anorgasmia. Inability to achieve orgasm.

anticipatory grief. A subjective state of emotional, physical, and social

responses to an anticipated loss of a valued entity. The grief response is

repeated once the loss actually occurs, but it may not be as intense as it

might have been if anticipatory grieving had not occurred.

antisocial personality disorder. A pattern of socially irresponsible,

exploitative, and guiltless behavior, evident in the tendency to fail to

conform to the law, develop stable relationships, or sustain consistent

employment; exploitation and manipulation of others for personal gain is

common.

anxiety. Vague diffuse apprehension that is associated with feelings of

uncertainty and helplessness.

associative looseness. Sometimes called loose associations, a thinking

process characterized by speech in which ideas shift from one unrelated

subject to another. The individual is unaware that the topics are

unconnected.

ataxia. Muscular incoordination.

attitude. A frame of reference around which an individual organizes

knowledge about his or her world. It includes an emotional element and

can have a positive or negative connotation.

autism. A focus inward on a fantasy world and distorting or excluding the

external environment; common in schizophrenia.

autistic disorder. The withdrawal of an infant or child into the self and into

a fantasy world of his or her own creation. There is marked impairment in

interpersonal functioning and communication and in imaginative play.

Activities and interests are restricted and may be considered somewhat

bizarre.

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behavior modification. A treatment modality aimed at changing undesir-

able behaviors, using a system of reinforcement to bring about the

modifications desired.

belief. An idea that one holds to be true. It can be rational, irrational, taken

on faith, or stereotypical.

bereavement overload. An accumulation of grief that occurs when an

individual experiences many losses over a short period and is unable to

resolve one before another is experienced. This phenomenon is common

among the elderly.

bipolar disorder. Characterized by mood swings from profound depression

to extreme euphoria (mania), with intervening periods of normalcy.

Psychotic symptoms may or may not be present.

borderline personality disorder. A disorder characterized by a pattern of

intense and chaotic relationships, with affective instability, fluctuating and

extreme attitudes regarding other people, impulsivity, direct and indirect

self-destructive behavior, and lack of a clear or certain sense of identity,

life plan, or values.

boundaries. The level of participation and interaction between individuals

and between subsystems. Boundaries denote physical and psychological

space individuals identify as their own. They are sometimes referred to as

limits.

catatonia. A type of schizophrenia that is typified by stupor or excitement:

stupor characterized by extreme psychomotor retardation, mutism,

negativism, and posturing; excitement by psychomotor agitation, in which

the movements are frenzied and purposeless.

circumstantiality. In speaking, the delay of an individual to reach the point

of a communication owing to unnecessary and tedious details.

clang associations. A pattern of speech in which the choice of words is

governed by sounds. Clang associations often take the form of rhyming.

codependency. An exaggerated dependent pattern of learned behaviors,

beliefs, and feelings that make life painful. It is a dependence on people

and things outside the self, along with neglect of the self to the point of

having little self-identity.

cognition. Mental operations that relate to logic, awareness, intellect,

memory, language, and reasoning powers.

cognitive therapy. A type of therapy in which the individual is taught to

control thought distortions that are considered to be a factor in the

development and maintenance of emotional disorders.

compensation. Covering up a real or perceived weakness by emphasizing a

trait one considers more desirable.

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concrete thinking. Thought processes that are focused on specifics rather

than on generalities and immediate issues rather than eventual

outcomes. Individuals who are experiencing concrete thinking are unable

to comprehend abstract terminology.

confidentiality. The right of an individual to the assurance that his or her

case will not be discussed outside the boundaries of the health-care team.

crisis. Psychological disequilibrium in a person who confronts a hazardous

circumstance that constitutes an important problem, which for the time

he or she can neither escape nor solve with usual problem-solving

resources.

crisis intervention. An emergency type of assistance in which the inter-

vener becomes a part of the individual’s life situation. The focus is to

provide guidance and support to help mobilize the resources needed to

resolve the crisis and restore or generate an improvement in previous

level of functioning. Usually lasts no longer than 6 to 8 weeks.

culture. A particular society’s entire way of living, encompassing shared

patterns of belief, feeling, and knowledge that guide people’s conduct and

are passed down from generation to generation.

curandera. A female folk healer in the Latino culture.

curandero. A male folk healer in the Latino culture.

cycle of battering. Three phases of predictable behaviors that are repeated

over time in a relationship between a batterer and a victim: the tension-

building phase; the acute battering incident; and the calm, loving respite

(honeymoon) phase.

cyclothymia. A chronic mood disturbance involving numerous episodes of

hypomania and depressed mood, of insufficient severity or duration to

meet the criteria for bipolar disorder.

delayed grief. Also called inhibited grief. The absence of evidence of grief

when it ordinarily would be expected.

delirium. A state of mental confusion and excitement characterized by

disorientation to time and place, often with hallucinations, incoherent

speech, and a continual state of aimless physical activity.

delusions. False personal beliefs, not consistent with a person’s intelligence

or cultural background. The individual continues to have the belief in spite

of obvious proof that it is false and/or irrational.

dementia. Global impairment of cognitive functioning that is progressive

and interferes with social and occupational abilities.

denial. Refusal to acknowledge the existence of a real situation and/or the

feelings associated with it.

depersonalization. An alteration in the perception or experience of the self

so that the feeling of one’s own reality is temporarily lost.

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derealization. An alteration in the perception or experience of the external

world so that it seems strange or unreal.

Diagnostic and Statistical Manual of Mental Disorders, 4th edition,

Text Revision (DSM-IV-TR). Standard nomenclature of emotional illness

published by the American Psychiatric Association (APA) and used by all

health-care practitioners. It classifies mental illness and presents guide-

lines and diagnostic criteria for various mental disorders.

displacement. Feelings are transferred from one target to another that is

considered less threatening or neutral.

double-bind communication. Communication described as contradictory

that places an individual in a “double bind.” It occurs when a statement is

made and succeeded by a contradictory statement or when a statement is

made accompanied by nonverbal expression that is inconsistent with the

verbal communication.

dyspareunia. Pain during sexual intercourse.

dysthymia. A depressive neurosis. The symptoms are similar to, if

somewhat milder than, those ascribed to major depression. There is no

loss of contact with reality.

dystonia. Involuntary muscular movements (spasms) of the face, arms,

legs, and neck; may occur as an extrapyramidal side effect of some

antipsychotic medications.

echolalia. The parrot-like repetition by an individual with loose ego

boundaries of the words spoken by another.

ego. One of the three elements of the personality identified by Freud as the

rational self, or “reality principle.” The ego seeks to maintain harmony

between the external world, the id, and the superego.

electroconvulsive therapy (ECT). A type of somatic treatment in which

electric current is applied to the brain through electrodes placed on the

temples. A grand mal seizure produces the desired effect. This is used

with severely depressed patients refractory to antidepressant

medications.

empathy. The ability to see beyond outward behavior and sense accurately

another’s inner experiencing. With empathy, one can accurately perceive

and understand the meaning and relevance in the thoughts and feelings

of another.

enmeshment. Exaggerated connectedness among family members. It

occurs in response to diffuse boundaries in which there is overinvest-

ment, overinvolvement, and lack of differentiation between individuals

or subsystems.

ethnicity. The concept of people identifying with each other because of a

shared heritage.

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exhibitionism. A paraphilic disorder characterized by a recurrent urge to

expose one’s genitals to a stranger.

extrapyramidal symptoms (EPS). A variety of responses that originate

outside the pyramidal tracts and in the basal ganglion of the brain.

Symptoms may include tremors, chorea, dystonia, akinesia, and akathisia,

and others may occur as a side effect of some antipsychotic medications.

family system. A system in which the parts of the whole may be the

marital dyad, parent-child dyad, or sibling groups. Each of these

subsystems is further divided into subsystems of individuals.

family therapy. A type of therapy in which the focus is on relationships

within the family. The family is viewed as a system in which the members

are interdependent, and a change in one creates change in all.

fight or flight. A syndrome of physical symptoms that result from an

individual’s real or perceived perception that harm or danger is imminent.

free association. A technique used to help individuals bring to

consciousness material that has been repressed. The individual is

encouraged to verbalize whatever comes into his or her mind, drifting

naturally from one thought to another.

gains. The reinforcements an individual receives for somaticizing.

gender identity disorder. A sense of discomfort associated with an

incongruence between biologically assigned gender and subjectively

experienced gender.

generalized anxiety disorder. A disorder characterized by chronic (at least

6 months), unrealistic, and excessive anxiety and worry.

genogram. A graphic representation of a family system. It may cover

several generations. Emphasis is on family roles and emotional related-

ness among members. Genograms facilitate recognition of areas

requiring change.

grief. A subjective state of emotional, physical, and social responses to the

real or perceived loss of a valued entity. Change and failure can also be

perceived as losses. The grief response consists of a set of relatively

predictable behaviors that describe the subjective state that accompanies

mourning.

group therapy. A therapy group, founded in a specific theoretical

framework, led by a person with an advanced degree in psychology,

social work, nursing, or medicine. The goal is to encourage improvement

in interpersonal functioning.

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hallucinations. False sensory perceptions not associated with real external

stimuli. Hallucinations may involve any of the five senses.

histrionic personality disorder. Conscious or unconscious overly

dramatic behavior used for drawing attention to oneself.

human immunodeficiency virus (HIV). The virus that is the etiological

agent that produces the immunosuppression resulting in AIDS.

hypersomnia. Excessive sleepiness or seeking excessive amounts of sleep.

hypertensive crisis. A potentially life-threatening syndrome that results

when an individual taking monoamine oxidase inhibitors (MAOIs) eats a

product high in tyramine or uses a selective serotonin reuptake inhibitor

too soon either before or after stopping an MAOI.

hypnosis. A treatment for disorders brought on by repressed anxiety. The

individual is directed into a state of subconsciousness and assisted,

through suggestions, to recall certain events that he or she cannot recall

when conscious.

hypomania. A mild form of mania. Symptoms are excessive hyperactivity

but not severe enough to cause marked impairment in social or occupa-

tional functioning or to require hospitalization.

id. One of the three components of the personality identified by Freud as the

“pleasure principle.” The id is the locus of instinctual drives, is present at

birth, and compels the infant to satisfy needs and seek immediate

gratification.

illusion. A misperception of a real external stimulus.

incest. Sexual exploitation of a child under 18 years of age by a relative or

nonrelative who holds a position of trust in the family.

integration. The process used with individuals with dissociative identity

disorder in an effort to bring all the personalities together into one;

usually achieved through hypnosis.

intellectualization. An attempt to avoid expressing actual emotions

associated with a stressful situation by using the intellectual processes of

logic, reasoning, and analysis.

introjection. The beliefs and values of another individual are internalized

and symbolically become a part of the self to the extent that the feeling of

separateness or distinctness is lost.

isolation. The separation of a thought or a memory from the feeling, tone,

or emotions associated with it (sometimes called emotional isolation).

justice. An ethical principle reflecting that all individuals should be treated

equally and fairly.

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kleptomania. A recurrent failure to resist impulses to steal objects not

needed for personal use or monetary value.

Korsakoff’s psychosis. A syndrome in alcoholics of confusion, loss of

recent memory, and confabulation, caused by a deficiency of thiamine. It

often occurs together with Wernicke’s encephalopathy and may be termed

Wernicke-Korsakoff syndrome.

libido. Freud’s term for the psychic energy used to fulfill basic physiological

needs or instinctual drives such as hunger, thirst, and sexuality.

limbic system. The part of the brain that is sometimes called the “emotional

brain.” It is associated with feelings of fear and anxiety; anger and

aggression; love, joy, and hope; and with sexuality and social behavior.

long-term memory. Memory for remote events, or those that occurred

many years ago. The type of memory that is preserved in the elderly

individual.

loss. The experience of separation from something of personal importance.

luto. The word for mourning in the Mexican-American culture, which is

symbolized by wearing black, black and white, or dark clothing and by

subdued behavior.

magical thinking. A primitive form of thinking in which an individual

believes that thinking about a possible occurrence can make it happen.

mania. A type of bipolar disorder in which the predominant mood is

elevated, expansive, or irritable. Motor activity is frenzied and excessive.

Psychotic features may or may not be present.

melancholia. A severe form of major depressive episode. Symptoms are

exaggerated, and interest or pleasure in virtually all activities is lost.

mental imagery. A method of stress reduction that employs the

imagination. The individual focuses imagination on a scenario that is

particularly relaxing to him or her (e.g., a scene on a quiet seashore, a

mountain atmosphere, or floating through the air on a fluffy white cloud).

milieu therapy. Also called therapeutic community, or therapeutic

environment. This type of therapy consists of a scientific structuring of the

environment in order to effect behavioral changes and to improve the

individual’s psychological health and functioning.

modeling. Learning new behaviors by imitating the behaviors of others.

mood. An individual’s sustained emotional tone, which significantly

influences behavior, personality, and perception.

mourning. The psychological process (or stages) through which the

individual passes on the way to successful adaptation to the loss

of a valued object.

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narcissistic personality disorder. A disorder characterized by an

exaggerated sense of self-worth. An individual lacks empathy and is

hypersensitive to the evaluation of others.

neologism. New words a psychotic person invents that are meaningless to

others but that have symbolic meaning to that individual.

neuroleptic. Antipsychotic medication used to prevent or control psychotic

symptoms.

neuroleptic malignant syndrome (NMS). A rare but potentially fatal

complication of treatment with neuroleptic drugs. Symptoms include

severe muscle rigidity, high fever, tachycardia, fluctuations in blood

pressure, diaphoresis, and rapid deterioration of mental status to stupor

and coma.

neurotransmitter. A chemical that is stored in the axon terminals of the

presynaptic neuron. An electrical impulse through the neuron stimulates

the release of the neurotransmitter into the synaptic cleft, which in turn

determines whether another electrical impulse is generated.

nursing diagnosis. A clinical judgment about individual, family, or

community responses to actual and potential health problems/life

processes. Nursing diagnoses provide the basis for selection of nursing

interventions to achieve outcomes for which the nurse is accountable.

nursing process. A dynamic, systematic process by which nurses assess,

diagnose, and identify outcomes; and plan, implement, and evaluate

nursing care. It has been called “nursing’s scientific methodology.”

Nursing process gives order and consistency to nursing intervention.

obesity. The state of having a body mass index of 30 or above.

object constancy. The phase in the separation/individuation process when

the child learns to relate to objects in an effective, constant manner. A

sense of separateness is established, and the child is able to internalize a

sustained image of the loved object or person when out of sight.

obsessive-compulsive disorder. Recurrent thoughts or ideas (obsessions)

that an individual is unable to put out of his or her mind, and actions that

an individual is unable to refrain from performing (compulsions). The

obsessions and compulsions are severe enough to interfere with social

and occupational functioning.

oculogyric crisis. An attack of involuntary deviation and fixation of the

eyeballs, usually in the upward position. It may last for several minutes

or hours and may occur as an extrapyramidal side effect of some antipsy-

chotic medications.

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panic disorder. A disorder characterized by recurrent panic attacks, the

onset of which is unpredictable and manifested by intense apprehension,

fear, or terror, often associated with feelings of impending doom and

accompanied by intense physical discomfort.

paranoia. A term that implies extreme suspiciousness. Paranoid

schizophrenia is characterized by persecutory delusions and

hallucinations of a threatening nature.

passive-aggressive behavior. Behavior that defends an individual’s own

basic rights by expressing resistance to social and occupational demands.

Sometimes called indirect aggression, this behavior takes the form of sly,

devious, and undermining actions that express the opposite of what the

person is really feeling.

pedophilia. Recurrent urges and sexually arousing fantasies involving

sexual activity with a prepubescent child.

perseveration. Persistent repetition of the same word or idea in response

to different questions.

personality. Deeply ingrained patterns of behavior, which include the way

one relates to, perceives, and thinks about the environment and oneself.

phobia. An irrational fear.

phobia, social. The fear of being humiliated in social situations.

postpartum depression. Depression that occurs during the postpartum

period. It may be related to hormonal changes, tryptophan metabolism,

or alterations in membrane transport during the early postpartum period.

Other predisposing factors may also be influential.

post-traumatic stress disorder (PTSD). A syndrome of symptoms that

develop following a psychologically distressing event that is outside the

range of usual human experience (e.g., rape, war). The individual is

unable to put the experience out of his or her mind and has nightmares,

flashbacks, and panic attacks.

preassaultive tension state. Behaviors predictive of potential violence.

They include excessive motor activity, tense posture, defiant affect,

clenched teeth and fists, and other arguing, demanding, and threatening

behaviors.

priapism. Prolonged painful penile erection; may occur as an adverse effect

of some antidepressant medications, particularly trazodone.

progressive relaxation. A method of deep muscle relaxation in which each

muscle group is alternately tensed and relaxed in a systematic order, with

the person concentrating on the contrast of sensations experienced from

tensing and relaxing.

projection. Attributing to another person feelings or impulses unacceptable

to oneself.

pseudodementia. Symptoms of depression that mimic those of dementia.

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psychomotor retardation. Extreme slowdown of physical movements.

Posture slumps, speech is slowed, and digestion becomes sluggish.

Common in severe depression.

psychotic disorder. A serious psychiatric disorder in which there is a gross

disorganization of the personality, a marked disturbance in reality testing,

and the impairment of interpersonal functioning and relationship to the

external world.

rape. The expression of power and dominance by means of sexual violence,

most commonly by men over women, although men may also be rape

victims. Rape is considered an act of aggression, not of passion.

rapport. The development between two people in a relationship of special

feelings based on mutual acceptance, warmth, friendliness, common

interest, a sense of trust, and a nonjudgmental attitude.

rationalization. Attempting to make excuses or formulate logical reasons

to justify unacceptable feelings or behaviors.

reaction formation. Preventing unacceptable or undesirable thoughts or

behaviors from being expressed by exaggerating opposite thoughts or

types of behaviors.

reframing. Changing the conceptual or emotional setting or viewpoint in

relation to which a situation is experienced and placing it in another

frame that fits the “facts” of the same concrete situation equally well or

even better and thereby changing its entire meaning.

regression. A retreat to an earlier level of development and the comfort

measures associated with that level of functioning.

reminiscence therapy. A process of life review by elderly individuals that

promotes self-esteem and provides assistance in working through

unresolved conflicts from the past.

repression. The involuntary blocking of unpleasant feelings and experiences

from one’s awareness.

ritualistic behavior. Purposeless activities that an individual performs

repeatedly in an effort to decrease anxiety (e.g., hand washing); common

in obsessive-compulsive disorder.

schizoid personality disorder. A profound defect in the ability to form

personal relationships or to respond to others in any meaningful,

emotional way.

schizotypal personality disorder. A disorder characterized by odd and

eccentric behavior, not decompensating to the level of schizophrenia.

self-esteem. The amount of regard or respect that individuals have for

themselves. It is a measure of worth that they place on their abilities and

judgments.

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shaman. The Native American “medicine man” or folk healer.

shaping. In learning, one shapes the behavior of another by giving

reinforcements for increasingly closer approximations to the desired

behavior.

short-term memory. The ability to remember events that occurred very

recently. This ability deteriorates with age.

social skills training. Educational opportunities through role-play for the

person with schizophrenia to learn appropriate social interaction skills

and functional skills that are relevant to daily living.

splitting. A primitive ego defense mechanism in which the person is unable

to integrate and accept both positive and negative feelings. In their view,

people, including themselves, and life situations are all good or all bad.

This trait is common in borderline personality disorder.

stereotyping. The process of classifying all individuals from the same

culture or ethnic group as identical.

sublimation. The rechanneling of personally and/or socially unacceptable

drives or impulses into activities that are tolerable and constructive.

substance abuse. Use of psychoactive drugs that poses significant hazards

to health and interferes with social, occupational, psychological, or

physical functioning.

substance dependence. Physical dependence is identified by the inability

to stop using a substance despite attempts to do so; a continual use of

the substance despite adverse consequences; a developing tolerance; and

the development of withdrawal symptoms upon cessation or decreased

intake. Psychological dependence is said to exist when a substance is

perceived by the user to be necessary to maintain an optimal state of

personal well-being, interpersonal relations, or skill performance.

substitution therapy. The use of various medications to decrease the

intensity of symptoms in an individual who is withdrawing from, or

experiencing the effects of excessive use of, substances.

superego. One of the three elements of the personality identified by Freud;

represents the conscience and the culturally determined restrictions that

are placed on an individual.

suppression. The voluntary blocking from one’s awareness of unpleasant

feelings and experiences.

symbiotic relationship. A type of “psychic fusion” that occurs between

two people; it is unhealthy in that severe anxiety is generated in one or

both if separation is indicated. A symbiotic relationship is normal

between infant and mother.

sympathy. The actual sharing of another’s thoughts and behaviors. Differs

from empathy in that with empathy one experiences an objective

understanding of what another is feeling rather than actually sharing

those feelings.

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systematic desensitization. A treatment for phobias in which the

individual is taught to relax and then asked to imagine various compo-

nents of the phobic stimulus on a graded hierarchy, moving from that

which produces the least fear to that which produces the most.

tangentiality. The inability to get to the point of a story. The speaker

introduces many unrelated topics until the original topic of discussion is

lost.

tardive dyskinesia. Syndrome of symptoms characterized by bizarre facial

and tongue movements, a stiff neck, and difficulty swallowing. It may

occur as an adverse effect of long-term therapy with some antipsychotic

medications.

thought-stopping technique. A self-taught technique that an individual

uses each time he or she wishes to eliminate intrusive or negative

unwanted thoughts from awareness.

triangles. A three-person emotional configuration that is considered the

basic building block of the family system. When anxiety becomes too

great between two family members, a third person is brought in to form a

triangle. Triangles are dysfunctional in that they offer relief from anxiety

through diversion rather than through resolution of the issue.

trichotillomania. The recurrent failure to resist impulses to pull out one’s

own hair.

tyramine. An amino acid found in aged cheeses or other aged, overripe,

and fermented foods; broad beans; pickled herring; beef or chicken liver;

preserved meats; beer and wine; yeast products; chocolate; caffeinated

drinks; canned figs; sour cream; yogurt; soy sauce; and some over-the-

counter cold medications and diet pills. If foods high in tyramine content

are consumed when an individual is taking MAOIs, a potentially life-

threatening syndrome called hypertensive crisis can result.

unconditional positive regard. Carl Rogers’ term for the respect and

dignity of an individual regardless of his or her unacceptable behavior.

undoing. A mechanism used to symbolically negate or cancel out a

previous action or experience that one finds intolerable.

universality. One curative factor of groups (identified by Yalom) in which

individuals realize that they are not alone in a problem and in the

thoughts and feelings they are experiencing. Anxiety is relieved by the

support and understanding of others in the group who share similar

experiences.

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values. Personal beliefs about the truth, beauty, or worth of a thought,

object, or behavior that influences an individual’s actions.

velorio. In the Mexican-American culture, large numbers of family and

friends gather following a death for a festive watch over the body of the

deceased person before burial.

Wernicke’s encephalopathy. A brain disorder caused by thiamine

deficiency and characterized by visual disturbances, ataxia, somnolence,

stupor, and, without thiamine replacement, death.

word salad. A group of words that are put together in a random fashion

without any logical connection.

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Note: Page numbers followed by f refer to figures/illustrations.

Abbreviations, 179–180

Abilify (aripiprazole), 128

Abnormal involuntary movement scale (AIMS),

41–44

Abused substances. See Substance use/abuse.

Abusive behavior, 168–171

child as victim of, 169, 170

disorders related to, DSM-IV-TR categories

of, 193

elderly as victim of, 175

escalation of anger to, 163–164

reporting of, 16

sexual, 169–170, 171

Addiction, 65. See also Substance use/abuse.

ADHD (attention deficit/hyperactivity disorder),

96–97

treatment of, 96–97, 114–115

Aging, 172–173. See also Geriatric patient(s).

AIMS (abnormal involuntary movement scale),

41–44

Alcoholism, screening for, 33

Alprazolam (Xanax), 127

Alternative therapies, 111

Alzheimer’s disease, 61, 62

vs. dementia with Lewy bodies, 63

Ambien (zolpidem), 162

Amitriptyline (Elavil), 128

Amnestic disorders, 61

DSM-IV-TR categories of, 183

AN (anorexia nervosa), 90

Anafranil (clomipramine), 132

Anger, 163–164

Anorexia nervosa (AN), 90

Antianxiety agents, 112–113

Antidepressants, 113

use of, in children, 115

Antiparkinsonian agents, 115

Antipsychotic agents, 113–114

adverse effects of, 116, 118–119

Anxiety disorders, 78–83

diagnosis of, tests preceding, 120

DSM-IV-TR categories of, 188

pharmacotherapy for, 112–113

Anxiolytics, 112–113

APIE (assessment-problem-intervention-

evaluation) charting, 58

Aripiprazole (Abilify), 128

Arkansas scale, for rating depression, 46–48

Artane (trihexyphenidyl), 159

Assault. See Abusive behavior.

Assessment, psychiatric, 20–58

Assessment-problem-intervention-evaluation

(APIE) charting, 58

Atarax (hydroxyzine), 140

Ativan (lorazepam), 143

Attention deficit/hyperactivity disorder (ADHD),

96–97

treatment of, 96–97, 114–115

Autonomic nervous system, 13

Battering, cycle of, 168. See also Abusive

behavior.

Benztropine (Cogentin), 129

Bipolar disorders, 73

DSM-IV-TR categories of, 188

BN (bulimia nervosa), 91

Borderline personality disorder (BPD), 93

Brain, function-specific areas of, 11f

limbic system of, 12f

Bulimia nervosa (BN), 91

Bupropion (Wellbutrin), 129

Buspirone (BuSpar), 130

CAGE screening questionnaire, for alcoholism,

Carbamazepine (Tegretol), 130

CD (conduct disorder), 97

Celexa (citalopram), 132

Central nervous system, 10, 11f, 12f

Charting/documentation systems, 57–58

Child(ren), 6–9

abuse of, 169, 170

antidepressant use in, 115

developmental tasks faced by, 6–9

psychiatric disorders in, 95–97

DSM-IV-TR categories of, 180–182

Chlordiazepoxide (Librium), 131

Chlorpromazine (Thorazine), 131

Citalopram (Celexa), 132

Clock-drawing test, 50

Clomipramine (Anafranil), 132

Clonazepam (Klonopin), 133

Clozapine (Clozaril), 133

monitoring of users of, 121

Cogentin (benztropine), 129

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Cognitive behavioral therapy, 109–110

Cognitive disorders, 61–64

DSM-IV-TR categories of, 182–183

Commitment, types of, 16

Communication, 101–102

nonverbal, 100

Complementary therapies, 111

Complicated grief, 167

Compulsions, 81

Conduct disorder (CD), 97

Confidentiality, 15–16

Consent, informed, 18

Corgard (nadolol), 146

Crisis intervention, 163

Cultural perceptions, differences among, 51–54

Cyclothymic disorder, 73

Cymbalta (duloxetine), 136

Dalmane (flurazepam), 138

D-Ark scale (Arkansas depression rating scale),

46–48

Data-action-response (DAR) charting, 57

Death and dying (Kübler-Ross), 167

Defense mechanisms, 5–6

Delirium, 61

DSM-IV-TR categories of, 182

Dementia, 61–64, 173

Alzheimer’s, 61, 62

vs. dementia with Lewy bodies, 63

diagnosis of, tests preceding, 120

DSM-IV-TR categories of, 182

Depakote (divalproex), 135

Dependence, 64, 66. See also Substance

use/abuse.

Depression, 73, 74, 75

DSM-IV-TR categories of, 188

geriatric, 173

scale for rating, 49

postpartum, 77

scale for rating, 44–46

tests preceding diagnosis of, 121

scales for rating, 44–49

tests preceding diagnosis of, 121

treatment of, 110, 113

in children, 115

Desipramine (Norpramin), 134

Desyrel (trazodone), 158

Developmental tasks, 6–9

Diagnostic and Statistical Manual of Mental

Disorders, 38–40, 180–193

Diathesis-stress model, 4

Diazepam (Valium), 134

Disasters, 166

Divalproex (Depakote), 135

Documentation/charting systems, 57–58

Doxepin (Sinequan), 135

Drug abuse. See Substance use/abuse.

Drug-herbal interactions, 116

Drug therapy, 112–115, 127–162

DSM-IV-TR, 38–40, 180–193

Duloxetine (Cymbalta), 136

Dying, 167

Dyskinesia, tardive, in users of antipsychotic

drugs, 116

Dysthymic disorder, 73

Eating disorders, 89–91

DSM-IV-TR categories of, 190

Edinburgh Postnatal Depression Scale (EPDS),

44–46

Effexor (venlafaxine), 160

Elavil (amitriptyline), 128

Elderly. See Geriatric patient(s).

Emsam (selegiline), 154

EPDS (Edinburgh Postnatal Depression Scale),

44–46

Erikson, E., developmental tasks identified by,

7–8

Escitalopram (Lexapro), 136

Eskalith (lithium), 142

Eszopiclone (Lunesta), 137

Ethical issues, 15–18

Ethnicity, 50

Ethnocultural assessment tool, 55–56

Ethnocultural perceptions, differences among,

51–54

Extrapyramidal symptoms, of adverse effects of

antipsychotic agents, 116

Family therapy, 107

Fight-or-flight response, 4

Fluoxetine (Prozac), 137

Fluphenazine (Prolixin), 138

Flurazepam (Dalmane), 138

Fluvoxamine (Luvox), 139

Focus charting, 57

Freudian theory, 5, 6–7

Gabapentin (Neurontin), 139

GAD (generalized anxiety disorder), 80

GAF (global assessment of functioning scale),

40–41

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Gender, 86

Gender identity disorders, 87, 89

DSM-IV-TR categories of, 190

General adaptation syndrome, 4

Generalized anxiety disorder (GAD), 80

Genogram(s), 107, 108f, 109f

Geodon (ziprasidone), 161

Geriatric patient(s), 172–176

abuse of, 175

assessment of, 172

dementia in, 173

depression in, 173

scale for rating, 49

pharmacokinetics in, 117, 174–175

pseudodementia in, 173

schizophrenia in, 173–174

suicide by, 176

Global assessment of functioning scale (GAF),

40–41

Grief, 167

Group interventions, 103–106

Hallucinations, 70

Haloperidol (Haldol), 140

Health, mental, 2, 3

sexual, 86

Health Insurance Portability and Accountability

Act (HIPAA), 16

Herbals, 25

drug interactions with, 116

Hierarchy of needs, identification of, by

Maslow, 3

HIPAA (Health Insurance Portability and

Accountability Act), 16

Hydroxyzine (Atarax), 140

Hyperactivity, and attention deficit, 96–97

treatment of, 96–97, 114–115

Hypoactive sexual desire disorder, 88

Illness, mental, 2. See also Psychiatric disor-

ders.

biological aspects of, 9

legal definition of, 2

Imipramine (Tofranil), 141

Impulse transmission, at synapse, 14f

Incest, 170

Inderal (propranolol), 151

Informed consent, 18

Internet addiction, 65

Interpersonal development, stages of, 7, 9

Interventions, 98–111, 163

Intoxication, 65. See also Substance use/abuse.

Invega (paliperidone), 149

Involuntary commitment, 16

Involuntary movement, abnormal, assessment

of, 41–44

Jahoda, M., mental health potentiators identi-

fied by, 3

Klonopin (clonazepam), 133

Laboratory reference values, 122–125

Laboratory tests, preceding diagnoses of

psychiatric disorders, 120–121

Lamotrigine (Lamictal), 141

Late-onset schizophrenia, 173–174

Legal issues, 15–18

Lewy bodies, dementia with, 63

Lexapro (escitalopram), 136

Librium (chlordiazepoxide), 131

Limbic system, 12f

Lithium (Eskalith), 142

Lorazepam (Ativan), 143

Loxapine (Loxitane), 143

Luminal (phenobarbital), 150

Lunesta (eszopiclone), 137

Luvox (fluvoxamine), 139

Mahler, M., developmental tasks identified by, 8

Mania, 76

diagnosis of, tests preceding, 121

MAOIs (monoamine oxidase inhibitors), 145

food/medication restrictions for users of,

117–118

Maslow, A., needs hierarchy identified by, 3

Medical history, recording of, 25–31

Mellaril (thioridazine), 156

Memory, problems with, 61

DSM-IV-TR categories of, 183

Mental health, 2

identification of potentiators of, by Jahoda, 3

Mental illness, 2. See also Psychiatric

disorders.

biological aspects of, 9

legal definition of, 2

Mental retardation, 95

Mental status assessment, 34–38

Michigan Alcoholism Screening Test, 33

Mind-body dualism, 9

Mini–Mental State Examination, 50

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Mirtazapine (Remeron), 144

Molindone (Moban), 144

Monoamine oxidase inhibitors (MAOIs), 145

food/medication restrictions for users of,

117–118

Mood disorders, 72–78. See also Depression.

DSM-IV-TR categories of, 188

Mood stabilizers, 113

therapeutic plasma levels of, 120

Movement, abnormal involuntary, assessment

of, 41–44

adverse effects of antipsychotics on, 116

Nadolol (Corgard), 146

NANDA (North American Nursing Diagnosis

Association) nomenclature, 196–201

behaviors correlated with, 194–196

Needs hierarchy, identification of, by Maslow, 3

Nefazodone (Serzone), 146

Neglect, 170. See also Abusive behavior.

Nervous system, 10–13

autonomic, 13

central, 10, 11f, 12f

peripheral, 10

Neuroleptics, 113–114

adverse effects of, 116, 118–119

Neurontin (gabapentin), 139

Neurotransmitters, 15

Nonverbal communication, 100

Norpramin (desipramine), 134

North American Nursing Diagnosis Association

(NANDA) nomenclature, 196–201

behaviors correlated with, 194–196

Nortriptyline (Pamelor), 147

Object relations theory, of personality develop-

ment, 8

Obsessive-compulsive disorder, 81

Obsessive-compulsive personality disorder, 92

Olanzapine (Zyprexa), 147

Olanzapine/fluoxetine (Symbax), 148

Older population. See Geriatric patient(s).

Oppositional defiant disorder, 97

Orap (pimozide), 150

Orientation, sexual, 86

Oxazepam (Serax), 148

Painful sexual dysfunctions, 86

Paliperidone (Invega), 149

Pamelor (nortriptyline), 147

Paraphilias, 87, 89

DSM-IV-TR categories of, 190

Parasympathetic nervous system effects, 13

Parkinsonism, pharmacotherapy for, 115

Paroxetine (Paxil), 149

Patient’s Bill of Rights, 18

Paxil (paroxetine), 149

Peplau, H., developmental tasks identified by, 9

phases of relationship development, 99

Peripheral nervous system, 10

Personality development, stages of, 6–9

Personality disorders, 92–94

Pharmacokinetics, 114

in elderly, 117, 174–175

Pharmacotherapy, 112–115, 127–162

Phenobarbital (Luminal), 150

PIE (problem-intervention-evaluation) charting, 58

Pimozide (Orap), 150

POR (problem-oriented record), 57

Postpartum depression, 77

diagnosis of, tests preceding, 121

scale for rating, 44–46

Posttraumatic stress disorder (PTSD), 82

Problem-intervention-evaluation (PIE) charting,

Problem-oriented record (POR), 57

Prolixin (fluphenazine), 138

Propranolol (Inderal), 151

Prozac (fluoxetine), 137

Pseudodementia, 61, 173

Psychiatric assessment, 20–58

Psychiatric disorders, 61–97

DSM-IV-TR categories of, 180–193

tests preceding diagnoses of, 120–121

Psychiatric interventions, 98–111

Psychiatric terminology, 201–214

Psychoanalytic theory, 5

Psychosexual development, stages of, 6–7

Psychosocial theory, of personality develop-

ment, 7–8

Psychotic disorders, 67–72

DSM-IV-TR categories of, 187

in geriatric patients, 173–174

tests preceding diagnosis of, 121

treatment of, 113–114

adverse effects of agents used in, 116,

118–119

Psychotropic drugs, 112–115, 127–162

interactions of, with herbals, 116

PTSD (posttraumatic stress disorder), 82

Quetiapine (Seroquil), 151

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Ramelteon (Rozerem), 152

Refusal of treatment, right to, 18

Remeron (mirtazapine), 144

Restraints, 17–18

Retardation, mental, 95

Risperidone (Risperdal), 153

Rozerem (ramelteon), 152

Safety plan, to escape abuser, 168

Schizophrenia, 67–72

diagnosis of, tests preceding, 121

DSM-IV-TR categories of, 187

late-onset, 173–174

treatment of, 113–114

adverse effects of agents used in, 116,

118–119

Screening, for alcoholism, 33

Seclusion, 17

Section 302 commitment, 16

Selegiline (Emsam), 154

Senior citizens. See Geriatric patient(s).

Serax (oxazepam), 148

Seroquil (quetiapine), 151

Serotonin syndrome, 119

Sertraline (Zoloft), 155

Serzone (nefazodone), 146

Sex, 86

Sexual abuse, 169–170, 171

Sexual desire disorder, hypoactive, 88

Sexual dysfunctions, 86, 88, 89

DSM-IV-TR categories of, 189–190

Sexual health, 86

Sexual orientation, 86

Short Michigan Alcoholism Screening Test, 33

SIGECAP mnemonic, for depression, 74

Sinequan (doxepin), 135

Sleep disorders, DSM-IV-TR categories of,

190–191

Somatoform disorders, 84–85

DSM-IV-TR categories of, 189

Sonata (zalephon), 161

Stress, response to, 4

traumatic, sequelae of, 82

Substance use/abuse, 64–67

disorders related to, 64–67

DSM-IV-TR categories of, 183–187

history of, recording of, 31–32

Suicide, 164–166

by elderly, 176

Sullivan, H. S., developmental tasks identified

by, 7

Symbax (olanzapine/fluoxetine), 148

Sympathetic nervous system effects, 13

Synapse, impulse transmission at, 14f

Tardive dyskinesia, in users of antipsychotic

drugs, 116

Tegretol (carbamazepine), 130

Terrorism, 166

Therapeutic milieu, 103

Therapeutic relationship, 98–99

Thioridazine (Mellaril), 156

Thorazine (chlorpromazine), 131

Thought disorders, 71

302 (Section 302) commitment, 16

Tofranil (imipramine), 141

Tolerance, 65. See also Substance

use/abuse.

Topiramate (Topamax), 157

Topographic model, of mind, 5

Traumatic stress, sequelae of, 82

Trazodone (Desyrel), 158

Trihexyphenidyl (Artane), 159

Uncomplicated grief, 167

Valium (diazepam), 134

Venlafaxine (Effexor), 160

Violence. See Abusive behavior.

Voluntary commitment, 16

War, 166

Wellbutrin (bupropion), 129

Withdrawal, 65. See also Substance

use/abuse.

Xanax (alprazolam), 127

Yalom, A., positive group experiences identified

by, 106

Zalephon (Sonata), 161

Ziprasidone (Geodon), 161

Zoloft (sertraline), 155

Zolpidem (Ambien), 162

Zyprexa (olanzapine), 147

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