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Copyright © 2008 by F. A. Davis.
1
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
Mahlers 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
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Copyright © 2008 by F. A. Davis.
2
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
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Copyright © 2008 by F. A. Davis.
3
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
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Copyright © 2008 by F. A. Davis.
4
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
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Copyright © 2008 by F. A. Davis.
5
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
Copyright © 2008 by F. A. Davis.
6
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.
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Copyright © 2008 by F. A. Davis.
7
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
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Copyright © 2008 by F. A. Davis.
8
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
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Copyright © 2008 by F. A. Davis.
9
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
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Copyright © 2008 by F. A. Davis.
10
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
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11
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
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Copyright © 2008 by F. A. Davis.
12
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
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13
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
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Copyright © 2008 by F. A. Davis.
14
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
Na
+
Na
+
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Copyright © 2008 by F. A. Davis.
15
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
Inhibitory
Excitatory
Inhibitory
Excitatory
Fine movement, emotional behavior.
Implicated in schizophrenia and
Parkinsons.
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)
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Copyright © 2008 by F. A. Davis.
16
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
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17
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
(Text continued on following page)
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18
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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ASSESS
19
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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20
ASSESS
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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21
ASSESS
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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22
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
ASSESS
23
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24
ASSESS
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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25
ASSESS
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
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26
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.
ASSESS
Head Injury
Loss of Consciousness
(LOC); how long?
Parkinsons Disease
Seizure Disorder
Other
Tremors
Stroke
Dementia
Multiple Sclerosis
Surgery
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27
ASSESS
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
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28
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
ASSESS
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
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29
ASSESS
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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30
ASSESS
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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31
ASSESS
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)
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32
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:
ASSESS
Modified from Townsend 5th ed., 2006, with permission
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33
CAGE Screening Questionnaire
(C) Have you ever felt the need to Cut Down on your drinking/use of
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.
All Rights Reserved.)
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)
ASSESS
(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)
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Age
Race/Ethnicity
Educational Level
Occupation
34
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
ASSESS
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35
ASSESS
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)
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36
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
ASSESS
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37
ASSESS
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)
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38
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:
ASSESS
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39
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
(Copyright 2000). American Psychiatric Association.
ASSESS
*See Tools Tab for DSM-IV-TR Classification/Codes
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Text/image rights not available.
40
ASSESS
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
91
90
81
80
71
70
61
60
51
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).
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41
Global Assessment of Functioning (GAF) Scale
Note: Use intermediate codes when appropriate
Code (e.g., 45, 68, 72).
50
41
40
31
30
21
20
11
10
1
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.
ASSESS
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)
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42
ASSESS
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.
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43
ASSESS
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
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
(Continued on following page)
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44
ASSESS
11. Current Problems With
Teeth and/or Dentures
12. Does Client Usually Wear
Dentures?
0: No 1: Yes
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
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45
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)
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46
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.
SOURCE: © 1987 The Royal College of Psychiatrists. The Edinburgh Post-
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
ASSESS
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47
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
ASSESS
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48
ASSESS
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.
“Depression-Arkansas Scale (D-ARK Scale),” Copyright 1997
University of Arkansas for Medical Sciences
4301 West Markham Street
Little Rock, AR 72205
Used with permission.
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49
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).
ASSESS
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50
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.
ASSESS
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51
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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)
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52
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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.
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53
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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.
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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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55
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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)
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56
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
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57
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
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
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ASSESS
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.
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59
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 Alzheimers Type (AD) (table) 62
Dementia of the Alzheimers 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
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60
Schizophrenia, Four As 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
DISORDERS/
INTERV
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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 Alzheimers 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 Alzheimers 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,
B
12
, 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-Alzheimers
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 Alzheimers 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.
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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).
64
DISORDERS/
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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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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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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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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 As of Schizophrenia
Eugen Bleuler in 1911 proposed four basic diagnostic areas for
characterizing schizophrenia. These became the 4 As:
A: Inappropriate Affect
A: Loosening of Associations
A: Autistic Thoughts
A: Ambivalence
These four As 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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DISORDERS/
INTERV
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/
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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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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
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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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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.
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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
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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
Tourettes, 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
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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:
previous
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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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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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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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-
related
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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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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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.
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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
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DISORDERS/
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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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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,
UA
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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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, Aspergers, 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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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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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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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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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 elses 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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DISORDERS/
INTERV
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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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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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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DISORDERS/
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Common Genogram Symbols
From Townsend 5e 2006, with permission.
A
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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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
50
71
72
33
52
52
23
23
21
16
16
32
32
1956
CA
1976 MI
1968
CA
1985 MI
1983
CA
1982
MI
1984
CVA
43
A
42
Abortion
1989
(m) 1958
(d) 1960
( Patient )
86
92
100
80
65
73
(s) 1961
(m) 1961
1945
CA
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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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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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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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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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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,
Parkinsons 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
1
/
2
12–15 h) is a better choice than
diazepam (T
1
/
2
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
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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: 103–105F 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
12
,
folate, UA, HIV, FTA-ABS (syphilis), depression
inventories/rating scales (Geriatric Rating Scale)
(R/O depression), CT/MRI
04Pederson (F)-04 6/25/07 7:48 PM Page 120
Copyright © 2008 by F. A. Davis.
121
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
3
or granulocyte count 1500 mm
3
— 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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Copyright © 2008 by F. A. Davis.
122
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
Ca
(calcium)
Calcitonin
Carbon dioxide (CO
2
)
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
/L
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
/L
167–1317 nmol sec
1
/L
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
Copyright © 2008 by F. A. Davis.
123
General Chemistry (Continued)
Lab Conventional SI Units
Iron (Fe)
Iron binding
capacity (IBC)
K
(potassium)
Lactic acid
LDH (lactic
dehydrogenase)
Lipase
Magnesium
Mg

(magnesium)
Na
(sodium)
Osmolality
Phosphorus
Potassium (K
)
Prealbumin
Protein, total
PSA
Pyruvate
Sodium (Na
)
T3
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
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
/L
Up to 2 arb. unit
0.8–1.3 mmol/L
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
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
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Copyright © 2008 by F. A. Davis.
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
T
3
Total 75–195 ng/100 mL 1.16–3.00 nmol/L
T
3
Uptake (RT
3
U) 25%–35% 0.25–0.35
T
3
Uptake Ratio 0.1–1.35 0.1–0.35
T
4
Total 4–12 g/100 mL 52–154 nmol/L
T
4
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
3
Female: 4.2–5.9 million/mm
3
Male: 13–18 g/100 mL
Female: 12–16 g/100 mL
Male: 45%–52%
Female: 37%–48%
4,300–10,800/mm
3
80–85 mL/kg
4.6–6.2 10
12
/L
4.2–5.9 10
12
/L
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
9
/L
0–5%
0–1%
1%–4%
25%–40%
10%–20%
60%–80%
2%–8%
54%–75%
150,000–350,000/mm
3
Male: 1–13 mm/hr
Female: 1–20 mm/hr
0.03–0.08 10
9
/L
0–0.01 10
9
/L
0.01–0.04 10
9
/L
0.25–0.40 10
9
/L
0.10–0.20 10
9
/L
0.60–0.80 10
9
/L
0.02–0.08 10
9
/L
0.54–0.75 10
9
/L
150–350 10
9
/L
Male: 1–13 mm/hr
Female: 1–20 mm/hr
04Pederson (F)-04 6/25/07 7:48 PM Page 124
Copyright © 2008 by F. A. Davis.
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
Copyright © 2008 by F. A. Davis.
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
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Copyright © 2008 by F. A. Davis.
DRUGS A-Z
127
Psychotropic Drugs A – Z (Alphabetical Listing)
Psychotropic Drug Tables that follow include each drug’s half life (T
1
/
2
), 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
T
1
/
2
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.
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Copyright © 2008 by F. A. Davis.
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-
related
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)
T
1
/
2
10–50 h
Protein binding
95%
Aripiprazole
(Abilify)
T
1
/
2
75 h;
dehydroari-
piprazole
94 h
Protein binding
 99%
05Pederson (F)-05 6/25/07 8:45 PM Page 128
Copyright © 2008 by F. A. Davis.
DRUGS A-Z
129
Benztropine
(Cogentin, Apo-
Benztropine)
T
1
/
2
Unknown
Bupropion
(Wellbutrin,
Wellbutrin SR,
Wellbutrin XL)
T
1
/
2
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
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Copyright © 2008 by F. A. Davis.
DRUGS A-Z
130
Buspirone
(BuSpar)
T
1
/
2
2–3 h
Protein binding
95%
Carbamazepine
(Tegretol, Tegre-
tol XR, Equetro,
Epitol, Apo-
Carbamazepine,
Tegretol CR)
T
1
/
2
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
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Copyright © 2008 by F. A. Davis.
DRUGS A-Z
131
Chlordiazepoxide
(Librium,
Libritabs, Apo-
Chlordiaze-
poxide)
T
1
/
2
5–30 h
Chlorpromazine
(Thorazine, Thor-
Prom, Chlorpro-
manyl, Largactil,
Novo-Chlorpro-
mazine)
T
1
/
2
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
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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)
T
1
/
2
35 h
Clomipramine
(Anafranil, Apo-
Clomipramine)
T
1
/
2
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).
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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)
T
1
/
2
18–50 h
Clozapine
(Clozaril,
FazaClo)
T
1
/
2
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/
mm
3
—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-
related
psychosis
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Copyright © 2008 by F. A. Davis.
DRUGS A-Z
134
Desipramine
(Norpramin,
Pertofrane)
T
1
/
2
12–27 h
Protein binding
90%–92%
Diazepam
(Valium, Apo-
Diazepam,
Vivol )
T
1
/
2
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
Copyright © 2008 by F. A. Davis.
135
DRUGS A-Z
Divalproex
sodium
(Depakote,
Depakote ER,
Epival)
[Valproate]
T
1
/
2
5–20 h
Doxepin
(Sinequan,
Zonalon,
Triadapin)
T
1
/
2
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
po
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
Copyright © 2008 by F. A. Davis.
DRUGS A-Z
136
Duloxetine
(Cymbalta)
T
1
/
2
12 h
Protein
binding
90%
Escitalopram
(Lexapro)
T
1
/
2
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
1
/
2
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