Johnson and Vanderhoef PMHNP Certification Review Manual

4TH
EDITION
Review and Resource Manual
PSYCHIATRIC-MENTAL HEALTH

Nurse Practitioner
Psychiatric-Mental Health
NURSE PRACTITIONER PSYCHIATRIC-
MENTAL HEALTH
Review and Resource Manual, 4th Edition
Are you looking into how to advance your professional development through
NURSE
certification? Need a reliable and credible reference resource? No matter where you
are in the process, make sure you have the most valuable review and resource tool
at your disposal.
The Nursing Knowledge Center’s Psychiatric-Mental Health Nurse Practitioner

Review and Resource Manual is a must-have tool for nurses planning to take the
American Nurses Credentialing Center’s (ANCC’s) Psychiatric-Mental Health
PRACTITIONER
Nurse Practitioner certification exam.
4th Edition
Based on the official ANCC certification exam test content outline, this
review and resource manual will help you:
n S
tudy and analyze comprehensive material and concepts written by
nursing experts.
n D
evelop a recommended seven-step plan to equip you for the exam
and map out what to do on the day of the exam.
n P
repare for and familiarize yourself with psychological-mental health practitioner
standards of practice.
n A
nd much more ... Nursing Certification Review Manual
Make the Psychiatric-Mental Health Nurse Practitioner Review Continuing Education Resource
and Resource Manual a key resource in your certification preparation. Clinical Practice Resource
Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC

Dawn Vanderhoef, PhD, DNP, PMHNP-BC, PMHCNS-BC
www.nursingknowledgecenter.org
Completion of this or any other course(s)/material(s) does not imply eligibility for certification or successful performance on any certification examination, nor is
it a requirement to qualify for certification. The American Nurses Credentialing Center (ANCC) does not endorse any products or services.
AMERICAN NURSES ASSOCIATION

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Nursing Knowledge Center is part of the American Nurses Association.
Psychiatric–
Mental
Health Nurse
Practitioner
4th Edition
CONTINUING EDUCATION SOURCE
NURSING CERTIFICATION REVIEW MANUAL
CLINICAL PRACTICE RESOURCE
Published by American Nurses Credentialing Center

NURSING
KNOWLEDGE
CENTER
Library of Congress Cataloging-in-Publication Data
Names: Johnson, Kathryn, 1947-, author. | Vanderhoef, Dawn, author. |

Nursing Knowledge Center, publisher.
Title: Psychiatric-mental health nurse practitioner review and resource
manual / Kathryn Johnson, Dawn Vanderhoe.
Other titles: Psychiatric-mental health nurse practitioner review manual
Description: 4th edition. | Silver Spring, MD : Nursing Knowledge Center,
American Nurses Association, 2016. | Preceded by Psychiatric-mental health
nurse practitioner review manual / by Kathryn Johnson and Dawn Vanderhoef.
3rd edition. 2013. | Includes bibliographical references and index.
Identifiers: LCCN 2016012871| ISBN 9781935213796 (pbk.) | ISBN 9781935213802
(ePub) | ISBN 9781935213819 (prc) | ISBN 9781935213826 (epdf)
Subjects: | MESH: Psychiatric Nursing--methods | Education, Nursing,
Continuing
Classification: LCC RC438 | NLM WY 18.5 | DDC 616.89/0231--dc23 LC record available at
http://lccn.loc.gov/2016012871
The American Nurses Association (ANA) is the only full-service professional organization
representing the interests of the nation’s 3.1 million registered nurses through its constituent/
state nurses associations and its organizational affiliates. The ANA advances the nursing
profession by fostering high standards of nursing practice, promoting the rights of nurses in the
workplace, projecting a positive and realistic view of nursing, and lobbying the Congress and
regulatory agencies on healthcare issues affecting nurses and the public.
© 2016 American Nurses Association

8515 Georgia Ave., Suite 400
Silver Spring, MD 20910
All rights reserved.
Third printing, August 2018
iii
CONTENTS
INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION

CREDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI
Chapter 1. Taking The Certification Examination. . . . . . . . . . . . . 1

General Suggestions for Preparing for the Exam 1
About the Certification Exams 8
Internet Resources 9
Chapter 2. Psychiatric–Mental Health Nurse Practitioner Role,

Scope of Practice, and Regulatory Process . . . . . . . 11
Nurse Practitioner Advanced Practice Core Content 11
Nurse Practitioner Advanced Practice Specialized
Content 12
History of the NP Role 13
Professional Role Responsibilities 16
Roles of the PMHNP 22
Culturally Competent Care and Special Populations 23
Case Study 1 29
Case Study 2 29
Answers to Case Study Discussion Questions 31
References and Resources 32
Chapter 3. Theoretical Basis of Care. . . . . . . . . . . . . . . . . . . . . . 37

Biopsychosocial Framework of Care 37
Classification of Psychiatric Disorders: DSM-5 38
iv CONTENTS
Therapeutic Relationship 38
Developmental Theories 40
Foundational Theories Supporting PMHNP Role 41
Nursing Theories 47
Case Study 1 48
Case Study 2 48
Chapter 4. Psychiatric–Mental Health Nurse Practitioner

Professional Role and Health Policy: Leadership,
Quality Improvement and Safety, Practice Inquiry,
and Health Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Leadership 51
Quality Improvement 55
Just Culture of Safety 55
Health Delivery Systems 56
Conflict of Interest 57
Rights of Clients 58
Health Policy Development 58
Case Study 59
Chapter 5. Neuroanatomy, Neurophysiology, and Behavior . . 63

The Nervous System 63
Neuroanatomy and the Brain 64
Neurophysiology and the Brain 68
Neuroimaging Assessment and Diagnostic
Procedures 71
Genomics 73
CONTENTS v
Case Study 1 76
Case Study 2 76
Chapter 6. Advanced Health and Physical Health Assessment. . 79

Physical Exam 79
Neurological Exam 80
Disease Prevention Activities 97
Gender-Based Medical Testing and Screening
Recommendations for the General Public 99
Health Behavior Guidelines 101
Public Health Principles 103
Case Study 1 105
Case Study 2 105
Chapter 7. Pharmacological Principles. . . . . . . . . . . . . . . . . . . . 111

Concepts in Pharmacological Management 111
PMHNP Pharmacological Management Role 114
Case Study 1 120
Case Study 2 120
Case Study 3 120
Chapter 8. Nonpharmacological Treatment . . . . . . . . . . . . . . . 125

Individual Therapy 125
Group Therapy 127
vi CONTENTS
Family Therapies 129

Complementary and Alternative Therapies (CATs) 132
Case Study 136
Chapter 9. Depressive Disorders and Bipolar Disorders. . . . . 139

Sadness as a Common Emotional State 139
Major Depressive Disorder (MDD) 140
Persistent Depressive Disorder (Dysthymia) 166
Grief and Bereavement 169
Premenstrual Dysphoric Disorder 173
Bipolar (BP) Disorder 173
Stevens Johnson Syndrome (SJS) 184
Cyclothymic Disorder 186
Case Study 189
Chapter 10. Anxiety Disorders, Obsessive–Compulsive Disorder,

and Trauma- and Stressor-Related Disorders. . . . . 195
Anxiety Disorders 196
Panic Disorder 207
Agoraphobia 210
Specific Phobias (Simple Phobias) 211
Social Anxiety (Phobia) Disorder 214
Generalized Anxiety Disorder (GAD) 215
Separation Anxiety Disorder 218
Obsessive–Compulsive Disorder (OCD) 218
Posttraumatic Stress Disorder (PTSD) 222
CONTENTS vii
Dissociative Disorders 225

Body Dysmorphic Disorder 226
Hoarding Disorder 226
Trichotillomania 226
Excoriation Disorder 226
Case Study 227
Chapter 11. Schizophrenia Spectrum and Other Psychotic

Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
General Description of Psychotic Disorders 233
Schizophrenia 235
Schizophreniform Disorder 258
Schizoaffective Disorder 260
Delusional Disorder 262
Brief Psychotic Disorder 264
Shared Psychotic Disorder (Folie á Deux) 266
Case Study 268
Chapter 12. Neurocognitive Disorders. . . . . . . . . . . . . . . . . . . . 271

Cognitive Disorders 271
Delirium 271
Dementia 277
Major or Minor Neurocognitive Disorder Due to
Traumatic Brain Injury 285
Case Study 291
viii CONTENTS
Chapter 13. Substance-Related and Addictive Disorders . . . . . 293

Substance-Related Disorders 293
Case Study 308
Chapter 14. Personality Disorders. . . . . . . . . . . . . . . . . . . . . . . . 313

Personality 313
Personality Disorders 314
Case Study 324
Chapter 15. Disorders of Childhood and Adolescence . . . . . . . 327

Assessment and Care Planning for Children and
Adolescents 327
Oppositional Defiant Disorder (ODD) 329
Conduct Disorder 332
Attention-Deficit Hyperactivity Disorder (ADHD) 335
Autism Spectrum Disorder 340
Rett Syndrome 343
Eating Disorders 346
Intellectual Disability 351
Disruptive Mood dysRegulation Disorder 355
Case Study 357
Chapter 16. Sleep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

General Considerations 361
Insomnia 362
CONTENTS ix
Case Study 1 369

Case Study 2 369
Case Study 3 369
Chapter 17. Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Intimate Partner Violence (IPV) 373
Assessment 375
Sexual Assault and Abuse 376
Lethality Assessment 379
Violence in School 380
Suicide Assessment 380
Homicide: Early Warning Signs 381
Threats of Violence 381
Case Study 383
Appendix A. Review Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Appendix B. Review Question Answers. . . . . . . . . . . . . . . . . . . . 409
INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
xi
INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION

CREDIT FOR STUDY OF THE PSYCHIATRIC–MENTAL HEALTH NURSE
PRACTITIONER REVIEW AND RESOURCE MANUAL, 4TH EDITION
The Nursing Knowledge Center offers continuing nursing education contact hours (CE) to those
who review and study this manual and successfully complete an online module. To obtain CE
credit you must purchase and review the manual, pay required fees to enroll in the online mod-
ule, and complete all module components by the published CE expiration date including disclo-
sures, pre- and posttests, and the course evaluation. The continuing nursing education contact
hours online module can be completed at any time prior to the published CE expiration date and
a certificate can be printed from the online learning management system immediately after suc-
cessful completion of the online module. To purchase the online module for this manual visit the
Nursing Knowledge Center’s online catalog at https://learn.ana-nursingknowledge.org/. Please
contact online support with any questions about the CE or module.
Inquiries or Comments
If you have any questions about the content of the manual please e-mail [email protected].
You may also mail any comments to Editorial Project Manager at the address listed below.
Nursing Knowledge Center

Attn: Editorial Project Manager
8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910-3492
Fax: (301) 628-5342
CE Provider Information
ANA’s Center for Continuing Education and Professional Development is accredited as a provider
of continuing nursing education by the American Nurses Credentialing Center’s Commission on
Accreditation.
ANCC Provider Number 0023.

ANA is approved by the California Board of Registered Nursing, Provider Number
CEP6178.
Disclaimer
Review and study of this manual and successful completion of the online module do not guaran-
tee success on a certification examination. Purchase of this manual and completion of the online
module are not required to obtain certification.
CHAPTER 1
TAKING THE CERTIFICATION EXAMINATION

When you sign up to take a national certification exam, you will be instructed to go on-
line and review the testing and review handbook (http://www.nursecredentialing.org/
GeneralTestingRenewalHandbook). Review it carefully and be sure to bookmark the site so you
can refer to it frequently. It contains information on test content and sample questions. This is
critical information; it will give you insight into the nature of the test. The agency will send you
information about the test site; keep this in a safe place until needed.
GENERAL SUGGESTIONS FOR PREPARING FOR THE EXAM

Step One: Control Your Anxiety
Everyone experiences anxiety when faced with taking the certification exam.
XX Remember, your program was designed to prepare you to take this exam.
XX Your instructors took a similar exam, and have probably talked to students who took
exams more recently, so they know how to help you prepare.
XX Taking a review course or setting up your own study plan will help you feel more
confident about taking the exam.
Step Two: Do Not Listen to Gossip About the Exam

A large volume of information exists about the tests based on reports from people who have
taken the exams in the past. Because information from the testing facilities is limited, it is hard
to ignore this gossip.
XX Remember that gossip about the exam that you hear from others is not verifiable.
XX Because this gossip is based on the imperfect memory of people in a stressful situa-
tion, it may not be very accurate.
XX People tend to remember those items testing content with which they are less com-
fortable; for instance, those with a limited background in women’s health may say
that the exam was “all women’s health.” In fact, the exam blueprint ensures that the
exam covers multiple content areas without overemphasizing any one.
2 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition
Step Three: Set Reasonable Expectations for Yourself

XX Do not expect to know everything.
XX Do not try to know everything in great detail.
XX You do not need a perfect score to pass the exam.
XX The exam is designed for a beginner level—it is testing readiness for entry-level
practice.
XX Learn the general rules, not the exceptions.
XX The most likely diagnoses will be on the exam, not questions on rare diseases or
atypical cases.
XX Think about the most likely presentation and most common therapy.
Step Four: Prepare Mentally and Physically

XX While you are getting ready to take the exam, take good physical care of yourself.
XX Get plenty of sleep and exercise, and eat well while preparing for the exam.
XX These things are especially important while you are studying and immediately before
you take the exam.
Step Five: Access Current Knowledge

General Content
You will be given a list of general topics that will be on the exam when you register to take the
exam. In addition, examine the table of contents of this book and the test content outline, avail-
able at http://nursecredentialing.org/FamilyPsychMentalHealthNP.
XX What content do you need to know?
XX How well do you know these subjects?
Take a Review Course

XX Taking a review course is an excellent way to assess your knowledge of the content
that will be included in the exam.
XX If you plan to take a review course, take it well before the exam so you will have
plenty of time to master any areas of weakness the course uncovers.
XX If you are prepared for the exam, you will not hear anything new in the course. You
will be familiar with everything that is taught.
XX If some topics in the review course are new to you, concentrate on these in your
studies.
XX People have a tendency to study what they know; it is rewarding to study some-
thing and feel a mastery of it! Unfortunately, this will not help you master unfamiliar
content. Be sure to use a review course to identify your areas of strength and weak-
ness, then concentrate on the weaknesses.
Taking The Certification Examination 3
Depth of Knowledge
How much do you need to know about a subject?
XX You cannot know everything about a topic.
XX Remember that the depth of knowledge required to pass the exam is for entry-level
performance.
XX Study the information sent to you from the testing agency, what you were taught in
school, what is covered in this text, and the general guidelines given in this chapter.
XX Look at practice tests designed for the exam. Practice tests for other exams will not
be helpful.
XX Consult your class notes or clinical diagnosis and management textbook for the ma-
jor points about a disease. Additional reference books can be found online at http://
nursecredentialing.org/PsychNP-TestReferenceList.
XX For example, with regard to medications, know the drug categories and the major
medications in each. Assume all drugs in a category are generally alike, and then fo-
cus on the differences among common drugs. Know the most important indications,
contraindications, and side effects. Emphasize safety. The questions usually do not
require you to know the exact dosage of a drug.
Step Six: Institute a Systematic Study Plan

Develop Your Study Plan
XX Write up a formal plan of study.
ZZ Include topics for study, timetable, resources, and methods of study that work
for you.
ZZ Decide whether you want to organize a study group or work alone.
ZZ Schedule regular times to study.
ZZ Avoid cramming; it is counterproductive. Try to schedule your study periods in
1-hour increments.
XX Identify resources to use for studying. To prepare for the examination, you should
have the following materials on your shelf:
ZZ A good pathophysiology text.
ZZ This review book.
ZZ A physical assessment text.
ZZ Your class notes.
ZZ Other important sources, including: information from the testing facility, a
clinical diagnosis textbook, favorite journal articles, notes from a review course,
and practice tests.
ZZ Know the important national standards of care for major illnesses.
ZZ Consult the bibliography on the test blueprint. When studying less familiar material,
it is helpful to study using the same references that the testing center uses.
XX Study the body systems from head to toe.
XX The exams emphasize health promotion, assessment, differential diagnosis, and plan
of care for common problems.
XX You will need to know facts and be able to interpret and analyze this information
utilizing critical thinking.
Personalize Your Study Plan

XX How do you learn best?
ZZ If you learn best by listening or talking, attend a review course or discuss topics
with a colleague.
XX Read everything the test facility sends you as soon as you receive it and several
times during your preparation period. It will give you valuable information to help
guide your study.
XX Have a specific place with good lighting set aside for studying. Find a quiet place
with no distractions. Assemble your study materials.
Implement Your Study Plan

You must have basic content knowledge. In addition, you must be able to use this information to
think critically and make decisions based on facts.
XX Refer to your study plan regularly.
XX Stick to your schedule.
XX Take breaks when you get tired.
XX If you start procrastinating, get help from a friend or reorganize your study plan.
XX It is not necessary to follow your plan rigidly. Adjust as you learn where you need to
spend more time.
XX Memorize the basics of the content areas you will be required to know.
Focus on General Material

XX Most of what you need to know is basic material that does not require constant
updating.
XX You do not need to worry about the latest information being published as you are
studying for the exam. Remember, it can take 6 to 12 months for new information to
be incorporated into test questions.
Pace Your Studying

XX Stop studying for the examination when you are starting to feel overwhelmed and
look at what is bothering you. Then make changes.
XX Break overwhelming tasks into smaller tasks that you know you can do.
XX Stop and take breaks while studying.
Work With Others

XX Talk with classmates about your preparation for the exam.
XX Keep in touch with classmates, and help each other stick to your study plans.
XX If your classmates become anxious, do not let their anxiety affect you. Walk away if
you need to.
XX Do not believe bad stories you hear about other people’s experiences with previous
exams.
XX Remember, you know as much as anyone about what will be on the next exam!
Consider a Study Group

XX Study groups can provide practice in analyzing cases, interpreting questions, and
critical thinking.
XX You can discuss a topic and take turns presenting cases for the group to analyze.
XX Study groups can also provide moral support and help you continue studying.
Step Seven: Strategies Immediately Before the Exam

Final Preparation Suggestions
XX Use practice exams when studying to get accustomed to the exam format and time
restrictions.
ZZ Many books that are labeled as review books are simply a collection of
examination questions.
ZZ If you have test anxiety, such practice tests may help alleviate the anxiety.
ZZ Practice tests can help you learn to judge the time it should take you to
complete the exam.
ZZ Practice tests are useful for gaining experience in analyzing questions.
ZZ Books of questions may not uncover the gaps in your knowledge that a more
systematic content review text will reveal.
ZZ If you feel that you don’t know enough about a topic, refer to a text to learn
more. After you feel that you have learned the topic, practice questions are a
wonderful tool to help improve your test-taking skill.
XX Know your test-taking style.
ZZ Do you rush through the exam without reading the questions thoroughly?
ZZ Do you get stuck and dwell on a question for a long time?
ZZ You should spend about 45 to 60 seconds per question and finish with time to
review the questions you were not sure about.
ZZ Be sure to read the question completely, including all four answer choices.
Choice “a” may be good, but “d” may be best.
The Night Before the Exam

XX Be prepared to get to the exam on time.
ZZ Know the test site location and how long it takes to get there.
ZZ Take a “dry run” beforehand to make sure you know how to get to the testing
site, if necessary.
ZZ Get a good night’s sleep.

ZZ Eat sensibly.
ZZ Avoid alcohol the night before.
ZZ Assemble the required material—two forms of identification, admission card,
pencil, and watch. Both IDs must match the name on the application, and one
photo ID is preferred.
ZZ Know the exam room rules.
XX You will be given scratch paper, which will be collected at the end of the
exam.
XX Nothing else is allowed in the exam room.
XX You will be required to put papers, backpacks, etc., in a corner of the room
or in a locker.
XX No water or food will be allowed.
XX You will be allowed to walk to a water fountain and go to the bathroom one
at a time.
The Day of the Exam

XX Get there early. You must arrive to the test center at least 15 minutes before your
scheduled appointment time. If you are late, you may not be admitted.
XX Think positively. You have studied hard and are well-prepared.
XX Remember your anxiety reduction strategies.
Specific Tips for Dealing With Anxiety

Test anxiety is a specific type of anxiety. Symptoms include upset stomach, sweaty palms,
tachycardia, trouble concentrating, and a feeling of dread. But there are ways to cope with test
anxiety.
XX There is no substitute for being well-prepared.
XX Practice relaxation techniques.
XX Avoid alcohol, excess coffee, caffeine, and any new medications that might sedate
you, dull your senses, or make you feel agitated.
XX Take a few deep breaths and concentrate on the task at hand.
Focus on Specific Test-Taking Skills

To do well on the exam, you need good test-taking skills in addition to knowledge of the content
and ability to use critical thinking.
All Certification Exams Are Multiple Choice

XX Multiple-choice tests have specific rules for test construction.
XX A multiple-choice question consists of three parts: the information (or stem), the
question, and the four possible answers (one correct and three distracters).
XX Careful analysis of each part is necessary. Read the entire question before
answering.
XX Practice your test-taking skills by analyzing the practice questions in this book and on
the ANCC website.
Analyze the Information Given

XX Do not assume you have more information than is given.
XX Do not overanalyze.
XX Remember, the writer of the question assumes this is all of the information needed
to answer the question.
XX If information is not given, it is not relevant and will not affect the answer.
XX Do not make the question more complicated than it is.
What Kind of Question Is Asked?

XX Are you supposed to recall a fact, apply facts to a situation, or understand and dif-
ferentiate between options?
ZZ Read the question thinking about what the writer is asking.
ZZ Look for key words or phrases that lead you (see Figure 1–1). These help
determine what kind of answer the question requires.
Read All of the Answers

XX If you are absolutely certain that answer “a” is correct as you read it, mark it, but
read the rest of the question so you do not trick yourself into missing a better
answer.
XX If you are absolutely sure answer “a” is wrong, cross it off or make a note on your
scratch paper and continue reading the question.
XX After reading the entire question, go back, analyze the question, and select the best
answer.
XX Do not jump ahead.
XX If the question asks you for an assessment, the best answer will be an assessment.
Do not be distracted by an intervention that sounds appropriate.
XX If the question asks you for an intervention, do not answer with an assessment.
avoid initial most

best first significant
except contributing to likely
not appropriate of the following
most consistent with
FIGURE 1–1.
EXAMPLES OF KEY WORDS AND PHRASES
XX When two answer choices sound very good, the best one is usually the least ex-
pensive, least invasive way to achieve the goal. For example, if your answer choices
include a physical exam maneuver or imaging, the physical exam maneuver is prob-
ably the better choice provided it will give the information needed.
XX If the answers include two options that are the opposite of each other, one of the
two is probably the correct answer.
XX When numeric answers cover a wide range, a number in the middle is more likely to
be correct.
XX Watch out for distracters that are correct but do not answer the question, combine
true and false information, or contain a word or phrase that is similar to the correct
answer.
XX Err on the side of caution.
Only One Answer Can Be Correct

XX When more than one suggested answer is correct, you must identify the one that
best answers the question asked.
XX If you cannot choose between two answers, you have a 50% chance of getting it
right if you guess.
Avoid Changing Answers

XX Change an answer only if you have a compelling reason, such as you remembered
something additional, or you understand the question better after rereading it.
XX People change to a wrong answer more often than to a right answer.
Time Yourself to Complete the Whole Exam

XX Do not spend a large amount of time on one question.
XX If you cannot answer a question quickly, mark it and continue the exam.
XX If time is left at the end, return to the difficult questions.
XX Make educated guesses by eliminating the obviously wrong answers and choosing a
likely answer even if you are not certain.
XX Trust your instinct.
XX Answer every question. There is no penalty for a wrong answer.
XX Occasionally a question will remind you of something that helps you with a question
earlier in the test. Look back at that question to see if what you are remembering
affects how you would answer that question.
ABOUT THE CERTIFICATION EXAMS

The American Nurses Credentialing Center Computerized Exam
The ANCC examination is given only as a computer exam, and each exam is different.
The order of the questions is scrambled for every test, so even if two people are taking the
same exam, the questions will be in a different order. The exam consists of 175 multiple-choice
questions.
XX 150 of the 175 questions are part of the test and how you answer will count toward
your score; 25 are included to refine questions and will not be scored. You will not
know which ones count, so treat all questions the same.
XX You will need to know how to use a mouse, scroll by either clicking arrows on the
scroll bar or using the up and down arrow keys, and perform other basic computer
tasks.
XX The exam does not require computer expertise.
XX However, if you are not comfortable with using a computer, you should practice us-
ing a mouse and computer beforehand so you do not waste time on the mechanics
of using the computer.
Know what to expect during the test.
XX Each ANCC test question is independent of the other questions.
ZZ For each case study, there is only one question. This means that a correct
answer on any question does not depend on the correct answer to any other
question.
ZZ Each question has four possible answers. There are no questions asking for
combinations of correct answers (such as “a and c”) or multiple-multiples.
XX You can skip a question and go back to it at the end of the exam.
XX You cannot mark key words in the question or right or wrong answers. If you want to
do this, use the scratch paper.
XX You will get your results immediately, and a grade report will be provided upon leav-
ing the testing site.
INTERNET RESOURCES
XX ANCC website: www.nursecredentialing.org
XX ANA bookstore: www.nursesbooks.org. Catalog of ANA nursing scope and stan-
dards publications and other titles that may be listed on your test content outline
XX National Guideline Clearinghouse: www.ngc.gov
CHAPTER 2
PSYCHIATRIC–MENTAL HEALTH NURSE

PRACTITIONER ROLE, SCOPE OF PRACTICE, AND
REGULATORY PROCESS
Starting in the 1950s with the seminal work of two psychiatric nurses, June Mellow (1968) and
Hildegard Peplau (1952), psychiatric nursing has been a well-established, well-recognized sub-
specialty of nursing. The emergence of the psychiatric–mental health nurse practitioner (PMHNP)
role reflects the growth of the advanced practice role, the acceptance of a brain-based etiology
of psychiatric disorders, and an awareness of the need to provide holistic nursing care that does
not artificially separate mind and body (Stuart, 2013).
The PMHNP role is built on fundamental, core advanced practice knowledge common to all
nurse practitioners. This base of knowledge is expanded to include the very specific knowledge
of the subspecialty of psychiatry. This chapter reviews the role of the PMHNP, the scope of prac-
tice, and the regulatory process.
Advanced practice nurses specializing in psychiatry are educationally prepared at the master’s
or doctoral level, possess in-depth knowledge and skills in the specialty area, and provide pri-
mary psychiatric care to individuals or families at risk for or currently experiencing a psychiatric
disorder.
NURSE PRACTITIONER ADVANCED PRACTICE CORE CONTENT

All nurse practitioners upon graduation are expected to meet a set of core competencies
(National Organization of Nurse Practitioner Faculties [NONPF], 2014). Specialty competencies,
such as the Psychiatric–Mental Health Nurse Practitioner Competencies, are then built upon
these core competencies (NONPF, 2013).
Nurse Practitioner Core Competencies

XX Scientific Foundations
XX Leadership
XX Quality
XX Practice Inquiry
XX Technology and Information Literacy
XX Policy
XX Health Delivery System
XX Ethics
XX Independent Practice
NURSE PRACTITIONER ADVANCED PRACTICE SPECIALIZED

CONTENT
The specialty competencies are specifically designed for entry-level psychiatric–mental health
nurse practitioners. These specialty competencies are to be used with the Nurse Practitioner
(NP) Core Competencies. The specialty competencies address the life-span PMHNP focus, in-
cluding families and populations. As changes occur within the healthcare system, these compe-
tencies will also change (NONPF, 2013).
Leadership Competencies
XX Participates in community and population-focused programs that evaluate programs
and promote mental health and prevent or reduce risk of mental health problems
XX Advocates for complex client and family medicolegal rights and issues
XX Collaborates with interprofessional colleagues about advocacy, policy to reduce
health disparities and improve outcomes for populations
Quality Competencies
XX Evaluates the appropriate uses of seclusion and restraints in the care process
Policy Competencies
XX Employs opportunities to influence health policy to reduce the impact of stigma on
services for prevention and treatment of mental health problems and psychiatric
disorders
Independent Practice Competencies

XX Develops age-appropriate treatment plans
XX Includes differential diagnosis
XX Assesses impact of acute and chronic medical problems on psychiatric treatment
XX Conducts individual and group psychotherapy
XX Applies supportive psychodynamic, cognitive, behavioral, and other evidence-based
psychotherapies to brief and long-term practice
XX Applies recovery-oriented principles
XX Demonstrates best practices of family care approaches
XX Plans care to minimize the development of complications and promote function
XX Treats acute and chronic psychiatric disorders and problems
Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 13
XX Safely prescribes pharmacologic agents

XX Ensures client safety through the appropriate prescription of pharmacologic and
nonpharmacologic interventions
XX Explains the risks and benefits of treatment to client and family
XX Identifies the role of PMHNP in risk mitigation strategies in areas of opiate use and
substance abuse
XX Seeks consultation
XX Uses self-reflection to improve care
XX Provides consultation to healthcare providers and others to enhance quality and cost
XX Guides the client in evaluating the appropriate use of complementary and alternative
treatment
XX Uses individualized outcome measure to evaluate psychiatric care
XX Manages psychiatric emergencies
XX Refers clients appropriately
XX Facilitates the transition of clients across levels of care
XX Uses outcomes to evaluate care
XX Attends to the client–NP relationship as a vehicle for change
XX Maintains a therapeutic relationship over time with individuals and groups
XX Therapeutically concludes the client–NP relationship
XX Demonstrates ability to address sexual and physical abuse, substance abuse, sexual-
ity, and spiritual conflicts
XX Applies therapeutic relationship strategies based on theory and research
XX Applies principles of self-efficacy, empowerment, and others to effect change
XX Identifies and maintains professional boundaries
XX Teaches clients, families, and groups
XX Provides psychoeducation
XX Modifies the treatment approach based on client readiness
XX Considers motivation and readiness to improve self-care
XX Demonstrates knowledge of appropriate use of seclusion and restraint
XX Documents appropriate use of seclusion and restraint
HISTORY OF THE NP ROLE

The NP role was introduced in 1965 by Loretta C. Ford, EdD, and Henry K. Silver, MD, at the
University of Colorado (Mirr Jansen & Zwygart-Stauffacher, 2006). They identified new roles in
which experienced registered nurses (RNs) with advanced education and skills were perform-
ing clinical duties traditionally reserved for physicians. Universities were slow to implement NP
programs at the master’s level. However, RNs embraced the new role and rushed into continuing
education programs of varying length, quality, and focus to accomplish the necessary educa-
tional preparation for this new role.
In 2008 the License, Accreditation, Certification, and Education (LACE) consensus model was
finalized and adopted by many nursing organizations. The consensus model identified four
Advanced Practice Registered Nurse roles: Certified Registered Nurse Anesthetist (CRNA),
Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), and Certified Nurse Practitioner
(CNP). As part of the LACE model, Psychiatric–Mental Health was identified as a population fo-
cus. The American Psychiatric Nurses Association (APNA) and International Society of Psychiatric
Nurses (ISPN) recommendation was for psychiatric–mental health nurse practitioners (PMHNPs)
to be prepared across the life span (APNA, 2011). As of 2015 APRNs in psychiatric–mental
health nursing have one certification examination, PMHNP–Life Span, with the American Nurses
Credentialing Center (ANCC, 2015). All previous psychiatric–mental health advanced practice
certification examinations have been retired as of December 2015 (ANCC, 2015).
Proven competence brought an acceptance of the NP role in the healthcare system, with ac-
ceptance and recognition of the title and role by consumers and other health professionals. NP
programs are accredited by one of two organizations to achieve standardization and control over
quality: the Commission on Collegiate Nursing Education (CCNE, 2016) and the Accreditation
Commission for Education in Nursing (ACEN, 2016). NPs are recognized providers under many
third-party insurance coverage plans (e.g., Medicare, Medicaid, CHAMPUS, federal programs
funding school-based clinics, U.S. military, Veterans Administration).
Growth of the NP Role

XX Facilitating factors for growth
ZZ Consumer demand for services
ZZ Acceptance of the advanced practice nursing role
ZZ Emergence of the PMHNP role
ZZ Decreasing stigmatization
ZZ Emphasis on integrated healthcare services
XX Constraining factors for growth
ZZ Growing competition in job market in general for NPs
ZZ Reimbursement struggles with Medicare and private insurance companies
ZZ Overlapping scope of practice with other NPs
ZZ Increased concerns over reimbursement fraud and abuse (e.g., issues of coding
and billing for services)
ZZ Scope of practice and need for formal supervisory or collaborative relationships
with physicians
Regulatory and Statutory Dimensions of the NP Role

XX State legislative statutes
ZZ Grant legal authority for NP practice
ZZ The Nurse Practice Act of every state
XX Provides title protection (who may be called a nurse practitioner)
XX Defines advanced practice
XX Prevailing state laws that define scope of practice (what NPs may do)
XX Places restrictions on practice
XX Sets NP credentialing requirements (e.g., educational requirements,
certification)
XX States grounds for disciplinary action:
ZZ Practicing without valid license
ZZ Falsification of records
ZZ Medicare fraud
ZZ Failure to use appropriate nursing judgment
ZZ Failure to follow accepted nursing standards
ZZ Failure to complete accurate nursing documentation
XX May specifically require that an NP develop a collaborative agreement with

a physician
ZZ Collaborative agreement: Also known as a protocol that describes what
types of drugs might be prescribed and defines some form of oversight
for NP practice
XX Statutory law
ZZ Rules and regulations differ for each state
ZZ May further define scope of practice and practice requirements
ZZ May provide restrictions in practice unique to specific state
XX Licensure
ZZ A process by which an agency of state government grants permission to
persons to engage in the practice of that profession
ZZ Also prohibits all others from legally doing protected practice
XX Credentialing
ZZ Process used to protect the public by ensuring a minimum level of professional
competence
XX Certification
ZZ A credential that provides title protection
ZZ Determines scope of practice (i.e., whom NPs can see and what NPs can treat)
ZZ The process by which a professional organization or association certifies that
a person licensed to practice as a professional has met certain predetermined
standards specified by that profession for specialty practice
ZZ Assures the public that a person has mastery of a specified body of knowledge
ZZ Assures that the person has acquired the skills necessary to function in a
particular specialty
ZZ The American Nurses Credentialing Center (ANCC), which is a subsidiary of the

American Nurses Association, is the only certifying body for advanced practice
psychiatric nursing.
XX Certification offered as a Psychiatric–Mental Health Nurse Practitioner–Life
Span (ANCC, 2015)
XX Scope of practice
ZZ Defines NP roles and actions
ZZ Identifies competencies assumed to be held by all NPs who function in a
particular role
ZZ Varies broadly from state to state
ZZ Advanced practice PMHNP standards are identified in Psychiatric-Mental Health
Nursing: Scope and Standards of Practice (ANA, 2014).
XX Standards of practice
ZZ Authoritative statements regarding the quality and type of practice that should
be provided
ZZ Provide a way to judge the nature of care provided
ZZ Reflect the expectation for the care that should be provided to clients with
various illnesses
ZZ Reflect professional agreement focused on the minimum levels of acceptable
performance
ZZ Can be used to legally describe the standard of care that must be met by a
provider
ZZ May be precise protocols that must be followed or more general guidelines that
recommend actions
PROFESSIONAL ROLE RESPONSIBILITIES

XX Confidentiality
ZZ The client’s right to assume that information given to the healthcare provider will
not be disclosed
ZZ Protected under federal statute through the Medical Record Confidentiality Act
of 1995 (S. 1360)
ZZ Pertains to verbal and written client information
ZZ Requires that the provider discuss confidentiality issues with clients, establish
consent, and clarify any questions about disclosure of information
ZZ Requires that provider obtain a signed medical authorization and consent form
to release medical records and information when requested by the client or
another healthcare provider
XX HIPAA
ZZ The first national comprehensive privacy protection act
ZZ Guarantees clients four fundamental rights:
1. To be educated about HIPAA privacy protection,

2. To have access to their own medical records,
3. To request amendment of their health information to which they object, and
4. To require their permission for disclosure of their personal information.
XX The Health Information Technology for Economic and Clinical Health Act (HITECH) of
2009 (Health Resources and Services Administration [HRSA], 2013)
ZZ Incentive payments for sharing specific electronic health record (EHR) data
ZZ Meaningful use incentives
ZZ Electronic health records can improve both individual and population-based
health outcomes (Friedman, Parrish, & Ross, 2013).
ZZ Electronic health records can improve quality, safety, efficiency, effectiveness,
and outcomes (U.S. DHHS, Office for Civil Rights, 2013).
XX E-prescribing
XX Computerized physician order sets
XX Tracking care and avoiding duplication of services
XX Telehealth
ZZ The use of telephone or videoconferencing tools to deliver mental health care
to clients who reside in rural areas or who may otherwise not be able to access
care
ZZ Must follow the same standards as care delivered in person
ZZ Must be practiced in accordance with international, federal, and state regulatory
agency standards
ZZ Must include provisions for emergency care of the client
ZZ The PMHNP must assure that HIPAA regulations regarding confidentiality and
maintenance of the health record are followed.
XX Exceptions to guaranteed confidentiality
ZZ When appropriate persons or organizations determine that the need for
information outweighs the principle of confidentiality
ZZ If a client reveals an intent to harm self or others
ZZ Information given to attorneys involved in litigation
ZZ Releasing records to insurance companies
ZZ Answering court orders, subpoenas, or summonses
ZZ Meeting state requirements for mandatory reporting of diseases or conditions
ZZ Tarasoff principle (Tarasoff v. Regents at the University of California, 1976): Duty
to warn potential victim of imminent danger of homicidal clients
ZZ In cases of child or elder abuse
XX Informed consent
ZZ The communication process between the provider and the client that results in
the client’s acceptance or rejection of the proposed treatment
ZZ An explanation of relevant information that enables the client to make an

appropriate and informed decision
ZZ The right of all competent adults or emancipated minors
XX Emancipated minors: Persons younger than 18 years old who are married,
parents, or self-sufficiently living away from the family domicile
ZZ Elements of informed consent
XX Nature and purpose of proposed treatment or procedure
XX Risks or discomforts and benefits of treatment
XX Risks and benefits of not undergoing treatment
XX Alternative procedures or treatments
XX Diagnosis and prognosis
ZZ Provider must document in the medical record that informed consent has been
obtained from the client.
ZZ PMHNP is responsible for ensuring that the client is cognitively capable of giving
informed consent.
XX Ethics
ZZ Important aspect of the NP role that deals with moral duties, obligations, and
responsibilities
ZZ What is right versus what is wrong
ZZ Ethical principles that provide foundation and direction for complex decisions:
XX Justice: Doing what is fair; fairness in all aspects of care
XX Beneficence: Promoting well-being and doing good
XX Nonmaleficence: Doing no harm
XX Fidelity: Being true and loyal
XX Autonomy: Doing for self
XX Veracity: Telling the truth
XX Respect: Treating everyone with equal respect
ZZ In 2015 the American Nurses Association (ANA) published the Code of Ethics for
Nurses with Interpretive Statements (ANA, 2015). Its nine provisions are:
1. The nurse practices with compassion and respect for the inherent dignity,
worth, and unique attributes of everyone.
2. The nurse’s primary commitment is to the client, whether an individual,
family, group, community, or population.
3. The nurse promotes, advocates for, and protects the rights, health, and
safety of the client.
4. The nurse has the authority, accountability, and responsibility for nursing
practice, makes decisions, and takes action consistent with the obligation
to promote health and provide optimal care.
5. The nurse owes the same duties to self as to others, including the
responsibility to promote health and safety, preserve wholeness of
character and integrity, maintain competence, and continue personal and
professional growth.
6. The nurse, through individual and collective effort, establishes, maintains,
and improves the ethical environment of the work setting and conditions of
employment that are conducive to safe, quality health care.
7. The nurse, in all roles and settings, advances the profession through
research and scholarly inquiry, professional standards development, and the
generation of both nursing and health policy.
8. The nurse collaborates with other health professionals and the public
to protect human rights, promote health diplomacy, and reduce health
disparities.
9. The profession of nursing, collectively through its professional organizations,
must articulate nursing values, maintain the integrity of the profession, and
integrate principles of social justice into nursing and health policy.
ZZ Important ethical principles in psychiatry
XX Clients must be involved in decision-making to the full extent of their
capacity (mutual decision-making).
XX Clients have a right to treatment in the least restrictive setting.
XX Clients have a right to refuse treatment unless a legal process resulting in a
mandatory court order for treatment has been obtained.
ZZ Ethical dilemma
XX Occurs in a situation in which there are two or more justifiable alternatives
XX Occurs when the choice is made to promote good
XX Which option sacrifices the fewest high-priority values (a harm reduction
approach)?
ZZ Theoretical approaches to ethical decision-making
XX Deontological Theory: An action is judged as good or bad based on the act
itself regardless of the consequences.
XX Teleological Theory: An action is judged as good or bad based on the
consequence or outcome.
XX Virtue Ethics: Actions are chosen based on the moral virtues (e.g., honesty,
courage, compassion, wisdom, gratitude, self-respect) or the character of
the person making the decision.
Ethics of Disclosure by Providers

XX Clients have a right to know what is happening during the course of their treatment.
XX Providers have an ethical responsibility to disclose medical errors, accidents, injuries,
and negative results to clients.
XX As a result of the disclosure, a client may have legal right to compensation for harm
suffered due to medical misadventures (Sadock, Sadock, & Ruiz, 2015).
2 0 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition
Risk vs. Benefits of Disclosure of Disability Regarding Employment

XX The Americans with Disabilities Act (ADA) works to prevent discrimination by
employers with 15 or more employees against qualified persons in hiring, firing,
advancement, job training, compensation, and workplace conditions (Buppert, 2012).
XX The ADA is federal legislation granting Americans who have disabilities, includ-
ing mental illness, the opportunity for employment on an equal basis with the
nondisabled.
XX Employers are required to make reasonable accommodations for qualified applicants
or employees with a disability.
Risk of Disclosure
XX Employers may find ways to avoid hiring persons known to have a disability.
XX Coworkers may harass or discriminate against persons with psychiatric illnesses.
XX Assumption that persons with psychiatric illnesses may be less productive
XX May limit an employee’s chance for advancement in career
XX Feedback for improvement may not be given to employee because others may at-
tribute the employee’s behavior to the psychiatric illness.
XX Labeling oneself as “disabled” may affect one’s beliefs or self-image.
Benefits of Disclosure
XX Able to request reasonable accommodations
XX Opportunity to have a job coach come to the worksite and communicate directly
with employer
XX Employee can involve an employment service provider, employee assistance pro-
gram, or other third party in the development of accommodations.
XX Easier for employee to come to work during an exacerbation of symptoms
XX May help with the recovery process
XX Allows coworkers to offer personal support
XX May empower another employee to disclose
Legal Considerations
XX Malpractice insurance
ZZ Provides financial protection against claims of malpractice
XX Coverage for negligent professional acts
XX Coverage for highly technical or professional skills required by health
professionals, including NPs
ZZ Recommended universally for all NPs
ZZ Does not protect NPs from charges of practicing outside their legal scope of
practice
ZZ Provides NPs their own legal representation to advocate for them even if their
agency also carries malpractice liability insurance protection
ZZ Four elements of negligence that must be established to prove malpractice:
1. Duty: The NP had a duty to exercise reasonable care when undertaking and
providing treatment to the client.
2. Breach of duty: The NP violated the applicable standard of care in treating
the client’s condition.
3. Proximate cause: There is a causal relationship between the breach in the
standard of care and the client’s injuries.
4. Damages: The client experiences permanent and substantial damages as a
result of the breach in the standard of care.
Competency
XX A legal, not a medical concept
XX A determination that a client can make reasonable judgments and decisions regard-
ing treatment and other health concerns
XX A person is considered competent until a court rules the person to be incompetent.
XX If a person is deemed incompetent, a court-appointed guardian will make health-
related decisions for that person.
Commitment
XX Process of forcing a person to receive involuntarily evaluation or treatment
XX Process may differ from state to state
XX Basic criteria include
ZZ Person has a diagnosed psychiatric disorder,
ZZ Person is harmful to self or others as a consequence of the disorder,
ZZ Person is unaware or unwilling to accept the nature and severity of the disorder,
and
ZZ Treatment is likely to improve functioning.
XX Involuntary admission
ZZ Admission to a hospital or other treatment facility against the person’s will
ZZ Clients maintain all civil liberties except the ability to come and go as they please
ZZ Amount of time clients can be kept against their wishes varies by state
XX Voluntary admission
ZZ Admission to a hospital or other treatment facility that a person desires or
agrees to
ZZ Client maintains all civil liberties
ZZ Client consents to potential confinement within the structure of a hospital setting
ROLES OF THE PMHNP

Scholarly Activities
XX It is important for NPs to engage in the following scholarly activities:
ZZ Publishing
ZZ Lecturing or presenting
ZZ Preceptorship
ZZ Continuing education
Mentoring
XX A process in which a more experienced NP agrees to guide and support a junior col-
league in the role, competencies, and skills
XX Requires mutual respect and an interactive process of learning
XX Needs involvement by both the mentor and the mentee in the relationship
Client Advocacy
XX Stand up for clients’ rights and empower them to become their own advocates
XX Reduce the stigma of mental illness
XX Help clients receive available services
XX Promote mental health by participating in one or more of these professional
organizations:
ZZ American Nurses Association (ANA)
ZZ American Psychiatric Nurses Association (APNA)
ZZ International Society of Psychiatric Nurses (ISPN)
Health Policy
XX Advanced practice nurses have a legal and ethical responsibility to be a client
advocate.
ZZ Participation in local, state, national, and international health policy activities
(Buppert, 2012)
ZZ Involvement: Testify at a public meeting, lobby, or work with the media to bring
awareness to an issue
ZZ Phases of policy-making: formulation, implementation, and evaluation (Abood,
2007)
Case Management
XX A system of controlled oversight and authorization of services and benefits provided
to clients
XX Consists of coordinating care, ensuring quality outcomes, monitoring plan of care,

and doing advocacy
XX Overall goal is to promote quality, cost-effective outcomes
Risk Assessment
XX Continuous monitoring for high-risk situations
XX Assessing persons for nonhealthy behaviors
Risk Management
XX Activities or systems designed to recognize and intervene to reduce the risk of injury
to clients
XX Appropriate interventions implemented to reduce nonhealthy behaviors in clients
and high-risk situations
XX Recognition and intervention to reduce subsequent claims against healthcare providers
Advance Directives
XX Durable power of attorney for health care. Also known as healthcare proxy
ZZ Legally binding in all 50 states
ZZ Designates, in writing, an agent to act on behalf of a person should he or she
become unable to make healthcare decisions
ZZ Not limited to terminal illness; also covers other aspects of illness, such as
making financial decisions during a person’s illness
ZZ Should be considered as an aspect of relapse planning for clients with chronic
psychiatric disorders
XX Living will: Document prepared while client is mentally competent to designate
preferences for care if client becomes incompetent or terminally ill
ZZ Not legally binding in all states
CULTURALLY COMPETENT CARE AND SPECIAL POPULATIONS

XX Treating clients from diverse cultures, viewing each client as a unique person, and
noting a potential relationship between clients’ cultural experiences and their symp-
tom presentation and perceptions
XX Assumes that if the NP becomes more sensitive to cultural issues influencing the
client’s symptoms and treatment, more comprehensive health care can be provided
XX Culture: The learned beliefs and behaviors or the socially inherited characteristics
that are common among all members of a group; may be a racial, social, ethnic, or
religious grouping
XX Culture-bound syndromes: Specific behaviors related to a person’s culture and not
linked to a psychiatric disorder
ZZ Be cognizant of inaccurately judging a client’s behavior as psychopathology
when it is really related to his or her culture.
Cultural Influences and Determinants of Health

XX Family: A group of adults and children who are usually related and whose adults
participate in carrying out the essential functions of providing food, clothing, shelter,
safety, and education of children
ZZ Concept broadened beyond the traditional husband–wife–children pattern
ZZ Family initially teaches the belief patterns, religion, culture, and mores of a society.
XX Ethnicity: Self-identified race, tribe, or nation with which a person or group identifies
and which greatly influences beliefs and behavior
XX Community: A group of families, often sharing the same race, tribe, or culture, who
have beliefs or behavior not shared by others
XX Environment: Includes both physical and psychosocial factors; the general circum-
stances of a person’s life:
ZZ Social contacts ZZ Fluoride in water
ZZ Housing surroundings ZZ Water contamination
ZZ Climate ZZ Crime
ZZ Altitude ZZ Poverty
ZZ Temperature ZZ Transportation
ZZ Air pollution
Homelessness
Homelessness is an enormous problem affecting the United States and the world. It can have
devastating effects on individuals’ and families’ emotional and physical health. Drugs, alco-
hol, violence, and behavioral problems are just a few major issues faced by persons who are
homeless. The practitioner must be aware of the challenges faced by this vulnerable popula-
tion. Possessing appropriate communication skills and knowledge of available resources are
invaluable.
XX Homeless person
ZZ Someone who does not have stable or consistent nighttime housing or who
maintains permanent residence at shelters, hotels, transitional housing, or
public places not appropriate for human beings to live in; someone intended to
be institutionalized who is in an institution for transitory residence
ZZ Men, women, and children make up the homeless population. The number of
homeless families is on the rise.
XX The majority of homeless families are headed by a single parent, usually a
woman.
ZZ Female-headed households are at high risk for becoming homeless
if the head of household has limited education or employment skills,
low-paying employment with little or no benefits, and limited access to
affordable housing.
ZZ Teen mothers are at high risk due to lack of education and incomes that
older parents possess.
ZZ Reasons for homelessness:

XX Mental illness
XX Addictive disorders
XX Poverty
XX Unemployment
XX Inadequate public assistance
XX Domestic violence
XX Lifestyle choice
XX Mental illness and addictive disorders in the homeless population:
ZZ Approximately 50% of homeless people have co-occurring substance use
disorders and serious mental illness, including bipolar disorder, schizophrenia,
and depression.
ZZ Schizophrenia accounts for 15% to 45% of the U.S. homeless population
(Sadock, Sadock, & Ruiz, 2015).
ZZ Symptoms are often active and untreated.
ZZ Untreated serious mental illness results in symptoms such as paranoia,
hallucinations, mania, anxiety, and depression, making it difficult for people to
maintain employment, relationships, and other activities of daily living.
ZZ Homeless people with co-occurring disorders are at a greater risk for violence,
medication noncompliance, and treatment resistance.
Strategies for Reducing Homelessness

XX Outreach: Introducing services to homeless persons with serious mental illness
in various settings, building an empathetic, consistent, and caring relationship to
provide treatment
XX Integrated care: Treatment combining mental health and medical care to improve
overall functioning in the community; may also include access to dental care and
pharmacy services
ZZ Colocation: Providing mental health and primary care services at a single site
XX Supporting services to persons in housing: Effective in moving homeless persons
with serious mental illness directly to independent housing with support and inten-
sive attention
XX Prevention: Beginning with discharge planning in inpatient settings, provide resourc-
es for mental health care, housing, transitioning service, and follow-up
Migrant and Seasonal Farm Workers

XX Migrants: Persons who leave their permanent residences to take agricultural jobs in
different locations
XX Seasonal: Workers who travel from their permanent residences seasonally for agri-
cultural employment
XX Men, women, and children of all cultures
XX It is estimated that more than 3 million migrant and seasonal farm workers work in
the United States (National Center for Farmworker Health, 2009).
ZZ Hard to get an accurate census because families and workers move a great deal
XX Working conditions, problems with the process of acculturation, isolation, discrimina-
tion, and impaired access to health care play a role in a high prevalence of mental
illness among migrant and seasonal farm workers.
XX Very high incidence of depression, anxiety, and substance abuse
XX Physical and emotional abuse of women is harder to address because of frequent
changes of location.
XX Meeting the mental health needs of this vulnerable population can pose a challenge
because of the ways specific cultures perceive mental illness. Displaying an em-
pathic, understanding, and culturally sensitive attitude is imperative when promoting
care to this population.
Sexual Orientation
Possessing a thorough understanding of sexuality is of great importance when communicating
with clients of different sexual orientations. The practitioner must possess an open, supportive,
sensitive, empathetic attitude toward the client. Understanding the client’s viewpoint and what
he or she is seeking will help facilitate an effective psychiatric evaluation. In addition, an aware-
ness of the factors the client may have faced because of his or her sexuality is crucial.
XX Sexual identity: How people identify psychologically on a continuum between female
and male and to whom they are sexually or affectionately attracted (Sadock, Sadock,
& Ruiz, 2015)
XX Gender identity: A person’s identity along a continuum between normative con-
structs of masculinity and femininity
ZZ Influences of gender identity may consist of biological and social factors.
ZZ Biological factors may include pre- and postnatal hormone levels and gene
expression.
ZZ Social factors may include gender messages from family, mass media, and
cultural attitudes.
XX Gender dysphoria: The formal diagnosis to describe a marked incongruence between
one’s experienced and expressed gender and the gender assigned at birth (American
Psychiatric Association [APA], 2013)
XX Sexual orientation: The direction of sexual attraction; preferred over “sexual prefer-
ence” or “lifestyle,” which imply choice, whereas “orientation” does not; some prefer
“sexual identity” because it allows people to determine their own identities. Sexual
orientation does not always relate to gender identity.
ZZ Asexual: Not attracted to either sex
ZZ Bisexual: Attracted to both sexes
ZZ Heterosexual: Attracted to the opposite sex
ZZ Homosexual: Attracted to the same sex
ZZ Transgender: Umbrella term describing persons whose gender identity does not
conform to gender norms associated with the gender they were assigned at
birth; does not imply a particular sexual orientation
ZZ Transsexual: Persons who identify as the opposite gender from the one they
were assigned at birth; some change their bodies hormonally and surgically to
conform to their gender identity
ZZ LGBTQ: Lesbian, gay, bisexual, transgender, and queer or questioning
ZZ Many clients seek treatment from a provider of the same orientation
XX Sexual behavior: The manner in which humans experience and express their sexual-
ity; includes attracting partners, sexual interactions, and social interactions (Sadock,
Sadock, & Ruiz, 2015)
Forensics and Corrections

In the 1970’s deinstitutionalization began, leaving many with a mental illness or intellectual dis-
ability in need of housing in the community. One of the places persons with a mental illness
are overrepresented is in the criminal justice system (Kennedy-Hendricks, Huskamp, Rutkow &
Berry, 2016, pg. 1077). Persons in the prison system have higher rates of serious mental illness-
es compared to those in the community (Prins, 2014). Prins found higher rates of post-traumatic
stress disorder, major depression, generalized anxiety disorder, dysthymia, bipolar disorder, so-
cial anxiety, panic, and schizophrenia in prison populations compared to community populations.
A large number of US prisoners need mental health care. A case study of inmates in Texas found
that approximately 15% to 24% of inmates reported symptoms of a psychotic disorder, 43% to
54% of inmates reported symptoms of mania, and 23% to 30% of inmates reported symptoms
of major depression. Unfortunately, lack of synchronized care among criminal justice, mental,
and public health systems results in repeat incarcerations (Baillargeon et al., 2010; Kushel, Hahn,
Evans, Bangsberg, & Moss, 2005). It is essential to remain neutral, calm, and objective, and be
skilled in self-reflective techniques as well as acknowledging one’s own emotional response and
biases when providing care for imprisoned clients. Lyons (2009) recommends that the practitio-
ner compartmentalize emotional responses and biases temporarily then debrief afterward.
XX Forensic: The application of scientific knowledge to legal problems and legal pro-
ceedings, for example, in forensic anthropology, forensic dentistry, forensic medicine
(legal medicine), forensic pathology, and forensic science
XX Forensic science: The application of a broad range of sciences to answer questions
of interest to the legal system; a high-technology field using electron microscopes,
lasers, ultraviolet and infrared light, advanced analytical techniques, and computer-
ized databanks to analyze and research evidence
XX Forensic nursing: The practice of nursing when health and legal systems intersect;
the forensic nurse provides direct services to individual clients; consultation services
to nursing, medical, and legal agencies; and expert court testimony in areas dealing
with trauma or investigations of questioned deaths, adequacy of services delivery,
and specialized diagnoses of specific conditions as related to nursing
Forensic Versus Correctional

XX Forensic: Nurse–client relationship based on crime committed and investigational
aspect of the interaction
XX Correctional: Nurse–client relationship based on offender’s current mental health and

medical conditions
XX Locations: Emergency departments, prisons (high-, medium-, and low-security units),
courts, and police stations (Lyons, 2009)
Forensic Knowledge Base

XX Relies on evidence-based practice as well as past clinical experience
XX Incorporates both criminal justice and mental health systems
XX The forensic PMHNP should possess theoretical and practical knowledge of the
criminal justice and mental health systems
ZZ Function of the court
ZZ Litigation procedures
ZZ Workings of the criminal justice system
ZZ Relevant case law and health litigation
ZZ Understanding of mental health, distorted thinking patterns, and impaired
cognition
ZZ Competence: Safety, security, management, and assessment of risk;
management of aggression and violence; therapeutic relationship; offending
behavior knowledge; prison culture; documentation; medical knowledge;
psychopharmacology; and crisis de-escalation (Lyons, 2009)
Forensic Risk Assessment vs. Risk Assessment

XX Forensic risk assessment: Protect the public from persons with known mental disor-
ders having dangerous, violent, and criminal histories
XX Risk assessment: Psychiatric evaluation performed in emergency department after
arrest and before person is confined to a correctional facility (Lyons, 2009)
CASE STUDY 1
Karen Harris is a newly graduated PMHNP. She worked as a psychiatric nurse for 5 years before
going to graduate school. She is considering a job at the local community mental health center.
The director of the center has told her that her role would consist of seeing mainly adult clients
with serious, chronic, and persistent mental illness.
On occasions when the psychiatrist is “busy,” Ms. Harris is told she may be expected to see a
few children in addition to adults. The director expects Ms. Harris to provide medication manage-
ment to well-known clients and occasionally to assist in diagnostic evaluations of new clients or
clients in crisis. He also expects that she will “from time to time” meet the emergent medical
needs of clients who have limited access to primary care providers, including the routine, ongo-
ing care of nonpsychiatric disorders such as diabetes, hypertension, and chronic pain. Ms. Harris
has many issues to consider before deciding to take or not take the position.
1. Would Ms. Harris be legally authorized to treat both children and adults?
2. What regulation, rule, or standard should Ms. Harris consult to determine if she is
legally allowed to treat both children and adults?
3. What regulation, rule, or standard should Ms. Harris consult to determine if she is
legally allowed to treat both physical and psychiatric disorders?
4. What is the role of professional psychiatric nursing organizations in assisting Ms.
Harris to determine the scope of practice that is appropriate for her as a new
graduate?
Ms. Harris decides not to take that job and instead has been working for about a year as a
PMHNP in a nurse-managed primary mental health clinic. One day she is asked to assess a
client who is clearly psychotic, experiencing hallucinations and delusions, and expressing verbal
threats against many persons at another clinical practice in town who had “malpracticed” them.
The client is adamant that he does not wish any treatment and that he is not ill. To care for this
client, Ms. Harris has many issues to consider.
5. Is Ms. Harris able to treat the client if he is not consenting to care?
6. What legal standards must be met if she is to treat this client without his consent?
About 5 weeks later the above-mentioned client returns to the clinic for follow-up care. He is
clinically stable, on medication, and showing no active symptoms. He is interested in developing
a relapse prevention plan and asks Ms. Harris to assist him in this process. Ms. Harris has many
issues to consider.
7. Is the inclusion of a durable power of attorney an appropriate strategy in relapse
planning for this client?
8. What quality indicators should be considered in planning the client’s care with him?
9. What risk management and liability issues should Ms. Harris consider?
CASE STUDY 2
A PMHNP working in a rural mental health clinic is asked by a women’s clinic to evaluate Ms. M.,
a 35-year-old female. Ms. M. insists she is not depressed, but that she has been feeling under-
standably distressed because she was fired from her job for excessive absenteeism related to
“head, neck, and back pain.” Ms. M. has difficulty falling and staying asleep, wakes up feel-
ing tearful, and doesn’t want to get out of bed. She has become socially isolative and spends
hours sitting in front of the television. She has been taking 50 mg of amitriptyline for the past 6
months. The medication has been prescribed by a physician’s assistant at a women’s clinic. She
was last seen at the women’s clinic 4 months ago. After evaluating Ms. M., the PMHNP de-
cides that she meets criteria for major depression. He decides to continue the amitriptyline but
increases the dose.
1. How should the PMHNP explain his rationale for increasing the dose of the amitrip-
tyline to the client?
2. Since amitriptyline is a tricyclic antidepressant, is it reasonable for the PMHNP to
continue and even adjust the dose of this medication—in other words, is this treat-
ment within the scope of the PMHNP’s practice?
ANSWERS TO CASE STUDY DISCUSSION QUESTIONS
Case Study 1
1. The key word here is “legally.” Professional standards and scope of practice docu-
ments suggest what is reasonable and prudent practice. Professional nursing
organizations will provide information on what is seen as acceptable educational
preparation for practice. However, the individual legislative regulations of each state
determine what constitutes legal practice for each individual PMHNP.
2. The Nurse Practice Act and related legislation of the state in which she practices will
delineate the legal boundaries of her practice.
3. Professional standards and scope-of-practice documents suggest what is reasonable
and prudent practice. The individual legislative regulations of each state determine
what constitutes legal practice for each individual PMHNP.
4. Professional nursing organizations provide information through a Scope and
Standards document about what is seen as an acceptable practice role for PMHNPs,
but the PMHNP’s practice is ultimately guided by the individual state’s Nurse
Practice Act.
5. Any client, including a psychiatric client, has the right to refuse treatment. Ms. Harris
is legally and ethically bound to honor the client’s rights.
6. Ms. Harris must meet the legal standard in the state where she practices to treat a
client against his or her wishes. This usually entails performing the legal task of com-
mitting a client and in most states, ensuring that the following criteria are met:
ZZ The person has a diagnosed psychiatric disorder
ZZ The person is unaware or unwilling to accept the nature and severity of disorder
ZZ As a result of a mental disorder, a person is harmful to self or others
ZZ As a result of a mental disorder, a person cannot take care of his or her basic
needs of food, clothing, and shelter
7. A durable power of attorney allows a person in a state of health to choose another
person to act on his or her behalf should he or she become unable to make his or
her own healthcare decisions. Chronic mental illness has the potential to render a
person unable to make healthcare decisions, and a durable power of attorney docu-
ment should be part of relapse planning.
8. Standardized client assessment and rating scales, evidence-based standards of
care, and measures of quality, including client and family satisfaction, should be
considered.
9. Ms. Harris should adhere to standards and scope of practice and identify factors
specific to this client that increase liability exposure.
Case Study 2
1. The PMHNP must discuss the treatment plan in the context of the client’s psychi-
atric symptoms. Without trying to convince the client that she has major depres-
sion, the PMHNP can discuss how chronic pain may have led to the distress she is
currently experiencing and that the medication may address many of her distressing
symptoms. He will also need to address the potential side effects from this tricyclic
antidepressant, and the usual course of treatment in terms of dosing and timeline.
2. Yes, if the PMHNP is using the medication to target the client’s depressive symp-
toms and if he believes the benefit-to-risk ratio is reasonable in this instance, it is
reasonable for the PMHNP to continue the medication and adjust the dose. The
PMHNP must do all the relevant medical tests to prescribe this medication.
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CHAPTER 3
THEORETICAL BASIS OF CARE

Although the psychiatric–mental health nurse practitioner (PMHNP) role is relatively new, psy-
chiatric–mental health nursing has a long, well-established, and cherished tradition of advanced
practice. As with all other specialty areas of nursing, advanced practice psychiatric nursing is
theoretically grounded, and a wide array of theories form the basis of the PMHNP role. These
theories help identify the foundational, core concepts of advanced-practice psychiatric nursing.
The scope of practice for the PMHNP is based on an understanding of foundational core con-
cepts and theories (Alligood, 2014).
This chapter reviews the concepts of biopsychosocial theories that underpin PMHNP practice.
BIOPSYCHOSOCIAL FRAMEWORK OF CARE

Recovery
XX Recovery is the single most important goal in the transformation of mental health
care of the past 2 decades. Four major dimensions of recovery include: health,
home, purpose, and community (U.S. Department of Health and Human Services
[DHHS], Substance and Mental Health Services Administration, 2015).
XX PMHNP interventions follow evidence-based practice guidelines, are always client
goal–directed, and take into account the client’s ethnicity and culture.
XX PMHNPs help clients to recognize strengths, set attainable goals, and have hope for
their future.
XX A key part of the PMHNP’s work is to use empirical evidence in educating their
clients, clients’ families, and the community about mental health, psychiatric illness,
and effective management of illness.
XX The PMHNP oversees and guides the psychiatric–mental health nurse in design-
ing evidence-based health information and educational programs that are geared to
consumer learning needs, ability, and readiness to learn.
XX PMHNPs care for people with co-occurring medical and psychiatric disorders.
XX Principles of mental health recovery are integrated into all levels of mental health
care (American Psychiatric Nurses Association [APNA], 2012).
CLASSIFICATION OF PSYCHIATRIC DISORDERS: DSM-5

XX Prior to May of 2013, psychiatric disorders were classified using standard criteria of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American
Psychiatric Association [APA], 2000).
XX Unlike previous editions, the DSM-5 does not use multiaxial classifications (APA,
2013).
XX The DSM-5 classifies mental illnesses on the basis of specific criteria that have been
tested for reliability when used by mental health professionals.
XX Emphasizes dimensional assessments
THERAPEUTIC RELATIONSHIP
XX Assumes the client and nurse enter into a mutual, interactive, interpersonal relation-
ship specifically to focus on the identified needs of the client
XX Therapeutic relationships are focused on the client’s needs, and are goal-directed,
theory-based, and open to supervision.
XX The following are a few characteristics of a therapeutic relationship:
ZZ Genuineness
ZZ Acceptance
ZZ Nonjudgment
ZZ Authenticity
ZZ Empathy
ZZ Respect
ZZ Professional boundaries
XX The therapeutic relationship has specific and sequential phases (see Table 3–1).
XX Transference and countertransference are key concepts in the nurse–client
relationship.
ZZ Transference: Displacement of feelings for significant people in the client’s past
onto the PMHNP in the present relationship
ZZ Countertransference: The nurse’s emotional reaction to the client based on her
or his past experiences
XX Signs indicating the presence of countertransference in the PMHNP include
ZZ Intense emotional reactions, positive or negative, on first contact with
client;
ZZ Recurrent anxiety or uneasiness while dealing with the client;
ZZ Uncharacteristic carelessness in interaction and follow-up with client;
ZZ Difficulty empathizing;
ZZ Resistance to others treating or interacting with the client;
ZZ Preoccupation with or dreaming about the client;
Theoretical Basis of Care 39
TABLE 3–1.
PHASES OF A THERAPEUTIC NURSE–CLIENT RELATIONSHIP
PHASE NURSING ACTION COMMON CLIENT BEHAVIOR

Introduction Creating a trusting environment Initial hesitancy by the client to
(Orientation) Establishing professional participate fully in assessment
boundaries and treatment planning (approach
avoidance)
Establishing the length of
anticipated interaction
Providing diagnostic evaluation
Setting mutually agreed-upon
treatment objectives
Working Clarifying client expectations and Transference—client
(Identification and mutually set goals (countertransference—nurse)
Exploitation) Implementing treatment plan Client resistance to care
Monitoring health practices
Undertaking preventative health Client resistance to change
care
Measuring outcomes of care
Evaluating outcomes of care
Reprioritizing plan and objectives as
indicated
Termination Reviewing client’s progress toward Client resistance to termination
(Resolution) objectives Regression
Establishing long-term plan of care Reemergence of symptoms or
Focusing on self-management problems
strategies
Disengaging from relationship
Referring client to other services as
needed
Note. Adapted from Keltner, N., Schwecke, L. H., & Bostrom, C. E. (2006). Psychiatric nursing
(5th ed.). St. Louis, MO: Mosby.
ZZ Frequently running overtime or cutting time short with client;

ZZ Depression or other strong emotions during or after interaction with
client; and
ZZ Feedback from others over involvement with client.
XX The PMHNP is expected to monitor her or his reaction to clients to

constantly assess for the presence of countertransference.
XX If identified, countertransference is usually dealt with through the
supervisory process and in talking to coworkers about the issues.
ZZ Provided in peer–peer or peer–supervisor relationship
ZZ Examines interpersonal dynamics inherent in the PMHNP’s relationship
with clients
DEVELOPMENTAL THEORIES
XX Growth, change, and development are a part of the dynamic, constant life process of
being human.
XX Humans develop uniquely from simple to complex.
XX The health states of individuals and families can be viewed over a continuum of
development.
XX Developmental stages and the milestones or tasks that accompany them give insight
into age-appropriate behaviors, measure levels of comprehension for client teaching,
and provide a context within which to evaluate assessment data (see Table 3–2).
TABLE 3–2.
ERIK ERIKSON’S (1902–1994) STAGES OF HUMAN DEVELOPMENT
INDICATIONS OF INDICATIONS OF
DEVELOPMENTAL DEVELOPMENTAL DEVELOPMENTAL DEVELOPMENTAL
STAGE AGE TASK MASTERY FAILURE
Infancy Birth–1 Trust vs. mistrust Ability to form Poor relationships, lack of
year meaningful future hope, suspicious of
relationships, hope others
about the future,
trust in others
Early childhood 1–3 Autonomy vs. Self-control, self- Poor self-control, low self-
years shame and doubt esteem, willpower esteem, self-doubt, lack
of independence
Late childhood 3–6 Initiative vs. guilt Self-directed Lack of self-initiated
years behavior, goal behavior, lack of goal
formation, sense of orientation
purpose
School-age 6–12 Industry vs. Ability to Sense of inferiority;
years inferiority work; sense of difficulty with working,
competency and learning
achievement
Adolescence 12–20 Identity vs. role Personal sense of Identity confusion, poor
years confusion identity self-identification in group
settings
Early adulthood 20–35 Intimacy vs. Committed Emotional isolation,
years isolation relationships, egocentrism
capacity to love
Middle adulthood 35–65 Generativity vs. Ability to give Self-absorption, inability
years self-absorption or time and talents to grow and change as a
stagnation to others, ability person, inability to care
to care for others for others
Late adulthood >65 Integrity vs. Fulfillment and Bitterness, sense of
despair comfort with life, dissatisfaction with life,
willingness to despair over impending
face death, insight death
and balanced
perspective on
life’s events
Note. Adapted from Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis
of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
ZZ Example: The mental status finding of concrete thinking in a 9-year-old client

would be normal and expected; however, the same finding in a 29-year-old client
is nonnormative and suggestive of psychopathology (see Table 3–3 for typical
age of onset for psychiatric disorders).
FOUNDATIONAL THEORIES SUPPORTING PMHNP ROLE

XX Psychodynamic (Psychoanalytic) Theory (Sigmund Freud, 1856–1939)
ZZ Focus is on concepts of intrapsychic conflict among the structures of the mind
ZZ Initially designed to explain neurosis and conditions of high anxiety such as
phobias and hysteria
ZZ Theory later expanded to include normal and abnormal development and
personality development
ZZ Basic tenets of psychodynamic theory
XX Psychoanalytical theory assumes that all behavior is purposeful and
meaningful. All behavior has meaning.
XX Principle of Psychic Determinism: Even apparently meaningless, random, or
accidental behavior is actually motivated by underlying unconscious mental
content.
ZZ Example: A person forgets where he parked the car because he really
does not wish to go wherever it was that he was headed.
XX Most mental activity is unconscious—urges, feelings, and fantasies that

would be unacceptable to the person’s values if consciously experienced.
XX Conscious behaviors and choices are affected by unconscious mental
content.
XX Childhood experiences shape adult personality.
TABLE 3–3.
EXAMPLES OF T
YPICAL AGE OF ONSET FOR COMMON PSYCHIATRIC DISORDERS
DISORDER AGE OF ONSET

Intellectual Disability Infancy—usually evident at birth
Attention deficit hyperactivity disorder Early childhood (per DSM-5, by age 12)
Schizophrenia 18 to 25 years for men

25 to 35 years for women
Major depression Late adolescence to young adulthood
Dementia Most common after age 85

Note. Adapted from Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s
synopsis of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
XX Instincts, urges, or fantasies function as drives that motivate thoughts,

feelings, and behaviors.
ZZ Two types of normal drives: sexual drives (libido) and aggressive drives
ZZ Drives affect behavior as an individual attempts to deal with the
associated feelings and seeks gratification through release of the
tension that the drives produce.
ZZ Normally, different actions or behaviors are used at different ages to
discharge tension from drives and seek gratification.
ZZ Psychosexual stages of development have been identified to show
the age-related behaviors commonly used for discharging drives and
obtaining gratification (see Table 3–4).
ZZ Three primary psychic structures make up the mind and personality and are
responsible for mental functioning:
1. The Id
ZZ Contains primary drives or instincts, urges (hunger, sex, or aggression),
or fantasies
ZZ Drives are largely unconscious, sexual, or aggressive in content, and
infantile in nature
ZZ Operates on the pleasure principle; seeks immediate satisfaction
ZZ Is present at birth and motivates early infantile actions
ZZ The id says, “I want”
TABLE 3–4.
FREUD’S PSYCHOSEXUAL STAGES OF DEVELOPMENT
PSYCHIATRIC
PRIMARY MEANS OF DISORDER LINKED
DISCHARGING DRIVES AND TO FAILURE OF
STAGE AGE ACHIEVING GRATIFICATION STAGE
Oral stage 0–18 Sucking, chewing, feeding, crying Schizophrenia
months Substance abuse
Paranoia
Anal stage 18 months– Sphincter control, activities of Depressive disorders
3 years expulsion and retention
Phallic stage 3–6 years Exhibitionism, masturbation with Sexual identity
focus on Oedipal conflict, castration disorders
anxiety, and female fear of lost
maternal love
Latency stage 6 years– Peer relationships, learning, motor- Inability to form
puberty skills development, socialization social relationships
Genital stage Puberty Integration and synthesis of Sexual perversion
forward behaviors from early stages, primary disorders
genital-based sexuality
Note. Adapted from Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis
of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
2. The Ego
ZZ Contains the concept of external reality
ZZ Rational mind; responsible for logical and abstract thinking
ZZ Functions in adaptation
ZZ Mediates between the demands of drives and environmental realities
ZZ Operates on the reality principle
ZZ Begins to develop at birth as infant struggles to deal with environment
ZZ Responsible for use of defense mechanisms
ZZ The ego says, “I think, I evaluate”
3. The Superego
ZZ Is the ego-ideal
ZZ Contains sense of conscience or right versus wrong
ZZ Also contains aspirations, ideals, and moral values
ZZ Regulated by guilt and shame
ZZ Begins to fully develop around age six as a child comes into contact
with external authority figures such as other parents, schoolteachers,
coaches, or religious figures
ZZ The superego says “I should or ought”
ZZ Psychic structures commonly come into conflict over what to do to achieve

gratification.
ZZ Although the exact nature of conflict is often unconscious, conflict is
experienced consciously as anxiety.
ZZ The function of anxiety is to alert the conscious mind to the presence of
conflict.
ZZ Conflict is normally dealt with through the use of defense mechanisms (see
Table 3–5), which
XX Are a function of the ego,
XX Are unconsciously called into action,
XX Are used to reduce anxiety,
XX Become part of the personality,
XX Maintain a sense of safety,
XX Promote self-esteem and a sense of well-being,
XX May be used episodically or habitually, and
XX May be used constantly and become fixed, as seen in neurosis.
XX Cognitive Theory (Jean Piaget, 1896–1980)
ZZ Piaget believed that human development evolves through cognition, learning,
and comprehending.
TABLE 3–5.
DEFENSE MECHANISMS
DEFENSE MECHANISM EXPLANATION

Denial Avoidance of unpleasant realities by unconsciously ignoring their
existence
Projection Unconscious rejection of emotionally unacceptable personal
attributes, beliefs, or actions by attributing them to other people,
situations, or events
Regression Return to more comfortable thoughts, behaviors, or feelings used
in earlier stages of development in response to current conflict,
stress, or threat
Repression Unconscious exclusion of unwanted, disturbing emotions,
thoughts, or impulses from conscious awareness
Reaction formation Often called overcompensation; unacceptable feelings, thoughts,
or behaviors are pushed from conscious awareness by displaying
and acting on the opposite feeling, thought, or behavior
Rationalization Justification of illogical, unreasonable ideas, feelings, or actions by
developing an acceptable explanation that satisfies the person
Undoing Behaviors that attempt to make up for or undo an unacceptable
action, feeling, or impulse
Intellectualization Attempts to master current stressor or conflict by expansion of
knowledge, explanation, or understanding
Suppression Conscious analog of repression; conscious denial of a disturbing
situation, feeling, or event
Sublimation Unconscious process of substitution of socially acceptable,
constructive activity for strong unacceptable impulse
Altruism Meeting the needs of others in order to discharge drives, conflicts,
or stressors
Note. Adapted from Shea, C. A., Pelletier, L., Poster, E. C., Stuart, G. W., & Verhey, M. P. (1999).
Advanced practice nursing in psychiatric and mental health care. St. Louis, MO: Mosby.
ZZ He believed that factors such as native endowment and biological and

environmental factors set the course for a child’s development.
ZZ He described four stages of cognitive development:
1. Sensorimotor (Birth–2 years): The critical achievement of this stage is object
permanence: the ability to understand that objects have an existence
independent of the child’s involvement with them
2. Preoperational (2–7 years): More extensive use of language and symbolism;
magical thinking
3. Concrete Operations (7–12 years): Child begins to use logic; develops
concepts of reversibility and conservation
ZZ Reversibility: The realization that one thing can turn into another and
back again (e.g., water and ice)
ZZ Conservation: Ability to recognize that although the shape of an object
may change, it will still maintain characteristics that enable it to be
recognized as that object (e.g., clay)
4. Formal Operations (12 years–adult): Ability to think abstractly; thinking

operates in a formal, logical manner
XX Interpersonal Theory (Harry Stack Sullivan, 1892–1949)
ZZ Behavior occurs because of interpersonal dynamics.
ZZ Interpersonal relationships and experiences influence one’s personality
development, which is called the self-system (the total components of
personality traits).
ZZ Understanding behavior requires understanding the relationships in the person’s
life.
ZZ Two drives for behavior: the drive for satisfaction (basic human drives such as
sleep, sex, hunger) and the drive for security (conforming to social norms of a
person’s reference group).
ZZ When the person’s need for satisfaction and security is interfered with by the
self-system, mental illness occurs.
ZZ Humans experience anxiety and behavior is directed toward relieving the
anxiety, which then results in interpersonal security.
ZZ Sullivan also described stages of interpersonal development (see Table 3–6).
XX Hierarchy of Needs Theory (Abraham Maslow, 1908–1970)
ZZ Health model rather than illness model
ZZ A hierarchical organization of needs
ZZ Hypothesizes that certain needs are more important to than others
ZZ States that a person will attempt to meet more important needs first before
satisfying other needs
ZZ Hierarchy of needs:
XX Survival
ZZ Water
ZZ Air
ZZ Food
ZZ Sleep
TABLE 3–6.
SULLIVAN’S STAGES OF INTERPERSONAL DEVELOPMENT
STAGE TIME PERIOD DEVELOPMENTAL TASK

Infancy Birth–18 months Oral gratification; anxiety occurs for the first time
Childhood 18 months–6 years Delayed gratification
Juvenile 6–9 years Forming of peer relationships
Preadolescence 9–12 years Same-sex relationships
Early adolescence 12–14 years Opposite-sex relationships
Late adolescence 14–21 years Self-identity developed
Note. Adapted from Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s
synopsis of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
XX Safety and security needs

ZZ Protection from harm: emotional and physical
XX Love and belonging

ZZ Affection, intimacy, and companionship
XX Self-esteem
ZZ Sense of worth
XX Self-actualization
ZZ Achieving one’s potential
ZZ Being all that one can be
XX Health Belief Model (Marshall Becker, 1940–1993)

ZZ Explains that healthy people do not always take advantage of screening or
preventative programs because of the following certain variables:
XX Perception of susceptibility
XX Seriousness of illness
XX Perceived benefits of treatment
XX Perceived barriers to change
XX Expectations of efficacy
XX Transtheoretical Model of Change
ZZ States that change such as in health behaviors occurs in six predictable stages
(Prochaska, Norcross, & DiClemente, 1992):
1. Precontemplation: The person has no intention to change.
2. Contemplation: The person is thinking about changing; is aware that there is
a problem but not committed to changing.
3. Preparation: The person has made the decision to change; is ready for
action.
4. Action: The person is engaging in specific, overt actions to change.
5. Maintenance: The person is engaging in behaviors to prevent relapse.
XX Motivational Interviewing (Miller & Rollnick, 1991)
ZZ Focused, goal-directive therapy
ZZ Builds on the Transtheoretical Model of Change
ZZ Motivation is elicited from the client
ZZ Nonconfrontational, nonadversarial
XX Self-Efficacy and Social Learning Theory (Albert Bandura, born 1925)
ZZ Behavior is the result of cognitive and environmental factors.
ZZ People learn by observing others, relying on role-modeling.
ZZ Self-efficacy is the perception of one’s ability to perform a certain task at a
certain level of accomplishment.
ZZ Behavioral change and maintenance are functions of outcome expectations and

efficacy expectations.
NURSING THEORIES
XX Theory of Cultural Care (Madeline Leininger, born 1925)
ZZ Regardless of the culture, care is the unifying focus and the essence of nursing.
ZZ Health and well-being can be predicted through cultural care.
XX Theory of Self-Care (Dorothy Orem, 1914–2007)
ZZ Self-care: Activities that maintain life, health, and well-being
XX Therapeutic Nurse–Client Relationship Theory or Interpersonal Theory (Hildegard
Peplau, 1909–1999)
ZZ First significant psychiatric nursing theory
ZZ Based in part on interpersonal theory (Sullivan, 1953)
ZZ Sees nursing as an interpersonal process in which all interventions occur within
the context of the nurse–client relationship
ZZ The therapeutic nurse–client relationship is central to nursing
ZZ Includes phases of the nurse–client relationship (see Table 3–2 above):
XX Orientation phase
XX Working phase (identification, exploitation)
XX Termination phase (resolution)
ZZ Promoting adaptive responses is the goal of nursing
ZZ Behavior represents the person trying to adapt to internal or environmental
forces
XX Caring Theory (Jean Watson, born 1940)
ZZ Caring is an essential component of nursing.
ZZ “Carative factors” guide the core of nursing and should be implemented in
health care.
ZZ Carative factors are those aspects of care that potentiate therapeutic healing
and relationships.
CASE STUDY 1
Thomas is a 19-year-old college freshman. During the second week of classes, he presented to
his college’s student health services clinic seeking help for “shyness.” The PMHNP is responsible
for assessment and care planning with this client.
As the PMHNP begins working with him, he gives a chief complaint of feeling uncomfortable
meeting new people and desiring to return home and drop out of school. The PMHNP has sev-
eral issues to consider as he or she continues to work with Thomas.
1. Chronologically, what stage of development should Thomas be experiencing?
2. What are the tasks of this stage?
3. How would the PMHNP assess the actual developmental issues that he is
experiencing?
4. What factors does the PMHNP need to consider to determine whether he is experi-
encing normative or nonnormative behaviors?
5. What characteristic does the PMHNP need to display to establish a therapeutic
relationship with him?
Thomas reported that he has not been sleeping well, has experienced a decrease in appetite,
and just wants to talk to someone about his problems in adjusting to school. In planning the
follow-up care for Thomas, the PMHNP has many issues to consider.
6. What would be the goal of continued work with Thomas?
7. If the PMHNP were to start therapy with him, what kind of therapy would he or she
consider?
8. According to DSM-5, does Thomas have a mental illness?
CASE STUDY 2
Jason is an 18-year-old, second-semester business major who presents to his university’s mental
health clinic because “my parents said I have to come here or they will pull me out of school. I
don’t think I need to be here.” Jason is on academic probation. The PMHNP learns that Jason’s
parents grew alarmed when, while home on holiday, Jason was brought home by police after he
and his friend were pulled over and friend was given a DUI. Jason allows that perhaps he “par-
tied too much” during his first semester at school, but insists he “doesn’t drink any more than
anybody else.” Jason reluctantly agrees to see the PMHNP for an evaluation and for 8 weekly
psychotherapy sessions “to please my parents.”
1. What defense mechanism(s) is Jason using?
2. How should the PMHNP approach working with this client?

Case Study 1
1. Thomas’s chronologic age should align with the developmental stage of
adolescence.
2. According to Erikson, the developmental task of adolescence is identity versus role
confusion.
3. The PMHNP should assess the degree of development of his personal sense of
identity.
4. The PMHNP must have an awareness of the normal milestones of development and
the behaviors that indicate failure of developmental stages. The client’s history and
behaviors are then matched to the known norm for comparison.
5. In order to develop a therapeutic relationship with Thomas, the PMHNP must display
genuineness, acceptance, nonjudgmental attitude, authenticity, empathy, and re-
spect professional boundaries.
6. The goals of continued work with Thomas are assisting Thomas to establish insight
into behaviors and to increase range and maturity of coping behaviors.
7. Options for psychotherapy depend on factors such as a client’s goals, motivation,
past experiences with counseling, expectations for therapy, and resources.
8. Mental illness causes a disruption in the usual constitutions of mental health. Mental
illness assumes an underlying psychopathology and can be defined as a clinically
significant behavioral or psychological syndrome or pattern that occurs in a person
that is associated with persistent distress or disability or with a significantly in-
creased risk of death, pain, or an important loss of freedom. Thomas appears to be
experiencing mental health concerns but based on available data, does not meet the
definition of mental illness.
Case Study 2
1. Jason is using denial and rationalization.
2. The PMHNP needs to work with Jason to establish goals using the principles of the
Transtheoretical Model of Change and motivational interviewing.

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Sadock, B., Sadock, V., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry (11th ed.).
New York, NY: Lippincott Williams & Wilkins.
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Books.
CHAPTER 4
PSYCHIATRIC–MENTAL HEALTH NURSE

PRACTITIONER PROFESSIONAL ROLE AND
HEALTH POLICY: LEADERSHIP, QUALITY
IMPROVEMENT AND SAFETY, PRACTICE INQUIRY,
AND HEALTH POLICY
LEADERSHIP
Nurses should be leaders and engage with health professionals to transform and redesign health
care (Institute of Medicine [IOM], 2010).
XX The nurse practitioner is educated to lead interdisciplinary treatment teams
ZZ Acts as full partner in health care
ZZ Designs, implements, evaluates, and advocates to redesign the U.S. healthcare
system
ZZ Translates research into practice
XX Team leadership model
ZZ Decision 1: Should the leader monitor the team or take action?
XX Seek out information to understand the team
XX Analyze information
XX Interpret the information and decide how to act
ZZ Decision 2: Should the leader intervene to meet the task or relational need?
XX Performance functions
XX Task functions
ZZ Decision 3: Should the leader intervene internally or externally?
XX Assess for conflicts between group members—action to maintain group

performance
ZZ Assess for unclear goals
ZZ Assess for proper support (Northouse, 2007, pp. 209–234)
Reflective Practice
XX Reflection uses a model or framework to systematically “make sense of experience”
(Sherwood & Horton-Deutsch, 2012, p. 4).
XX Process to tell a story about self and others to gain insight into practice
XX Enhances critical thinking to problem-solve and enhance clinical reasoning and
decision-making
XX Link theory to practice
Conflict Resolution, Negotiation, Mediation, and Professional

Civility
XX Conflict: occurs when a person believes his or her needs, interests, or values are
incompatible with others’
XX Conflict resolution: directed by a neutral third party who facilitates a “win-win”
situation
XX Negotiation: discussion among two or more people with the goal of reaching an
agreement
XX Mediation: voluntary and confidential process in which a third party facilitates discus-
sion to reach an agreement
XX Arbitration: process in which a third party reviews evidence from both sides and
makes a decision to settle the case
XX Professional civility: behavior that shows respect toward another person
Critical Thinking
XX Defined as the acquisition of knowledge with an attitude of deliberate inquiry
XX Making clinical decisions based on evidence-based practice
ZZ Decreases the difficulty of choosing from conflicting or multiple
recommendations when diagnosing and treating clients
XX Develops self-awareness though a metacognitive process to gain new insights about
self, and in relation to others
Research
XX Research utilization: Process of synthesizing, disseminating, and using research-gen-
erated knowledge to make a change in practices; a subset of the broader evidence-
based practice
PSYCHIATRIC–MENTAL HEALTH NURSE PRACTITIONER PROFESSIONAL ROLE AND HEALTH POLICY 53
XX Evidence-based practice: The integration of best research evidence with clinical

expertise and client values and needs. PMHNPs need to know the effectiveness of
evidence-based interventions and select the intervention to meet the client need
(Perese, 2012, p. 29).
XX Research utilization and evidence-based practice are two models for reducing the
gap between research findings and application to practice
ZZ Research utilization process
XX Critique research
XX Synthesize the findings
XX Apply the findings
XX Measure the outcomes
XX Develop a clinical question using the PICO method
P = patient, population of patients, problem
I = intervention
C = comparison (another treatment or therapy, placebo)
O = outcome
XX Systematically search for relevant research evidence
ZZ Critique the research evidence
XX Quanitative hierarchy (Fineout-Overholt, Melnyk, & Schultz, 2005)
ZZ Randomized controlled trials (RCT), meta-analysis, or systematic review
ZZ Evidence-based guidelines based on systematic review
ZZ Evidence from RCT without randomization
ZZ Evidence from systemic review of descriptive and qualitative studies
ZZ Evidence from expert opinion or committee reports
XX Qualtitative hierarchy (Fineout-Overholt, Melnyk, & Schultz, 2005)

ZZ Evidence from systematic reviews of descriptive and qualitative studies
ZZ Evidence from a single descriptive or qualitative study
ZZ Evidence from expert opinion or committee
ZZ Evidence-based guideline based on systematic review of RCTs
ZZ Evidence from well-designed controlled trials without randomization
ZZ Systematic reviews or meta-analysis
ZZ Evidence from at least one well-designed RCT
ZZ Make an evidence-based decision regarding implementation

ZZ Implement the change, depending on the above decision
ZZ Evaluate the change
XX Dissemination
ZZ Present at local, regional, and national conferences
ZZ Publish in peer-reviewed journals

ZZ Publish in professional newsletters (Melnyk, Fineout-Overholt, Stillwell, &
Williamson, 2010)
XX Concepts in interpreting research findings
ZZ Internal validity: The independent variable (the treatment) caused a change in the
dependent variable (the outcome)
ZZ External validity: The sample is representative of the population and the results
can be generalized
ZZ Descriptive statistics: Used to describe the basic features of the data in the
study; numerical values that summarize, organize, and describe observations;
can be generated by either quantitative or qualitative studies
XX Examples include
ZZ Mean: Average of scores
ZZ Standard deviation: Indication of the possible deviations from the mean
ZZ Variance: How the values are dispersed around the mean; the larger
the variance, the larger the dispersion of scores
ZZ Inferential statistics: Numerical values that enable one to reach conclusions that
extend beyond the immediate data alone; generated by quantitative research
designs
XX Examples include
ZZ t test: Assesses whether the means of two groups are statistically
different from each other
ZZ Analysis of variance (ANOVA): Tests the differences among three or
more groups
ZZ Pearson’s r correlation: Tests the relationship between two variables
ZZ Probability: Likelihood of an event occurring; lies between 0 and 1;
an impossible event has a probability of 0, and a certain event has a
probability of 1
ZZ P value: Also known as level of significance; describes the probability
of a particular result occurring by chance alone (if P = .01, there is a 1%
probability of obtaining a result by chance alone)
XX Ethical considerations in research

ZZ Institutional Review Boards (IRBs) ensure that
XX Risks to participants are minimized,
XX Participant selection is equitable,
XX Adverse events are reported and risks and benefits are reevaluated,
XX Informed consent is obtained and documented,
XX Data and safety monitoring plans are implemented when indicated, and
XX Overall, that the rights and welfare of human research participants are
protected, and has the authority to approve, require modifications, or
disapprove of any research activities.
XX All investigators or persons involved in research studies must take and pass a test on
protection of human participants
QUALITY IMPROVEMENT
XX Agency-specific projects that aim to improve systems, decrease cost, and improve
productivity
XX Provides standardized method to identify gaps in practice and systems to evaluate
ways to improve structure, function, and resources in care delivery within complex
health systems
XX Institute of Medicine’s quality aims (IOM, 2001)
ZZ Safe
ZZ Effective
ZZ Client-centered
ZZ Timely
ZZ Efficient
ZZ Equitable
XX Examine internal processes
XX New knowledge is specific to an organization
XX Donabedian model
ZZ Structure
ZZ Process
ZZ Outcome
XX Process of quality improvement can be PDSA cycle:
ZZ Plan: Plan the change
ZZ Do: Carry out the plan
ZZ Study: Examine the results
ZZ Act: Decide what actions will improve the process
XX Translation of research into practice using quality improvement efforts and clini-
cal inquiry leads to improved systems and process, which create improved health
outcomes
JUST CULTURE OF SAFETY

XX American Nurses Association Position Statement (ANA, 2010)
ZZ Supports collaboration efforts among state boards of nursing, professional
organizations, patient safety centers, and health systems to develop Just
Culture initiatives
ZZ Holds people accountable for their behaviors and investigates errors
ZZ Goal of creating open and fair learning environment to design safe systems and
manage choices
ZZ Mindset that affects work environment to proactively look for system
breakdowns and identify ways to improve systems
HEALTH DELIVERY SYSTEMS

XX Health care is complex and fragmented; complexity science provides a framework to
understand, design, and structure change.
XX Focus is on the interaction of the parts and relationships
XX Nonlinear process
Access to Care
Access to care is a client-centered care model based on the principle that healthcare services
should be coordinated and directed by a single physician or other provider. In this model, clients
can access services from multiple entry points. Services can be located in the same facility, or
an integrated care network of providers in different locations can be accessed when needed.
Quality of Care
The National Committee for Quality Assurance (NCQA) has developed Health Effectiveness Data
Information Sets (HEDIS) to measure health outcomes. Currently, eleven HEDIS measures exist
for behavioral health:
1. Antidepressant medication management
2. Follow-up care for children prescribed ADHD medication
3. Follow-up after hospitalization for mental illness
4. Diabetes screening for people with schizophrenia and bipolar disorder who are using
antipsychotic medications
5. Diabetes monitoring for people with diabetes and schizophrenia
6. Cardiovascular monitoring for people with cardiovascular disease and schizophrenia
7. Adherence to antipsychotic medications for individuals with schizophrenia
8. Use of multiple concurrent antipsychotics in children and adolescents
9. Metabolic monitoring for children and adolescents on antipsychotic medication
10. Use of first-line psychosocial care for children and adolescents on antipsychotic
medication
11. Mental health utilization
Organization of Practices
With the Affordable Care Act (ACA; 2010), practices are being reorganized and redesigned to pro-
vided integrated care, including medical and psychiatric care. The client-centered medical (health)
home has support of the Health Resources and Services Administration (HRSA) and initiatives to
provide client-centered, evidenced-based, coordinated, and quality care are moving forward.
Patient-Centered Care Model (PCC)

XX Welcoming environment: Provide a physical space and an initial personal interaction
that is welcoming and familiar, not intimidating.
XX Respect for clients’ values and expressed needs: Obtain information about the
client’s care preferences and priorities; inform and involve the client and family or
caregivers in decision-making; tailor care to the person; and promote a mutually
respectful, consistent client–provider relationship.
XX Client empowerment or “activation”: Educate and encourage the client to expand his
or her role in decision-making, health-related behaviors, and self-management.
XX Sociocultural competence: Understand and consider culture, economic and educa-
tional status, health literacy level, family patterns and situation, and traditions (includ-
ing alternative and folk remedies); communicate in language and at a level that the
client understands.
XX Coordination and integration of care: Assess the client’s need for formal and informal
services that may affect health or treatment; provide team-based care, care manage-
ment, and referrals as needed; advocate for the client and family; and ensure smooth
transitions between different providers and phases of care.
XX Comfort and support: Emphasize physical comfort, privacy, emotional support, and
involvement of family and friends.
XX Access and navigation skills: Provide what the patient can consider a “medical
home”; keep waiting times to a minimum; provide convenient service hours; pro-
mote access and client flow; help client attain skills to better navigate the healthcare
system.
XX Community outreach: Make demonstrable, proactive efforts to understand and reach
out to the local community (Silow-Carroll, Alteras, & Stepnick, 2006).
Health Care Home (Substance Abuse and Mental Health Services

Administration [SAMHSA], 2015)
XX Defined in the Affordable Care Act (2010) as an approach to primary care that pro-
vides coordinated care to persons with multiple chronic health conditions, including
mental health and substance use
XX Offers team-based care
XX Builds on community supports
CONFLICT OF INTEREST
A conflict of interest (COI) is a situation in which a person’s financial, professional, or personal
situation may affect or appear to affect the person’s judgment in his or her professional respon-
sibilities, including healthcare decisions, research, and other matters, with the potential for
personal or professional gain or advantage—or, conversely, loss or disadvantage—of any kind

and the possibility of potential harm to clients.
XX Disclosure of potential COIs should be done at least annually and whenever new
significant financial interests are received.
XX Disclosure must be reported to employers, boards, professional agencies, and wher-
ever there is potential for a COI.
XX Action should be carried out to resolve potential or actual COIs and reduce bias.
XX Healthcare agencies and educational and research institutions have policies to
require the disclosure of any potential COI and to define the limits allowed in any
relationship with external organizations and companies.
XX A COI form indicating any financial or other relationship with the products being dis-
cussed must be completed prior to any professional presentation. In addition, if any
off-label uses of medications or medical devices will be discussed, this information
must also be disclosed.
XX Types of conflict of interest:
ZZ Relationships with pharmaceutical, medical supply, or insurance companies
ZZ Money, gifts in kind
ZZ Referrals
ZZ Fee splitting
RIGHTS OF CLIENTS
XX Confidentiality
XX Least restrictive treatment
XX Give consent for treatment and withdraw consent at any time
HEALTH POLICY DEVELOPMENT

Health policy is decisions, actions, and plans to achieve specific healthcare goals (World Health
Organization [WHO], 2016).
XX Four components of health policy:
1. Process: formulation, implementation, and evaluation
2. Policy reform: changes in programs and practices
3. Policy environment: arena the process takes place in (government, media,
public)
4. Policy makers: key players and stakeholders
XX Health policies are developed through law and regulations.
ZZ Branches of law: executive (implement law), legislative (initial formulation), and
judicial (interpret law)
CASE STUDY
A PMHNP who is working at a federally qualified health center (FQHC) is asked to implement
routine depression screening for all clients who present to the clinic. The PMHNP is excited
about the project but has never implemented a system change and is not sure how to proceed.
The PMHNP does have access to the quality improvement department and the clinical manager
to get guidance.
1. What depression screening measures are in the public domain and have been found
to be sensitive to and specific for depression screening?
2. What is the first step the PMHNP should complete to begin her system change
process?
3. Who are key players that should be part of the PMHNP’s quality improvement team?
4. What model or framework can the PMHNP use to guide her quality improvement
project?
5. When conducting a literature review on depression screening in an FQHC, the
PMHNP finds two RCT studies and two expert opinion articles. Which type has the
highest level of evidence?

1. The screening measures in the public domain, sensitive to and specific for depres-
sion screening are: Patient Health Questionnaire–2 (PHQ2) and Patient Health
Questionnaire–9 (PHQ9).
2. The first step in beginning a systems change project is to conduct a systemic needs
assessment of the organization.
3. The key players that need to be part of the team include all members of the clinic
who will be affected by implementation of the depression screening project.
4. The two models that can be used to conduct a quality improvement project include
Donabedian model and Plan Do Study Act cycle.
5. The highest level of evidence in the literature when evaluating quantitative research
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health_policy/en/
CHAPTER 5
NEUROANATOMY, NEUROPHYSIOLOGY, AND

BEHAVIOR
A tremendous expansion of knowledge about the brain has occurred in the past 2 decades. As
more has been learned about the brain and its complex functioning, assessment and treatment
for psychiatric disorders have been altered dramatically. Increasingly, the links among genetics,
altered brain anatomy and physiology, and the symptoms of psychiatric disorders have been
identified (Sadock, Sadock, & Ruiz, 2015).
This growing knowledge base will continue to alter the treatment of psychiatric disorders. As
new knowledge is disseminated, it is helping diminish the stigma long associated with psychiat-
ric illness.
This chapter reviews the basics of neuroanatomy and physiology that provide the scientific
rationale for many of the psychiatric–mental health nurse practitioner (PMHNP) care practices, in-
cluding psychopharmacological interventions described elsewhere in this review book. PMHNPs
need a solid grounding in neurobiology. Increasingly, the roles of the PMHNP require the applica-
tion of this knowledge to clinical practice.
THE NERVOUS SYSTEM

XX All human thoughts, feelings, and actions are seated in and start with actions of the
nervous system.
XX Necessary for the PMHNP’s role functioning is an understanding of the following
basic neuroanatomy and physiology:
ZZ Neurodeficits that underlie psychiatric disorders
ZZ Actions of and client responses to psychopharmacological treatment agents
XX The nervous system’s primary function is to transfer and exchange information.
The Neuron (“Nerve Cells”)

XX The basic cellular unit of the nervous system
XX The microprocessor of the brain responsible for conducting impulses from one part
of the body to another
XX Components of the neuron:

ZZ Cell body: Also known as soma; made up of the nucleus and cytoplasm within
cell membrane
ZZ Stem or axon: Transmits signals away from the neuron’s cell body to connect
with other neurons and cells
ZZ Dendrites: Collect incoming signals from other neurons and send the signal
toward the neuron’s cell body
Nervous System
XX Composed of two separate, interconnected divisions:
ZZ Central nervous system (CNS)
XX Composed of the spinal cord and the brain
ZZ Peripheral nervous system (PNS)
XX Composed of the peripheral nerves that connect the CNS to receptors,
muscles, and glands
XX Includes the cranial nerves just outside the brain stem
XX Comprises the somatic nervous system and the autonomic nervous
system:
ZZ Somatic nervous system: Conveys information from the CNS to
skeletal muscles; responsible for voluntary movement
ZZ Autonomic nervous system: Regulates internal body functions to
maintain homeostasis; conveys information from the CNS to smooth
muscle, cardiac muscle, and glands; responsible for involuntary
movement; divided into the sympathetic nervous system and the
parasympathetic nervous system:
XX Sympathetic nervous system: The excitatory division; prepares the
body for stress (fight or flight); stimulates or increases activity of
organs
XX Parasympathetic nervous system: Maintains or restores energy;
inhibits or decreases activity of organs
NEUROANATOMY AND THE BRAIN

XX Brain tissue is categorized as either white matter or gray matter.
ZZ White matter is the myelinated axons of neurons.
ZZ Gray matter is composed of nerve cell bodies and dendrites; it is the working
area of the brain and contains the synapses, the area of neuronal connection.
XX Outermost surface of the brain: Structured to contain grooves and dips of corrugated
wrinkles within the brain tissue that provide anatomical landmarks or reference
points
Neuroanatomy, Neurophysiology, and Behavior 65
ZZ Functions to increase brain’s surface area

XX Increases working area and cell communication area
ZZ Grooves and dips named by size and depth
XX Sulci: Small shallow grooves
XX Fissures: Deeper groves extending into the brain
ZZ Gyri are the raised tissue areas.
XX Distinct anatomical areas of brain
ZZ The brain is subdivided into the cerebrum and the brainstem.
Cerebrum
XX Largest part of the brain, which is divided into two halves, the right and left cerebral
hemispheres
ZZ Left hemisphere: Dominant in most people; controls most right-sided body
functions
ZZ Right hemisphere: Controls most left-sided body functions
ZZ Normal functioning requires effective coordination of two hemispheres.
ZZ Both hemispheres connected by a large bundle of white matter, the corpus
callosum, an area of sensorimotor information exchange between the two
hemispheres
ZZ Each hemisphere is divided into four major lobes, which work in an interactive
and integrated manner, and each with a distinct function:
XX Frontal lobe: Largest and most developed lobe. Functions include:
ZZ Motor function: Responsible for controlling voluntary motor activity of
specific muscles
ZZ Premotor area: Coordinates movement of multiple muscles
ZZ Association cortex: Allows for multimodal sensory input to trigger
memory and lead to decision-making
ZZ Seat of executive functions: Working memory, reasoning, planning,
prioritizing, sequencing behavior, insight, flexibility, judgment, impulse
control, behavioral cueing, intelligence, abstraction
ZZ Language (Broca’s area): Expressive speech
ZZ Personality variables: The most focal area for personality development
ZZ Problems in the frontal lobe can lead to personality changes, emotional,
and intellectual changes
XX Temporal lobe; functions include:

ZZ Language (Wernicke’s area): Receptive speech or language
comprehension
ZZ Primary auditory area
ZZ Memory
ZZ Emotion
ZZ Integration of vision with sensory information
ZZ Problems in the temporal lobe can lead to visual or auditory
hallucinations, aphasia, and amnesia
XX Occipital lobe; functions include:

ZZ Primary visual cortex
ZZ Integration area: Integrates vision with other sensory information
ZZ Problems in the occipital lobe can lead to visual field defects, blindness,
and visual hallucinations
XX Parietal lobe; functions include:

ZZ Primary sensory area
ZZ Taste
ZZ Reading and writing
ZZ Problems in the parietal lobe can lead to sensory–perceptual
disturbances and agnosia
XX Cerebrum includes the cerebral cortex, limbic system, thalamus, hypothalamus, and
basal ganglia.
ZZ Cerebral cortex
XX Controls wide array of behaviors
XX Controls the contralateral (opposite) side of the body: The right hemisphere
controls the left side of the body, and the left hemisphere controls the right
side of the body.
XX Sensory information is relayed from the thalamus and then processed and
integrated in the cortex.
XX Responsible for much of the behavior that makes us human: speech,
cognition, judgment, perception, and motor function
ZZ Limbic system
XX Essential system for the regulation and modulation of emotions and
memory
XX Composed of the hypothalamus, thalamus, hippocampus, and the amygdala
ZZ Hypothalamus: Plays key roles in various regulatory functions such
as appetite, sensations of hunger and thirst, water balance, circadian
rhythms, body temperature, libido, and hormonal regulation
ZZ Thalamus: Sensory relay station except for smell; modulates flow of
sensory information to prevent overwhelming the cortex; regulates
emotions, memory, and related affective behaviors
ZZ Hippocampus: Regulates memory and converts short-term memory
into long-term memory
ZZ Amygdala: Responsible for mediating mood, fear, emotion, and
aggression; also responsible for connecting sensory smell information
with emotions
ZZ Basal ganglia: Also known as the corpus striatum

XX Serves as a complex feedback system to modulate and stabilize somatic
motor activity (information conveyed from the CNS to skeletal muscles)
XX Plays a role in movement initiation; complex motor functions with
association connections
XX Functions in learning and automatic actions such as walking or driving a car
XX Contains extrapyramidal motor system or nerve tract
XX Functions in involuntary motor activities (e.g., muscle tone, posture,
coordination of muscle movement and common reflexes)
XX Many psychotropic medications can affect the extrapyramidal motor nerve
track, causing involuntary movement side effects
XX Contains both the caudate and the putamen
XX Problems in the basal ganglia can lead to bradykinesia, hyperkinesias, and
dystonia.
Brainstem
XX Made up of cells that produce neurotransmitters
XX Includes the midbrain, pons, medulla, cerebellum, and reticular formation
ZZ Midbrain: Houses the ventral tegmental area and the substantia nigra (areas of
dopamine synthesis)
ZZ Pons: Houses the locus ceruleus (area of norepinephrine synthesis)
ZZ Medulla: Together with the pons, contains autonomic control centers that
regulate internal body functions
ZZ Cerebellum: Responsible for maintaining equilibrium; acts as a gross movement
control center (e.g., control movement, balance, posture)
XX Each hemisphere of cerebellum has ipsolateral control (same side of body).
XX Problems with the cerebellum can lead to ataxia (uncoordinated and
inaccurate movements).
XX Romberg test is important for detecting deficiencies in cerebellar
functioning.
ZZ Reticular formation system: The primitive brain
XX Receives input from cortex; an integration area for input from postsensory
pathways
XX Innervates thalamus, hypothalamus, and cortex
XX Regulation functions include:
ZZ Involuntary movement
ZZ Reflex
ZZ Muscle tone
ZZ Vital sign control
ZZ Blood pressure
ZZ Respiratory rate
ZZ Critical to consciousness and ability to mentally focus, to be alert and
pay attention to environmental stimuli
NEUROPHYSIOLOGY AND THE BRAIN

XX Two classes of cells are in the nervous system: glia and neurons.
ZZ Glia: Structures that form the myelin sheath around axons and provide
protection and support
ZZ Neurons: Nerve cells responsible for conducting impulses from one part of the
body to another
XX Components of a neuron include:
ZZ Cell body: Also known as soma; made up of the nucleus and cytoplasm within
the cell membrane
ZZ Dendrites: Receive information to conduct impulse toward the cell body
ZZ Axon: Sends or conducts information away from cell body
XX Synapse or synaptic cleft—The connection site and area of communication between
neurons where neurotransmitters are released
ZZ The synapse converts an electrical signal (action potential) from the presynaptic
neuron into a chemical signal (neuron transmitter) that is transferred to the
postsynaptic neuron.
ZZ Neurotransmitters are released at the synaptic cleft as the result of an electrical
activity (action potential).
ZZ The two phases of an action potential are:
XX Depolarization: The initial phase of the action potential (an excitatory
response), when sodium and calcium ions flow into the cell; and
XX Repolarization: The restoration phase (an inhibitory response), when
potassium leaves the cell or chloride enters the cell.
ZZ Problems in either the structure or chemistry of the synapse interrupt normal
flow of impulses and stimuli, which then contribute to symptoms commonly
seen in psychiatric disorders.
XX Neurotransmitters: Chemicals synthesized from dietary substrates that communi-
cate information from one cell to another.
ZZ The neurotransmitter will be released from the presynaptic neuron, cross the
synapse, and then bind to a specific receptor on the postsynaptic neuron.
ZZ Specific criteria must be met for a molecule to be classified as a
neurotransmitter (see Table 5–1).
ZZ Categories of neurotransmitters: Monoamines, amino acids, cholinergics,
neuropeptides
TABLE 5–1.
CLASSIFICATION REQUIREMENTS FOR NEUROTRANSMITTERS
Criteria 1. Neurotransmitter must be present in the nerve terminal.

2. Stimulation of neuron must cause release of neurotransmitter in sufficient
quantities to cause an action to occur at postsynaptic membrane.
3. Effects of exogenous transmitter on postsynaptic membrane must be similar to
those caused by stimulation of presynaptic neuron.
4. A mechanism for inactivation or metabolism of the neurotransmitter must exist
in the area of the synapse.
5. Exogenous drugs should alter the dose–response curve of the neurotransmitter
in a manner similar to the naturally occurring synaptic potential.
Note. Adapted from Sadock, B., Sadock, V., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of
psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer
XX Monoamines: “Biogenic amines”—dopamine, norepinephrine, epinephrine,

serotonin
ZZ Dopamine: Known as a catecholamine; produced in the substantia
nigra and the ventral tegmental area; precursor is tyrosine; removed
from the synaptic cleft by monoamine oxidase (MAO) enzymatic action
XX Four dopaminergic pathways: Mesocortical, mesolimbic,
nigrostriatal, tuberoinfundibular (see Chapter 10)
ZZ Norepinephrine: Also known as a catecholamine; produced in the
locus ceruleus of the pons; precursor is tyrosine; removed from the
synaptic cleft and returned to storage via an active reuptake process;
major neurotransmitter implicated in mood, anxiety, and concentration
disorders
ZZ Epinephrine: Also known as a catecholamine; produced by the adrenal
glands; epinephrine system also referred to as the adrenergic system
ZZ Serotonin: Known as an indole; produced in the raphe nuclei of the
brainstem; precursor is tryptophan; removed from the synaptic
cleft and returned to storage via an active reuptake process; major
neurotransmitter implicated in mood and anxiety disorders
XX Amino acids: Glutamate, aspartate, γ-aminobutyric acid (GABA), glycine

ZZ Glutamate: Universal excitatory neurotransmitter; major
neurotransmitter involved in process of kindling, which is implicated in
seizure disorders and possibly bipolar disorder; imbalance implicated in
mood disorders and schizophrenia
ZZ Aspartate: Another excitatory neurotransmitter; works with glutamate
ZZ GABA: Universal inhibitory neurotransmitter; site of action of
benzodiazepines, alcohol, barbiturates, and other CNS depressants
ZZ Glycine: Another inhibitory neurotransmitter; works with GABA
XX Cholinergics: Acetylcholine
ZZ Acetylcholine: Synthesized by the basal nucleus of Meynert; precursors
are acetylcoenzyme A and choline
XX Neuropeptides: Nonopioid type (substance P, somatostatin); opioid type

(endorphins, enkephalins, dynorphins)
ZZ Modulate pain; decreased amount of neuropeptides is thought to
cause substance abuse
ZZ See Table 5–2 for identification of neurotransmitters’ role in symptom expression

in common psychiatric disorders.
ZZ Recovery and degradation of neurotransmitters
XX After the neurotransmitter reaches the postsynaptic neuron, it may then
diffuse off its receptor to be destroyed by enzymes or to be transported
back to the presynaptic neuron for reuse.
XX Enzymatic destruction occurs either in the cytosol or in the synapse. The
neurotransmitter can be destroyed by the enzymes monoamine oxidase
(MAO) in the cytosol or catechol-O-methyl transferase (COMT) intracellularly
or in the synapse.
TABLE 5–2.
COMMON PSYCHIATRIC DISORDERS AND NEUROTRANSMITTERS IMPLICATED IN THE
COMPLEX PATHOPHYSIOLOGY OF COMMON PSYCHIATRIC DISORDERS
SUSPECTED
NEUROTRANSMITTER IMBALANCE PSYCHIATRIC PRESENTATION
Acetylcholine Decrease Alzheimer’s disease
Impaired memory
Increase Parkinsonian symptoms
Dopamine Increase Schizophrenia
Psychosis
Decrease Substance abuse
Anhedonia
Parkinson’s disease
Norepinephrine Decrease Depression
Increase Anxiety
Serotonin Decrease Depression
Obsessive–compulsive disorder, anxiety
disorders
Schizophrenia
γ-Aminobutyric acid (GABA) Decrease Anxiety disorders
Glutamate Increase Bipolar affective disorder

Psychosis from ischemic neurotoxicity or
excessive pruning
Decrease Memory and learning difficulty
Negative symptoms of schizophrenia
Opioid neuropeptides Decrease Substance abuse
Note. Adapted from Thibodeau, G., & Patton, K. (2015). Anatomy and physiology (9th ed.). St.
Louis, MO: Mosby.
XX Reuptake pumps can remove the neurotransmitter from acting in the

synapse. The neurotransmitter will be reloaded into the presynaptic neuron
and will be recycled.
ZZ Function of neurotransmitters: see Table 5–3
TABLE 5–3.
COMPARISON OF COMMON CNS NEUROTRANSMITTERS
NEURO- GENERAL SYMPTOMS OF SYMPTOMS OF

TRANSMITTER RECEPTORS FUNCTION DEFICIT EXCESS
Dopamine D1-like Thinking Mild: Mild:
D2-like Decision-making Poor impulse Improved creativity
Reward-seeking control Improved ability for
behavior Poor spatiality abstract thinking
Fine muscle action Lack of abstractive Improved
Integrated thought executive
cognition functioning
Severe: Improved spatiality
Parkinson’s disease
Endocrine Severe:
alterations Disorganized
Movement thinking
disorders Loose association
Tics
Stereotypic
behavior
Norepinephrine α1 Alertness Dullness Anxiety
α2 Focused attention Low energy Hyperalertness
Orientation Depressive affect Increased startle
Primes “fight or Paranoia
flight” Decreased
Learning appetite
Memory
Serotonin 5HT1a Regulation of sleep Irritability Sedation
5HT1d Pain perception Hostility Increased
5HT2 Mood states Depression aggression
5HT2a Temperature Sleep Hallucinations
dysregulation (rare)
5HT3 Regulation of
5HT4 aggression Loss of appetite
Libido Loss of libido
Precursor for
melatonin
CONTINUED
NEURO- GENERAL SYMPTOMS OF SYMPTOMS OF

TRANSMITTER RECEPTORS FUNCTION DEFICIT EXCESS
Acetylcholine Nicotinic Attention Lack of inhibition Over-inhibition
Muscarinic Memory Decreased Anxiety
Thirst memory Depression
Mood regulation Euphoria Somatic
REM sleep Antisocial action complaints
Sexual behavior Speech decrease Self-consciousness
Muscle tone Dry mouth, blurred Drooling
vision, constipation Extrapyramidal
movements
GABA GABAa Reduces arousal Irritability Reduced cellular

GABAb Reduces Hostility excitability
aggression Tension and worry Sedation
Reduces anxiety Anxiety Impaired memory
Reduces excitation Seizure activity
Glutamate AMPA Memory Poor memory Kindling

MNDA Sustained Low energy Seizures
automatic Distractible Anxiety or panic
functions
Peptides: μ (mu) Modulate Hypersensitivity to Insensitivity to pain

Opioid type k (kappa) emotions pain and stress Catatonic-like
ε (epsilon) Reward-center Decreased movement
function pleasure sensation disturbance
δ (delta)
Consolidation of Dysphoria Auditory
σ (sigma) memory hallucinations
Modulate reactions Decreased
to stress memory
Note. Adapted from Sadock, B., Sadock, V., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of
psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
NEUROIMAGING ASSESSMENT AND DIAGNOSTIC PROCEDURES

XX Techniques that permit observation of the brain can be divided into three categories:
structural imaging, functional imaging, and combined structural and functional imaging.
ZZ Structural imaging: Provides evidence of size and shape of anatomical structures
XX Common structural imaging tests include:
ZZ Computed tomography (CT): Provides a three-dimensional view of the
brain structures; differentiates structures based on density; provides
suggestive evidence of brain-based problems but no specific testing for
psychiatric disorders
XX Advantages: Widely available, relatively inexpensive
XX Disadvantages: Lack of sensitivity, cannot differentiate white
matter from gray matter; cannot view structures close to the bone
tissue; underestimation of brain atrophy; inability to image sagittal
and coronal views
ZZ Magnetic resonance imaging (MRI): Provides a series of two-dimensional

images that represent the brain
XX Advantages: Can view brain structures close to the skull and can separate
white matter from gray matter; readily available; resolution of brain tissue
superior to CT scanning
XX Disadvantages: Expensive; many contraindications to its use (e.g., clients
with pacemakers or any metallic implants such as orthopedic screws or
plates, or on ventilators); clients with claustrophobia often are unable to
complete study because of design of machinery (an enclosed tubelike
structure with a confining environment)
ZZ Functional imaging: Technique that measures function of areas of the brain
and bases the resulting assessment on blood flow; may use radioactive
pharmaceuticals to cross the blood-brain barrier; mainly used for research
XX Common functional imaging tests include
ZZ EEG and evoked potentials testing: Least expensive tests that convey
information on electrical functioning of the CNS
ZZ Magnetoencephalography (MEG): Similar to the EEG but detects
different electrical activities; often used in a complementary fashion
with EEG testing
ZZ Single photon emission computed tomography (SPECT): Provides
information on the cerebral blood flow; limited availability; expensive
but less than positron emission tomography
ZZ Positron emission tomography (PET): Provides images of the brain
when positron-emitting radionuclei interact with an electron; expensive
procedure that requires extensive resources and support team
ZZ Combined structural and functional imaging: The newest imaging; attempts

to examine structure in conjunction with function; currently mainly used for
research
XX Available tests include
ZZ Functional MRI (fMRI)
ZZ Three-dimensional, event-related functional MRI (3fEMRI)
ZZ Fluorine magnetic spectroscopy
ZZ Dopamine D2 receptor binding
GENOMICS
Family History, Family Tree, or Pedigree
XX Tool in determining likelihood of genetic disorder in family, inheritance patterns, and
risk of recurrence in family members
XX Surgeon General recommended that families know their family history (U.S.
Department of Health and Human Services, n.d.)
XX Pedigree symbols in drawing a family tree indicate male, female, marriage, divorce,
adoption, twins, pregnancy, consanguinity (relatives having children), conditions
XX Family history starts with current family and moves back to grandparents.
XX Autosomal-dominant conditions may be present in more than one generation and in
up to 50% of offspring when one parent is affected (e.g., Marfan syndrome).
XX Recessive conditions appear only in one generation, affecting people who have two
copies of a faulty gene, one from each (unaffected) parent (e.g., hemochromatosis,
cystic fibrosis).
XX X-linked disorders are caused by faulty genes on an X chromosome (e.g., fragile X
syndrome, color blindness).
XX Risk assessment is based on inheritance patterns and may be by percentage of risk.
Genetic Counseling
XX Genetic counseling is a communication process used when a client has a genetic
risk and often involves offering a test that could provide information about the ge-
netic status of the person and possible implications for the family.
XX A genetic counselor is someone whose primary role is to offer information and sup-
port to people concerned about an illness that may have a genetic basis.
XX A referral to a genetic counselor may be needed when a client is anticipating a preg-
nancy and concerned for the health of the fetus.
Genetic Terms
XX Chromosomes are structures of DNA (deoxyribonucleic acid) in the nucleus of cells;
there are normally 46 total (23 pairs) in humans.
XX DNA is made up of two twisted, paired strands, composed of sugars linked by four
nucleotide bases—adenine (A), thymine (T), cytosine (C), and guanine (G)—specify-
ing the amino acids that make proteins. A is always paired with T and G is always
paired with C.
XX Genes are a sequence of DNA that cause human characteristics to be passed to the
next generation; genes direct the production of proteins.
XX Messenger RNA (mRNA) codes for an amino acid.
XX The Human Genome Project mapped the entire nucleotide sequence of the human
genome in 2003. The genome is a complete set of DNA.
XX A phenotype is the observable characteristic of a specific trait and is connected
to the genetic contributions to that trait (e.g., fast metabolizer of CYP4502D6
medications).
XX Gene therapy involves replacing a faulty copy of a gene with a healthy copy of the
same gene.
XX Personalized medicine is health care based on genetic variability.
Studies of Population Genetics

XX Family studies investigate the occurrence of disorders in first-degree relatives (par-
ents, siblings, and offspring) and second-degree relatives (grandparents, cousins,
aunts, and uncles).
XX Twin studies survey the concordance rate (presence) of a disorder in monozygotic
(identical) and dizygotic (fraternal) twins.
XX Adoption studies investigate the risk of a disorder developing in children raised in a
different environment from the biological parent with a specific disorder.
XX Strong genetic contributions have been found for most psychiatric disorders, with a
range of 40% to 90% heritability for some disorders (e.g., attention-deficit hyperac-
tivity disorder, bipolar disorder).
XX Genes are risk factors that make a person vulnerable to developing the illness when
combined with certain environmental risk factors that increase susceptibility of
developing the disorder.
XX Environmental risk factors include prenatal insults, stress, infections, poor nutrition,
exposure to toxins, catastrophic loss, and physical and sexual abuse.
XX Most diseases are multifactorial, caused by both environmental and genetic factors;
single-gene disorders are rare.
Gene Expression and Disease

XX Single nucleotide polymorphisms (SNP) detect single base changes in DNA
sequence.
XX Reduced penetrance of a gene decreases chances of disease in person at genetic
risk.
XX Variable expression of a gene for a disorder occurs at the cellular level.
Pharmacogenomics
XX Genes account for differences in the way enzymes metabolize drugs.
XX Medications may act differently based on how genes affect metabolism.
XX Genetic testing or profiling helps identify the presence of gene variants that may
help determine dosing of medication (e.g., CYP450 test of CYP4502D6, CYP450
2C19, and methylene tetrahydrofolate reductase [MTHFR] genes—see Chapter 7 for
further information on pharmacokinetics).
XX Testing for presence of HLA-B*1502 allele, an inherited variant of HLA-B gene, is
required by the FDA in people of Asian descent prior to prescribing the anticonvul-
sant carbamazepine due to risk of Stevens-Johnson syndrome and toxic epidermal
necrolysis (TEN).
CASE STUDY 1
Ms. Franklin is a 24-year-old sales clerk. She has a strong family history of mental illness and is
worried that she may experience some problems in her life because of her family history. She
presents to her local primary care provider complaining of the following symptoms:
XX Hyperalertness
XX Increased startle response
XX Concern that people are staring at her and watching what she eats
XX Decreased appetite
XX Difficulty falling asleep
Ms. Franklin is trying to determine if these experiences are the beginning of a mental illness.
She wants to have a brain scan done to determine the answer. She also is getting married soon
and wants to know what the risk is that her future children will experience mental illness, be-
cause she believes it runs in her family. In working with Ms. Franklin, the PMHNP must consider
many issues.
1. Are the symptoms described by Ms. Franklin consistent with a psychiatric disorder?
2. Do psychiatric disorders run in families, as Ms. Franklin believes?
3. Do the symptoms as described by Ms. Franklin link with any known neuroanatomical
or neurophysiologic deficit?
4. Is a brain scan warranted for Ms. Franklin?
5. Can the risk of Ms. Franklin’s children developing psychiatric disorders be
determined?
CASE STUDY 2
Joel is an 18-year-old college freshman who developed psychotic symptoms necessitating a brief
hospitalization at his university’s medical center. Joel is given haloperidol (Haldol) 5 mg IM with
lorazepam (Ativan) 1 mg IM and diphenhydramine (Benadryl) 50 mg IM upon admission and is
started on risperidone (Risperdal). One day after admission, Joel presents to the nurses’ station
complaining of a painful “stiff neck” and “thick tongue.”
1. What is the best description of Joel’s presentation?
2. What is the best explanation for Joel’s presentation?
3. Which neurotransmitters are involved in Joel’s presentation?
4. How should the PMHNP address this scenario?
5. In formulating diagnostic conclusions about Joel, what should the PMHNP consider?

Case Study 1
1. More assessment would be needed to determine whether Ms. Franklin’s symptoms
are consistent with a psychiatric disorder, but they may be consistent with an anxiety
or mood disorder.
2. Most psychiatric illnesses have been shown to have, in part, a genetic link and there-
fore, do tend to run in families.
3. Ms. Franklin’s symptoms are consistent with excessive levels of norepinephrine.
4. No. There is insufficient data to warrant the cost of a brain scan at this time.
5. Yes, the risk of Ms. Franklin’s children developing psychiatric disorders can be deter-
mined but only if Ms. Franklin meets criteria for an actual psychiatric illness. Once
this is determined, the genetic risk to her children can be identified through the use
of such things as concordant rate tables.
Case Study 2
1. Joel’s presentation is consistent with acute dystonia.
2. Both haloperidol and risperidone are high-potency D2 antagonists. Although Joel
received prophylactic diphenhydramine, adding risperidone, particularly with aggres-
sive dosing, increases the risk of extrapyramidal side effects.
3. CNS dopamine (DA) and acetylcholine (ACH) have a reciprocal relationship. As DA
receptors are antagonized by antipsychotic medication, acetylcholine levels increase,
giving rise to extrapyramidal side effects. This is particularly true of first-generation
antipsychotics, but also of high-potency second-generation agents.
4. Administer diphenhydramine or benztropine (Cogentin) IM immediately and hold
subsequent doses of risperidone until dystonia completely resolves. Resume risperi-
done at a lower dose along with an oral anticholinergic medication. Adjust the dose
of the antipsychotic as indicated. If Joel continues to experience extrapyramidal side
effects, switching to a lower-potency antipsychotic may be necessary.
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CHAPTER 6
ADVANCED HEALTH AND PHYSICAL HEALTH

ASSESSMENT
This chapter reviews the role of psychiatric–mental health nurse practitioners (PMHNPs) in
physical health and advanced health assessment. In this chapter you will review information on
the process of completing a physical exam and differential diagnosis, and the appropriate use
of diagnostic and laboratory testing in providing competent nursing care for clients and families
experiencing psychiatric disorders. The chapter specifically highlights the PMHNP role in the
identification of physical health problems.
PHYSICAL EXAM
XX Reasons to be familiar with the physical exam in psychiatry:
ZZ To be able to detect underlying medical problems
ZZ To be familiar with a screening neurological exam and to be able to rule out
neurological problems that may manifest as symptoms of a psychiatric problem
ZZ To be able to differentiate normal and abnormal signs and symptoms
ZZ To know when to refer
XX Done by the PMHNP in the context of his or her primary psychiatric care role
XX Goals are identifying presence of psychiatric disorders, identifying general health
status, and screening for other nonpsychiatric disorders
XX Focuses on physical assessment required to accomplish differential diagnoses to
determine client health needs
XX Specifically focuses on assessing for disorders or conditions that explain client
presentation
ZZ Psychiatric disorders
ZZ Nonpsychiatric disorders
XX Not intended to replace the role of primary healthcare provider for the client
ZZ PMHNP should assist client to establish primary care provider if he or she does
not already have one.
XX Avoids highly personal or intrusive procedures (e.g., Pap exam, male genital exam,
rectal exam, breast exam) that may make the formation of a therapeutic alliance
more difficult, but it is important to be familiar with these exams and be able to dif-
ferentiate normal from abnormal
XX Requires the PMHNP to have depth of knowledge regarding the common health
disorders that can mimic symptoms of a psychiatric disorder
ZZ Differential diagnostic considerations
XX Requires the PMHNP to have depth of knowledge regarding the common psychiatric
disorders that can mimic or produce symptoms of other disorders
ZZ Differential diagnostic considerations
ZZ Comorbid conditions and clinical management issues
XX Generally, if client’s health issues are determined to be nonpsychiatric, client is
referred to primary care providers other than the PMHNP.
XX Because of the brain-based nature of psychiatric disorders, the PMHNP role requires
the ability to perform an in-depth neurological exam.
NEUROLOGICAL EXAM
XX Reflexes (biceps, triceps, brachioradialis, patellar, Achilles, plantar)
ZZ Grade reflexes and note symmetry between right and left sides.
ZZ Check primitive reflexes in infants (head lag, flexion, rooting, grasping, Moro,
glabellar, Babinski).
ZZ A positive Babinski (fanning of toes and dorsiflexion of the great toe) is normal in
infants up to age 2 years.
XX Cranial nerves (mnemonic italicized in parentheses)
ZZ Olfactory: 1st (On)
XX Test sense of smell and ensure patency of the nasal passages.
XX Have the client close eyes and test each nostril separately while other is
occluded, asking the client to identify familiar odors.
ZZ Optic: 2nd (Old)
XX Test vision using Snellen chart or other suitable chart depending on the
client’s acuity and ability to cooperate.
XX Examine the inner aspect of the eyes with the ophthalmoscope.
XX Test peripheral vision using the confrontation test.
ZZ Oculomotor: 3rd (Olympus’)
XX This is the motor nerve to the five extrinsic eye muscles. Test together with
cranial nerve 4 (trochlear) and cranial nerve 6 (abducens; see below).
XX Test the extraocular movements (EOMs).
XX Check the equality of pupils, their reaction to light, and their ability to
accommodate.
XX Test the corneal light reflex (when shining a light at the bridge of the nose,
the light should appear symmetrically in both eyes).
Advanced Health and Physical Health Assessment 81
ZZ Trochlear: 4th (Towering)

XX Use the same process as cranial nerve 3 (oculomotor) and cranial nerve 6
(abducens).
ZZ Trigeminal: 5th (Motor division; Top)
XX Palpate the masseter muscles with the fingertips while the client clenches
his or her teeth.
XX Look for disparity in tension between the two muscles, which can indicate
paralysis on the weak side.
XX Look for tremor of the lips, involuntary chewing movements, and spasm of
the masticatory muscles.
ZZ Trigeminal: 5th (Sensory division)
XX Test tactile perception of the facial skin by touching with a wisp of cotton.
XX Test corneal reflex with wisp of cotton.
XX Test superficial pain of the skin and mucosa with pinpricks.
XX Test the sense of touch in the oral mucosa.
ZZ Abducens: 6th (A)
XX Use the same process as for cranial nerves 3 (oculomotor) and 4 (trochlear).
ZZ Facial: 7th (Motor division; Finn)
XX Inspect the face in repose for evidence of flaccid paralysis.
XX Test by asking the client to elevate eyebrows, wrinkle forehead, close eyes,
frown, smile, and puff cheeks.
ZZ Facial: 7th (Sensory division)
XX Test taste for sugar, vinegar, and salt.
ZZ Acoustic: 8th (And)
XX Check hearing with the audiometer or by the whisper test.
XX Check for hearing loss using the Weber and the Rinne tests.
ZZ Glossopharyngeal: 9th (German)
XX Test together with cranial nerve 10 (vagus; see below).
ZZ Vagus: 10th (Viewed)
XX Test for elevation of the uvula by having the client open his or her mouth
and say “ah.”
XX Test the gag reflex by touching the back of throat with a tongue blade.
ZZ Accessory spinal: 11th (Some)
XX Test the strength of the sternocleidomastoid and trapezius muscles against
resistance of your hands.
ZZ Hypoglossal: 12th (Hops)
XX Look for tremors and other involuntary movement when the client
protrudes his or her tongue.
XX Coordination and fine-motor skills

ZZ Equilibrium: Check by administering the Romberg test: have the client stand
up straight with feet together, arms by sides, and eyes closed. Only slight
swaying would be normal, and the client will be able to sustain this pose for
approximately 5 seconds. More than slight swaying suggests cerebellar ataxia
or vestibular dysfunction.
ZZ Diadochokinesia: Ability to perform rapid alternating movements (such as patting
knees alternating palm and back of hands, touching thumb to each finger); the client
should be able to smoothly execute these movements and maintain the rhythm.
ZZ Dyssynergia: Finger-to-nose test, heel-to-knee test
ZZ Handwriting
ZZ Gait: Observe client walking.
XX Sensory functions
ZZ Pain: Check sensation to pain with pinprick, and compare on each side of body.
ZZ Temperature: Check temperature if sensation to pain is abnormal.
ZZ Superficial touch: Test with wisp of cotton.
ZZ Two-point discrimination: Apply pins to skin simultaneously; ask the client if he
or she feels one or two pinpricks.
ZZ Stereognosis: Tests the ability to distinguish forms by placing objects in the
client’s hands while his or her eyes are closed.
ZZ Graphesthesia: Tests the ability to identify figures, letters, or words by tracing
the figure on the skin of the palm of the hand.
XX Motor functions
ZZ Muscle mass: Measure muscle mass to check for atrophy or hypertrophy.
ZZ Muscle tone: Tension is present when the muscle is resting.
ZZ Muscle strength: Check muscular strength against resistance.
Be aware of abnormal muscle movements.
XX Neurological soft signs
ZZ Dysdiadochokinesia: Inability to perform rapid alternating movements; result of a
lesion to the posterior lobe of the cerebellum
ZZ Astereognosis: Inability to discriminate between objects based on touch alone;
result of a lesion in the parietal lobe
ZZ Choreiform movements
ZZ Tics
ZZ Agraphesthesia: Inability to recognize letters or numbers “drawn” on the client’s
hand with a pointed object
ZZ Facial grimacing
ZZ Impaired fine-motor skills
ZZ Abnormal blinking
ZZ Abnormal motor tone
Be alert for extrapyramidal symptoms (as in Parkinsonism, dystonia, akathisia) in the cli-
ent taking antipsychotics.
XX Vital signs
ZZ Measure height, weight, blood pressure (on children ages two or older), pulse,
respirations, temperature, and head circumference (during the first 2 years).
ZZ Use growth charts for infants and children.
XX Greater than 85th percentile for body mass index (BMI) places a child at
increased risk for being overweight.
ZZ Use BMI charts
XX Normal: 20 to 25
XX Overweight: 26 to 29
XX Obese: 30 to 35
ZZ High BMI is a risk factor for diabetes, heart disease, stroke, hypertension,
osteoarthritis, and some forms of cancer.
Be alert for high BMI if the client also is being prescribed psychotropic meds with a pro-
pensity for weight gain, especially atypical antipsychotics.
ZZ If a client is presenting with elevated temperature and also is taking
psychotropic meds such as carbamazepine (Tegretol) or clozapine (Clozaril), be
alert for agranulocytosis.
XX Head, skin, nails
ZZ Note the color and integrity of the skin and whether lesions are present.
ZZ Note if the skin is well-hydrated, dry, or scaly.
ZZ Assess skin turgor.
ZZ Palpate the skin’s temperature.
ZZ Note any unusual moles or other lesions.
ZZ Look at hair texture and distribution.
ZZ Determine the quality of the nails, noting splitting, clubbing, or onychomycosis.
ZZ Check capillary refill.
ZZ Examine head, scalp, sutures, and fontanelles (if infant).
ZZ Check cranial nerve 7 (facial nerve) for symmetry (have client smile, frown,
wrinkle forehead, puff cheeks).
Be alert for Stevens-Johnson syndrome (life-threatening rash), especially if the client is
taking carbamazepine or lamotrigine (Lamictal).
ZZ Cancerous moles can be detected by using the acronym ABCDE—asymmetry,
border irregularity, color variation, diameter greater than 6 millimeters, and
elevation.
XX Eyes
ZZ Check visual acuity using the Snellen chart (tests cranial nerve 2: optic nerve).
ZZ Test peripheral vision using the confrontation test (tests cranial nerve 2: optic
nerve).
ZZ Note the symmetry of eyes and the appearance of orbits, eyelids, and brows.
ZZ Inspect the sclera.
ZZ Assess corneal sensation with wisp of cotton (tests cranial nerves 5 and 7).
ZZ Assess papillary reaction to light and accommodation (tests cranial nerves 3, 4,
and 6).
ZZ Assess the six cardinal fields of gaze (extraocular movements; tests cranial
nerves 3, 4, and 6).
ZZ Assess corneal light reflex. Light reflections should appear symmetrically in both
pupils (tests cranial nerves 3, 4, and 6).
ZZ Examine the inner aspect of the eyes with the ophthalmoscope (tests cranial
nerve 2).
Be aware that many psychotropics can cause blurry vision (an anticholinergic side effect).
ZZ Quetiapine (Seroquel) may cause cataracts.
XX Ears
ZZ Check for configuration, position, and alignment of auricles.
ZZ Test auditory acuity (cranial nerve 8) with the whisper test or audiometer.
ZZ Inspect external auditory canals with otoscope for redness, swelling, or excess
cerumen.
ZZ Tympanic membrane should be translucent pearly gray without retractions or
bulges.
XX Nose and sinuses
ZZ Note the appearance of the external nose and whether it is smooth, intact,
symmetric, midline, has discharge, or is flaring.
ZZ Assess nasal patency.
ZZ Assess sense of smell.
ZZ Inspect internal nasal cavity for patency and septal deviation.
ZZ Palpate maxillary and frontal sinuses.
XX Neck
ZZ Palpate the lymph nodes (preauricular, postauricular, tonsillar, submandibular,
submental, anterior cervical) for swelling or masses.
ZZ Palpate thyroid (usually not palpable except in very thin people).
ZZ Palpate and auscultate carotid pulse and note any bruits.
XX Back
ZZ Inspect skin and respiratory pattern on posterior chest.
ZZ Palpate cervical, thoracic, lumbar, and sacral spine.
ZZ Palpate thoracic expansion.
ZZ Percuss posterior chest for tympany.
ZZ Auscultate posterior chest for vesicular or bronchovesicular sounds and note any
adventitious breath sounds.
XX Thorax and lungs

ZZ Assess respiratory rate and depth, regularity, and ease of respirations.
ZZ Note anterior–posterior (AP) diameter, which should be less than the transverse
diameter.
ZZ Percuss anterior chest for resonance and note the quality and symmetry of
percussion notes.
ZZ Auscultate anterior chest for lung sounds; normal breath sounds include
vesicular over peripheral lung, bronchovesicular over first and second intercostal
spaces at the sternal border, and bronchial over the trachea.
XX Breasts
ZZ Inspect breasts in different positions: with client arms relaxed and by side,
with arms elevated above head, and with hands on hips. Look for dimpling,
retractions, and orange-peel appearance.
ZZ Palpate breasts for lumps, including Tail of Spence.
ZZ Palpate axillary and epitrochlear lymph nodes.
ZZ Palpate supraclavicular lymph nodes (also known as sentinel or Virchow nodes).
Be aware that typical antipsychotics as well as atypical antipsychotics may cause
galactorrhea.
XX Heart
ZZ Inspect, palpate, and auscultate the carotid pulse.
ZZ Palpate peripheral pulses and check for symmetry (carotid, brachial, radial,
femoral, popliteal, pedal, and posterior tibial).
ZZ Assess heart rate, rhythm, amplitude, and contour.
ZZ Assess anatomic location of the apical pulse.
ZZ Palpate precordium for pulsations, thrills, heaves, and lifts.
ZZ Auscultate heart sounds with bell and diaphragm and note characteristics of the
first and second heart sounds.
ZZ Assess for jugular venous distention (JVD).
Be alert for possible electrocardiogram (ECG) changes if the client is taking tricyclic anti-
depressants or antipsychotics.
Be aware that lithium and anorexia nervosa can cause peripheral edema.
XX Abdomen
ZZ Inspect the contour of the abdomen and check for scars, abdominal aortic
pulsations, and the umbilical cord in the newborn.
ZZ Auscultate for bowel sounds and the abdominal aorta for bruits.
ZZ Percuss the abdomen, and note areas of tympany and dullness. It is normal to
hear tympany over the small and large intestines and dullness over organs and a
distended bladder.
ZZ Percuss the size of liver and spleen.
ZZ Palpate the abdomen for masses and tenderness. Also palpate the liver and
spleen, which are not normally palpable (sometimes the liver can be palpable in
thin clients).
XX Musculoskeletal
ZZ Assess client’s posture for alignment of extremities and spine and for symmetry
of body parts.
ZZ Test muscle strength of upper and lower extremities.
ZZ Note symmetry of muscle mass, tone, and strength.
ZZ Assess active range of motion in neck and upper and lower extremities, and
note any presence of pain with movement.
ZZ Palpate muscles and joints to elicit pain, deformities, crepitus, and passive range
of motion.
ZZ Check for hip dysplasia in infants.
ZZ Check for scoliosis in children and adolescents.
XX Common indicators of physical child abuse
ZZ History of unexplained multiple fractures
ZZ Burns, hand or bite marks
ZZ Injuries at various stages of healing
ZZ Evidence of neglect
ZZ Bruising on padded parts of body
Diagnostic and Laboratory Testing

XX Assessment of diagnostic and laboratory testing is an essential element of the
PMHNP role. It is important for the PMHNP to know when to order such tests, how
to interpret the findings, and how to appropriately alter care based on the findings.
XX Reasons to assess diagnostic and laboratory testing in psychiatry:
ZZ To assist in the establishment of a diagnosis; as knowledge of underlying
pathophysiology grows, diagnostic and laboratory testing use will grow as well
ZZ Used to rule out other disorders such as medical causes of psychiatric
symptoms; helpful in differential diagnostic assessment
ZZ Used to determine whether a client’s symptoms are better explained by a
nonpsychiatric disorder or by factors such as drug use or abuse
ZZ For routine ongoing monitoring such as general health screening, monitoring
drug levels of certain psychiatric meds, and assessment and monitoring for
complications of psychiatric disorders or adverse effects of drugs
XX Thyroid function tests
ZZ Function of thyroid gland is to take iodine from the circulating blood, combine
it with the amino acid tyrosine, and convert it to the thyroid hormones T3 and T4.
ZZ The thyroid gland also stores T3 and T4 until they are released into the
bloodstream under the influence of thyroid-stimulating hormone (TSH) released
from the pituitary gland.
ZZ Only a small amount of T3 and T4 are bound to protein.
ZZ The free portion of the thyroid hormones is the true determinant of thyroid status.
XX Free thyroxine T4 (FT4; normal values 0.8 to 2.8 ng/dl)
ZZ FT4 composes a small portion of the total thyroxine, is available to the tissues,
and is the metabolically active form of this hormone.
ZZ FT4 test is commonly done to determine thyroid status, to rule out hypo- and
hyperthyroidism, and to evaluate thyroid therapy.
XX Diseases that have increased thyroid levels include:
ZZ Graves’ disease
ZZ Thyrotoxicosis due to T4
ZZ Hashimoto’s thyroiditis
ZZ Acute thyroiditis
XX Diseases that have decreased thyroid levels include:

ZZ Primary hypothyroidism
ZZ Secondary hypothyroidism (pituitary insufficiency)
ZZ Tertiary hypothyroidism (hypothalamic failure)
ZZ Thyrotoxicosis due to T3
ZZ Renal failure
ZZ Cushing’s syndrome
ZZ Cirrhosis
XX Interfering factors:
ZZ Values can be increased during treatment with heparin, aspirin, and
propranolol.
ZZ Values can be decreased during treatment with furosemide (Lasix) or
methadone.
XX Thyroid-stimulating hormone (normal values 2–10 mU/l)

ZZ Stimulation of the thyroid gland by TSH causes release and distribution of stored
thyroid hormones.
XX When T4 and T3 are high, TSH secretion decreases.
XX When T4 and T3 are low, TSH secretion increases.
XX In primary hypothyroidism, TSH levels rise because of low levels of thyroid
hormone.
XX If the pituitary gland fails, TSH is not secreted and blood levels of TSH fall.
ZZ TSH testing is commonly performed to establish the diagnosis of primary

hypothyroidism.
XX Diseases that have increased thyroid levels include:
ZZ Primary hypothyroidism
ZZ Thyroiditis
XX Diseases that have decreased thyroid levels include:

ZZ Hyperthyroidism
ZZ Secondary and tertiary hypothyroidism
ZZ Values can be decreased during treatment with T3, acetylsalicylic acid,
corticosteroids, and heparin.
ZZ Values can be increased during drug therapy with lithium.
XX Systemic effects of hypothyroidism (decreased T4, increased TSH)

ZZ Mimics symptoms of unipolar mood disorders
XX Confusion XX Fluid retention
XX Decreased libido XX Muscle aching and
stiffness
XX Impotence
XX Slowed reflexes
XX Decreased appetite
XX Somatic discomfort
XX Memory loss
including aching and joint
XX Lethargy stiffness
XX Constipation XX Slowed speech and
XX Headaches thinking
XX Slow or clumsy XX Sensory disturbances,

movements including hearing
XX Syncope XX Cerebellar ataxia

XX Weight gain XX Loss of amplitude in ECG
XX Systemic effects of hyperthyroidism (increased T4, decreased TSH)
ZZ May mimic symptoms of bipolar affective disorders

XX Motor restlessness XX Increase in appetite
XX Emotional lability XX Abdominal pain
XX Short attention span XX Excessive sweating
XX Compulsive movement XX Flushing
XX Fatigue XX Elevated upper eyelid
leading to decreased
XX Tremor
blinking, staring, fine
XX Insomnia tremor of eyelid
XX Impotence XX Tachycardia
XX Weight loss XX Dysrhythmias
XX Electrolytes
ZZ Carried out as a part of routine screening in acute and critical illness or where
there is a known or suspected disorder associated with fluid, electrolyte, or
acid-base balance.
XX Calcium (Ca; normal values 8.8–10.5 mg/dl)
ZZ Abnormal values:
XX <7.0 mg/dl associated with tetany
XX >11.0 mg/dl associated with hyperparathyroidism
XX >13.5 mg/dl associated with hypercalcemic coma and metastatic cancer.
ZZ Most Ca (99%) is located in bone and the remainder is in the plasma and body cells.
ZZ Of the Ca in the plasma, 50% is bound to plasma proteins and 40% is in the
free or ionized form. The remaining fraction circulates in the blood.
ZZ Ca is the major cation for the structure of bones and teeth.
ZZ Functions:
XX Enzymatic cofactor for blood clotting
XX Required for hormone secretion
XX Required for function of cell receptors
XX Required for plasma membrane stability and permeability
XX Required for transmission of nerve impulses and the contraction of muscles
ZZ Ca balance is mediated by interactions among three hormones: parathyroid
hormone, vitamin D, and calcitonin.
ZZ Acting together, these substances determine the amount of dietary Ca
absorbed and the renal reabsorption and excretion of Ca by the kidney.
XX Increased levels of Ca can cause:
ZZ Acidosis
ZZ Hyperparathyroidism
ZZ Cancers (for example, of bone, leukemia, myeloma)
ZZ Drugs (such as thiazide diuretics, hormones, vitamin D, Ca)
ZZ Vitamin D intoxication
ZZ Addison’s disease
ZZ Hyperthyroidism
XX Decreased levels of Ca can cause:

ZZ Alkalosis
ZZ Hypoparathyroidism
ZZ Renal failure
ZZ Pancreatitis
ZZ Inadequate dietary intake of calcium, vitamin D
ZZ Drugs, including barbiturates, anticonvulsants, acetazolamide,
adrenocorticosteroids
ZZ Values are higher in children because of growth and active bone
formation.
ZZ Values can be increased by excessive ingestion of milk or during
treatment with lithium, thiazide diuretics, alkaline antacids, or vitamin D.
ZZ Values can be decreased during treatment with anticonvulsants,
aspirin, calcitonin, corticosteroids, heparin, laxatives, diuretics,
albuterol, and oral contraceptives.
XX Systemic effects of hypocalcemia (Ca <8.5 mg/dl):

ZZ Increase in ZZ Convulsions
neuromuscular ZZ Tetany
excitability
ZZ Continuous severe
ZZ Confusion muscle spasm
ZZ Paresthesias around ZZ ECG changes:
the mouth and in the prolonged QT interval
digits
ZZ Intestinal cramping
ZZ Muscle spasms in the
hands and feet ZZ Hyperactive bowel
sounds
ZZ Hyperreflexia
XX Systemic effects of hypercalcemia (Ca >12.0 mg/dl):

ZZ Fatigue ZZ Behavioral changes
ZZ Weakness ZZ Impaired renal
function
ZZ Lethargy
ZZ ECG changes:
ZZ Anorexia
shortened QT
ZZ Nausea interval, depressed
ZZ Constipation T-waves
ZZ Bradycardia
ZZ Heart block
XX Sodium (Na; normal values 135–148 mEq/l)

ZZ Na accounts for 90% of the extracellular fluid cations and is the most powerful
cation in the extracellular fluid.
ZZ Na regulates osmolality (interstitial and intravascular fluid volume).
ZZ Na works with potassium and calcium to maintain neuromuscular irritability for
conduction of nerve impulses.
ZZ Na regulates acid-base balance.
ZZ Na participates in cellular chemical reactions and membrane transport.
ZZ Na regulates renal retention and excretion of water.
ZZ Na maintains systemic blood pressure.

XX Increased levels of Na can cause:
ZZ Hypovolemia
ZZ Dehydration
ZZ Diabetes insipidus
ZZ Excessive salt ingestion
ZZ Gastroenteritis
ZZ Drugs such as adrenocorticosteroids, methyldopa, hydralazine, or
cough medication
XX Decreased levels of Na can cause:

ZZ Addison’s disease
ZZ Renal disorder
ZZ GI fluid loss from vomiting, diarrhea, nasogastric suction, ileus
ZZ Diuresis
ZZ Drugs such as lithium, vasopressin, or diuretics
ZZ Systemic effects of hyponatremia (Na <135 mEq/l):

XX Lethargy XX Tachycardia
XX Headache XX Decreased urine output
XX Confusion XX Weight gain
XX Apprehension XX Edema
XX Seizures XX Ascites
XX Coma XX Jugular vein distention
XX Hypotension
ZZ Systemic effects of hypernatremia (Na >147 mEq/l):

XX Convulsions XX Hypotension
XX Pulmonary edema XX Tachycardia
XX Thirst XX Low jugular venous
pressure
XX Fever
XX Restlessness
XX Dry mucous membranes
XX Magnesium (Mg; normal values 1.3–2.1 mEq/l)
ZZ Mg is a major intracellular cation; 40% to 60% is stored in bone and muscle,
with 30% in cells.
ZZ A small amount is in the serum, where one-third is bound to plasma proteins
and the rest is in ionized form.
ZZ Regulation of Mg metabolism is primarily by the kidney.
ZZ Low serum levels cause renal conservation of Mg.
ZZ Mg is a cofactor in intracellular enzymatic reactions.

ZZ Mg is a cause of neuromuscular excitability.
XX Increased levels:
ZZ Addison’s disease ZZ Dehydration
ZZ Adrenalectomy ZZ Hypothyroidism
ZZ Renal failure ZZ Hyperthyroidism
ZZ Diabetic ketoacidosis
XX Decreased levels:
ZZ Hyperaldosteronism ZZ GI loss from vomiting,
diarrhea, nasogastric
ZZ Hypokalemia
suction, and fistula
ZZ Diabetic ketoacidosis
ZZ Malabsorption
ZZ Malnutrition syndrome
ZZ Alcoholism ZZ Pregnancy-induced
ZZ Acute pancreatitis hypertension
ZZ Hemolysis of a sample leads to falsely elevated levels.
ZZ Numerous drugs can alter levels.
ZZ Values can be increased by drugs such as antacids, laxatives containing
Mg, salicylates, and lithium.
ZZ Values can be decreased by drugs such as thiazide diuretics, calcium
gluconate, insulin, amphotericin B, neomycin, aldosterone, and ethanol.
ZZ Systemic effects of hypomagnesemia (Mg <1.5 mEq/l):

XX Depression XX Ataxia
XX Confusion XX Nystagmus
XX Irritability XX Tetany
XX Increased reflexes XX Convulsions
XX Muscle weakness
ZZ Systemic effects of hypermagnesemia (Mg >2.5 mEq/L):
XX Nausea and vomiting XX Respiratory depression
XX Muscle weakness XX Depressed skeletal
muscle contraction and
XX Hypotension
nerve function
XX Bradycardia
XX Chloride (normal values 98–106 mEq/L)
ZZ Chloride is the major anion in the extracellular fluid.
ZZ It provides electroneutrality in relation to sodium (see above).
ZZ Transport of chloride is passive and follows the active transport of sodium so
that increases or decreases in chloride are proportional to changes in sodium.
ZZ Acidosis ZZ Renal failure
ZZ Hyperkalemia, ZZ Cushing’s syndrome
hypernatremia ZZ Hyperventilation
ZZ Dehydration ZZ Anemia
ZZ Alkalosis ZZ Diuresis
ZZ Hypokalemia ZZ Overhydration
ZZ Hyponatremia ZZ Addison’s disease
ZZ GI loss from vomiting, ZZ Burns
diarrhea, nasogastric
suction, and fistula
ZZ Elevated serum triglyceride levels and myeloma proteins may lead to
falsely decreased levels.
ZZ Values can be increased by potassium chloride, acetazolamide,
methyldopa, diazoxide, and guanethidine.
ZZ Values can be decreased by ethacrynic acid, furosemide, thiazide diuretics, and

bicarbonate.
ZZ No specific symptoms are associated with chloride increase or decrease.
XX Potassium (K+; normal values 3.5–5.1 mEq/l)
ZZ K+ is the major intracellular electrolyte.
ZZ Total body K+ is about 4,000 mEq, with most of it located in the cells.
ZZ Intracellular concentration of K+ is 150 to 160 mEq/l; extracellular concentration
is 3.5 to 4.5 mEq/l.
ZZ As the predominant intracellular ion, K+ regulates intracellular fluid osmolality
and provides the balance for intracellular electrical neutrality.
ZZ K+ is required for glycogen deposition in liver and skeletal muscle cells.
ZZ K+ maintains resting membrane potential and assists in transmission and
conduction of nerve impulses, maintenance of normal cardiac rhythms, and
skeletal and smooth muscle contraction.
ZZ K+ balance is regulated by the kidney, aldosterone levels, insulin secretion, and
changes in pH.
ZZ Acidosis ZZ Hypoaldosteronism
ZZ Insulin deficiency ZZ Infection
ZZ Addison’s disease ZZ Dehydration
ZZ Acute renal failure
ZZ Alkalosis ZZ Surgery
ZZ Excessive insulin ZZ Cushing’s syndrome
ZZ GI loss ZZ Hyperaldosteronism
ZZ Laxative abuse ZZ Thyrotoxicosis
ZZ Burns ZZ Anorexia nervosa
ZZ Trauma ZZ Diet deficient in meat
and vegetables
ZZ False elevations can occur with vigorous pumping of the hand during
venipuncture, hemolysis of the sample, or high platelet counts during
clotting.
ZZ False decreases are seen in anticoagulated samples left at room
temperature.
ZZ Values can be decreased by drugs such as furosemide, ethacrynic acid,
thiazide diuretics, insulin, aspirin, prednisone, cortisone, gentamycin,
lithium, and laxatives.
ZZ Values can be increased by drugs such as amphotericin B, tetracycline,
heparin, epinephrine, potassium-sparing diuretics, and isoniazid.
ZZ Chronic marijuana use can elevate K+ level.
ZZ Systemic effects of hyperkalemia (K+ >5.5 mEq/l):

XX Muscle weakness
XX Paralysis
XX Tingling of lips and fingers
XX Restlessness
XX Intestinal cramping
XX Diarrhea
XX ECG changes: narrow and taller T-waves
ZZ Mild hyperkalemia: shortened QT interval
ZZ Severe hyperkalemia: depressed ST segment, prolonged PR interval,
widened QRS complex leading to cardiac arrest
ZZ Systemic effects of hypokalemia (K+ <3.5 mEq/l):

XX Impaired carbohydrate metabolism
XX Impaired renal function
XX Polyuria
XX Polydipsia
XX Skeletal muscle weakness
XX Smooth muscle atony
XX Cardiac dysrhythmias
XX Paralysis and respiratory arrest
XX Liver function tests
ZZ Used to monitor liver disease or damage caused by hepatotoxic drugs, as
confirmed by elevated levels
XX Alanine aminotransferase (ALT; normal values 5–35 U/l)
ZZ Formerly known as glutamic-pyruvic transaminase (SGPT), ALT is an enzyme
produced by the liver that acts as a catalyst in the transamination reaction
necessary for amino acid production.
ZZ ALT is found in liver cells in high concentrations and in moderate amounts in
body fluids, heart, kidneys, and skeletal muscles.
ZZ When liver damage occurs, serum levels of ALT rise to as much as 50 times
normal.
XX Pronounced elevated levels (>300 U/l):
ZZ Liver disease or damage, such as hepatic cancer, hepatitis, or
infectious mononucleosis
XX Moderately elevated levels (100–300 U/l):

ZZ Biliary tract obstruction
ZZ Recent cerebrovascular accident
ZZ Muscle injury from intramuscular injections, trauma, infection, and
seizures
ZZ Muscular dystrophy
ZZ Acute pancreatitis
ZZ Intestinal injury
ZZ Myocardial infarction
ZZ Congestive heart failure
ZZ Renal failure
ZZ Severe burns
ZZ Uremia and hemodialysis can cause falsely decreased levels.
ZZ Values can be increased with acetaminophen, allopurinol, aspirin,
ampicillin, carbamazepine, cephalosporins, codeine, digitalis,
indomethacin, heparin, isoniazid, methotrexate, methyldopa, oral
contraceptives, phenothiazines, propranolol, tetracycline, and
verapamil.
XX Aspartate aminotransferase (AST; normal values 5–40 U/l)

ZZ Previously known as serum glutamate oxaloacetate transaminase (SGOT), AST
measures the level of the enzyme that catalyzes the reversible transfer of an
amino group between the amino acid, aspartate, and alphaketoglutamic acid.
ZZ AST exists in large amounts in both liver and myocardial cells and in smaller but
significant amounts in skeletal muscles, kidneys, the pancreas, and the brain.
ZZ Serum AST rises when there is cellular damage to the tissues in which the
enzyme is found.
XX Pronounced elevation (>5× normal):
ZZ Acute hepatocellular damage
ZZ Shock
ZZ Acute pancreatitis
ZZ Infectious mononucleosis
XX Moderate elevation (3–5× normal):

ZZ Biliary tract ZZ Liver tumors
obstruction ZZ Chronic hepatitis
ZZ Cardiac arrhythmias ZZ Muscular dystrophy
ZZ Congestive heart ZZ Dermatomyositis
failure
XX Slight elevation (2–3× normal):

ZZ Pericarditis
ZZ Cirrhosis, fatty liver
ZZ Pulmonary infarction
ZZ Delirium tremens
ZZ Cerebrovascular accident
ZZ Hemolytic anemia
ZZ Numerous drugs may elevate levels, including antihypertensives,
cholinergic agents, anticoagulants, digitalis, erythromycin, isoniazid,
methyldopa, oral contraceptives, opiates, salicylates, hepatotoxic
medications, and verapamil.
ZZ Exercise can cause increased levels.
XX Gamma glutamyl transpeptidase (GGT; normal values 10–38 IU/l)

ZZ GGT is an isoenzyme of alkaline phosphatase and assists with the transfer of
amino acids and peptides across cellular membranes.
ZZ Hepatobiliary tissues and renal tubular and pancreatic epithelium contain large
amounts of GGT.
ZZ Other sources of GGT include the prostate gland, brain, and heart.
ZZ GGT is used to evaluate and monitor a client with known or suspected alcohol
abuse, because levels rise even after ingestion of small amounts of alcohol.
ZZ Also used to evaluate elevated alkaline phosphatase of uncertain etiology.
ZZ Pronounced early increases in GGT are found in in hepatic disease.
ZZ Modest elevation in GGT occurs in cirrhosis and in pancreatic or renal disease.

XX Elevated GGT:
ZZ Hepatobiliary tract disorders
ZZ Hepatocellular carcinoma
ZZ Hepatocellular degeneration such as cirrhosis
ZZ Hepatitis
ZZ Pancreatic or renal cell damage or neoplasm
ZZ Congestive heart failure
ZZ Acute myocardial infarction (after 4–10 days)
ZZ Hyperlipoproteinemia
ZZ Diabetes mellitus with hypertension
ZZ Seizure disorder
ZZ Significant alcohol ingestion
ZZ Alcohol, barbiturates, and phenytoin can elevate GGT levels.
ZZ Late pregnancy, oral contraceptives, and clofibrate can lower GGT levels.
DISEASE PREVENTION ACTIVITIES

Immunization
Immunizations are critical to preventing disease, according to the U.S. Centers for Disease
Control and Prevention (CDC). Immunizations protect individual children and adults from develop-
ing potentially serious diseases while also protecting the community by reducing the spread of
infectious disease.
XX Schedules for children and adults are available on the CDC website at www.cdc.gov/
vaccines/schedules/index.html.
XX Seasonal influenza vaccination (as live attenuated influenza vaccine or as inactivated
type).
XX All persons age 6 months or older should receive annual influenza vaccination.
ZZ Children 6 months to 8 years of age require two doses of influenza vaccine (4
weeks apart) during their first season of vaccinations.
ZZ LAIV should not be used in persons younger than 2 years of age or older than
49 years of age.
ZZ Persons with egg allergy should always receive the vaccination from a health
care provider familiar with potential reaction and should be observed for at least
30 minutes post injection for signs of reaction.
ZZ Immunocompromised persons should not receive live vaccination.
ZZ Use live vaccine or inactivated vaccine for healthy nonpregnant adults younger
than 50 years of age with no high-risk medical conditions. All others should
receive the inactivated vaccine only (Grohskopf et al., 2015).
XX HPV vaccination for girls is recommended at age 11 or 12 years with catch-up vacci-
nation at ages 13 through 26 years to prevent genital human papillomavirus infection,
which can cause cervical cancer and genital warts.
ZZ HPV4 may be administered to males age 9 through 26 years to prevent genital
warts.
XX Measles, mumps, rubella (MMR; live vaccine)
ZZ Not for pregnant women; people with cancer, weakened immune systems, or
HIV or AIDS with T-cell counts below 200; or people currently being treated with
high-dose steroids or who have received a blood transfusion within the previous
2 weeks
XX Diphtheria, tetanus, acellular pertussis
ZZ Td (tetanus, diphtheria) vaccine should be given every 10 years beginning at age
11 years, with Tdap (tetanus, diphtheria, acellular pertussis) substituted once for
Td but no less than 5 years after the last DTaP dose was given. DTaP should not
be given to anyone 7 years of age or older.
XX Shingles (also known as herpes zoster) vaccine (CDC, 2015b)
ZZ Recommended for anyone age 60 or older who has had chickenpox.
ZZ Do not give shingles vaccine to persons with weakened immune systems or
HIV or AIDS with T-cell counts below 200, or to persons being treated with high-
dose steroids.
ZZ Shingles is an inflammatory condition in which a virus produces painful vesicular
eruptions along the distribution of the nerves from one or more dorsal root
ganglia.
XX Varicella (chickenpox) vaccine
ZZ Not for pregnant women; persons with weakened immune systems, HIV or
AIDS with T-cell counts below 200, or cancer; or for people being treated with
high-dose steroids or who received a blood transfusion within the previous 2
weeks
Anticipatory Guidance
Anticipatory guidance is a framework for implementation of prevention strategies.
XX Based on the premise that information can be provided to people to help them cope
more effectively with events that occur along the life span. Within the framework of
anticipatory guidance, the practitioner seeks to determine the specific informational
needs of the client in a systematic, standard way.
XX Pediatrics: Soliciting information from parents about their concerns in parenting and
providing information specific to their concerns. Teaching parents about health haz-
ards and strategies to prevent harm, such as car seat safety, water safety, wearing
helmets, and so forth.
XX Bright Futures (www.brightfutures.org/) is a national health promotion initiative
(launched by the Health Resources and Services Administration in partnership with
other agencies) dedicated to the principle that every child deserves to be healthy and
that optimal health involves trusting relationships among the health professional, the
child, the family, and the community as partners in health practice. Expansion of the
model includes screening, care management, and education about mental health
problems and disorders in developmental context.
XX In specific healthcare situations, anticipatory guidance can be used to assist people
in meeting healthcare challenges across the life span. Some examples include
ZZ Coping with terminal illness or death and dying (anticipatory grief)
ZZ Coping with disease progression, such as with Alzheimer’s dementia, in a loved
one
ZZ Coping with change and limitations resulting from spinal cord injuries
ZZ Can be implemented in each “well check” to identify information needs
pertinent to the client’s current life situation. Some examples:
XX Responsible alcohol use for the adolescent going off to college
XX Domestic violence
XX Life after the loss of a loved one (through divorce or death)
XX Planning for retirement
GENDER-BASED MEDICAL TESTING AND SCREENING

RECOMMENDATIONS FOR THE GENERAL PUBLIC
Tanner Stages Assessment
Defines physical measurements of development in children, adolescents, and adults. The de-
velopment of primary and secondary sex characteristics (breasts, genitalia, and pubic hair) are
assessed by stages to describe the onset and progression of puberty in both males and females.
Because of natural variability, males and females pass through the stages at different rates based
on timing of puberty.
Girls: Breast Development

Stage 1: Prepubertal
Stage 2: Breast bud stage with elevation of breast and papilla; enlargement of areola
Stage 3: Further enlargement of breast and areola; no separation of their contour
Stage 4: Areola and papilla from a secondary mound above level of breast
Stage 5: Mature stage: projection of papilla only, related to recession of areola (Jarvis, 2011)
Boys: Development of External Genitalia

Stage 1: Prepubertal
Stage 2: Enlargement of scrotum and testes; scrotum skin reddens and changes in
texture
Stage 3: Enlargement of penis (length at first); further growth of testes
Stage 4: Increase in size of penis with growth in breadth and development of glans;
testes and scrotum larger, scrotum skin darker
Stage 5: Adult genitalia (Jarvis, 2011)
Boys and Girls: Pubic Hair

Stage 1: Prepubertal (can see vellus hair similar to abdominal wall)
Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of
penis or along labia
Stage 3: Darker, coarser, and curlier hair, spreading sparsely over junctions of pubes
Stage 4: Adult-type hair, but covering smaller area than in adult, no spread to medial
surface of thighs
Stage 5: Adult type and quantity, with horizontal distribution (Jarvis, 2011)
Women
Ages 18 through 39
XX Monthly: Skin and oral self-exams
XX Yearly: Blood pressure; blood tests and urinalysis; physical exam; Pap smear (begin-
ning at age 21 or within 3 years of sexual activity, whichever comes first), pelvic
exam, sexually transmitted infection (STI) detection
XX All persons age 13 to 64 should be tested at least once for HIV (CDC, 2016)
Ages 40 through 49
XX Yearly: Blood pressure; blood tests and urinalysis; physical exam; Pap smear (every
2 or 3 years after three consecutive negative smears), pelvic exam, STI detection;
electrocardiogram (ECG) every 4 years
Ages 50+
XX Yearly: Blood pressure; blood tests (complete blood count, metabolic panel, thyroid-
stimulating hormone) and urinalysis; physical exam; Pap smear (65 and older not rec-
ommended if person had proper recent normal Pap smear and is not at high risk for
cervical cancer), pelvic exam, STI detection; mammography every 2 years; routine
bone density screening starting at age 65 and older (beginning at 60 if increased risk
for osteoporotic fractures)
XX Every 4 years: Electrocardiogram (ECG)
XX Every 5 years through age 75: flexible sigmoidoscopy or double-contrast barium
enema or CT colonography (if any of these tests are positive, a colonoscopy should
be done), or colonoscopy every 10 years
XX Consult provider: Hearing, vision
Additional Colorectal Cancer Screening for High-Risk Women

The American Cancer Society recommends that some people be screened using a different
schedule because of their personal or family history.
Men
Ages 18 through 39
XX Monthly: Self-exams (testicles, skin, and oral)
stimulating hormone) and urinalysis; physical exam
XX Screening at least once a year for syphilis, chlamydia, and gonorrhea for all sexually
active gay, bisexual, and men who have sex with men up to age 64 (CDC, 2016)
XX All persons age 13 to 64 should be tested at least once for HIV (CDC, 2016)
Ages 40 through 49
XX Monthly: Testicles, skin, and oral self-exams
stimulating hormone) and urinalysis; physical exam; ECG every 4 years
Ages 50+
XX Monthly: Testicles, skin, and oral self-exams
stimulating hormone) and urinalysis; physical exam; electrocardiogram (ECG) every 3
years
XX Every 5 years through age 75: Flexible sigmoidoscopy or double-contrast barium
enema or CT colonography (if any of these tests are positive, a colonoscopy should
be done), or colonoscopy every 10 years
XX Consult provider: Testosterone blood test; hearing and vision screening
HEALTH BEHAVIOR GUIDELINES

Exercise
Exercise benefits both physical and mental health. Inactivity has a direct link to obesity, a major
health problem in this country. In results of recent studies, exercise has demonstrated effects
comparable to antidepressant therapy in the treatment of depression.
XX Key factor in staying healthy: strengthens bones, heart, and lungs, tones muscles,
improves vitality, relieves depression, and helps to improve sleep. It is particularly
beneficial to persons with comorbid medical conditions such as diabetes, obesity,
and hypertension.
XX Mind–body connection: improves cognition and enhances mood
XX Neurobiological explanation: promotes increased concentrations of serotonin, norepi-
nephrine, and endorphins
XX Integrative psychiatry includes strategies to improve lifestyle practices (diet, exer-
cise, smoking cessation, decrease or cease drug and alcohol use) and reduce stress
to prevent illness.
XX Client teaching regarding exercise:
ZZ Check with provider before starting an exercise program.
ZZ Begin exercising gradually. Don’t expect results overnight. If you are consistent,
you will see improvement within 3 months.
ZZ Work hard enough to sweat, but not so hard that you cannot carry on a
conversation.
ZZ Plan an exercise routine that lasts at least 30 minutes, and perform the workout
at least 3 to 5 days a week. Warming up before exercise helps avoid injury.
ZZ Include both aerobic and strengthening activities in exercise program.
ZZ Exercise programs need to be modified for children, pregnant women, the
elderly, clients who are obese or disabled, and heart attack survivors as well as
modified for high altitudes and extreme hot or cold conditions.
ZZ Monitor the intensity of exercise by measuring heart rate. The target heart rate
during physical activity should be 60% to 90% of the maximum heart rate. Use
the following formula to calculate target heart rate:
XX 220 (beats per minute) minus age = maximum heart rate
XX Maximum heart rate multiplied by the intensity level = target heart rate
XX Physical activity at 60% to 70% of the maximum heart rate is considered
moderate-intensity exercise.
ZZ CDC recommends 60 minutes (1 hour) or more of physical activity each day for
children and adolescents.
ZZ CDC recommends 150 minutes of moderate-intensity aerobic activity (such as
brisk walking) every week and muscle-strengthening activities 2 or more days a
week for adults, including healthy older adults (CDC, 2015a).
Self-Awareness
XX Requires reflection on one’s personal beliefs, thoughts, emotions, motives, biases,
and limitations and being aware of how they influence behavior toward others
XX A trusted person who can give open, honest feedback to self-examination is helpful.
XX Personal experiences influence communication patterns and responses to clients.
XX Social biases, feelings, and beliefs projected onto the client may affect the nurse–
client relationship.
XX Being nonjudgmental and objective cultivates trust in the relationship.
XX Clinical supervision by colleague provides ongoing feedback for therapeutic develop-
ment of the helper, including supporting change as needed.
XX If personal values and beliefs make it difficult to be therapeutic with a particular cli-
ent, refer the client to another provider.
Self-Disclosure
XX Revealing personal information to the client changes the focus away from the client.
XX When asked personal questions, self-disclosure can be limited by redirecting, giv-
ing a vague answer, or reminding the client that you will not share your personal
information.
XX Self-disclosure may be therapeutic only when it is purposeful and has an identified
therapeutic outcome, such as role modeling.
Health Promotion and Disease Prevention Education

XX Preventative care and screening practices are essential aspects of the PMHNP role.
XX Screening for physical health problems in the psychiatric client
XX Usually guided by Healthy People 2020 (U.S. Department of Health and Human
Services, 2016), which identifies national health objectives, including behavioral
health
XX Mental health promotion and education includes:
ZZ Teaching about interventions and ways to cope with specific stressors
ZZ Validating “normalcy” of feelings; ensuring clients that they are not “crazy”
ZZ Helping clients recognize and identify their feelings or behaviors
ZZ Helping clients identify resources in the community
PUBLIC HEALTH PRINCIPLES

XX Primary prevention: Aimed at decreasing the incidence (number of new cases) of
mental disorders
ZZ Helping people avoid stressors or cope with them more adaptively
XX Example: Stress management classes for graduate students, smoking
prevention classes, Drug Abuse Resistance Education (DARE) Keepin’ It
REAL elementary and middle school curriculum (DARE, 2015)
XX Secondary prevention: Aimed at decreasing the prevalence (number of existing
cases) of mental disorders
ZZ Early case finding
ZZ Screening
ZZ Prompt and effective treatment
XX Example: Telephone hotlines, crisis intervention, disaster responses
XX Tertiary prevention: Aimed at decreasing the disability and severity of a mental
disorder
ZZ Rehabilitative services
ZZ Avoidance or postponement of complications
XX Example: Day treatment programs; case management for physical, housing,
or vocational needs; social skills training
Risk Factors
XX Predisposing characteristics that make it more likely that a person will develop a
disorder
XX Biological risk factors: History of mental illness in family, poor nutritional status, poor
general health
XX Psychological risk factors: Poor self-concept, external locus of control, poor ego
defenses
XX Social risk factors: Stressful occupation, low socioeconomic status, poor level of
social integration
Preventative Factors
XX Factors that prevent or protect the person from the disorder
XX Coping mechanisms or resources that facilitate a healthy response to stress
XX Biological preventative factors: No history of mental illness in the family, healthy
nutritional status, good general health
XX Psychological preventative factors: Good self-esteem or self-concept, internal locus
of control, healthy ego defenses
XX Social preventative factors: Low-stress occupation, higher socioeconomic status,
higher level of education
CASE STUDY 1
Mr. J. is a 79-year-old married man, being treated by the PMHNP for major depression. Mr. J.
was started on citalopram 10 mg 4 weeks ago and has now been taking 20 mg p.o. q.a.m. for
the past 3 weeks.
Pertinent medical history includes hypertension, which is well controlled by benazepril and hydro-
chlorothiazide (Lotensin HCT). He also takes finasteride (Proscar) for benign prostatic hyperplasia.
1. How should the PMHNP think about what may be going on with Mr. J.?
2. How should the PMHNP intervene?
Mr. J. arrives at his follow-up appointment, accompanied by his spouse. He tells you his primary
care provider checked his sodium level, which was low, and Mr. J. was instructed to stop the
citalopram. He is not on any antidepressant treatment and reports he has been feeling progres-
sively more tired, his stomach has been upset, and he feels “a little foggy.” These symptoms
began “about a week ago.”
3. How would this presentation change the PMHNP’s treatment plan?
4. What is the appropriate intervention for Mr. J.?
CASE STUDY 2
Ms. Smith, a 27-year-old single woman who works in a retail store, has been referred by her
primary care provider to the PMHNP for evaluation and treatment of “mood swings.” Ms. Smith
tells the PMHNP that she has been feeling “pretty good” for the past week after coming through
a 3-week period of depression. Her PCP discontinued her fluoxetine 20 mg several days ago.
She is mildly euphoric, but there is also evidence of irritability. Her speech is pressured and she
is hyperverbal, but she is easily redirected. She reports she has been sleeping “about 4 to 5
hours a night,” and describes her energy as “pretty good!” There is no evidence of psychosis.
Her insight and judgment are intact, and she tells the NP “I think I’m a little high. I’m worried it’s
going to get me in trouble at work.”
Past psychiatric history is significant for depressive episodes beginning in early teens, during
which she experienced suicidal ideation. She has been treated with many selective serotonin
reuptake inhibitors (SSRIs) over the years, all prescribed by her primary care provider and in
each case, she noticed rapid improvement of her mood and discontinued the drug after several
months. She denies a history of hypomania until the past year.
Medical history is noncontributory.
Family history is significant for bipolar I disorder in dad and possibly paternal grandmother.
Mother has a long history of untreated “depression and anxiety.”
The PMHNP and Ms. Smith discuss treatment options and decide to start lithium carbonate.
1. What client teaching should be included in preparation for beginning lithium?
2. What tests should be ordered before beginning this drug?
3. If Ms. Smith were an older adult, what additional test should be ordered before
treating her with lithium?
Three months after beginning lithium, Ms. Smith presents with lethargy, constipation, and
bradycardia.
4. What should the PMHNP consider as etiology?
5. What labs tests should be ordered?
6. What adjustment should be made to the client’s medication?

Case Study 1
1. All SSRIs and some other antidepressants have been implicated in hyponatremia.
Owing to diminished renal functioning and frequent polypharmacy, hyponatremia is
more common in the elderly. In addition to citalopram, Mr. J. is taking hydrochloro-
thiazide, which may also cause hyponatremia.
2. The signs and symptoms of hyponatremia vary, depending on how quickly sodium
levels drop. Slow decrease in sodium may lead to a subtle presentation such as
feeling tired, and slightly “foggy.” Clients experiencing a more precipitous drop will
present with dramatic changes in level of consciousness and severe headache owing
to cerebral edema. The PMHNP should assess for signs and symptoms of hypona-
tremia and order a sodium level.
3. An assessment should be made if the client has had trials on another SSRI.
Assessment of his depression needs to be completed and use of a depression
scale, such as the PHQ-9 or GDS, are indicated.
4. If the client has not had another trial on a SSRI it is indicated to place Mr. J. on a
SSRI and follow his response.
Case Study 2
1. The client should be taught about the potential risks and benefits of taking lithium.
Women of childbearing age should be educated about the risk of birth defects,
including Ebstein’s anomaly. Consideration of lithium dose and maintenance blood
levels should be included in discussing the relative risk. The client should be taught
about the signs and symptoms of lithium toxicity.
2. Baseline labs consisting of a metabolic panel, TSH, and complete blood count (CBC)
should be done. Women of childbearing age should have a pregnancy test.
3. Clients over the age of 65 or those who have a history of heart disease should have
a baseline ECG.
4. Lethargy and constipation may be due to hypothyroidism or hypercalcemia, both of
which may be caused by lithium.
5. The client should have TSH, free T4, and electrolytes drawn.
6. The lithium should be tapered off and an alternative medication used for mood
stabilization.

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CHAPTER 7
PHARMACOLOGICAL PRINCIPLES
Psychopharmacology, one of the most active and developing areas of psychiatric research, is
the use of psychotropic medication to treat psychiatric disorders. Psychiatric–mental health
nurse practitioners (PMHNPs) must have a thorough understanding of the science and art of
prescribing—of the pharmacokinetic and pharmacodynamic actions of a given drug, as well as
the client’s motivation to take the drug. The basic pharmacological principles are discussed in this
chapter.
CONCEPTS IN PHARMACOLOGICAL MANAGEMENT

XX Pharmacology: Study of what drugs do and how they do it
XX Pharmacokinetics: Study of what the body does to drugs; includes absorption, distri-
bution, metabolism, and excretion
XX Pharmacodynamics: Study of what drugs do to the body; target sites for drug actions
include receptors, ion channels, enzymes, and carrier proteins
Pharmacokinetics
XX Absorption: Method and rate at which drugs leave the site of administration
ZZ With oral medications, absorption normally occurs in the small intestine and
then in the liver.
XX Distribution: Occurs after the drug leaves the systemic circulation and enters the
interstitium and cells
ZZ Drugs are redistributed in organs according to their fat and protein content.
ZZ Most psychotropic medications are lipophilic and highly protein-bound. Only the
unbound (free) portion of the drug is active. Therefore, people with low protein
(albumin) levels, such as in malnutrition, wasting, or aging, can potentially
experience toxicity (see below) from an increased amount of free drug. People
with high fat-to-lean body mass ratio (as in older adults) will have erratic
amounts of active drug in their system.
XX Metabolism: Process by which the drug becomes chemically altered in the body
XX First-pass metabolism: Process by which the drug is metabolized by cytochrome
P450 (P450) enzymes in the intestines and liver prior to going to the systemic
circulation
XX Elimination: Process by which the drug is removed from the body
XX Half-life (T ½): Time needed to clear 50% of the drug from the plasma
ZZ The half-life also determines the dosing interval and the length of time to reach
a steady state.
XX Steady state: Point at which the amount of drug eliminated between doses is ap-
proximately equal to the dose administered.
ZZ Drugs usually are administered once every half-life to achieve a steady state.
ZZ It takes approximately five half-lives to achieve a steady state and five half-lives
to completely eliminate a drug.
XX Alterations in pharmacokinetics
ZZ Hepatic cytochrome P450 enzyme interactions can induce or inhibit the
metabolism of certain drugs, thus changing their desired concentration levels
(see Table 7–1).
ZZ Approximately 10% of Caucasians are poor metabolizers of the P450 2D6
enzyme.
ZZ Approximately 20% of Asians may have reduced activity of the P450 2C19
enzyme.
ZZ First-pass metabolism activity of P450 enzymes 2C9, 2C19, 2D6, and 3A4
in young children may exceed rates of adolescents and adults and give rise
to underexposure to certain medications Conversely, the ontogeny of the
1A2 pathway is delayed, possibly leading to toxic effects from drugs that are
substrates of this pathway (e.g., some antipsychotics).
ZZ Enzyme inducers can decrease the serum level of other drugs that are
substrates of that enzyme, thus possibly causing subtherapeutic drug levels.
TABLE 7–1.
CYTOCHROME P450 INHIBITORS AND INDUCERS
INHIBITORS INDUCERS
Buproprion Carbamazepine
Clomipramine Hypericum (St. John’s Wort)
Cimetidine Phenytoin
Clarithromycin Phenobarbital
Fluoroquinolones Tobacco
Grapefruit and grapefruit juice
Ketoconazole
Nefazodone
SSRIs
Pharmacological Principles 113
ZZ Enzyme inhibitors can increase the serum level of other drugs that are
substrates of that enzyme, thus possibly causing toxic levels.
ZZ Liver disease will affect liver enzyme activity and first-pass metabolism, possibly
resulting in toxic plasma drug levels.
ZZ Kidney disease or drugs that reduce renal clearance, such as nonsteroidal anti-
inflammatory drugs (NSAIDs), may increase serum concentration of drugs that
are excreted by the kidneys (such as lithium). Older adults are more sensitive
to psychotropics because of their decreased intracellular water, protein binding,
low muscle mass, decreased metabolism, and increased body fat concentration.
XX Most psychotropics are lipophilic and highly protein-bound. Thus, because
older adults have more body fat and less protein, they are more likely to
develop toxicity due to accumulation and erratic blood levels of drug.
Pharmacodynamics
XX Target sites for drug actions include receptors. Several types of pharmacodynamics
involve receptors:
ZZ Agonist effect: Drug binds to receptors and activates a biological response
ZZ Inverse agonist effect: Drug causes the opposite effect of agonist; binds to
same receptor
ZZ Partial agonist effect: Drug does not fully activate the receptors
ZZ Antagonist effect: Drug binds to the receptor but does not activate a biological
response
XX Another site for drug actions is ion channels, which exist for many ions such as
sodium, potassium, chloride, and calcium and can be open at some times and closed
at other times. Neurotransmitters or drugs may be excitatory or inhibitory depending
on the type of ion channel they gate.
ZZ Excitatory response: Depolarization; involves the opening of sodium and calcium
channels so these ions go into the cell
ZZ Inhibitory response: Repolarization; involves the opening of chloride channels so
chloride goes into the cell, potassium leaves, or both
XX Another site for drug actions are enzymes, which are important for drug metabolism
and play an important role in the chemical alteration of the drug. Some drugs (e.g.,
monoamine oxidase inhibitors [MAOIs]) inhibit the action of a particular enzyme,
thus increasing the availability of the neurotransmitter.
XX Another site for drug actions is carrier proteins or reuptake pumps, which transport
neurotransmitters out of the synapse and back into the presynaptic neuron to be
recycled or reused. Some drugs, such as selective serotonin reuptake inhibitors
(SSRIs), will inhibit reuptake pumps, thus increasing the synaptic availability of the
neurotransmitter.
Other Terminology
XX Potency: Relative dose required to achieve certain effects
XX Therapeutic index: Relative measure of the toxicity or safety of a drug; ratio of the
median toxic dose to the median effective dose
ZZ Drugs with a high therapeutic index (e.g., divalproex, 50–125 mcg/ml) have a
high margin of safety; that is, the therapeutic dose and the toxic dose are far
apart.
ZZ Drugs with a low therapeutic index (e.g., lithium, 0.5–1.2 mEQ/L) have a low
margin of safety; that is, the therapeutic dose and the toxic dose are close
together.
XX Tolerance: The process of becoming less responsive to a particular drug over time
XX Tachyphylaxis: An acute decrease in the therapeutic response
PMHNP PHARMACOLOGICAL MANAGEMENT ROLE

XX Pharmacological management process:
ZZ Make a diagnosis and identify the target symptoms.
ZZ Consider the phase of illness (such as acute, relapse, recurrence).
ZZ Assess prior personal and family history of response to certain medications.
ZZ Assess the client’s motivation for and any misgivings about treatment.
ZZ Identify potential interactions between the currently prescribed medications.
ZZ Identify cultural implications of certain drugs.
ZZ Discuss the risks and benefits of the treatment.
ZZ Document informed consent and the client’s understanding of target symptoms,
benefits, risks, and alternatives to treatment.
ZZ Monitor response and side effects.
XX Follow-up and role of the PMHNP
ZZ Use of standards of care:
XX Assist in determining length of treatment.
XX Do relapse planning.
ZZ It is helpful and advised to use standardized clinical rating scales to establish
the client’s baseline and to monitor progress or decompensation over time.
Screening tests also will aid in making a diagnosis and ruling out other disorders.
(See corresponding chapters for a list of relevant screening tools.)
ZZ It is important to recognize the large body of evidence-based data supporting
the combined use of pharmacological and nonpharmacological treatments
as offering psychiatric clients the best possibility for significant clinical
improvement.
ZZ Nonadherence is a common problem with all chronic illness, including
psychiatric disorders, and should be a continuous focus of concern for the
PMHNP.
ZZ Common medications used in the clinical management of psychiatric disorders

and usually prescribed by the PMHNP are identified in Table 7–2. See
corresponding chapters for specific information on each medication.
ZZ A Drug Enforcement Administration (DEA) number is required for prescription of
controlled substances.
XX Schedule of controlled substances
ZZ Schedule I
XX Nonmedicinal substances
TABLE 7–2.
MEDICATIONS COMMONLY USED IN THE CLINICAL MANAGEMENT OF PSYCHIATRIC
DISORDERS
MEDICATIONS USED TO TREAT SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Typical Antipsychotics Haloperidol (Haldol), haloperidol decanoate (Haldol Decanoate)
Loxapine (Loxitane)
Thioridazine (Mellaril)
Thiothixene (Navane)
Fluphenazine (Prolixin), fluphenazine decanoate (Prolixin Decanoate)
Mesoridazine (Serentil)
Trifluoperazine (Stelazine)
Chlorpromazine (Thorazine)
Perphenazine (Trilafon)
Second-Generation Clozapine (Clozaril)
Antipsychotics
Ziprasidone (Geodon)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Olanzapine (Zyprexa)
Aripiprazole (Abilify)
Paliperidone (Invega)
Iloperidone (Fanapt)
Asenapine (Saphris)
Lurasidone (Latuda)
MEDICATIONS USED TO TREAT MOOD DISORDERS AND BIPOLAR AFFECTIVE DISORDERS
Mood Stabilizers Valproic acid (Depakene)
Divalproex sodium (Depakote)
Lithium carbonate (Eskalith, Lithobid, Lithonate, Lithotabs)
Lamotrigine (Lamictal)
Carbamazepine (Tegretol)
Carbamazepine ER (Equetro)
Oxcarbazepine (Trileptal; off-label)
CONTINUED
MEDICATIONS USED TO TREAT MOOD DISORDERS, UNIPOLAR AFFECTIVE DISORDERS,

AND DEPRESSIVE DISORDERS
Tricyclics (TCAs) Clomipramine (Anafranil)
Amoxapine (Asendin)
Amitriptyline (Elavil)
Desipramine (Norpramin)
Nortriptyline (Pamelor)
Doxepin (Sinequan)
Trimipramine (Surmontil)
Imipramine (Tofranil)
Protriptyline (Vivactil)
Serotonin Selective Citalopram (Celexa)
Reuptake Inhibitors
Fluvoxamine (Luvox)
(SSRIs)
Paroxetine (Paxil)
Paroxetine mesylate (Pexeva)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Monoamine Oxidase Phenelzine (Nardil)
Inhibitors (MAOIs)
Tranylcypromine sulfate (Parnate)
Selegiline transdermal (EMSAM)
SNRIs and Other Agents Trazodone (Desyrel)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Bupropion (Wellbutrin, Forfivo, Aplenzin)
Duloxetine (Cymbalta)
Vilazodone (Viibryd)
Vortioxetine (Brintellix)
Levomilnacipran (Fetzima)
MEDICATIONS USED TO TREAT ANXIETY DISORDERS
Benzodiazepines (BNZs) Lorazepam (Ativan)
Clonazepam (Klonopin)
Chlordiazepoxide (Librium)
Oxazepam (Serax)
Clorazepate (Tranxene)
Alprazolam (Xanax)
Anxiolytics Buspirone (BuSpar)
Other Agents Propranolol (Inderal)
Atenolol (Tenormin)
MEDICATIONS USED TO TREAT ATTENTION DEFICIT DISORDER AND ATTENTION DEFICIT

HYPERACTIVITY DISORDER
Stimulants Amphetamine/dextroamphetamine (Adderall)
Dexmethylphenidate (Focalin)
Dextroamphetamine (Dexedrine)
Methylphenidate (Ritalin)
Methylphenidate (Concerta)
Lisdexamfetamine dimesylate (Vyvanse)
Other Agents Guanfacine (Intuniv)
Clonidine (Kapvay)
Atomoxetine (Strattera)
Antidepressants such as desipramine (Norpramin), venlafaxine
(Effexor), and bupropion (Wellbutrin) are also used in the clinical
management of ADHD.
XX High abuse potential

XX Used for research purposes only
XX Not legally available by prescription
XX Examples include heroin and marijuana
ZZ Schedule II
XX Medicinal drugs in current use
XX High potential for abuse and dependency
XX Written prescription only
XX No telephone orders allowed
XX No refills allowed on prescription
XX Examples include morphine sulfate, codeine, fentanyl,
methadone, hydromorphone (Dilaudid), oxycodone (OxyContin,
Percocet), hydrocodone (Vicodin and others), amphetamine salts,
methylphenidate
ZZ Schedule III
XX Medicinal drugs with less abuse potential than Schedule II drugs
XX Still greater potential for abuse than Schedule IV drugs
XX Telephone orders if followed by written prescription
XX Prescription must be renewed every 6 months
XX Refills limited to five
XX Examples include appetite suppressants, butalbital, testosterone,
buprenorphine/naloxone
ZZ Schedule IV
XX Medicinal drugs with less abuse potential than Schedule III drugs
XX Examples include dextropropoxyphene (Darvon), pentazocine

(Talwin), benzodiazepines (such as alprazolam [Xanax],
chlordiazepoxide [Librium], clonazepam [Klonopin], diazepam
[Valium], clorazepate [Tranxene], and lorazepam [Ativan]), modafinil
(Provigil), phenobarbital, zolpidem (Ambien), eszopiclone (Lunesta),
temazepam (Restoril), armodafinil (Nuvigil)
ZZ Schedule V
XX Medicinal drugs with the lowest abuse potential
XX Handled in manner similar to noncontrolled drugs
XX Examples include buprenorphine (Buprenex), cheratussin
(Robitussin) with codeine, promethazine (Phenergan) with codeine,
diphenoxylate/atropine (Lomotil)
Other Pharmacological Considerations

XX It is vital to be aware of the teratogenic nature of many psychotropic agents. It is
important to discuss the risks versus the benefits of medications during pregnancy.
ZZ Possible risks of psychotropic medications during pregnancy include:
XX Problems with appetite
XX Transient agitation or sedation
XX Premature labor
XX Drug discontinuation symptoms
XX Teratogenic effects of certain psychotropics
ZZ Possible risks of not taking psychotropic medications during pregnancy include
XX Recurrence of symptoms
XX Adverse effects on mother–infant bonding
XX Poor maternal self-care
XX Federal Drug Administration (FDA) pregnancy ratings for medications
ZZ A: Controlled studies show no risk
ZZ B: No evidence of risk in humans
ZZ C: Risk cannot be ruled out
ZZ D: Positive evidence of risk
ZZ X: Absolutely contraindicated in pregnancy
XX Teratogenic risks of common psychiatric medications
ZZ Benzodiazepines: Floppy baby syndrome, cleft palate
ZZ Carbamazepine (Tegretol): Neural tube defects
ZZ Lithium (Eskalith): Epstein anomaly
ZZ Divalproex sodium (Depakote): Neural tube defects, specifically spina bifida,
atrial septal defect, cleft palate, and possible long-term developmental deficits
XX Some common medications can induce depression or mania (see Table 7–3).
XX Remember that some medications can possibly cause a false urinary drug screen
result (see Table 7–4).
TABLE 7–3.
MEDICATIONS THAT INDUCE DEPRESSION OR MANIA
MEDICATIONS THAT INDUCE

DEPRESSION MEDICATIONS THAT INDUCE MANIA
• Beta blockers • Steroids
• Steroids • Disulfiram (Antabuse)
• Interferon • Isoniazid (INH)
• Isotretinoin (Accutane) • Antidepressants in persons with bipolar
disorder
• Some retroviral drugs
• Antineoplastic drugs
• Benzodiazepines
• Progesterone
TABLE 7–4.
MEDICATIONS THAT CAN CAUSE DRUG SCREEN FALSE POSITIVE RESULTS
FALSE POSITIVE
FOR DRUG RESPONSIBLE
Amphetamines • Stimulants (i.e., amphetamine/dextroamphetamine [Adderall], methyl-
phenidate [Ritalin])
• Bupropion (Wellbutrin)
• Fluoxetine (Prozac)
• Trazodone
• Ranitidine
• Nefazodone (Serzone)
• Nasal decongestants
• Pseudoephedrine
Alcohol • Valium
Benzodiazepines • Sertraline (Zoloft)
Cocaine • Amoxicillin
• Most antibiotics
• NSAIDs
Heroin or • Quinolones
morphine
• Rifampin
• Codeine
• Poppy seeds
Methadone or • Over-the-counter cough medicine (such as Nyquil) Dextromethorphan
PCP
CASE STUDY 1
Ms. J., a 74-year-old client whom the PHMNP has been seeing for depression, presented at her
appointment with complaints of tremors, diaphoresis, headache, and nausea over the past week.
She is currently being prescribed amitriptyline (50 mg q.h.s.), which was increased at her last
visit, and sertraline (100 mg q.d.). She denies depression but admits to increased confusion and
memory problems.
1. What is the biggest pharmacological concern with the combination of medication the
client is being prescribed?
2. What would be the PHMNP’s plan of action?
3. What pharmacokinetics should the PHMNP keep in mind when treating older adults?
CASE STUDY 2
Ms. M. is a 30-year-old married Chinese woman who is in the midst of a first major depres-
sive episode. Ms. M. is employed as a grade school teacher but is currently on summer break.
Despite participating in 6 months of cognitive behavioral therapy with an experienced therapist,
her symptoms have not improved. Ms. M describes feeling sad and cries easily. She feels anx-
ious and has trouble shutting her thoughts off, particularly when trying to fall asleep at night. She
feels tired upon awakening, despite getting 7 to 8 hours of sleep, and she has trouble getting out
of bed. Her energy remains low throughout the day. She notes a worsening in her motivation as
well. Her weight and appetite are unchanged. She denies suicidal ideation. After careful evalua-
tion, the PMHNP suggests a trial of fluoxetine and prescribes 20 mg p.o. q.a.m. with food.
Ms. M. calls the PMHNP before her scheduled follow-up appointment, requesting to come in
sooner because she feels “worse.” She describes more difficulty falling asleep, feels “revved
up” much of the time, and is having mild nausea and headaches.
1. What are possible reasons for Ms. M. feeling “worse”?
2. What should the PMHNP suggest as the next intervention for Ms. M.?
CASE STUDY 3
Ms. S. is a 22-year-old woman who presents to the PMHNP with signs and symptoms of major
depression. Ms. S. has a strong family history of major depression and both her mother and
older sister have been treated with an antidepressant. Ms. S. herself has never been treated for
depression before, and she says she is nervous about taking medication because she “gets side
effects from everything.”
1. How should the PMHNP respond to Ms. S.’s concerns about taking medication?
2. How should the PMHNP begin to think about medication management for Ms. S.?
Ms. S. is started on sertraline 50 mg. She calls within a few days of starting the drug and says
that she is experiencing an upset stomach, headache, difficulty sleeping, and an overall feeling of
being “edgy.”
3. What is the most likely reason for Ms. S.’s reported side effects?
4. What is the most reasonable intervention by the PMHNP?
5. Other than potential side effects, what information should the PMHNP include in
client teaching when starting a person on a new medication?

Case Study 1
1. The SSRI is potentially increasing the concentration of the TCA to toxic levels.
2. Check the blood level of amitriptyline and decrease the dose; consider tapering Ms.
J. off the TCA.
3. Higher body fat content, decreased gastric acid secretion, and decreased hepatic
and renal functioning all predispose an older adult to the potential toxic effects of
medications. Anticholinergic effects and orthostasis are particularly common and
problematic.
Case Study 2
1. Fluoxetine may cause uncomfortable activation in some clients. In addition, Ms. M.
appears to be having multiple side effects. Fluoxetine is metabolized primarily by cy-
tochrome P450 2D6. People who are deficient in 2D6 are considered “slow metabo-
lizers,” and may need significantly lower doses of medications that are substrates
of 2D6. Finally, all clients started on antidepressants must be monitored closely for
a switch from depression to hypomania or mixed mania. While Ms. M.’s increase in
insomnia and feeling “revved up” and “worse” are likely side effects from fluoxetine,
this could signal beginning symptoms of a shift into a bipolar spectrum mood state.
2. Unless agitation is prominent, the first prudent intervention would be to lower the
dose of the fluoxetine. If this is not helpful in diminishing side effects, prescribing a
low dose of lorazepam or other benzodiazepine used as a “bridge” medication until
the SSRI is effective may be prudent. If neither of these interventions proves helpful,
the medication should be changed.
Case Study 3
1. The PMHNP should ask Ms. S. to tell her more about being anxious about taking
medicine, and ask about the medications her immediate family members are taking,
whether or not the family members have had problems with side effects, and finally,
whether any medication has been particularly helpful to her family members.
2. A genetic polymorphism screening test to determine gene variants may be reason-
able. Because mood and anxiety disorders have a genetic component, beginning
with a medication that has been beneficial in the treatment of similar symptoms in a
first-degree relative is a reasonable starting point of treatment.
3. The sertraline was started at too high a dose.
4. Lower the dose to 25 mg. Make sure Ms. S. is taking the medication with food. If
not already doing so, switch the time of dosing to after breakfast.
5. During client teaching, the PMHNP should cover the usual course of treatment: typi-
cal time until benefit, typical therapeutic dosing, and expected length of treatment.
The PMHNP should also emphasize that most side effects are transient and can
usually be managed, such as by adjusting the dose.

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CHAPTER 8
NONPHARMACOLOGICAL TREATMENT
This chapter discusses nonpharmacological interventions such as individual psychotherapies,
group therapy, family therapies, and complementary and alternative therapies. Because medi-
cations alone do not treat a person’s environmental or interpersonal stressors and his or her
responses to these stressors, an integrated approach is the most beneficial in treating mental
illnesses. Although some people seek counseling for self-discovery, the most common issues
for individual therapy are:
XX Losses
XX Interpersonal conflicts
XX Symptomatic presentations such as panic, phobias, and negativity
XX Unfulfilled expectations at life transitions
XX Characterological issues such as narcissism or aggressiveness
Confidentiality may be broken when there is increased potential for self-harm or harm to others;
abuse of a child, older adult, or person with disabilities; when the therapist determines that the
person needs hospitalization; and when clients request that their information be released to a
third party.
INDIVIDUAL THERAPY
XX Psychoanalytic Therapy
ZZ Originated by Sigmund Freud (1856–1939), who believed that behavior is
determined by unconscious motivations and instinctual drives (see also
Chapter 3)
ZZ Promotes change by the development of greater insight and awareness of
maladaptive defenses
ZZ Attends to past developmental and psychodynamic factors, which shape present
behaviors
XX Cognitive Therapy
ZZ Originated by Aaron Beck (born 1921)
ZZ Purports that external events do not cause anxiety or maladaptive responses

ZZ States that a person’s expectations, perceptions, and interpretations of events
cause anxiety
ZZ Allows clients to view reality more clearly through an examination of their
central distorted cognitions
ZZ Goal is to change clients’ irrational beliefs, faulty conceptions, and negative
cognitive distortions
XX Behavioral Therapy
ZZ Originated by Arnold Lazarus (born 1932)
ZZ Focuses on changing maladaptive behaviors by participating in active behavioral
techniques such as exposure, relaxation, problem-solving, and role-playing
XX Dialectical Behavioral Therapy
ZZ Originated by Marsha Linehan (born 1943)
ZZ Commonly used with people with borderline personality disorder
ZZ Focuses on emotional regulation, tolerance for distress, self-management skills,
interpersonal effectiveness, and mindfulness, with an emphasis on treating
therapy-interfering behaviors
ZZ Goals
XX Decrease suicidal behaviors
XX Decrease therapy-interfering behaviors
XX Decrease emotional reactivity
XX Decrease self-invalidation
XX Decrease crisis-generating behaviors
XX Decrease passivity
XX Increase realistic decision-making
XX Increase accurate communication of emotions and competencies
XX Existential Therapy
ZZ Originated by Viktor Frankl (1905–1997)
ZZ A philosophical approach in which reflection on life and self-confrontation is
encouraged
ZZ Emphasizes accepting freedom and making responsible choices
ZZ States that a basic dimension of humans includes finding meaning and purpose
in life—“Why am I here? What is my purpose?”
ZZ Goals are to live authentically and to focus on the present and on personal
responsibility
XX Humanistic Therapy
ZZ Originated by Carl Rogers (1902–1987)
ZZ Also known as person-centered therapy
Nonpharmacological Treatment 127
ZZ Concepts include self-directed growth and self-actualization; people are born

with the capacity to direct themselves toward self-actualization
ZZ Each person has the potential to actualize and find meaning.
XX Interpersonal Therapy
ZZ Originated by Gerald L. Klerman (1928–1992) and Myrna M. Weissman (born
1940)
ZZ Evidence-based therapy with focus on interpersonal issues that are creating
distress
ZZ Time-limited, active, focused on the present and on interpersonal distress
ZZ Developed to treat aspects of depression and is effective for adults and
adolescents
ZZ Has been applied to treat interpersonal distress related to other disorders,
including bipolar, substance use, and eating disorders
XX Eye Movement Desensitization and Reprocessing (EMDR)
ZZ Originated by Francine Shapiro (born 1948)
ZZ A form of behavioral and exposure therapy
ZZ Involves the use of bilateral stimulation—moving the eyes back and forth,
alternating tapping on hand or knee, or sounds in ears
ZZ Most commonly used in post-traumatic stress disorder
ZZ Goal is to achieve adaptive resolution
ZZ Desensitization phase: The client visualizes the trauma, verbalizes the negative
thoughts or maladaptive beliefs, and remains attentive to physical sensations.
This process occurs for a limited time while the client maintains rhythmic eye
movements. He or she is then instructed to block out negative thoughts; to
breathe deeply; and then to verbalize what he or she is thinking, feeling, or
imagining.
ZZ Installation phase: The client installs and increases the strength of the positive
thought that he or she has declared as a replacement of the original negative
thought.
ZZ Body scan: The client visualizes the trauma along with the positive thought and
then scans his or her body mentally to identify any tension within.
GROUP THERAPY
XX Benefits
ZZ Increases insight about oneself
ZZ Increases social skills
ZZ Is cost-effective
ZZ Develops sense of community
XX Irvin Yalom (born 1931) was the first person to put a theoretical perspective on group
work and identified 10 therapeutic factors that differentiate group therapy from indi-
vidual therapy.
1. Instillation of hope: Participants develop hope for creating a different life.
Members are at different levels of growth; thus, they gain hope from others that
change is possible.
2. Universality: Participants discover that others have similar problems, thoughts,
or feelings and that they are not alone.
3. Altruism: This results from sharing oneself with another and helping another.
4. Increased development of socialization skills: New social skills are learned, and
maladaptive social behaviors are corrected. The group can provide a “natural
laboratory.”
5. Imitative behaviors: Participants are able to increase their skills by imitating the
behaviors of others.
6. Interpersonal learning: Interacting with others increases adaptive interpersonal
relationships.
7. Group cohesiveness: Participants develop an attraction to the group and other
members as well as a sense of belonging.
8. Catharsis: Participants experience catharsis as they openly express their
feelings, which were previously suppressed.
9. Existential factors: Groups enable participants to deal with the meaning of their
own existence.
10. Corrective refocusing: Participants reexperience family conflicts in the group,
which allows them to recognize and change behaviors that may be problematic.
XX Group phases (Tuckman, 1965)
ZZ Pregroup phase: The leader considers the direction and framework of the group.
XX Purpose
XX Goals
XX Membership criteria
XX Membership size
XX Pregroup interview
XX Informed consent
ZZ Forming phase: Members are concerned about self-disclosure and being
rejected. Goals and expectations are identified, and boundaries are established.
The development of trust and rapport is very important.
ZZ Storming phase: Members are resistant and may begin to use testing behaviors.
Issues related to inclusion, control, and affection begin to surface. Leaders’
tasks are to allow expression of both positive and negative feelings, assist the
group in understanding the underlying conflict, and examine nonproductive
behaviors.
ZZ Norming phase: Resistance to the group is overcome by members. A

strong attraction to the group and others emerges. Open and spontaneous
communication occurs, and the group norms are established.
ZZ Performing phase: The group’s work becomes more focused. Creative problem-
solving and solutions begin to emerge. Experiential learning takes place. Group
energy is directed toward completion of goals.
ZZ Adjourning phase: Preparation is made to end the group. (Remember that the
work of termination begins during the first stage of the group.) Both members
and leaders express their feelings about each other and termination. A
discussion and overview of what has been learned, as well as what issues still
need to be worked on, takes place.
XX Reminiscence Therapy
ZZ Characterized by a progressive return of memories of past experiences
ZZ Used with older adults
ZZ Enables participants to search for meaning in their lives and strive for some
resolution of past interpersonal and intrapsychic conflicts
FAMILY THERAPIES
XX Family system concepts
ZZ A system is any unit structured on feedback—such as the family.
ZZ The process by which all family members operate together is referred to as the
family system.
ZZ Family systems theory is based on the idea that one could not understand any
family member (part) without understanding how all family members operate
together (system).
ZZ The family system operates based on a set of rules that may be overt or covert.
ZZ Boundaries: Barriers that protect and enhance the functional integrity of
families, individuals, and subsystems. System boundaries can be physical or
psychological.
ZZ Types of boundaries
XX Clearly defined boundaries: Maintain person’s separateness while
emphasizing belongingness
XX Rigid or inflexible boundaries: May lead to distant relationships and to
disengagement
XX Diffuse boundaries: Blurred and indistinct boundaries; lead to enmeshment
ZZ Circular causality: An ongoing feedback loop; a series of actions and
reactions that maintain a problem. Individuals and emotional problems are
best understood within the context of relationships and through assessing
interactions within an entire family.
ZZ Family homeostasis: Tendency of families to resist change and to maintain a
steady state
ZZ Morphogenesis: A family’s tendency to adapt to change when changes are

necessary
ZZ Morphostasis: A family’s tendency to remain stable in the midst of change
XX Family Systems Therapy
ZZ Originated by Murray Bowen (1913–1990), who believed that a person’s
problematic behavior may serve a function or purpose for the family or be a
symptom of dysfunctional patterns
ZZ Focus is on chronic anxiety within families
ZZ Treatment goals are to increase the family’s awareness of each member’s
function within the family and to increase levels of self-differentiation (the level
at which one’s sense of self-worth is not dependent on external relationships,
circumstances, or occurrences).
XX Triangles: Dyads that form triads to decrease stress; the lower the level of
family adaptation, the more likely a triangle will develop
XX Nuclear family emotional system: Level of differentiation of the parents is
usually equal to the level of differentiation for the entire family
XX Multigenerational transmission process: Dysfunction present over several
generations
XX Family projection process: Parents transmitting their own level of
differentiation on the most susceptible child
XX Emotional cutoffs: Attempting to break contact with the family of origin
XX Sibling position: Influences interactions and personality characteristics
XX Structural Family Therapy
ZZ Originated by Salvador Minuchin (1913–1990), who placed emphasis on how,
when, and to whom family members relate in order to understand and then
change the family’s structure
ZZ A person’s symptoms are rooted in the context of family transaction patterns.
The symptom is a function of the health of the whole family and is maintained
by structural problems in the system.
ZZ The main treatment goal is to produce a structural change in the family
organization to more effectively manage problems—changing transactional
patterns and family structure.
XX Family structure: An invisible set of functional demands that organize the
way members interact with each other, made up of subsystems (e.g.,
marital, parental, sibling), coalitions (e.g., two members joining forces
against a third member), and boundaries
XX Structural mapping (genogram): Mapping relationships using symbols to
represent overinvolvement, conflict, coalitions, and so forth
XX Hierarchies: Distribution of power
XX Experiential Therapy
ZZ Originated by Virginia Satir (1916–1988)
ZZ Behavior is determined by personal experience and not by external reality.
ZZ Focus is on being authentic, on freedom of choice, on human validation, and on

experiencing the moment
ZZ Treatment goals are to develop authentic, nurturing communication and
increased self-worth of each family member; overall goal is growth rather than
symptom reduction alone.
ZZ It does not focus on particular techniques.
XX Strategic Therapy
ZZ Originated by Jay Haley (1923–2007)
ZZ Symptoms are viewed as metaphors and reflect problems in the hierarchal
structure. Symptoms are a way to communicate metaphorically within a family.
ZZ Treatment goal is to help family members behave in ways that will not
perpetuate the problem behavior.
ZZ Interventions are problem-focused. Strategic therapy is more symptom-focused
than structural therapy.
ZZ Strategic family therapists are concerned mainly with those techniques that
change the sequence of interactions that is maintaining the problem.
ZZ Techniques are straightforward directives, paradoxical directives, and reframing
belief systems.
XX Straightforward directives: Tasks that are designed in expectation of the
family member’s compliance
XX Paradoxical directives: A negative task that is assigned when family
members are resistant to change and the member is expected to be
noncompliant (use this technique with caution)
XX Reframing belief systems: Problematic behaviors are relabeled to have
more positive meaning (e.g., jealousy reframed to caring)
XX Solution-Focused Therapy
ZZ Originated by Steve deShazer (1940–2005), Bill O’Hanlon (born 1952), and Insoo
Berg (1934–2007)
ZZ Focus is to rework for the present situation solutions that have worked
previously
ZZ Treatment goal is effective resolution of problems through cognitive problem-
solving and use of personal resources and strengths.
ZZ Techniques include the use of miracle questions, exception-finding questions,
and scaling questions.
XX Miracle questions: “If a miracle were to happen tonight while you were
asleep, and tomorrow morning you awoke to find that the problem no
longer existed, what would be different?” “How would you know the
miracle took place?” “How would others know?”
XX Exception-finding questions: Directing clients to a time in their lives when
the problem did not exist, which helps them move toward solutions by
assisting them in searching for any exceptions to the pattern. “Was there a
time when the problem did not occur?”
XX Scaling questions: “On a scale of 1–10, with 10 being very anxious and
depressed, how would you rate how you are feeling now?” This is useful
for highlighting small increments of change.
COMPLEMENTARY AND ALTERNATIVE THERAPIES (CATS)

XX CATs deal with the connection between the mind and the body and are viewed as
holistic health care (dealing with the biopsychosocial and spiritual components of the
person).
ZZ Complementary therapies: Used in addition to traditional medical practices
ZZ Alternative therapies: Used in place of traditional medical practices
ZZ Integrative therapies: Recent term used to describe the use of traditional
complementary therapies
XX Why people use CATs
ZZ Desire for more control over decision-making
ZZ Decreased insurance coverage for traditional medical therapies, therefore
making the use of CATs cheaper
ZZ Preference for natural rather than synthetic medications
ZZ Increased costs of prescriptions and services
ZZ Failure of conventional medications
XX Mind–body interventions
ZZ Guided imagery
ZZ Meditation
ZZ Yoga
ZZ Biofeedback
XX Biologically based therapies
ZZ Herbal products
ZZ Vitamins
ZZ Supplements
ZZ Aromatherapy
XX Manipulative and body-based therapies
ZZ Acupressure and acupuncture
ZZ Massage
ZZ Reflexology
XX Acupressure and Acupuncture
ZZ Based on the basic tenet of Chinese medicine that vital energy (chi) flows
along specific pathways that have many points of access and that manipulating
these points, by either hands or needles, corrects imbalances by stimulating or
removing blockages to energy flow
ZZ Thought to produce effects by regulating the nervous system and aiding the
activity of endorphins and immune system cells at different sites in the body
ZZ Also thought to alter brain chemistry by changing the release of neurohormones
and neurotransmitters
XX Biofeedback
ZZ A process providing a person with visual or auditory information about the
autonomic physiologic functions of his or her body, such as blood pressure,
muscle tension, and brain wave activity
ZZ The person learns to consciously control these processes, which were
previously regarded as involuntary.
ZZ Uses
XX Stress-related symptoms (e.g., anxiety)
XX Pain
XX Insomnia
XX Neuromuscular problems (e.g., migraines, muscular tension, tension
headaches, Raynaud’s disease, urinary incontinence)
XX Neurobehavioral disorders
XX Enhancement of healing
XX Athletic and work performance
ZZ Desired outcome
XX Positive change in baseline measures
XX Demonstrated skill at self-regulation
XX Improvement in symptoms
XX Improved use of skills in daily life
XX Reduction of muscle bracing
XX Increased sense of self-efficacy
XX Aromatherapy
ZZ Therapeutic use of plants or oils to obtain many therapeutic effects, such as
analgesic, psychological, and antimicrobial benefits
ZZ In psychiatry, olfactory stimulation used to elicit feelings or memories during
psychotherapy
XX Herbal Products and Supplements
ZZ Practice of herbal medicine originated in China and is the oldest system of
medicine
ZZ Relies on plants to cure illnesses and maintain health
ZZ Similar to prescription medications, many plants contain active compounds that
produce physiological effects
ZZ Food and Drug Administration (FDA) approval is not required; thus no uniform
standards ensure quality control or potency
ZZ Common supplements and interactions include:

XX Omega-3 fatty acids
ZZ Used for attention deficit hyperactivity disorder, dyslexia, cognitive
impairment, dementia, cardiovascular disease, asthma, lupus, and
rheumatoid arthritis
ZZ Interacts with warfarin (Coumadin), increasing anticoagulant effect
(people cautioned to stop using before surgery)
XX Sam-e
ZZ Used for depression, osteoarthritis, and liver disease
ZZ May cause hypomania, hyperactive muscle movements, and possible
serotonin syndrome
XX Tryptophan
ZZ Used for depression, obesity, insomnia, headaches, and fibromyalgia
ZZ Found in high concentrations in turkey
ZZ Increased risk of serotonin syndrome with use of selective serotonin
reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs),
and St. John’s wort
XX Vitamin E
ZZ Used for enhancing the immune system and protecting cells against
effects of free radicals
ZZ Used for neurological disorders, diabetes, and premenstrual syndrome
ZZ Interacts with warfarin, increasing anticoagulant effect; antiplatelet
drugs; and statins, increasing additive effect and risk of rhabdomyolysis
XX Melatonin
ZZ Used for insomnia, jet lag, shift work, and cancer
ZZ Sets timing of circadian rhythms and regulates seasonal responses
ZZ Interacts with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
beta blockers, corticosteroids, valerian, kava kava, and alcohol
ZZ Can inhibit ovulation in large doses
XX Fish oil
ZZ Used for bipolar disorder, hypertension, lowering triglycerides, and
decreasing blood clotting
ZZ Interacts with warfarin, aspirin, NSAIDs, garlic, and ginkgo
ZZ May alter glucose regulation
ZZ Most herbals are contraindicated during pregnancy and, because they are
secreted in breast milk, during lactation.
ZZ Common herbals with psychoactive effects include:
XX Black cohosh: Menopausal symptoms, premenstrual syndrome,
dysmenorrhea
XX Belladonna: Anxiety
XX Catnip: Sedation
XX Chamomile: Sedation, anxiety
XX Ginkgo: Delirium, dementia, sexual dysfunction caused by SSRIs
XX Ginseng: Depression, fatigue
XX Valerian: Sedation
XX Massage
ZZ Believed to increase blood circulation, improve lymph flow, improve
musculoskeletal tone, and have a relaxing effect on the mind
XX Meditation
ZZ Consciously directing one’s attention to alter one’s state of consciousness
ZZ Produces physiological effects such as decreased heart rate, blood pressure,
and respiratory rate; decreased anxiety; and increased alpha brain waves
XX Reflexology
ZZ Stimulates the body’s natural healing power through massaging the feet, hands,
and ears
ZZ Alleviates tension by cleaning crystalline deposits under the skin that may
interfere with the natural flow of the body’s energy
ZZ Based on the mapping of body parts on the soles and sides of the feet, hands,
and ears
ZZ Treats disorders related to the represented body parts by application of pressure
ZZ Used for back pain, migraines, infertility, sleep disorders, digestive disorders,
and stress-related conditions
XX Macrobiotics
ZZ Foods classified as yin (cold and wet) and yang (hot and dry)
ZZ Goal is to keep the dietary yin and yang in balance in attempt to live in harmony
with nature
XX Yoga
ZZ Originated in Indian religious practices
ZZ Combines mind and body connection
ZZ Uses breathing, physical movements, and meditation
CASE STUDY
You are a psychiatric–mental health nurse practitioner working with Jill, who has depression. In
session Jill states, “Nothing good ever happens to me. I’m just a failure and should accept that
people at work think I’m inadequate to do my job.”
1. What therapeutic approach would be most helpful in working with Jill?
2. Specifically, what cognitive and behavioral techniques would be helpful for Jill?
3. Which scales would be helpful to use in assessing her depression and negative
thoughts?
4. If you chose a CBT approach to work with Jill, what is the three-question technique?
5. What types of distortions does Jill have and, as her therapist, how would you begin
to address her distortions?

1. The therapy that would be most helpful for Jill is cognitive behavioral therapy.
2. In working with Jill, having her complete a thought record to identify situations that
lead to automatic thoughts, emotions, and her responses would be helpful.
3. Scales that would be useful to track Jill’s progress in therapy include: PHQ-9, Beck
Depression Scale, and Schema questionnaire.
4. The three-question technique when using CBT involves Socratic questioning. For
example, asking the following: (1) Evidence for her negative belief; (2) How else can
she interpret the situation?; (3) If it is true, what are the implications?
5. The types of distortions Jill has are all-or-nothing thinking and overgeneralization. A
technique that would be helpful to address Jill’s distortion are using a scale will help
her put the distortions on a continuum to help her respond differently to low scale
items.

Corey, M., Corey, G., & Corey, C. (2010). Groups: Process and practice (8th ed.). Pacific Grove,
CA: Brooks/Cole.
Goldenberg, I., & Goldenberg, H. (2013). Family therapy: An overview (8th ed.). Boston, MA:
Brooks/Cole Cengage Learning.
Scharf, R. (2013). Theories of psychotherapy and counseling (5th ed.). Boston, MA: Brooks/Cole
Cengage Learning.
Snyder, M., & Lindquist, R. (Eds.). (2010). Complementary & alternative therapies in nursing (6th
ed.). New York, NY: Springer.
Tusaie, K., & Fitzpatrick, J. (2013). Advanced practice psychiatric nursing integrating psychother-
apy, psychopharmacology, and complementary and alternative approaches. New York, NY:
Springer Publishing Company.
Weisz, J. & Kazdin, A. (2010). Evidence-based psychotherapies for children and adolescents (2nd
ed.). New York, NY: Guilford Press.
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse (2nd ed.). New
York, NY: Springer Publishing Company.
Yalom, I. (2005). Theory and practice of group psychotherapy (5th ed.). New York, NY: Basic
Books.
CHAPTER 9
DEPRESSIVE DISORDERS AND BIPOLAR

DISORDERS
This chapter reviews the mood disorders and evidence-based practice guidelines that
psychiaric–mental health nurse practitioners (PMHNPs) use in treating clients who have these
disorders. As a childhood disorder, Disruptive Mood Dysregulation Disorder will be discussed in
Chapter 15.
Mood disorders are the most common of all psychiatric illnesses.
It has become increasingly common for mood disorders to be treated in primary care settings,
and often clients first present in such settings because of the high degree of somatic symptom-
atology that accompanies these disorders.
Sadness is a common, normal human emotion. PMHNPs caring for clients who present for
evaluation of depression must distinguish between normal levels of sadness and pathological
levels that are symptomatic of an underlying brain-based illness called major depression. Major
depression requires treatment and generally will not fully abate without therapeutic intervention.
Untreated, major depression predisposes people to other serious health problems, so pathologi-
cal levels of depression should not go untreated.
SADNESS AS A COMMON EMOTIONAL STATE

XX Sadness, one of the most common human emotions, exists on a continuum ranging
from the absence of depression at one end to pathological levels that produce sig-
nificant symptoms of a psychiatric disorder called major depression at the other.
XX Cultural differences affect behavioral manifestations of depression.
XX Mild depression can be a healthy reaction to life stressors that motivates a person to
deal with events and emotions
ZZ Sadness can be pathological if:
XX It is disproportionate to events and sustained over a significant time period;
XX It significantly impairs normal social functioning (e.g., occupational, social,
school, relational functioning);
XX It significantly impairs normal somatic functioning (e.g., loss of appetite,

altered sleep, altered self-care activities, altered sexual functioning); or
XX It is apparently unrelated to any identifiable event or situation in a person’s
life.
MAJOR DEPRESSIVE DISORDER (MDD)

Description
XX One of the most common psychiatric disorders; the primary unipolar affective
disorder
XX A complex brain-based illness with a primary characteristic of a persistent distur-
bance in mood
XX An excessive or distorted degree of sadness that manifests with behavioral, affec-
tive, cognitive, and somatic symptoms
XX May have a known precipitating event, situation, or concern but often occurs without
any precipitating stressor identified
XX Significantly interferes with daily functioning and goal attainment
XX Has complex genetic, biochemical, and environmental etiological factors
Etiology
XX Multiple theories of the etiology of depression fall into two categories: psychological
and neurobiological.
XX Psychodynamic theories
ZZ Object Loss Theory (Ronald Fairbairn, D. W. Winnicott, Harry Guntrip; Gilbert,
2006)
XX This theory assumes that early psychological developmental issues lay the
foundation for depressive responses in later life; that the accomplishment
of the first stage of development in which the child is able to form
relationships is normal; and that, during second stage of development,
the child experiences traumatic separation from significant objects of
attachment (usually a maternal object).
XX Loss may be related to maternal death, illness, or emotional lack of
availability and is unexpected and overwhelming.
XX Depth of loss produces constellation of responses dominated by separation
anxiety, grief, mourning, and despair.
XX This critical object loss event predisposes the child to respond in similar
ways to any future losses or significant separation.
ZZ Aggression-Turned-Inward Theory (Sigmund Freud)
XX This theory assumes that early psychological developmental issues lay the
foundation for depressive responses in later life; that the accomplishment
of the first stage of development in which the child is able to form
Depressive Disorders and Bipolar Disorders 141
relationships is normal; and that, during second stage of development, the

child experiences the loss of the significant mothering person.
XX The loss can be a real or imagined and is unexpected and overwhelming.
XX The loss may be related to maternal death, illness, or emotional lack of
availability or to the birth of a new sibling and the child’s perception of
losing undivided, individualized attention from the mother. The child’s initial
reaction is anger; however, the child feels unsafe to express this anger
openly and directly. This may relate to the child’s fearing further loss if he or
she responds with anger or his or her subjective perception that anger is
unacceptable.
XX The child uses defense mechanisms to deal with conflict created by desire
for the love object but co-occurring with anger for the love object.
XX Instead of anger being expressed outward at the maternal figure, it turns
inward because it is more acceptable and safer to be angry at oneself than
at the mother.
XX Anger at oneself is rationalized as the child assumes that loss of the
mother was related to something bad that he or she did rather than to the
caregiver’s actions.
XX Excessive guilt becomes a manifestation of the process of dealing with
aggression experienced with the loss of the mother’s attention.
XX A similar emotional reaction (such as low self-esteem, excessive guilt,
inability to cope with anger, self-destructive impulses) occurs as an adult
whenever a loss is experienced.
ZZ Cognitive Theory (Aaron Beck, 1979)
XX This theory represents a cognitive diathesis–stress model in which
developmental experiences sensitize a person to respond to stressful life
events in a depressed manner.
XX Cognitive theory assumes that people with a tendency to be depressed
think about the world differently than nondepressed people and that
depressed people are more negative and believe that bad things are going
to happen to them because of their own personal shortcomings and
inadequacies.
XX This thinking promotes low self-esteem and beliefs that the person
deserves to have bad things happen to him or her and promotes
pessimistic perceptions about the world at large and about his or her future,
as well as globalizes the negativity to all events, situations, and people in
his or her life.
XX When confronted by stressful events, these people tend to appraise
them and the potential consequences in a negative, hopeless manner and
therefore are more depressed than people with different cognitive styles.
ZZ Learned Helplessness-Hopelessness Theory (Martin Seligman)
XX This theory is a modified aspect of cognitive theory, which assumes that
a person becomes depressed due to perceptions of lack of control over
life events and experiences. These perceptions are learned over time,
especially as the person perceives others seeing him or her as inadequate.
XX Perceptions of lack of control lead to the person not adapting or coping.
XX The person’s behavior becomes passive and nonreactive because of self-
perceptions of personal characteristics of being helpless, hopeless, and
powerless.
XX Biological theories
ZZ Genetic predisposition
XX There is a clear genetic predisposition to depressive disorders; one
assumption is a polygenic single nucleotide polymorphism (SNP) disorder.
XX Having a depressed parent is the single strongest predictor of depression.
Children of depressed parents are three times more likely to experience
MDD in their lifetimes than the general population and have a 40% chance
of having a depressive episode before age 18 years.
XX The earlier the age of onset for MDD and the more severe the symptoms,
the more likely it is that a person has a strong genetic predisposition for
depression.
ZZ Endocrine dysfunction
XX MDD has symptoms that suggest endocrine abnormalities as part of the
etiologic picture.
XX Neurovegetative symptoms commonly seen in MDD (e.g., sleep
disturbances, appetite disturbances, libido disturbances, lethargy,
anhedonia) are related to functions of the hypothalamus and pituitary and
the hormones they secrete.
XX A high incidence of postpartum mood disturbances is suggestive of
endocrine dysfunction.
XX Dysphoria is often triggered by changes in levels of sex steroids that occur
during the menstrual cycle.
XX Deregulation of the hypothalamic–pituitary–adrenal axis (HPA, which
controls the physiological response to stress and consists of interconnected
feedback pathways between the hypothalamus, pituitary gland, and adrenal
glands) is another theory of an endocrine basis for MDD. In this theory,
MDD is presumed to be, at least in part, a result of an abnormal stress
response related to HPA dysregulation.
ZZ In response to stress, the hypothalamus releases corticotropin-
releasing hormone (CRH), which then stimulates the pituitary to
release adrenocorticotropic hormone (ACTH). This then stimulates the
adrenals to release cortisol.
ZZ Hyperactivity of the HPA has been shown to be present in people with
MDD, as have possible elevated cortisol levels.
ZZ Over time, elevated cortisol levels damage the central nervous system
(CNS) by altering neurotransmission and electrical signal conduction.
Depressive Disorders and Bipolar Disorders 14 3
ZZ Evidence supports that cortisol over time can cause changes in size
and function of brain tissue.
ZZ Evidence supports that major depression may be associated with
proinflammatory cytokine activation
XX HPA dysregulation is the rationale and scientific basis for the

dexamethasone suppression test (DST), a screening test for depression,
which has proved to be too nonspecific and is not commonly used in clinical
practice.
ZZ Abnormalities of neurotransmitter function
XX All of the following are possible neurotransmitter function abnormalities
causing depression:
ZZ Dysregulation of one or more biogenic amine neurotransmitters:
dopamine, serotonin, norepinephrine
ZZ Low levels of endogenous catecholamines in specific areas of the brain
ZZ Serotonin levels were shown to be low in postmortem studies on
people who commit suicide and in people with MDD.
ZZ Low level of precursor tryptophan
ZZ Low levels of serotonin metabolite 5HTIAA
ZZ Receptor sensitivity for neurotransmitters set unusually high in specific
areas of the brain
XX A stronger neurotransmitter receptor cascade is required to induce
neuronal activity.
ZZ Low density of receptor sites in specific areas of the brain
ZZ Hypometabolism in specific areas of the brain regulating mood,
appetite, and cognition
ZZ Complexity of brain functions implies that the etiology of complex
disorders such as MDD involves the relative balance of available
neurotransmitters and not just a low level of one neurotransmitter.
ZZ Structural brain changes

XX Neuroimaging has shown consistent abnormalities in certain structures of
the brain in people with chronic and severe depression.
ZZ Hypovolemic hippocampus
ZZ Hypovolemic prefrontal cortex–limbic striatal regions
XX MDD is a common comorbidity in people who have experienced brain

damage, including damage from stroke and trauma.
ZZ Chronobiological theory
XX Desynchronization of circadian rhythms produces the symptom
constellation collectively called MDD.
XX Circadian rhythms control biological processes that are frequent problems
in depressed persons.
ZZ Interrupted sleep–rest cycle
ZZ REM abnormalities
ZZ Frequent waking
ZZ Intensified dreaming
ZZ Diurnal variations to circadian-related behaviors
ZZ Decreased arousal and energy levels
ZZ Decreased activity patterns
ZZ Increased cortisol secretion
ZZ Increased emotional reactivity
Incidence and Demographics

XX MDD is a common illness, with approximately 5% of the U.S. population ages 18
and older in a given year, or 15 million U.S. adults, having the disorder.
XX MDD is the leading cause of disability in the United States and is the most common
psychiatric illness seen in primary care practices; however, only 50% of people with
MDD ever receive treatment.
XX MDD can occur at any age; however, the average age of onset is mid-20s.
XX During reproductive years, the lifetime risk for MDD varies with gender—25% for
women, 12% for men; the risk is equal for the genders before puberty and after
menopause.
XX MDD is a greater source of morbidity for women than any other illness.
XX MDD is associated with high mortality; 15% of people with MDD will die by suicide.
People with MDD have a 4-times-greater risk of premature death than the normal
control population.
XX The disease course is variable and can involve isolated episodes separated by many
years, clusters of episodes, or a severe episode with some remission of symptoms
but with chronic symptoms persisting over time.
XX If left untreated, an episode of MDD usually lasts four months or longer.
XX MDD tends to be a chronic, recurrent illness.
XX One year after initial diagnosis of MDD, symptoms often persist.
ZZ 40% of clients have significant enough symptoms to meet full Diagnostic
and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric
Association, 2013) criteria for MDD.
ZZ 20% of clients do not meet full DSM-5 criteria but still have a significant
symptom level that impairs functioning.
ZZ 40% have no symptoms.
XX The number of prior episodes predict the likelihood of future episodes (Judd et. al.,
2000).
XX People with first episode of major depression have approximately a 60% risk of a
second episode.
ZZ People who experience a second episode have approximately a 70% risk of a

third episode.
ZZ People who experience a third episode have approximately a 90% risk of a
fourth episode.
Risk Factors
XX Genetic loading
ZZ Family history, especially a first-degree relative
XX Prior episode of MDD
XX Female gender
XX Postpartum period
XX Medical comorbidity
XX Single marital status
XX Significant environmental stressors, especially multiple losses
Prevention and Screening

XX Provide at-risk family education.
XX Provide community education to help reduce stigma, to convey signs and symptoms
of illness, and to emphasize the treatment potential for control of symptoms.
XX Provide significant screening efforts to help recognize, intervene, and initiate treat-
ment early.
XX Provide healthcare provider education to facilitate early recognition and effective
treatment.
XX Significant and protracted prodromal symptom period usually noted before full onset
of illness.
Assessment
Conduct baseline screening with a tool such as the Patient Health Questionnaire 9 (PHQ-9) or
Edinburgh Postnatal Depression Scale (EPDS) (Siu & U.S. Preventive Task Force, 2016). Or the
Beck Depression Inventory (BDI), or Hamilton Depression Rating Scale (HAM-D),and repeat
throughout the course of treatment to evaluate initial symptoms and response to treatment.
History
XX Detailed history of present illness, including time frame, progression, and any associ-
ated symptoms
XX Social history, including present living situation, marital status, occupation, spiritual-
ity; education, alcohol, tobacco, and illicit drug use
XX Medication use, including prescription, over-the-counter, alternative, supplements,
and home remedies
XX Recent medical illness or surgery

XX Initial and periodic functional history and assessment
XX Validation of history with family member
ZZ Initial presentation: often manifests as vague somatic complaints
XX Bodily aches, pains
XX Headaches
XX Muscle pains
XX Lack of energy
XX Gastrointestinal problems
XX When mood is the presenting complaint, often client word choice may be vague or
indirect.
ZZ The person may describe mood as depressed, discouraged, sad, “blue,” “blah,”
or “down in the dumps.”
ZZ Irritable mood is a frequent subjective state validated by a significant person in
the client’s life.
XX Characteristic low energy is seen, so assess for individual activity intolerance with-
out other apparent cause.
XX Anhedonia is almost always present to some degree.
XX Sleep disturbance is almost always present.
ZZ Typically problems occur with middle or terminal insomnia.
ZZ Hypersomnia can be present.
ZZ Diurnal variations can be present.
XX A prodromal episode consisting of a high level of subjective anxiety and mild depres-
sive symptoms often develops over days to weeks before onset of a full episode.
XX Women often report symptoms occurring in fixed pattern around several days before
onset of menses, so assess menstrual history.
XX Psychotic features can be present, so always assess for their presence.
XX Assess for client’s symptoms according to diagnostic criteria for MDD:
ZZ Anhedonia or a depressed mood, or both
ZZ Depressed mood most of the day, nearly every day, as indicated by subjective
reports or observations of others
XX In children, irritable mood
ZZ Marked anhedonia in all or almost all activities of daily living
ZZ At least three or more significant symptoms present during the same 2-week
period that represent a change in previous functioning
ZZ Significant, unintentional weight loss or gain of more than 5% of body weight;
with increased appetite and usually a concurrent craving for specific foods, such
as carbohydrates or sweets
ZZ Hypersomnia or insomnia nearly every day
ZZ Psychomotor agitation or retardation

ZZ Fatigue or loss of energy
ZZ Self-deprecating comments or thoughts
ZZ Feelings of worthlessness or excessive or inappropriate guilt nearly every day
ZZ Decreased concentration and memory
ZZ Recurrent morbid thoughts or suicidal ideation
ZZ Symptoms that begin within 2 months of significant loss such as death of
a loved one and do not persist beyond 2 months are generally considered
bereavement and not MDD.
Physical Exam Findings

XX There are no specific physical findings.
XX People with certain other disorders (such as diabetes, myocardial infarction, carcino-
mas, stroke) have a statistically significant increased risk for MDD.
ZZ Prognosis for treatment of other disorders is poor if MDD is not recognized and
effectively treated.
XX Clients with MDD may have trouble participating in assessments related to the cog-
nitive problems of the disorder.
ZZ Impaired ability to report chronological timeline of illness
ZZ Poor decision-making
ZZ Slowed thought processes
ZZ Poor concentration
XX Clients with MDD often have psychomotor findings.
ZZ Agitation
ZZ Retardation
Mental Status Exam Findings

XX Appearance
ZZ Unkempt
ZZ Tired-looking
ZZ Clothing showing little attention or care about how the person looks
ZZ Dark-colored, loose-fitting clothing
ZZ Significant weight change from baseline
XX Mood
ZZ Sad
ZZ “Depressed”
ZZ Anxious
ZZ Irritable
XX Affect
ZZ Constricted or blunted
ZZ Sad, tearful
ZZ Anxious
ZZ Irritable
XX Speech
ZZ Underproductive
ZZ Slowed response times
ZZ Monotonal intonation
XX Thought process
ZZ Usually organized but may be disorganized if psychosis present
ZZ Slowing
ZZ Distractible
ZZ Ruminative
XX Thought content
ZZ Morbid preoccupation
ZZ Suicidal ideation exists on continuum of severity:
XX Guilt for not being able to overcome the depression or for what they are
“putting loved ones through”
XX Thoughts that others would be better off if the person was “gone”
XX Transient recurrent thoughts of suicide
XX Nonspecific thoughts of active action to commit suicide
XX Specific plan for committing suicide
XX Specific plan with timeline for completion
XX Specific plan with acquisition of the means to carry out plan (suicidal
motivation differs for different clients)
XX Desire to give up struggle
XX Attempt to end significant emotional pain
XX Lack of any visible options for dealing with stressors, hopeless, helpless
XX Anger and frustration with poor impulse control
ZZ Research evidence supports that it is not possible to predict accurately whether
or when a person will attempt suicide (see Table 9–1 for review of suicide
assessment).
ZZ Suicide risk especially high for persons with certain symptoms or history:
XX Presence of psychotic symptoms
XX History of past attempts
XX History of first-degree relative who committed suicide
TABLE 9–1.
ASSESSING FOR SUICIDAL BEHAVIOR
Past history for suicide attempts or completed suicide in client or family

Negativity and morbidity
Suicidal ideation currently
Plan and intent for suicide action
Means and access to commit suicide
Perceived social supports
Lethality of intended suicide action:
High lethality: Jumping from significant height, gun, hanging
Moderate lethality: Overdose of toxic agents (such as aspirin, sleeping pills)
Low lethality: Superficial wrist-cutting, breath-holding
Impulsivity
Substance abuse or dependence
History of psychiatric disorder
XX Concurrent substance abuse or dependency

XX Current serious health problem (see below for clinical management of
suicidality)
XX Orientation
ZZ Client is usually oriented to person, place, and time unless psychosis is present.
XX Memory
ZZ Usually impaired recent and short-term memory
XX Concentration
ZZ Usually significantly impaired
XX Abstraction
ZZ Abstract ability on proverb testing usually intact
ZZ If concrete, assess for other psychotic findings
XX Insight
ZZ May be intact or impaired
XX Judgment
ZZ May be impaired for self-welfare
Diagnostic and Laboratory Findings

XX No lab findings specific to MDD exist
XX Complete blood count (CBC), chemistry profile, thyroid function tests, or B12 and folate
levels to rule out metabolic causes or unidentified conditions; consider referral for
sleep study if snoring, apnea, or suspicion of other sleep disorder
XX Drug toxicity screening, if indicated by history
XX Depression related to a differential diagnosis
ZZ Endocrine disorders
XX Hypothyroidism
XX Diabetes
XX Hyperaldosteronism
XX Cushing’s or Addison’s disease
ZZ Neurological disorders
XX Stroke
XX Epilepsy
XX Dementia
XX Huntington’s disease
XX Sleep apnea
XX Wilson’s disease
XX Neoplasms
XX Head trauma
XX Multiple sclerosis
XX Parkinson’s disease
ZZ Cardiac disorders
XX Myocardial infarction
XX Congestive heart failure
XX Hypertension
ZZ Infectious and inflammatory states
XX Mononucleosis
XX AIDS
XX Pneumonia: viral and bacterial
XX Systemic lupus erythematous
XX Temporal arteritis
XX Tuberculosis
ZZ Nutritional disorders
XX Pernicious anemia
XX Pellagra
ZZ Other disorders
XX Fibromyalgia
XX Chronic fatigue syndrome
XX Bereavement or grief reaction
XX Electrolyte imbalance
XX Uremia and other renal conditions
ZZ Psychiatric disorders
XX Anxiety disorders
XX Eating disorders
XX Bipolar affective disorder
XX Substance dependence–related disorders
ZZ Medications that can cause altered mood states as side effects
XX Steroids
XX Estrogen compounds
XX Antihypertensive agents
XX Anti-Parkinson’s agents
XX Antineoplastic agents
XX Antibacterial and antifungal agents
XX Analgesics
XX Isotretinoin (Accutane)
XX Benzodiazepines
Clinical Management
XX The top goal in the acute phase of MDD is ensuring client safety.
XX A general consideration is to rule out or treat any conditions that may contribute to
depression and cognitive impairment.
XX Assess for the acuity level of client presentation.
ZZ Reasons for brief hospitalization during acute episodes of MDD:
XX Ensure client safety
XX Initiate medication change, when doing so as an outpatient poses undue risk
XX Restabilize on medication
XX Monitor suicidality
XX Ensure client compliance with treatment to reach stabilization.
ZZ Clinical management during nonacute episodes occurs most often in community
settings.
XX Obtain baseline labs as indicated before initiation of treatment.
ZZ Pharmacological management
ZZ Nonpharmacological management (psychotherapy)
Pharmacological Management
XX Inform client that therapeutic effect may take at least 4 to 6 weeks.
XX Once started, continue antidepressants for a minimum of 6 to 12 months.
ZZ If client has more than two prior episodes of MDD, consider continuing
antidepressants indefinitely.
XX Not all symptoms of MDD will respond to pharmacological interventions.

ZZ Identify clear, measurable target symptoms and educate the client about these
symptoms (see Table 9–2).
XX Research has found that the most effective intervention is a combination of medica-
tion and psychotherapy.
XX Antidepressant rebound is common when stopping antidepressants abruptly, particu-
larly when drugs with short half-lives are involved.
XX Antidepressants may induce mania or mixed mania in susceptible persons.
XX All antidepressants have “black box” warnings regarding suicidality for children,
adolescents, and young adults.
XX Classes of antidepressants
ZZ Selective serotonin reuptake inhibitors (SSRIs)
XX Act primarily to increase serotonin levels in central nervous system (CNS)
by inhibiting their presynaptic reuptake
XX See Table 9–3 for examples
ZZ Tricyclic antidepressants (TCAs)
XX Elevate serotonin and norepinephrine levels primarily by inhibiting their
presynaptic reuptake
XX See Table 9–4 for examples.
ZZ Monoamine oxidase inhibitors (MAOIs)
XX Elevate serotonin and norepinephrine levels primarily by inhibiting MAO, the
enzyme that breaks down monoamine neurotransmitters
ZZ Serotonin norepinephrine reuptake inhibitors (SNRIs)
XX Inhibit dual reuptake of norepinephrine and serotonin
XX Action very selective on neurotransmitters
TABLE 9–2.
TARGET SYMPTOMS OF ANTIDEPRESSANT TREATMENT
Depressed mood
Sleep–rest disturbances
Anxiety
Irritability
Impaired concentration
Impaired memory
Appetite disturbance
Agitation
Anhedonia
Impaired energy and motivation
TABLE 9–3.
DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS—SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
DOSAGE
BRAND FORMS DAILY
AGENT NAME DOSAGE SIDE EFFECTS COMMENTS
Citalopram Celexa Tablet Sedation Pregnancy Category C
20–40 mg/day Sexual dysfunction Lactation Category L2
Agitation 2011 warning about
Yawning prolonged QTc interval in
doses above 40 mg (20
GI disturbances mg in older adults) and
Weight gain in those susceptible to
prolonged QTc
Escitalopram Lexapro Tablet Somnolence Pregnancy Category C
10–20 mg/day Headache Lactation Category L2
Sexual dysfunction
GI disturbances
Fluoxetine Prozac Capsule, Insomnia Long half-life
tablet, or liquid Headache Pregnancy Category C
20–80 mg/day GI disturbances Lactation Catagory L2
Sexual dysfunction Discontinuation syndrome
unlikely
Fluvoxamine Luvox Tablet Sedation Doses above 150 mg
100–300 mg/ Sexual dysfunction should generally be given
day b.i.d.
Agitation
Pregnancy Category C
GI disturbances
Lactation Category L2
Paroxetine Paxil Tablet or liquid Headache Pregnancy Category D
CR, 20–60 mg/day GI disturbances Lactation Category L2
Pexeva
Somnolence Discontinuation syndrome
Sexual dysfunction very common
Sertraline Zoloft Tablet Sexual dysfunction Pregnancy Category C
50–200 mg/ GI disturbances Lactation Category L2
day Somnolence
Headache
Serotonin partial agonist reuptake inhibitor (SPARI)
Vilazodone Viibryd Tablet Diarrhea Pregenancy Category C
20–40 mg Nausea Lactation Category:
Dry mouth Unknown, is excreted in
breast milk
(lower risk of sexual
side effects)
XX Elevate serotonin and norepinephrine levels by inhibiting their presynaptic

reuptake
TABLE 9–4.
TRICYCLIC ANTIDEPRESSANTS
BRAND DOSAGE FORMS

AGENT NAME DAILY DOSAGE COMMENTS
Amitriptyline Elavil Tablet or IM Also used for chronic pain (particularly
50–300 mg/day neuropathic), insomnia
Clomipramine Anafranil Capsule Approved for obsessive–compulsive disorder;
100–250 mg/day 250 mg/day maximum because of increased
seizure risk
Desipramine Norpramin Tablet or capsule Also used for attention-deficit hyperactivity
100–300 mg/day disorder (off-label for pediatric clients and for
ADHD)
Doxepin Sinequan Capsule or liquid Also used for insomnia
100–300 mg/day Pregnancy Category C
Lactation Category L5 Avoid
Imipramine Tofranil Tablet, capsule, Also used for enuresis and separation anxiety
or IM Pregnancy Category D
100–300 mg/day Lactation Category L2
Nortriptyline Pamelor Capsule or liquid Also used for enuresis and attention deficit
50–150 mg/day hyperactivity disorder
Pregnancy Category D
Protriptyline Vivactil Tablet Pregnancy Category C
15–60 mg/day Lactation Category: Inadequate data
Trimipramine Surmontil Capsule Pregnancy Category C
100–300 mg/day Lactation Category: Inadequate data
XX Norepinephrine dopamine reuptake inhibitors (NDRIs)

ZZ Inhibit dual reuptake of norepinephrine and dopamine
ZZ Action very selective on neurotransmitters
ZZ Elevate dopamine and norepinephrine levels by inhibiting their
presynaptic reuptake
ZZ See Table 9–6 for examples.
XX Serotonin agonist and reuptake inhibitors (SARIs)

ZZ Dual action
ZZ Agonist of serotonin 5HT-2 receptors
ZZ Action very selective on neurotransmitters
ZZ Elevate serotonin levels by inhibiting serotonin reuptake
TABLE 9–5.
MONOAMINE OXIDASE INHIBITORS
DOSAGE FORMS
BRAND
DRUG NAME DAILY DOSAGE COMMENTS
Isocarboxazid Marplan Tablet Also used for panic disorder, phobic
20–60 mg/day disorders, selective mutism
Caution: High-tyramine diet;
Phenelzine Nardil Tablet
sympathomimetic agents
45–90 mg/day
Divided dosing: b.i.d. and q.i.d.
Tranylcypromine Parnate Tablet All Pregnancy Category C
30–60 mg/day Lactation Category: Inadequate
Information
Selegiline EMSAM Transdermal patch No dietary restrictions with 6 mg
6–12 mg dosage; may need higher dose to see
antidepressant effect
Lactation Catagory L4 Avoid
TABLE 9–6.
TYRAMINE-FREE DIETARY CONSIDERATIONS
CATEGORY OF FOOD SPECIFIC FOODS TO AVOID

Cheeses Aged cheeses, such as blue, brie, Camembert, and Roquefort
Meat Smoked, aged, and cured meats such as sausages, pastrami, and
salami
Fish Smoked, aged, and cured fish such as pickled herring and salted
fish
Beverages Any aged and fermented beverages such as red wine, aged liquors,
whiskey (gin and vodka permissible), beer (bottled and pasteurized
permissible)
Other Bean curd (tofu), soy products, sauerkraut, miso, yeast extract,
MSG, ripe bananas, avocado
ZZ See Table 9–6 for examples.
XX The various antidepressants differ markedly in characteristics such as

ZZ Cost
ZZ Side-effect profile
ZZ Safety in overdose
ZZ Safety in clients with other disorders
ZZ Drug–drug interactions
ZZ Cytochrome P450 liver effects
XX To achieve best control of symptoms, match client’s symptom profile

to the pharmacodynamic and pharmacokinetic properties of specific
antidepressant agents.
SSRIs
XX First-line treatment for first episode of major depression with mild to moderate
symptoms
XX Serious side effects are rare
XX Much safer in overdose than TCAs
XX Also effective for panic disorder, obsessive–compulsive disorder, bulimia, general-
ized anxiety disorder, social phobia, posttraumatic stress disorder, and premenstrual
dysphoric disorder
TCAs
XX Considered second-line drugs for treating MDD (see Table 9–4).
XX Affect many neurotransmitters, leading to more side effects and possibly poor
adherence.
ZZ Anticholinergic: Dry mouth, blurred vision, constipation, memory problems
(from muscarinic receptor blockade)
ZZ Antiadrenergic: Orthostatic hypotension (from alpha 1 receptor blockade)
ZZ Antihistaminergic: Sedation and weight gain (from histamine receptor blockade)
ZZ Electrocardiogram (EKG) changes and cardiac dysrhythmias possible; avoid in
clients known to have susceptibility (personal or family history). Monitor EKG
before treatment and annually in older adults.
ZZ Unsafe in many co-occurring disorders (such as cardiac disease)
ZZ Known to induce hypomania in susceptible clients
XX Well-identified serum blood levels guide dosing (particularly nortriptyline) and predict
toxicity.
XX Inexpensive and available in generic forms.
XX Anticholinergic properties may be highly problematic but may also be useful in those
who have significant bowel irritability.
XX Avoid abrupt withdrawal because of significant discontinuation syndrome.
XX Avoid prescribing to people who are at high risk for suicide; lethal dose is 1,000 mg
or more (a week’s supply of an average dose).Combination of TCAs with MAOIs
can cause lethal serotonin syndrome, hypertensive crisis, or both; adhere to 2-week
washout period (5 weeks for fluoxetine) before switching between the two classes
of medications.
XX Use caution if the person is taking both a TCA and an SSRI, because the SSRI can
elevate TCA concentrations because of pharmacodynamic or pharmacokinetic inter-
actions. Monitor TCA levels.
MAOIs
XX Not first or second-line agents for MDD because of dangerous food and drug interac-
tions (see Tables 9–5 and 9–6).
ZZ Hypertensive crisis occurs when MAOIs are taken in conjunction with foods
containing tyramine, a dietary precursor to norepinephrine.
ZZ When MAO is inhibited, tyramine exerts a strong vasopressor effect, stimulating
the release of catecholamines, epinephrine, and norepinephrine, which can
increase blood pressure and heart rate.
ZZ Hypertensive crisis is life-threatening and cannot be reversed unless more MAO
is produced by the body.
XX Hypertensive crisis and death also can occur when MAOIs are taken in
conjunction with certain medications:
ZZ Meperidine
ZZ Decongestants
ZZ TCAs
ZZ Atypical antipsychotics
ZZ St. John’s wort
ZZ L -tryptophan
ZZ Stimulants and other sympathomimetics
ZZ Asthma medications
XX Symptoms of hypertensive crisis:

ZZ Sudden, explosive-like headache, usually in occipital region
ZZ Elevated blood pressure
ZZ Facial flushing
ZZ Palpitations
ZZ Pupillary dilation
ZZ Diaphoresis
ZZ Fever
XX Treatment of hypertensive crisis:
ZZ Discontinue the MAOI.
ZZ Give phentolamine (binds with norepinephrine receptor sites, blocks
norepinephrine).
ZZ Stabilize fever.
ZZ Reevaluate the person’s diet and adherence, and reiterate medication
guidelines as necessary.
ZZ People on MAOIs must follow a tyramine-free diet and must avoid many
medications, including most over-the-counter cold and allergy preparations.
ZZ Combining an MAOI with a serotonergic agent is contraindicated, because this
may cause serotonin syndrome.
XX Symptoms of serotonin syndrome
ZZ Agitation, restlessness
ZZ Rapid heart rate and elevation in blood pressure
ZZ Headache
ZZ Sweating, shivering, and goose bumps
ZZ Myoclonic jerking and loss of coordination
ZZ Confusion, fever, seizures, unconsciousness
XX Treatment of serotonin syndrome includes discontinuing the offending

agents and supportive treatment of symptoms. Mild symptoms such
as restlessness may respond to removal of the offending agent, close
monitoring, and judicious use of a benzodiazepine. More severe symptoms
constitute a medical emergency necessitating hospitalization and treatment
such as cyproheptadine, anticonvulsants, and autonomic support.
XX Can be fatal in overdose.
XX Side-effect profile and stringent dietary restrictions often lead to poor client
adherence.
XX Clients who are on MAOIs must be taught to recognized the signs and symptoms
of hypertensive crisis and serotonin syndrome and understand that they must seek
immediate medical attention should they suspect either one of occurring.
XX Clinically significant side effects of MAOIs include
ZZ Insomnia
ZZ Hypertensive crisis
ZZ Weight gain
ZZ Anticholinergic side effects
ZZ Lightheadedness and dizziness
ZZ Sexual dysfunction
XX MAOIs are unsafe in many co-occurring disorders.
Other Antidepressants
XX Other antidepressants used in the treatment of MDD may be classified as SNRIs,
NDRIs, and SARIs. See Table 9–7 and Table 9–8.
XX Psychotic features can be present with MDD and Bipolar I Disorder.
ZZ Routinely assess for the presence of psychotic symptoms during periods of
symptom exacerbation
ZZ Features are usually mood-congruent.
ZZ Can be managed with short-term use of antipsychotic medications (see
Chapter 11)
XX Comorbidities are common and include various medical conditions (as noted
earlier in the chapter) as well as psychiatric comorbidities such as panic disorder,
obsessive–compulsive disorder, and substance abuse or dependence.
XX Altered appetite and sleep–rest patterns predispose clients with MDD to decreased
overall health status.
XX Increased mortality exists in people with MDD.
TABLE 9–7.
SNRIS
DRUG BRAND DOSAGE FORMS

(CLASS) NAME DAILY DOSAGE SIDE EFFECTS COMMENTS
Venlafaxine Effexor, Capsule (XR), or Diaphoresis Can raise BP
(SNRI) Effexor tablet Headache QD for XR capsules
XR 75–375 mg/day Dizziness b.i.d.–t.i.d. dosing for
XR 75–225 mg/d GI disturbances tablets
Full SNRI effect at doses
at or above 150 mg
Safer in overdose than
TCAs
Has significant
discontinuation syndrome
if stopped abruptly
Duloxetine Cymbalta Capsule Dizziness Once-daily dosing
(SNRI) 30–120 mg Headache Can elevate BP
GI disturbances Can elevate liver function
tests
Has significant
discontinuation syndrome
if stopped abruptly
Vortioxetine Brintellix Tablet (5, 10, Nausea Pregnancy Category C
(5HT-3 and 5HT7 20mg) Diarrhea Lactation Category:
antagonist, 20 mg q.d. Dizziness Inadequate Information
5HT 1A agonist)
Levomilnacipran Fetzima Tablet Nausea and vomiting Pregnancy Category C
(SNRI) (20,40,80,120mg) Constipation Lactation Category:
40-120 mg q.d. Sweating Inadequate Information
Palpitations
Urinary hesitancy
Hypertension
Hypotension
Decreased appetite
Nonpharmacological Management
XX Electroconvulsive therapy (ECT)
ZZ Grand mal seizure induced in anesthetized person
ZZ Usual course is 6 to 12 treatments
ZZ Mechanism of action:
XX Neurotransmitter theory: Increases dopamine, serotonin, and
norepinephrine
TABLE 9–8.
OTHER ANTIDEPRESSANT AGENTS
DRUG BRAND DOSAGE FORMS

(CLASS) NAME DAILY DOSAGE SIDE EFFECTS COMMENTS
Bupropion Wellbutrin Tablet Headache Contraindicated if client
(NDRI) 150–450 mg/day Nervousness has seizures, eating
disorder
Tremors
SR offers b.i.d. dosing; XL
Tachycardia offers once-daily dosing
Insomnia Can increase energy level
Decreased Also used for attention-
appetite deficit hyperactivity
disorder and smoking
cessation
Bupropion Wellbutrin SR Sustained release Caution with caffeine
SR/XL 150–400 mg/day and in people with panic
disorder
Extended release
150–450 mg/day
Mirtazapine Remeron Tablet Sedation Inverse relationship
(alpha2/5HT2 15–45 mg/day Weight gain between dosage and
antagonist) sedation
Increased
cholesterol Pregnancy Category C
Nefazodone Serzone Tablet Headache Must monitor LFTs
(SARI) 300–600 mg/day Drowsiness Can cause liver failure
GI disturbances Safer in overdose than
TCAs
q.h.s. or b.i.d. dosing
Potent P450 3A4 inhibitor
Pregnancy Cateogory C
Avoid
Trazodone Desyrel Tablet Sedation Safer in overdose than
(SARI) 200–600 mg/day Nausea TCAs
Headache Priapism possible
Hypotension Not well tolerated at
antidepressant dosage
because of sedation
Most commonly used
as hypnotic at 50–200
mg/h.s.
May prolong QTc interval
Pregnancy Category B
XX Neuroendocrine theory: Releases hormones such as prolactin,

thyroid-stimulating hormone, pituitary hormones, endorphins, and
adrenocorticotropic hormone
XX Anticonvulsant theory: Exerts an anticonvulsant effect, which then produces
an antidepressant effect
ZZ Situations in which ECT is used:
XX Client preference
XX Need for rapid response because of severity of illness
XX MDD with psychotic features
XX Risk of other treatment outweighs risk of ECT
XX Treatment resistance
ZZ Possible contraindications:
XX Cardiac disease
XX Compromised pulmonary status
XX History of brain injury or brain tumor
XX Anesthesia medical complications
ZZ Adverse effects:
XX Possible cardiovascular effects
XX Systemic effects (e.g., headaches, muscle aches, drowsiness)
XX Cognitive effects (e.g., memory disturbance and confusion)
XX Transcranial magnetic stimulation (TMS)
ZZ Option for clients who have not had adequate response to medications and
psychotherapy (treatment-resistant depression)
ZZ Involves placement of small wire coil on scalp to conduct electrical current,
creating a magnetic field through the tissues of the head
ZZ Performed in office setting, without anesthesia
ZZ Sessions typically last 40 minutes and typical course is 5 sessions per week for
6 weeks.
ZZ Side effects are minimal but may include headache, scalp discomfort, tingling
or twitches to facial muscles, lightheadedness, and hearing discomfort from
procedure noise.
ZZ Seizures, although rare, have been reported.
XX Vagal nerve stimulation (VNS)
ZZ Option for clients who have not had adequate response to medications and
psychotherapy (treatment-resistant depression)
ZZ Pacemaker-like device implanted in left side of chest to stimulate left branch of
nerve; transcutaneous devices being tested
ZZ Generally done as outpatient procedure, but anesthesia is required
ZZ Side effects generally occur as the pulse generator stimulates the vagal nerve
and include voice changes, hoarseness, cough, throat or neck pain, chest
spasms, dyspnea on exertion, tingling of skin, dysphagia
ZZ Intended for use along with traditional treatments
XX Phototherapy
ZZ 2,500 to 10,000 lux light for 30 minutes up to 2 hours, 1 to 2 times daily
(Sadock, Sadock, & Ruiz, 2015)
XX Individual therapy (See Chapter 8. Nonpharmacological Treatment)
ZZ Psychodynamic psychotherapy
ZZ Cognitive behavioral therapy (CBT)
XX Modify perceptions
XX Decrease negativity
XX Increase sense of internal control
XX Enhance coping skills
XX Modify environmental factors contributing to illness
ZZ Brief therapy (solution-focused therapy)
XX Focus on precipitant stressor
XX Cope with immediate impact of MDD on personal life
XX Modify contributory environmental factors
ZZ Group therapy
XX Improve decision-making
XX Improve socialization skills
XX Improve assessment of individual strengths
XX Gain new coping skills
ZZ Family therapy
XX Enhance family coping
XX Improve knowledge base
XX Plan for relapse
XX Gain insight into effects of MDD on family unit
XX Undertake psychoeducation for family members about the illness state of
MDD
Clinical Management of Suicidality

XX Pay significant attention to positive assessments for suicidality.
XX Always assume client is serious when he or she vocalizes suicidal thoughts.
XX Identify current stressors that may be contributing to crisis.
XX Generally do not manage in community setting during acute suicidal ideation periods
unless client is able to make “no harm” agreement.
XX Consider hospitalization.
XX Consider mobilizing available social resources.
ZZ Risk factors for suicide:
XX Ages 45 or older if male
XX Ages 55 or older if female
XX Divorced, single, or separated
XX White
XX Living alone
XX Psychiatric disorder
XX Physical illness
XX Substance abuse
XX Previous suicide attempt
XX Family history of suicide
XX Recent loss
XX Male gender
Life Span Considerations: Children

XX Core symptoms of MDD are the same for children. However, some symptoms are
more pronounced in children.
ZZ Irritability
ZZ Somatic complaints
ZZ Social withdrawal
XX Some core symptoms are less common in children before onset of puberty:
ZZ Psychosis
ZZ Motor retardation
ZZ Hypersomnia
ZZ Increased appetite
XX MDD often has a strong separation anxiety component in children.
XX Children usually do not respond well to tricyclics; however, they do respond well to
SSRIs.
XX All antidepressants indicated for children, adolescents, and young adults carry a
black box warning about an increase in suicidal thoughts; monitor closely for suicidal
thoughts, behavior, agitation, and aggression in children taking antidepressants.
Life Span Considerations: Older Adults

XX Persons with MDD admitted to a long-term-care facility have significantly shorter life
spans than control population.
XX 65% are more likely to die within the first year in a long-term-care facility.
XX Cognition and memory symptoms of MDD in the older adult population often are
confused with dementia-related symptoms (pseudodementia).
ZZ Clients with dementia usually have a premorbid history of slowly declining
cognition.
ZZ In MDD, cognitive changes have a relatively acute onset and are significant
when compared to premorbid functioning.
XX It is important to complete a functional assessment for older adults.
ZZ Determines the degree to which the person’s abilities and performance match
the demands of his or her life
ZZ Determines the impact of illness on overall functioning
ZZ Skill deficit: Inability to perform a functional skill despite the physical ability, as in
dementia
ZZ Performance deficit: Ability to perform a functional skill but lacks the motivation
to do so, as in depression
XX Reasons for performing functional assessment:
ZZ To correctly diagnose (for example, to differentiate depression from dementia)
ZZ To track client improvement or decompensation
ZZ To help families set realistic expectations
XX Components of functional assessment:
ZZ Activities of daily living (ADLs): Basic self-care skills, such as bathing, dressing,
eating, and toileting
ZZ Instrumental activities of daily living (IADLs): Complex activities needed for
independent functioning, such as shopping, cooking, driving, and housekeeping
ZZ Executive functioning: Judgment and planning; ability to maintain calendar,
manage money and appointments, and prioritize activities
XX The degree of change over time and the speed of change are better observed with
objective recording and when the assessment is measured at intervals such as every
6 months.
Follow-up
XX Follow-up care practices for the PMHNP to consider
ZZ Include teaching client the goals, risks, benefits, and potential side effects of
medication treatment
ZZ Continuously monitor client’s response to medication; the treatment goal is
complete remission of symptoms.
ZZ Utilize screening tool such as PHQ-9 in follow-up appointments.
ZZ Teach clients the symptoms of depression and that it is a chronic illness; establish
a relapse plan for all clients.
ZZ Assess for suicidality during every client contact.
ZZ Assess for the presence of psychotic symptoms during every client contact.
ZZ Assess and manage client for side effects of treatment, including sexual side
effects, in an attempt to increase medication compliance.
ZZ Observe all clients treated with antidepressants for development of serotonin
syndrome (overstimulation of serotonin receptors usually caused by drug–drug
interactions).
XX Drug combinations that can cause serotonin syndrome:
ZZ SSRIs and MAOIs
ZZ Drug and herbal interactions
ZZ SSRIs and St. John’s wort
XX Symptoms of serotonin syndrome:

ZZ Autonomic instability
ZZ Altered sensorium
ZZ Restlessness
ZZ Agitation
ZZ Myoclonus
ZZ Hyperreflexia
ZZ Hyperthermia
ZZ Diaphoresis
ZZ Tremor
ZZ Chills
ZZ Diarrhea and cramps
ZZ Ataxia
ZZ Headache
ZZ Insomnia
ZZ Monitor for adverse effects over time.
ZZ Some SSRIs are known to increase blood glucose and contribute to
hyperlipidemia, and others may elevate liver function tests.
ZZ Discontinue SSRIs slowly to prevent discontinuation syndrome.
XX Symptoms of discontinuation syndrome:
ZZ Flu-like symptoms (due to cholinergic rebound; particularly problematic
with TCAs)
ZZ Fatigue and lethargy
ZZ Myalgia
ZZ Decreased concentration
ZZ Nausea and vomiting
ZZ Impaired memory
ZZ Paresthesias, including “shock-like” sensations

ZZ Irritability
ZZ Anxiety
ZZ Insomnia
ZZ Crying without provocation
ZZ Dizziness and vertigo
XX Risk factors for discontinuation syndrome:

ZZ Medications with short half-life
ZZ Abrupt discontinuation
ZZ Noncompliant, irregular use pattern
ZZ High dose range
ZZ Long-term treatment
ZZ Prior history of discontinuation syndrome
XX Expected course of MDD

ZZ Evidence indicates the best treatment outcomes if medications are used in
conjunction with appropriate therapy.
ZZ Evidence indicates that clients should take an antidepressant agent for at least
12 months after remission of symptoms.
ZZ Clients who have had 3 or more episodes of MDD usually require lifelong
medication.
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)

Description
XX A disorder similar to MDD but with less acute symptoms; with a more protracted,
chronic disease course; and without any manifestations of psychotic symptoms
XX Less discrete episodes of illness than MDD
XX Symptoms often go undetected and therefore untreated for years
XX Vegetative symptoms (e.g., sleep, appetite, weight changes) much less common in
dysthymic disorder than in MDD
Etiology
XX Similar to MDD

XX Affects 5.4% of the U.S. population ages 18 or older, or 10.9 million Americans.
XX People with dysthymia have an increased risk for developing MDD; 15% to 25% of
people diagnosed with dysthymic disorder will have a lifetime episode of MDD.
XX People with onset of symptoms before age 21 have a 75% likelihood of a lifetime
episode of MDD.
XX Women are 2 to 3 times more likely to develop dysthymic disorder than men.
Risk Factors
XX Genetic predisposition
XX A first-degree relative with MDD
XX A first-degree relative with dysthymic disorder
XX Female gender

XX At-risk family education
XX Community education
XX Stigma reduction
XX Signs and symptoms of illness
XX Treatment potential for control of symptoms
XX Early recognition, intervention, and initiation of treatment
XX Because of chronic nature of disorder, symptoms become a part of clients’ day-to-
day existence and often go unreported unless solicited by direct questioning
XX Aggressive screening procedure required
Assessment
History
XX Assess for the following:
ZZ Chronically depressed mood that occurs for most of the day, more days than
not, for at least 2 years
ZZ Prominent presence of low self-esteem, self-criticism, and a perception of
general incompetence compared to others
ZZ Other common symptoms:
XX Low energy and fatigue
XX Poor concentration
XX Difficulty with decision-making
XX Feelings of hopelessness
XX Feelings of inadequacy
XX Mild anhedonia
XX Social withdrawal
XX Brooding about past issues

XX Subjective irritability or anger
XX Decreased productivity and activity
ZZ Less common symptoms:
XX Alteration in appetite
XX Alteration in sleep–rest patterns

XX Similar to MDD

XX Similar to MDD
XX Usually no vegetative findings
XX Mood described as sad, “down for all of my life”

XX Nonspecific
Polysomnographic Findings
XX Similar to those found in MDD
Differential Diagnosis
XX Similar to MDD
Clinical Management
XX Because of increased risk for development of MDD, dysthymia is often treated with
antidepressant medications in a manner similar to MDD.
XX Similar to MDD
XX Often good clinical outcomes with nonpharmacological management if client is
willing
Common comorbidities
XX MDD is often superimposed on dysthymia (“double depression”)
XX The subjective worsening of symptoms or onset of new symptoms such as vegeta-
tive ones often brings the person into treatment.
XX When dysthymia precedes MDD, clinical management is more complex and out-
comes can be less positive.
XX Dysthymic disorder is associated with personality disorders.

ZZ Borderline
ZZ Histrionic
ZZ Narcissistic
ZZ Avoidant
ZZ Dependent
Life Span Considerations

XX Similar to MDD
XX In children, prevalence rates of dysthymia are equal for boys and girls.
XX Associated with several childhood disorders:
ZZ Attention-deficit hyperactivity disorder
ZZ Conduct disorder
ZZ Anxiety disorders
ZZ Learning disorders
XX Period of symptoms required for diagnosis is only 1 year, compared with 2 years for
adults.
XX In children, the mood usually described as irritable rather than sad but may report
both irritability and sadness
XX Low self-esteem, poor social skills, and pessimism
Follow-up
XX Similar to MDD
GRIEF AND BEREAVEMENT

Description
XX Involve a wide range of normal responses that can become abnormal and excessive
XX Involve normative emotional, cognitive, and behavioral reactions to death or loss of a
significant person or object
XX Unlike in major depression, self-esteem is usually preserved in the grieving person
XX Involve nonnormative psychological responses to an identifiable stressor that can
result in the development of clinically significant emotional or behavioral symptoms
ZZ Stressor encompassing elements of perceived loss
ZZ Develops within 3 months of stressor
XX Single event
ZZ End of relationship
ZZ Death of relative or partner
XX Recurring event
ZZ Living with person with terminal illness
XX Developmental event
ZZ Leaving home to go away to school
ZZ Getting married
ZZ Becoming a parent
ZZ Retiring from work
XX PMHNP assessment is needed to separate normal, healthy grieving from pathologi-

cal grieving, which may represent an adjustment disorder or major depression. The
PMHNP must consider:
ZZ Severity of response
ZZ Duration of response
ZZ Effects of response on normal daily functioning
ZZ Person’s perception of impact of stressor
XX When severity or duration is excessive, the grieving may be abnormal.
XX In the absence of other significant clinical symptoms, grief usually is classified as
adjustment disorder:
ZZ Adjustment disorder with depressed mood
ZZ Adjustment disorder with anxiety
ZZ Adjustment disorder with mixed anxiety and depression
ZZ Adjustment disorder with disturbed conduct
Etiology
XX Significant loss
XX Limited coping skills
XX Limited social supports

XX Normal grief is universally experienced.
XX Grief is common in older adults as their social sphere begins to decrease.
XX 20% of older adults who lose a spouse experience depression within the first year
of that loss.
XX Lifetime prevalence for adjustment disorder is 2% to 8% in the U.S. population.
XX Grief occurs in 12% of general hospital clients.
XX Grief occurs in 50% of clients after cardiac surgery.
Risk Factors
XX Limited social network
XX Poor physical health
XX Limited coping skills

XX Ask about losses.
XX Identify at-risk persons.
XX Do preventative counseling.
XX Begin early recognition, intervention, and initiation of treatment.
ZZ Routine screening at all healthcare settings.
Assessment
XX Often clients will not disclose grieving or bereavement issues unless directly asked.
History
ZZ Recent losses
ZZ Anniversary dates of past losses
ZZ Reaction to loss
ZZ Functional impairment
ZZ Social and family support systems
ZZ Insomnia
ZZ Anorexia
ZZ Presence of dysfunctional coping
XX Suicidal thoughts
XX Substance abuse
XX Denial

XX Nonspecific

XX Depressed mood
XX Anxious affect
XX Crying uncontrollably

XX CBC, chemistry profile, thyroid function tests, and B12 level to rule out metabolic
causes or unidentified conditions
XX Normal grieving
XX Major depressive disorder (MDD)
XX Anxiety disorders (see Chapter 10)
XX Substance-related disorders (see Chapter 13)
Clinical Management
XX If needed
ZZ Short-term use of anti-anxiety agents
XX BNZs
ZZ Short-term use of sleep-induction agents
XX BNZs
XX Nonbenzodiazepine hypnotic such as zolpidem
XX Tricyclic or other sedating antidepressants
XX Antihistamines
XX Encourage expression of grief and loss.
XX Use support groups.
XX Offer community resources.
XX Offer psychoeducation on grief reactions and responses.
XX With significant functional impairment, consider psychotherapy (e.g., crisis therapy,
brief solution-focused therapy, CBT).

XX Can occur at any age
XX Older adults are at greater risk because of higher numbers of losses that may be-
come cumulative in their impact.
Follow-up
XX Follow up weekly during acute period.
XX Monitor for development of MDD.
XX Monitor for impact on general health state.
XX Maintain supportive follow-up over time.
XX Be sensitive to nontraditional losses that may be significant to the person:
ZZ Loss of a pet
ZZ Loss of status in work or school setting
PREMENSTRUAL DYSPHORIC DISORDER

Description
XX Dysphoric symptoms that occur in response to changing sex steroid hormones
which occur during the ovulatory menstrual cycle.
XX Symptoms generally begin during the luteal phase, approximately 1 week before
onset of menses, and generally lift within a day or two after menses has begun.
XX Common symptoms include:
ZZ Marked lability
ZZ Irritability
ZZ Depressed mood
ZZ Anxiety
ZZ Low energy
ZZ Sleep disturbances
XX Symptoms occur repeatedly during each menstrual cycle and there must be a
symptom-free period in the follicular phase, after menses has occurred.
XX Symptoms may worsen as the woman becomes perimenopausal.
XX Symptoms cause marked impairment in functioning and sense of well-being.
XX A careful evaluation must be completed to rule out other mood disorder.
XX Treatment may consist of hormonal contraceptives, SSRI antidepressants, or both.
BIPOLAR (BP) DISORDER

Description
XX Complex brain-based illness with a primary characteristic of disturbance in mood
XX Mood disturbance often of both polarities:
ZZ Depressive
ZZ Expansive or manic
XX Several patterns:
ZZ Single-polarity symptoms only (mania)
ZZ Distinct symptom patterns of alternating polarity—manic symptoms alternating
with depressive symptoms
ZZ Mixed, co-occurring symptoms
XX Presents with excessive or distorted degree of sadness or elation, or both
XX Manifests with behavioral, affective, cognitive, and somatic symptoms
XX May have precipitating event, situation, or concern but often occurs without any
precipitating stressor identified
XX Has complex genetic, biochemical, and environmental etiological factors
Etiology
XX Multiple theories ranging from psychological to neurobiological
XX Probable multifactorial etiological profile
ZZ Biological theories
XX GABA deregulation
XX Increased noradrenergic activity
XX Voltage-gated ion channel abnormalities
XX Abnormalities lead to abnormal balances of intracellular and extracellular
levels of neurotransmitters, which then cause subsequent disruption of
electric signal transmission in brain regions.
XX Kindling: Process of neuronal membrane threshold sensitivity dysfunction
ZZ Long-lasting, epileptogenic changes induced by daily subthreshold
brain stimulation
ZZ Brain becomes overly sensitive to electrical stimuli
ZZ Neuronal misfiring occurs
ZZ Process becomes automatic; neuronal firing occurs even without
stimuli.

XX Less common than MDD
XX 0.7% of general population at risk
XX Affects 2.3 million American adults; 1.2% of the U.S. adult population older than age
18
XX Mean age of onset is early 20s
XX May present in childhood (rare) or adolescent years
XX Prevalence for males and females is the same.
Risk Factors
XX Genetic loading
XX Family history of first-order relative having MDD or BP disorder
XX 24% increased risk if relative has BP disorder Type I (see below)
XX 5% increased risk if relative has BP disorder Type II (see below)
XX 25% increased risk if relative has MDD
XX For BP disorder Type II, similar to MDD

ZZ Stigma reduction
ZZ Signs and symptoms of illness
ZZ Treatment potential for control of symptoms
ZZ Significant and protracted prodromal symptom period usually noted before full
onset of illness
ZZ Usually mild manifestations of criteria symptoms before full clinical syndrome is
apparent
ZZ The longer time between onset of symptoms and diagnosis, the more difficult
to interrupt cyclicity of illness.
ZZ Depressive episodes predominate, making misdiagnosis common.
Assessment
History
ZZ Detailed history of present illness, including time frame, progression, and any
associated symptoms
ZZ Social history, including present living situation; marital status; occupation;
education; and alcohol, tobacco, and illicit drug use
ZZ Medication use, including prescription, over-the-counter, alternative,
supplements, and home remedies
ZZ Initial and periodic functional history and assessment
ZZ Corroborative information from family member when possible
XX Diagnostic criteria
ZZ Period of abnormally or persistently elevated, expansive, or irritable mood,
lasting for at least 1 week
ZZ Mood episode has rapid development and escalation of symptoms over a few
days
ZZ Often precipitated by significant environmental stressor
ZZ Mood disturbance may result in brief psychotic symptoms
ZZ Manic episodes last days to several months
ZZ Briefer duration and ending more abruptly than major depressive episodes
ZZ In 60% of people, a major depressive episode immediately precedes or follows
the manic episode
ZZ Persistence of other suggestive symptoms:
XX Decreased need for sleep
XX Feels rested after 3 hours sleep on average
XX Usually a marked difference from normal baseline sleep pattern
XX Inflated self-esteem
XX Grandiosity
XX Increased goal-directed activities
XX Excessive involvement in pleasurable activities with a high potential for
painful consequences
XX Unrestrained buying sprees
XX Sexual indiscretions
XX Unsound business ventures
XX Excessive substance use or abuse
XX Highly recurrent depressive episodes
ZZ Recurrent shifts in polarity
XX Major depressive episode shifting to a manic episode
XX Manic episode shifting to a major depressive episode
XX Major depressive episode shifting to a mixed episode.
ZZ Expansive or elated mood symptoms
XX Manic
ZZ Symptoms as described above
XX Hypomanic
ZZ Similar to mania
ZZ More brief in duration
ZZ Episode not as severe as mania
ZZ Does not require hospitalization
ZZ Does not cause significant functional impairment
XX Two common types

ZZ Type I
XX Clinical history characterized by occurrence of one or more manic or mixed
episodes
ZZ Type II
XX Clinical history characterized by occurrence of one or more major
depressive episodes accompanied by at least one manic or hypomanic
episode
XX In a small subset of people with BP disorder, the recurrent shifts in polarity
can occur more frequently—rapid cycling.
ZZ Occurrence of 4 or more mood episodes during the previous 12
months
ZZ Mood episodes are either major depressive or manic
ZZ Other than occurring more frequently, mood episodes are same as
nonrapid-cycling episodes
ZZ 20% of people with BP disorder have rapid cycling
ZZ Most rapid cyclers are women (90%).
XX Identifying rapid cycling is important.

XX Antidepressants may accelerate the cycling.
XX Persons with rapid cycling have a poorer prognosis.

XX Nonspecific
XX Clinical findings consistent with thyroid dysfunction
Mental Status Exam Findings in Mania or Hypomania

XX Appearance
ZZ Psychomotor restlessness or agitation
ZZ Frequent change of dress
ZZ Prone to bright-colored, often sexualized dress
ZZ Dramatic or flamboyant dress usually out of character for person when
compared to nonsymptomatic periods
XX Speech
ZZ Rapid
ZZ Loud
ZZ Pressured
ZZ Difficult to interrupt
ZZ Joking, irrelevant, amusing
ZZ Word clanging in severely ill clients
XX Affect
ZZ Labile
ZZ Irritable
ZZ Overly theatrical and dramatic
XX Mood
ZZ Euphoric
ZZ Cheerful
ZZ High
ZZ Expansive
ZZ Irritable
XX Thought process
ZZ Thoughts racing
ZZ Flight of ideas
ZZ Thoughts disorganized and incoherent in severely ill clients
XX Thought content
ZZ Inflated self-esteem
ZZ Indiscriminate enthusiasm
ZZ Inflated sense of abilities bordering on delusional
ZZ Increased sexual content
XX Orientation
ZZ Fully oriented
XX Memory
ZZ Impaired short-term
ZZ Impaired recall
XX Concentration
ZZ Highly distractible
XX Abstraction
ZZ Generally abstractive
ZZ Can be concrete on proverb testing during psychotic episodes
XX Judgment
ZZ Poor
ZZ Prone to imprudent behavioral choices with potential for negative consequences
XX Insight
ZZ The person usually does not recognize that he or she is ill
ZZ Resists treatment options

XX Drug toxicity screening if indicated by history
XX If first onset of manic symptoms occurs after age 40, most likely symptoms are
caused by another medical condition.
XX Many medical conditions mimic manic symptoms:
ZZ Endocrine disorders
ZZ Hyperthyroidism
ZZ Intoxication or withdrawal from illicit drug use:
XX Amphetamines
XX Cocaine
XX Hallucinogens
XX Opiates
XX Medications:
ZZ Captopril
ZZ Cimetidine
ZZ Corticosteroids
ZZ Cyclosporine
ZZ Disulfiram
ZZ Hydralazine
ZZ Isoniazid
XX Mania can be precipitated by treatment of MDD or other unipolar mood disorders in
susceptible persons.
ZZ Antidepressants
ZZ ECT
ZZ Light therapy
Clinical Management
XX Rule out or treat any conditions that may contribute to current symptom
manifestation.
XX Assess and identify client’s level of acuity.
XX Determine severity of illness.
XX Determine duration of illness.
XX Ascertain history of response to treatment.
XX During acute manic episodes or significant depressive episodes, client may require
brief hospitalization
ZZ To ensure client safety,
ZZ To ensure client adherence with treatment to reach stabilization, or
ZZ To rapidly stabilize on medication.
XX Clinical management during nonacute episodes occurs most often in community
settings.
Pharmacological Treatment
XX Pharmacological management should generally not entail the use of an antidepres-
sant agent if a mood-stabilizing agent is not in place.
ZZ Especially important in clients who are rapid-cycling
ZZ May precipitate shift from depression to hypomania, mania, or dysphoric
hypomania (mixed state)
XX Mood-stabilizing agents
ZZ Commonly used pharmacological agents
XX Lithium
ZZ Gold standard for treating manic episodes
ZZ Evidence of antisuicidal effects
ZZ Action largely unknown
ZZ Long history of use; drug profile well established
ZZ Evidence exists showing some effectiveness on depressive symptoms
as well as on manic symptoms
ZZ Has many clinically significant side effects; clients on this drug require
careful monitoring (see Table 9–10)
ZZ Narrow therapeutic window
ZZ Therapeutic effect and potential for adverse side effects monitored by
use of serum lithium level
XX Drawn at trough level
XX 12 hours post-dose
XX Therapeutic serum range 0.5 to 1.2 mEq/l
XX Level greater than 1.2 mEq/l increases risk for toxic side effects.
ZZ Baseline labs before initiation of lithium to ensure safety and efficacy:
XX Thyroid panel
XX Serum creatinine
XX Blood urea nitrogen (BUN)
XX Pregnancy test
XX ECG for clients older than age 50
TABLE 9–9.
CLINICALLY SIGNIFICANT SIDE EFFECTS OF LITHIUM
ORGAN SYSTEM AFFECTED CLINICAL FINDING

Endocrine Weight gain
Impaired thyroid functioning
Central nervous system Fine hand tremors
Fatigue
Mental cloudiness
Headaches
Coarse hand tremors with toxicity
Nystagmus
Dermatological Maculopapular rash
Pruritus
Acne
Gastrointestinal GI upset
Diarrhea
Vomiting
Cramps
Anorexia
Renal Polyuria with related polydipsia
Diabetes insipidus
Edema
Microscopic tubular changes
Cardiac T-wave inversions
Dysrhythmias
Hematological Leukocytosis
ZZ Rapid-cycling clients seldom respond to lithium monotherapy

ZZ Must educate client (and significant others) about side effects and
signs and symptoms of lithium toxicity
XX Anticonvulsant medication
ZZ Carbamazepine
XX Black box warning for carbamazepine: agranulocytosis and aplastic
anemia
XX Valproic acid/divalproex sodium
XX Black box warning for valproic acid/divalproex sodium:
hepatotoxicity and pancreatitis
ZZ Lamotrigine
XX Black box warning for lamotrigine: serious rash
ZZ Baseline labs before carbamazepine or valproic acid/divalproex sodium
XX CBC
XX Liver function tests (LFTs)
182
TABLE 9–10.
DRUGS FOR MOOD DISORDERS: ANTICONVULSANTS
THERAPEUTIC
BRAND DAILY PLASMA
AGENT NAME DOSSAGE LEVEL SIDE EFFECTS COMMENTS
Lithium Eskalith 1,200–2,400 0.8–1.2 mEq/l Common: Nausea, fine-hand tremors, Established standard treatment for bipolar
carbonate Lithobid mg/day (acute) 0.6–1.2 mEq/l increased urination and thirst disorder
900–1,200 Toxicity: Slurred speech, confusion, Pregnancy Category D
mg/day severe GI effect Lactation Category L3
(maintenance)
Risk of hypothyroidism
Avoid in pregnancy, especially 1st trimester
Monitoring kidney functioning is essential
Concurrent use of NSAIDs and angiotensin-
converting enzyme inhibitors (ACEIs) may
double lithium level
Carbamazepine Tegretol 10–20 mg/kg/ 6–12 mcg/ml Common: Nausea, dizziness, Hepatic enzyme inducer
day sedation, headache, dry mouth, Monitor LFTs
constipation, skin rash
Alternative to lithium or valproic acid
Rare: Agranulocytos/aplastic anemia,
Pregnancy Category D
Stevens-Johnson syndrome,
particularly in Asians (screen for Lactation Category L2
HLA-B 1502 allele before initiating)
Valproic acid, Depakene, 15–40 mg/kg/ 50–125 mcg/ml Common: Nausea, diarrhea, Depakote minimizes GI effects
divalproex Depakote day abdominal cramps, sedation, tremor More effective than lithium for rapid cycling
sodium Rare: Increased liver enzymes, and mixed bipolar
Stevens-Johnson syndrome (unlike Loading dose: 20 mg/kg
Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition
carbamazepinedivalproex does not Pregnancy Category D

carry screening directive for HLA-B
1502 antigen at this time) Lactation Category L2
Lamotrigine Lamictal 25–600 mg/ Blood Common: Dizziness, ataxia, Indication for maintenance only
day monitoring not somnolence, diplopia, nausea, Helps in depressive phase of bipolar affective
necessary headache, hepatotoxicity disorder
Rare: Life-threatening rashes, Titrate slowly: 25 mg p.o, q.d.x 2 weeks, then
including Stevens-Johnson syndrome 50 mg p.o. q.d. x 2 weeks, etc. Concomitant
(unlike carbamazepine, lamotrigine use with divalproex may double lamotrigine
does not carry directive to screen level and should be factored into dosing
for HLA-B 1502 antigen at this time),
leukopenia Concomitant use with carbamazepine may
increase metabolism and should be factored
into dosing
Often used in combination with lithium,
second-generation antipsychotics, and
antidepressants
Depressive Disorders and Bipolar Disorders
183
ZZ Labs drawn 1 week after start of carbamazepine, valproic acid/

divalproex sodium
XX 12-hour trough serum drug level
XX CBC
XX LFTs
ZZ Response to treatment with lithium or anticonvulsant medications is 1 to 2 weeks.
STEVENS JOHNSON SYNDROME (SJS)

SJS is a rare, potentially life-threatening immune reaction to a foreign antigen that can occur with
exposure to any anticonvulsant drug. Treatment includes stopping the offending agent with sup-
portive measures, often in a hospital burn unit. Signs and symptoms of SJS include:
XX facial swelling
XX tongue swelling
XX macules, papules, and “burning,” confluent erythematic rash
XX skin sloughing
XX prodromal headache, malaise, arthralgia, and painful mucous membranes may occur
before rash occurs
Clinical Managment
XX Somatic treatments
ZZ Treatment as previously discussed for MDD episodes
XX Therapies
ZZ Treatment as previously discussed for MDD episodes
XX During acute phase of manic episode:
ZZ Monitor and help client meet nutritional needs.
ZZ Help client meet sleep–rest needs.
ZZ Monitor for safety.
XX During less acute periods:
ZZ CBT
ZZ Behavioral therapies
ZZ Interpersonal therapies
ZZ Supportive groups
ZZ Milieu therapy
XX Provides for structure and safety needs
XX Provides socialization and interpersonal support
XX Encourages independence
XX Client and family education

ZZ Explain underlying pathology of illness.
ZZ Discuss signs and symptoms.
ZZ Help identify strategies for living with illness.
XX Help understand and make decisions regarding care options
XX Relapse prevention plan
XX Overall health promotion
Common Comorbidities
XX Hypothyroidism
XX Substance abuse
General Health Considerations

XX High-risk activities from manic behavior
ZZ Sexual
XX Client education for sexually transmitted infections (STIs)
XX Assessment and monitoring for STIs
ZZ Financial and legal
XX Client access to community resources
XX Nutritional counseling
XX Client health education

XX Adolescent manic episodes present differently from adult episodes.
ZZ More psychotic features
ZZ Often associated with antisocial behavior
ZZ Often associated with substance abuse
ZZ Prodromal period of significant behavioral problems
XX School truancy
XX Failing grades
Follow-up
XX Clients initially should be seen weekly to titrate medications and monitor serum
blood levels of pharmacological agents.
XX Treatment duration and success rates vary with individual characteristics and motivation.
XX Clients and significant others should be taught symptoms of mania and depression
and that the disorders are chronic illnesses.
XX Relapse is common and occurs frequently.
XX Relapse plans need to be developed.
XX Client teaching should include risks, benefits, potential side effects, and signs and
symptoms of medication toxicity.
XX Educate about potential dietary and fluid intake effects on lithium level
XX Lithium and divalproex sodium are teratogenic.
ZZ Women of child-bearing years need effective contraceptive care while on BP
disorder treatment medication.
XX Routine use of lab tests to monitor for therapeutic serum levels of anticonvulsants
and lithium is needed.
ZZ Routine evaluation of CBC, renal function, and thyroid and parathyroid function
(thyroid-stimulating hormone and calcium levels) is needed for clients taking
lithium long-term.
XX Assessment for suicidality should occur during every client contact.
XX All clients should be observed for development of adverse effects of pharmacologi-
cal management.
XX Standardized rating scales help to monitor clinical status, establish baseline function-
ing, and monitor disorder course over time:
ZZ Young Mania Rating Scale (YMRS; Young, Biggs, Ziegler, & Meyer, 1978)
ZZ A daily mood chart that tracks mood, energy, and specific information about
sleep is helpful in informing both diagnosis and treatment
CYCLOTHYMIC DISORDER
Description
XX Chronic, fluctuating mood disorder with symptoms similar to but less severe than BP
disorder
XX Numerous periods of hypomanic and dysthymic symptoms.
Etiology
XX Similar to BP disorder

XX Lifetime prevalence 0.4% to 1%
XX Insidious onset
XX Chronic course
XX Begins early in life
XX 15% to 50% of persons with cyclothymic disorder subsequently develop BP

disorder.
Risk Factors
XX Genetic loading
XX Family history
XX BP disorder Type I
XX Substance abuse

ZZ Stigma reduction
onset of illness
ZZ The longer the time period between onset of symptoms and diagnosis, the
more difficult to interrupt cyclicity of illness.
Assessment
History
ZZ Fluctuating mood episodes
ZZ Affected people can function well during hypomanic episodes
ZZ May experience clinically significant distress or impaired function related to cyclicity
ZZ Unpredictable mood changes
ZZ Often regarded by others as temperamental, moody, unpredictable,
inconsistent, and unreliable
ZZ No psychotic episodes

XX Similar to MDD and BP disorder

XX Similar to MDD and BP disorder but with less severity of symptoms

XX Nonpsychiatric
ZZ Similar to MDD and BP disorder
XX Psychiatric
ZZ BP disorder
ZZ Dysthymia
ZZ Substance abuse
Clinical Management
XX Because of increased risk for development of BP disorder, commonly treated with
medication

XX Usually begins in adolescence
XX Onset in later life usually suggests general medical condition such as multiple
sclerosis.
Follow-up
CASE STUDY
Ms. M., a 35-year-old homemaker and mother of two children, presents to the PMHNP on refer-
ral from her primary care provider. Accompanied by her husband, Mary describes worsening
insomnia and poor energy. The symptoms are affecting her ability to take care of her children and
the household. Husband reports that Ms. M. often has crying spells, is not eating, and cannot
seem to concentrate. When questioned further, husband reports that Ms. M. has mentioned not
wanting to live, but he thought that she was just having a bad day.
Past Psychiatric History

XX Reports depression off and on since late adolescence
XX No history of treatment
XX Husband adds that Ms. M. had “the baby blues” for several months after the births
of both of their children
Past Medical History

XX Seasonal allergies and stress-induced asthma
XX No significant surgical history, except for a tonsillectomy when she was a child
XX Normal pregnancies and deliveries
XX No chronic health problems identified
Family History
XX Significant for grandmother and father, who had “breakdowns.”
XX Father had alcoholism.
Social History
Ms. M. is a homemaker and has two children, ages 8 and 10. She and her husband moved to the
area 6 months ago. She does not smoke or use drugs but drinks socially. She has an MA degree
in English and had planned to go back to school to get her teaching certificate when her children
began high school.
Mental Status Exam

Client appears disheveled. Hair is not combed. She appears very tired. She avoids eye contact,
talks very softly, and is slow to respond to questions. She hardly moves during the interview.
Affect is constricted and sad. She says she has no energy, and her mood is “very sad.” She does
not hear voices or have hallucinations. Her thoughts are appropriate and organized. She does
admit to having episodic thoughts of suicide and has a vague plan to ingest an overdose of aspi-
rin, acetaminophen, and alcohol when the children are with their father but has no clear timeline
or planned intent. She is unable to do serial number testing and shows impaired short-term
memory. She exhibits a few problems with immediate recall. She has difficulty concentrating but
no difficulty with abstractions. She is oriented times 3, and shows good judgment and insight.
She has above-average intelligence.
Current Medications
Ms. M. takes cetirizine for allergies and is now on ethinyl estradiol/norgestimate contraceptive
pills.
Labs
XX Platelets 230/mm3
XX WBC 6,000/mm3
XX Hematocrit 40%, hemoglobin 13.0
XX NA 140, K 4.0, Cl 101, CO2 26, BUN 15, creatinine 0.9, glucose 102
XX TSH 1.1, T3 179, T4 1.3
There are several issues to consider in planning care for Ms. M.

1. What is the most probable diagnosis?
2. What further assessment is needed?
3. What target symptoms does the client display that are consistent with the probable
diagnosis?
4. What medications would be considered?
5. If client had psychotic features with her depression, how would this change the
treatment plan?
6. What nonmedication treatment would be indicated for a client with MDD with psy-
chotic features?
7. How would the plan differ if client had a heart condition and was taking no other
medications?
8. Assume Ms. M. has started an antidepressant and returns after 2 weeks on the
medication. Her speech has normalized and is now more spontaneous. If Ms.
M now tells you that she feels “better” and that her energy and motivation have
improved, but that she is still having difficulty falling and staying asleep, would your
diagnosis change?
9. What further assessment should be done?
10. How would you change the treatment plan?
11. If Ms. M. returns for her follow-up appointment reporting irritable mood, racing
thoughts, rapid speech and inability to sleep, should your diagnosis and treatment
plan change?

1. The client’s most probable diagnosis is consistent with major depressive disorder.
2. Further assessment needed is to ensure that the client meets the DSM-5 criteria for
major depression. Complete physical assessment and use common symptom rating
scale such as Beck’s Depression Inventory or PHQ-9. Complete assessment for any
other physical health states. The PMHNP should explore what “inability to sleep”
means in specific detail.
3. The target symptoms for this client include: depressed mood most of the day nearly
every day, lack of energy, suicidal ideation, MSE findings consistent with MDD.
4. The medications to be considered for this client are SSRIs as this class of antide-
pressant medication is often considered the first-line agent for treatment of MDD.
5. If the client had psychotic symptoms, clinical management would include the short-
term use of an antipsychotic agent to control psychotic symptoms. If used, an atypi-
cal antipsychotic is usually best tolerated.
6. For clients with severe MDD, with psychosis ECT might be considered.
7. If the client had cardiovascular disease, the PMHNP must look at compatibility
issues to ensure that the medication choice for treatment of MDD does not have
significant risk for adverse cardiac side effects. TCAs are contraindicated.
8. If the client presented for a follow-up appointment stating that she is feeling better,
but still has residual symptoms of sleep problems your diagnosis would not change
because the symptoms Ms. M. reports are consistent with a depressive episode
that is beginning to resolve.
9. Further assessment of this client should include an assessment for mood, anhedo-
nia, suicidal ideation, and activities over the past 2 weeks and for any indication that
the antidepressant may be fueling a switch from depression to hypomania or mixed
state.
10. In this client, if the treatment plan changes, monitor for further improvements. Teach
Ms. M about sleep hygiene measures. Discuss expected outcomes and the impor-
tance of monitoring for any significant increase in goal-directed activities, decreased
need for sleep, racing thoughts, and shift in mood to euphoria or irritability. Begin
psychotherapy.
11. If Ms. M. returns for a follow-up appointment reporting irritable mood, racing
thoughts, rapid speech and inability to sleep, yes, your treatment plan should
change. Rule out unspecified bipolar disorder, bipolar II disorder, and bipolar I disor-
der. The antidepressant dose should be lowered and a medication with mood stabiliz-
ing properties should be added. The client should be monitored closely and reevalu-
ated within several days.

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CHAPTER 10
ANXIETY DISORDERS, OBSESSIVE–COMPULSIVE

DISORDER, AND TRAUMA- AND STRESSOR-
RELATED DISORDERS
This chapter reviews the psychiatric–mental health nurse practitioner’s (PMHNP’s) evaluation
of and treatment of people who have anxiety-related disorders. Anxiety disorders are among
the most common of all psychiatric illnesses, and can initially manifest as a number of physical
illness states. Often only after extensive, unnecessary assessment and diagnostic evaluation
is a client’s problem correctly identified as an anxiety disorder. Because of the high degree of
somatic symptomatology, it is common for clients to present to a primary care setting and thus
receive initial care from a primary care provider.
Anxiety is a very common and normal human emotion. PMHNPs caring for clients who pres-
ent for evaluation of anxiety must be able to distinguish between normal levels of anxiety and
pathological levels that are symptomatic of an underlying brain-based illness. Pathological levels
of anxiety require treatment and generally will not fully abate without therapeutic intervention.
Untreated high levels of anxiety predispose people to other serious health problems; therefore,
pathological levels of anxiety should not go untreated (Narrow, Rae, & Regier, 1998).
XX Normal emotion of anxiety
ZZ Anxiety is one of the most common human emotions.
ZZ Anxiety exists on a continuum ranging from the absence of anxiety at one end
to pathological levels that produce significant symptoms of psychiatric disorder
at the other (see Table 10–1).
ZZ Anxiety can be a normal, healthy reaction to life stressors that motivates a
person to deal with events and emotions.
ZZ Anxiety can be pathological if it is disproportionate to events, if it is sustained
over a significant time frame, if it significantly impairs functioning, or if it is
apparently unrelated to any identifiable event or situation in a person’s life.
ZZ High pathological levels of anxiety interfere with perceptions, memory,
judgment, and motor responses.
TABLE 10–1.
ASSESSING LEVELS OF ANXIETY
LEVEL OF PHYSIOLOGICAL SIGNS PSYCHOLOGICAL SIGNS

ANXIETY DEFINITION AND SYMPTOMS AND SYMPTOMS
Level I: Normative level Vital signs normal, pupils Perceptual field broadened,
Mild experienced by all, constricted, minimal increase heightened awareness of
which functions to in muscle tone environment
motivate
Level II: Normative level Vital signs normal, mild Subjective feeling of
Moderate experienced by increased heart rate, tension or worry, narrowed
most in response moderate increase in muscle perceptions
to significant tone
stressors
Level III: Pathological level Autonomic nervous system Perceptual field greatly
Severe triggered, fight-or-flight narrowed, difficulty with
response, pupils dilated, vital problem-solving, distorted
signs increased, diaphoresis, perception of time, selective
muscles rigid, hearing inattention, dissociative
decreased, pain threshold sensations, automatic
increased, urinary frequency, behavior
diarrhea
Level IV: Pathological level Severe symptoms markedly Scattered perceptions, unable
Panic increased: client is pale, to attend to environmental
hypotensive, has poor eye– stimuli, illogical thinking,
hand coordination, muscle may exhibit hallucinations or
pains, marked decrease in delusions
hearing, dizziness, shortness
of breath
ZZ Cultural differences can affect behavioral manifestations of anxiety.

XX “Ataques de nervios” is a Latino cultural syndrome usually provoked by
disruptions in family bonds and may be manifested by trembling, crying,
and screaming. The attacks are usually experienced in the presence of
others and the person often feels relief afterward.
XX “Khyal” (wind) attacks are a common manifestation among Cambodian and
other Asian cultures, and commonly manifest in neck soreness and tinnitus.
ZZ Older adults often express anxiety as somatic concerns and anxiety disorders
may overlap with medical conditions.
ZZ Psychotherapy is the first-line treatment for children and adolescents who are
diagnosed with an anxiety disorder.
ZZ The role of the PMHNP in assessing anxiety is to separate normal versus
pathological levels of anxiety, to intervene to lower the level of anxiety, and to
improve overall functioning.
ANXIETY DISORDERS
Description
XX Anxiety disorders are the most common group of psychiatric disorders and are
characterized by the degree of anxiety experienced by the client, by the duration
Anxiety Disorders, Obsessive–Compulsive Disorder, and Trauma- and Stressor-Related Disorders 197
TABLE 10–2.
DSM-5 ANXIETY, OBSESSIVE–COMPULSIVE DISORDER (OCD), AND TRAUMA- AND
STRESSOR-RELATED DISORDERS
OBSESSIVE–COMPULSIVE TRAUMA AND STRESSOR-

ANXIETY DISORDERS AND RELATED DISORDERS RELATED DISORDERS
• Panic Disorder • Obsessive–Compulsive • Reactive Attachment
Disorder Disorder
• Agoraphobia
• Body Dysmorphic • Disinhibited Social
• Specific Phobia
Disorder Engagement Disorder
• Social Anxiety (Social
• Hoarding Disorder • Posttraumatic Stress
Phobia)
Disorder
• Trichotillomania (Hair-
• Selective Mutism
Pulling Disorder) • Acute Stress Disorder
• Generalized Anxiety
• Excoriation (Skin-Picking • Dissociative Identity
Disorder
Disorder) Disorder
• Substance- or • Dissociative Amnesia
Medication-Induced • Depersonalization or
Obsessive–Compulsive Derealization Disorder
and Related Disorder
and severity of the anxiety, and by the typical behavioral manifestation of anxiety
observed in the client. Anxiety ranges from acute states to chronic disorders and is
accompanied by multiple somatic symptoms.
XX People most often present first in primary care settings with nonspecific physical
concerns.
ZZ Panic attacks are often confused with cardiac and respiratory disorders, so
careful differential diagnostic assessment is essential.
XX Frequent comorbidity exists with substance abuse, depression, and eating disorders.
XX Symptoms significantly impair functioning and occur more days than not for a period
of at least 6 months, with the person reporting little or no volitional control over the
symptoms.
XX Nine specific anxiety disorders are identified in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association, 2015) and are de-
scribed in more detail in this chapter.
Etiology
XX Multiple theories range from psychological to neurobiological; however, most likely
there is a multifactorial etiological profile.
ZZ Psychodynamic Theory
XX This theory is based on work of Sigmund Freud (1856–1939), who believed
that anxiety initially occurs in response to the stimulation of birth and need
of the infant to adapt to the changed environment.
XX Subsequent anxiety results from intrapsychic conflict.
XX The process of unconscious repression of sexual drive is at the core of

much of the conflict.
XX Conflict exists between instinctual needs of the id and the superego
(conscience); anxiety signals the person of the need to deal with the id–
superego conflict.
XX Conflict is unconscious, but anxiety is consciously perceived.
XX Conflict entails fear of punishment and of doing wrong.
XX Defense mechanisms are unconsciously used by the person to deal with
the conflict.
XX The behavioral manifestations of anxiety disorders stem from the
pathological overuse of defense mechanisms.
ZZ Interpersonal Theory
XX This theory is based on work of Harry Stack Sullivan (1892–1949), who
believed that humans are goal-directed toward attainment of satisfaction
and security needs.
XX Satisfaction and security needs are normally met in interpersonal
interactions.
XX Anxiety arises when a person’s needs are unmet.
XX Anxiety is first experienced in an infant’s interactions with his or her mother.
XX Subsequent anxiety arises because of interpersonal conflict.
XX Conflict occurs when a person perceives his or her needs will not be met
because of rejection, feelings of inferiority, or inability to engage with
significant others.
XX Sense of self becomes based on the person’s perception of how others
view him or her.
ZZ Neurobiological Theory
XX Pathological levels of anxiety result from neurobiological deficits in normal
brain functioning.
XX Deficits are genetically mediated by and involve predominantly the limbic
system, midline brainstem area, and sections of the cortex.
XX Deficits predispose the person to abnormal stress responses, with
hyperactivity of autonomic nervous system causing symptoms such as
increased heart rate and blood pressure, diaphoresis, papillary dilation,
tremors, and increased respiratory rate.
XX Problems with the hypothalamic pituitary adrenal (HPA) axis:
ZZ Threat is perceived, and amygdala signals the hypothalamus to secrete
corticotrophin-releasing hormone (CRH).
ZZ The amygdala also activates the sympathetic nervous system to start
the fight-or-flight response.
ZZ The pituitary is stimulated to release adrenocorticotropic hormone
(ACTH).
ZZ The adrenal glands are then stimulated to release cortisol, which shuts
off the alarm system and restores the body to homeostasis.
XX In anxiety disorders, the amygdala may not be able to shut off the response
(overactive amygdala), or there may not be enough cortisol to stop the fight-
or-flight response.
XX Neurobiological deficits result in low levels of the neurotransmitter gamma-
aminobutyric acid (GABA), the chemical responsible for inhibitory responses
of neurons, and in high levels of norepinephrine, the chemical associated
with the fight-or-flight response
XX Neurotransmitters involved in suppressing the HPA axis are serotonin and
GABA.

XX Anxiety disorders are common, with a lifetime prevalence of 28.8% among the
general U.S. population.
XX Except for obsessive–compulsive disorder (OCD) and social phobia, anxiety disorders
are more common in girls and women than in boys and men.
XX Most anxiety disorders manifest in adolescence and early adulthood (Narrow, Rae, &
Regier, 1998).
XX Median age at onset is 11 years of age.
Risk Factors
XX Genetic loading (National Institute of Mental Health, Genetics Workgroup, 1998)
ZZ A first-degree relative of a person with panic disorder is up to 8 times more
likely than general population to develop panic disorder.
ZZ If a first-degree relative of a person developed panic disorder before age 20, that
person is up to 20 times more likely than general population to develop panic
disorder.
XX Limited range of coping skills.
XX History of trauma
XX High levels of parental distress affect a child’s ability to cope with traumatic events

ZZ Stigma reduction

ZZ Teach at-risk persons to recognize and manage anxiety levels.
ZZ Help at-risk persons reduce anxiety through improved coping activities.
Assessment
History
ZZ Detailed history of present illness, including time frame and progression, any
associated symptoms
education level
ZZ Clients initially may be more troubled by, and complain more often of, physical
symptoms and may not identify anxiety as a concern.
ZZ Explore the client’s subjective sensations of being nervous, tense, worried,
anxious, or stressed out.
ZZ Identify current environmental stressors as experienced by the client.
ZZ Determine if anxiety is normative or pathological.
ZZ Pathological levels of anxiety indicative of underlying anxiety disorder:
XX Anxiety is perceived of as distressing and out of the control of the person..
XX Anxiety is unlinked and not seen as caused by life events.
XX Anxiety is accompanied by somatic complaints, which is more uncommon
in normal anxiety levels.
XX Anxiety interferes with social, occupational, and recreation activities and
with activities of daily living.
ZZ Determine the level of the client’s anxiety using the 4-point scale of mild to
panic levels (1 = mild to 4 = panic; see Table 9–1).
ZZ Use standardized rating scales such as the Hamilton Rating Scale for Anxiety
(HAM-A; Hamilton, 1959) for establishing and monitoring the client’s anxiety
level over time.
ZZ Assess general level of health and presence of concomitant illnesses.
ZZ Assess for dysfunctional coping:
XX Alcohol use or abuse
XX Illicit substance use or abuse
XX Caffeine use
XX Increased nicotine use
XX Misuse of anti-anxiety medications
Anxiety Disorders, Obsessive–Compulsive Disorder, and Trauma- and Stressor-Related Disorders 2 01
ZZ Assess for specific psychological symptoms of anxiety:

XX Fear of dying, losing one’s mind, or a sense of unreality
XX Belief that he or she is very ill, with no findings to support this belief
XX Narrowed perceptions
XX Limited eye contact

XX Possible physical manifestations:
ZZ Diaphoresis
ZZ Headaches
ZZ Dizziness and lightheadedness
ZZ Missing hair on scalp, eyebrows, or eye lashes (for trichotillomania or excoriation
disorders)
ZZ Increased muscle tone
ZZ Palpitations, often with tightness in chest
ZZ Tachycardia
ZZ Hypertension
ZZ GI problems such as nausea, diarrhea, or abdominal discomfort

XX Appearance
ZZ Psychomotor restlessness
ZZ Tremors
ZZ Hand wringing
XX Speech
ZZ Overproductive
ZZ Rapid
ZZ Distractible speech patterns
ZZ Thought blocking
XX Mood
ZZ Nervous
ZZ Worried
XX Affect
ZZ Anxious
ZZ Worried
ZZ Tearful
XX Thought process
ZZ Overall organized
ZZ Goal-directed
ZZ Redirectable
XX Thought content
ZZ Thematic for worry
ZZ Mild perseveration on topics of concern
XX Orientation
ZZ Usually fully oriented
XX Memory
ZZ Impaired short-term and immediate memory
ZZ Forgetful
XX Concentration
ZZ Inattentive
XX Abstraction
ZZ Abstract on proverbs and similarities
XX Judgment
ZZ Intact
XX Insight
ZZ Intact or limited insight

XX Obtain baseline labs such as complete blood count (CBC), chemistry profile, thyroid
function tests, and B12 level to rule out metabolic causes or unidentified conditions.
XX Obtain drug toxicity screening if indicated by history.
XX In some cases, clients may have labs reflecting compensated respiratory alkalosis:
ZZ Decreased carbon dioxide levels
ZZ Decreased bicarbonate levels
ZZ Normal pH
XX Many medical conditions can cause worry, fear, and normal levels of anxiety (see
Table 10–3).
XX Ensure that client symptoms meet criteria for anxiety disorders.
General Clinical Management

XX Rule out or treat any conditions that may contribute to pathological levels of anxiety.
TABLE 10–3.
MEDICAL CONDITIONS THAT MAY MIMIC ANXIETY DISORDERS
GENERAL CATEGORY OF DISORDER SPECIFIC ILLNESS

Cardiovascular Congestive heart failure
Mitral valve prolapse
Myocardial infarct
Arrhythmias, especially tachycardic arrhythmias
Pulmonary embolism
Coronary artery disease
Respiratory Asthma
Chronic obstructive pulmonary disorder
Pneumonia
Endocrine Hyperthyroidism
Hyperparathyroidism
Cushing’s disease
Neurological Seizure disorders
Transient ischemic attacks
Cerebral vascular accident
Encephalitis
Central nervous system (CNS) neoplasms
Metabolic Hypoglycemia
Vitamin B deficiency
Porphyria
Substance abuse or dependency Intoxication with CNS stimulants (e.g., cocaine,
amphetamines, caffeine)
Withdrawal from CNS depressants (e.g., alcohol,
marijuana)
XX Most of the medications known to improve symptoms of anxiety act directly or
indirectly on the GABA system.
ZZ Selective serotonin reuptake inhibitors (SSRIs)
XX Considered first-line agents for chronic anxiety disorders
XX Action on serotonin system and indirectly on GABA system
XX Carry no risk of dependency
XX Cannot be used p.r.n.
XX Generally well tolerated
XX Takes time to reach symptom control (usually 3–4 weeks)
XX Best when combined with psychotherapy
XX Black box warning for increased suicidality in children, adolescents, and
young adults
ZZ Benzodiazepines (BNZs)
XX Potentiate the effect of GABA
XX Rapid onset of action
XX Can be used p.r.n.
XX Limit to lowest possible dose and short-term use if possible, because long-
term use may lead to tolerance, dependence, memory impairment, and
depression.
XX Use should be limited to period of excessive symptoms, period of high
stress, or in unremitting symptoms.
XX Use with extreme caution in clients with history of substance dependence.
ZZ Effective but carry risk for addiction, especially in persons who have a
history of substance abuse.
XX The use of benzodiazepines has been associated with Alzheimer’s disease.

XX BNZs with longer half-lives require less frequent dosing, have less severe
withdrawal, and have less rebound anxiety.
XX BNZs with longer half-lives are more useful for continuous, moderate to
severe anxiety or as bridge medications while waiting for efficacy of SSRI:
ZZ Clonazepam (Klonopin)
ZZ Diazepam (Valium)
XX BNZs with shorter half-lives require more frequent dosing, have more
severe withdrawal, and have more rebound anxiety:
ZZ Alprazolam (Xanax)
ZZ Lorazepam (Ativan)
XX Advantages of BNZs with short half-lives

ZZ BNZs with short half-lives are often useful for intermittent or infrequent
moderate to severe anxiety
XX Less daytime sedation
XX Less drug accumulation
XX Quick onset of action
XX Useful for treatment of insomnia
XX Disadvantages of BNZs with short half-lives:

ZZ Increased risk of addiction
ZZ Tricyclics (TCAs)
XX Effective but affect multiple receptors and have problematic side-effect
profiles
XX Side effects often affect compliance
TABLE 10–4.
NON-BENZODIAZEPINE ANXIOLYTICS FOR ADULTS
DOSAGE
GENERIC BRAND RANGE SIDE EFFECTS COMMENTS
Buspirone Buspar 20–60 mg Dizziness, insomnia, Helpful adjunct for anxiety
daily tremors, akathisia, stomach
upset, dry mouth
Tiagabine Gabitril 4–56 mg Dizziness, somnolence, Helpful adjunct for anxiety
daily stomach upset, tremors, Off-label use
dry mouth
Gabapentin Neurontin 300– Ataxia, decreased Used for anxiety,
3,600 mg coordination, sedation, neuropathic pain,
daily disequilibrium fibromyalgia, and as an
anti-craving medication
Off-label use
Propranolol Inderal 10–20 mg Bradycardia, hypotension Performance anxiety
daily p.r.n. Off-label use
ZZ Non-BNZ anxiolytics (see Table 10–4)

XX Buspirone (BuSpar)
ZZ Must be taken regularly, not as p.r.n.
XX Tiagabine (Gabitril)—off-label use

XX Gabapentin (Neurontin)—off-label use
XX Beta blockers (propranolol, atenolol)—off-label use
ZZ Usually adjunctive use with other pharmacological agent

XX In children, alpha-agonists are often used for anxiety.
ZZ Clonidine (Catapres), .003–.01 mg/kg/d, off-label use
ZZ Guanfacine (Tenex), .015–.05 mg/kg/d), off-label use
XX Behavioral therapy
ZZ Systematic desensitization
ZZ Exposure therapy
ZZ Relaxation therapies
ZZ Biofeedback
XX Cognitive behavioral therapy (CBT)
XX Interpersonal therapies
XX Community self-help groups
XX Alternative therapies as adjunctive treatments
Comorbidities
XX Anemia
XX Cardiac disorders, especially in clients with dysrhythmias
XX Endocrine disorders
ZZ Cushing’s disease
ZZ Hyperthyroidism
ZZ Hypoglycemia
XX Pulmonary conditions
ZZ Chronic obstructive pulmonary disorder
ZZ Asthma
ZZ Pulmonary embolism
ZZ Pneumothorax
XX Adverse medication reactions
ZZ Caffeine
ZZ Nicotine
ZZ Anticholinergics
ZZ Antihistamines
ZZ Antipsychotics
ZZ Steroids
ZZ Bronchodilators
ZZ Anesthetics
XX Mood disorders
XX Substance abuse–related disorders

XX Chronic anxiety is wearing on the body; therefore, assess for effects on the cardio-
vascular system.
XX Perform a general assessment for a healthy lifestyle.
Follow-up
XX General considerations
ZZ Clients should initially be seen weekly or biweekly to titrate medications.
ZZ Client teaching should include risks, benefits, and potential side effects of
medication treatment.
XX If the client is taking BNZs, monitor for appropriate use and potential
dependence.
XX If the client is taking SSRIs, monitor for common side effects and adverse
effects.
ZZ Clients should be taught symptoms of anxiety and the fact that disorders are
chronic illnesses; a relapse plan should be established for all clients.
ZZ Assessment for suicidality should occur during symptom exacerbation periods.
ZZ Because of frequent comorbidity with major depressive disorder, assess
frequently for depression levels using standardized rating scales (see below).
ZZ Medication should be combined with therapy to reach maximum control of
symptoms.
ZZ Clients may need encouragement to continue treatment, especially after initial
symptom relief occurs.
XX Standardized rating scales for anxiety disorders
ZZ Zung’s Self-Rating Anxiety Scale (Zung, 1971)
ZZ Hamilton Rating Scale for Anxiety (HAM–A; Hamilton, 1959)
ZZ Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989).
PANIC DISORDER
Description
XX Panic disorder is experienced as discrete episodes or attacks with sudden onset of
intense apprehension, fearfulness, or terror, often associated with sense of impend-
ing doom.
XX Attacks occur without warning and in the absence of any real danger.
XX Attacks build to a peak of intensity within a short, self-limiting time, usually within 10
minutes of onset.
XX Panic disorder is more common in women than in men.
Assessment
History
ZZ Diagnostic criteria of panic disorder:
XX Discrete episode in which client experiences 4 or more of the following
symptoms having a sudden onset and peaking within 10 minute of onset:
ZZ Paresthesias
ZZ Chills or hot flushing
ZZ Fear of losing control or of going crazy
ZZ Fear of dying
ZZ Shortness of breath or smothering sensation
ZZ Palpitations, pounding, or accelerated heart rate
ZZ Chest pain, tightness, or discomfort
ZZ Sweating
ZZ Trembling or shaking
ZZ Nausea or abdominal distress
XX After first attack, persistent concern over having another attack, worry over
the consequences of initial attack, or a significant behavioral change related
to attack
XX With high somatic sensations, clients are often sensitive to new somatic
experiences or perceptions.
XX Often intolerant of or concerned with common side effects of medication
treatments
ZZ Discouraged or ashamed about “failure” to control emotions and over concern
about dying when no other pathology identified
XX In two-thirds of cases, major depression occurs first, followed by panic
disorder symptoms.
XX In one-third of cases, panic disorder symptoms precede major depression
symptoms.

XX Nonspecific, especially when client not experiencing panic attack
XX Nonspecific cardiac-related complaints during panic episodes often bring client into
treatment:
ZZ Chest pain
ZZ Numbness and paresthesia
ZZ Shortness of breath

XX General findings of anxiety as described earlier
XX Findings very pronounced during panic episodes and less pronounced during non-
panic periods
XX High level of anticipatory anxiety between panic episodes

XX None specific
XX Rule out general medical conditions known to produce similar symptoms, including
ZZ Hyperthyroidism
ZZ Hyperparathyroidism
ZZ Pheochromocytosis
ZZ Vestibular dysfunction
ZZ Seizure disorders
ZZ Cardiac arrhythmias such as supraventricular tachycardia (SVT)
ZZ Use of CNS stimulants, including
XX Cocaine
XX Amphetamines
XX Caffeine
ZZ Another anxiety disorder such as posttraumatic stress disorder (PTSD) or
phobias
ZZ Separation anxiety disorder
ZZ Consider general medical disorder if
XX First episode of panic attack symptoms occurs after age 45
XX Panic symptoms are atypical, such as
ZZ Vertigo
ZZ Loss of consciousness
ZZ Incontinence
ZZ Headache
ZZ Slurred speech
ZZ Amnesic pattern after attacks
XX Differentiated from other anxiety conditions by

ZZ Sudden onset of attack
ZZ Discrete, self-limiting nature of symptoms
ZZ Paroxysmal symptom profile
ZZ Level 3–4 anxiety symptoms with somatic symptoms that are experienced as
distressing and severe by the client
Clinical Management
XX Follow guidelines of general clinical management of anxiety disorders.
XX SSRIs
XX BNZs, usually used for short-term symptom control or “bridge” medication when
starting an SSRI or other antidepressant
ZZ Buspar effective as an adjunct to an antidepressant
ZZ Other non-benzodiazepine anxiolytic meds used as adjuncts
XX CBT
XX Individual or group therapy
XX Exposure therapy
XX Relaxation therapies
XX Frequent with major depressive disorder
XX Estimated between 10% and 65%, depending on source:
ZZ Social phobia
ZZ OCD
ZZ Substance abuse
AGORAPHOBIA
Description
XX Agoraphobia is characterized by avoidance of places or situations from which escape
may be difficult or embarrassing or in which help may not be available in the event
of perceived need, such as a panic attack. Up to 50% of people meeting criteria for
agoraphobia report panic attacks or panic disorder preceded onset of agoraphobia.
XX The anxiety usually leads to avoidant behavior that impairs a person’s ability to travel,
to work, or to carry out responsibilities of daily living.
XX Differential diagnosis is assisted by the awareness that people with agoraphobia
feel better and report less significant concerns with anxiety when accompanied by a
trusted companion.
XX When people meet criteria for agoraphobia and panic or other anxiety disorder, both
diagnoses should be assigned.
Assessment
History
ZZ Clinical presentation meets diagnostic criteria for agoraphobia:
XX Presence of agoraphobic anxiety related to fear of developing panic-like
symptoms
XX Never met criteria for panic disorder
XX Avoidant behavior as a result of the agoraphobic anxiety

XX Nonspecific for agoraphobia

XX Consistent with finding for anxiety
XX Thought content consistent with criteria for agoraphobia

XX Nonspecific for agoraphobia
Clinical Management
XX Follow guidelines of general clinical management of anxiety disorders
XX SSRIs
XX BNZs for short-term use
XX Beta blockers (off-label use) used for discrete episodes of social anxiety
XX CBT
XX Supportive group therapy
XX Desensitization therapy
XX Panic disorder
SPECIFIC PHOBIAS (SIMPLE PHOBIAS)

Description
XX In specific phobias is a clinically significant level of marked and persistent fear that
is clearly observable and is, by client perception, clearly related to specific objects or
situations.
XX In adults, but not in children, exists the conscious recognition that the fear is exces-
sive or unreasonable.
XX In children, the degree of insight to the unreasonable nature of the fear increases as
age increases.
Risk Factors
XX Traumatic past exposure
ZZ Having been bitten by dog, having choked on food, and so forth.
XX Observation of another’s trauma
ZZ Seeing others be bitten by dog, seeing others choking on food, and so forth.
XX Excessive informational transmission
ZZ Repeated graphic parental warnings of dangers of certain events or situations.
XX Genetic loading
ZZ Having family member with specific phobia
ZZ Blood-injection-injury type is most familial

ZZ Subtype aggregation patterns noted within families; for example, if a person’s
first-degree relative has animal subtype, the risk is highest for him or her to
develop animal subtype
Assessment
History
ZZ The content of phobias, which can vary with culture, ethnicity, and age
ZZ Phobic diagnosis should occur only when accompanied by significant functional
impairment, such as full avoidance of school related to fear of encountering a spider.
ZZ Exposure to the specific feared object or situation immediately provokes the
onset of clinically significant levels of anxiety
XX This anxiety may fit the criteria for cued panic attack.
XX The level of anxiety is directly related to how physically close the object or
situation is to the person and the degree to which escape from the object
or situation is possible.
XX Children manifest fear and anxiety as crying, freezing, tantrums, or
excessive clinging behavior.
XX Children normatively express a transient fear of animals and other natural
objects.
ZZ Person engages in avoidant behavior to prevent reaction to object or situation or
endures object or situation with dread.
XX Avoidant behavior is distressful and has implications for social, recreational,
and occupational or school functioning.
XX Assess for subtypes:
ZZ There are five common subtypes: situational, natural environment, blood
injection injury, animal, and other.
XX A person can experience more than one subtype at a time.
XX A phobia to one object or situation in a subclass predisposes a person to
another phobia within the same subclass (e.g., fear of rats increases the
risk for fear of spiders).
1. Situational Type: Cued by specific situations; examples include driving,
enclosed spaces, tunnels or bridges, or flying
ZZ Most common adult form
ZZ In older adults, fear of closed-in situations most common
ZZ Bimodal peak of onset
XX First peak, childhood
XX Second peak, mid-20s
2. Natural Environment Type: Fear cued by objects in the natural environment;

examples include storms, lightning, water, or heights
ZZ Second most common adult form
ZZ Onset usually during childhood
3. Blood-Injection-Injury Type: Cued by seeing blood or an injury or by receiving

an injection or other invasive medical procedure
ZZ Third most common adult form
ZZ Strong vasovagal component that can produce other somatic
sensations
XX May exacerbate underlying cardiac or respiratory disorders
XX Person often presents with fainting as chief complaint
XX Experiences paroxysmal tachycardia and hypertension followed by
deceleration of heart rate and drop in blood pressure
XX Clinical presentation and disease natural history similar to panic
disorder with agoraphobia
4. Animal Type: Fear cued by animals or insects; examples include rats,

snakes, or spiders
ZZ Fourth most common adult form
ZZ Onset usually during childhood
5. Other Type: Fear cued by range of other stimuli; examples include fear of
choking, vomiting, or fear of a specific illness
ZZ In children, often manifests as fear of loud sounds or costumed
characters

XX Nonspecific

XX Thought content consistent with criteria for phobia

XX Nonspecific
XX Avoidance behavior in PTSD, OCD, separation anxiety disorder, or psychotic
disorders
Clinical Management
XX Follow guidelines of general clinical management of anxiety disorders
XX SSRIs
XX TCAs
XX Short term use of BNZs
XX CBT
XX Biofeedback
XX Desensitization therapy
SOCIAL ANXIETY (PHOBIA) DISORDER

Description
XX Social anxiety disorder is a marked and persistent fear of social or performance situa-
tions in which embarrassment may occur.
XX Anxiety levels often are sufficient to fit criteria for a situationally bound panic attack.
XX The disorder has an estimated 3% to 13% prevalence rate among the U.S.
population.
XX Rates are equal for the genders.
Assessment
History
ZZ Some degree of social anxiety is common and normative in adolescence.
ZZ Social phobia should be diagnosed only if symptoms persist for longer than 6
months.
ZZ Onset is in the mid-teens, often following stressful or humiliating experience,
and tends to remit with age.
XX Differential diagnosis is assisted by awareness that people with social phobia do
not feel better or experience decreased anxiety when accompanied by a trusted
companion.
ZZ Common descriptive features:
XX Hypersensitivity to criticism
XX Negative self-evaluations
XX Sensitivity to rejection
XX Low self-esteem
XX Inferiority feelings
XX Lack of assertiveness
ZZ Protracted anticipatory anxiety may occur days or weeks before the feared
social situation.
ZZ Levels of subjective distress and impaired functioning can be significant and
have been associated with suicidal ideation.
Physical Exam Findings for a Person Who Is Acutely Anxious

XX Sweating
XX Tremors
XX Palpitations
XX Muscle tension
XX Diarrhea
XX Blushing

XX Consistent for anxiety
XX Thought content consistent with criteria for social anxiety
Diagnostic and laboratory findings

XX Nonspecific
Clinical Management
XX SSRIs
XX BNZs, for short-term use
XX Beta blockers
ZZ Used for discrete episode relief
ZZ For example, before having to attend a scheduled social function
XX CBT
XX Exposure therapy
XX Relaxation therapy
GENERALIZED ANXIETY DISORDER (GAD)

Description
XX In GAD, excessive worry, apprehension, or anxiety about events or activities occurs
more days than not for a period of at least 6 months.
ZZ The person finds it hard to control the anxiety.
ZZ No clear link exists to life events or stressors.

ZZ Worry and anxiety interfere with activities of daily living.
ZZ The nature and focus of worry shift frequently.
ZZ A pattern of waxing and waning of symptoms exists.
XX Symptoms worsen as life events stress the person.
Assessment
History
ZZ In GAD, anxiety and worry are out of proportion to the actual likelihood or effect
of the feared event.
ZZ People report subjective distress caused by the constant worry but do not
always describe the worry as excessive.
ZZ Excessive anxiety and worry last for more days than not for at least 6 months.
ZZ The person finds it difficult to control anxiety.
XX Differential diagnosis
ZZ PTSD
ZZ Adjustment disorder with anxiety
ZZ Obsessions in OCD
ZZ Anxiety associated with another disorder such as hypochondriasis or social
phobia

XX Nonspecific
XX Associated with other health states
ZZ Irritable bowel syndrome
ZZ Migraine and other headache disorders
XX Physical signs of anxiety
ZZ Muscle tension
ZZ Generalized muscle ache and soreness
ZZ Tremors
ZZ Twitching
ZZ Subjective complaints of shakiness
ZZ Shortness of breath
ZZ Autonomic hyperarousal signs
ZZ Tachycardia
ZZ Increased respiratory rates

ZZ Dizziness
ZZ Numbness
ZZ Easily fatigued, often experienced as activity intolerance
ZZ Muscle tension and increased tone
ZZ Sleep disturbance

XX Appearance
ZZ Psychomotor restlessness
XX Mood
ZZ Anxious
ZZ Feeling keyed up or on edge
ZZ Irritability
XX Concentration
ZZ Difficulty concentrating
XX Thought content
ZZ Thematic for the anxiety and worry
ZZ Descriptive of the significant distress and impairment in daily functioning caused
by GAD

XX Nonspecific
Clinical Management
XX SSRIs
XX Buspar
XX BNZs as p.r.n. agents
XX Good candidates for therapy as single treatment modality
XX CBT
XX Stress management
XX Supportive counseling
XX Mood disorders
XX Other anxiety disorders
XX Substance-related disorders

XX Children
ZZ Anxiety is common in children, but it is important to assess normal versus
pathological levels.
ZZ Anxiety is manifested in excessive worry over competence or quality of
performance in school, work, sports, or other activities.
ZZ Common worry often manifests as anxiety over punctuality or catastrophes
such as earthquakes or war.
ZZ Often accompanied by
XX Overly conforming behavior
XX Perfectionist self-expectations
XX Excessive seeking of approval of others
XX Need for frequent reassurance about performance
SEPARATION ANXIETY DISORDER

XX Developmentally inappropriate and excessive distress occurring after the age of 4
when faced with separation from a major attachment figure.
XX Refer to Chapter 15: Disorders of Childhood and Adolescence
XX May persist into adulthood and in the DSM-5 it can be diagnosed in adulthood
OBSESSIVE–COMPULSIVE DISORDER (OCD)

Description
XX OCD is the presence of anxiety-provoking obsessions or compulsions that function
to reduce the person’s subjective anxiety level.
ZZ Obsession
XX Defined as recurrent and persistent thoughts, impulses, or images that are
experienced and cause anxiety and distress
XX Experienced as intrusive and inappropriate
XX Ego-dystonic experience in which a person feels the content of obsession
is alien to his or her belief structure and not the kind of common thought,
impulse, or image he or she usually experiences
ZZ Compulsion
XX Defined as repetitive behaviors or mental actions that a person feels driven
to perform in response to an obsession.
Risk Factors
ZZ Familial transmission pattern
XX Disease rates higher in people with a first-degree relative who has OCD
than in the general population.
XX Rates are also higher in people with a first-degree relative who has
Tourette’s syndrome than in the general population.
XX PANDAS (pediatric autoimmune neuropsychiatric disorders associated with
streptococcal infections) should be considered in all children with sudden-
onset OCD symptoms
Assessment
History
ZZ Diagnostic criteria:
XX Presence of either obsessions or compulsions
XX The person recognizing that the obsession or compulsion is excessive or
unreasonable
XX The obsession or compulsion is causing marked distress, is time-
consuming, or interferes with normal daily activity.
ZZ Common obsessions include:
XX Repeated thoughts about contamination, dirt, or germs
XX Repeated doubts, such as having hit someone with a car or having left an
oven on, without evidence
XX Need to have things in a specific order, with marked distress when that
order is disturbed
XX Aggressive or horrific thoughts
XX May occur in pregnancy and postpartum periods and manifest as intrusive
thoughts about something happening to their baby or doing something to
their baby; the thoughts are highly ego-dystonic
XX Sexual imagery
ZZ Obsessions usually do not involve real-world worries such as concern over
finances.
ZZ The person recognizes that the thoughts, impulses, or images are a product of
his or her own mind.
ZZ The person attempts to ignore or suppress thoughts, impulses, or images or to
override them with other thoughts or actions.
ZZ People often avoid situations in which the content of obsession may be
encountered (e.g., avoiding public restrooms to avoid contamination)
ZZ Common compulsions include

XX Repetitive actions, usually behavioral, and often called rituals
ZZ Handwashing
ZZ Excessive cleaning
ZZ Checking to see, for example, if the lights are turned off, the stove is
turned off, or the doors are locked
ZZ Needing to place objects in certain order
XX Common mental actions include

ZZ Counting
ZZ Silently repeating words
ZZ Praying
XX Behaviors or mental acts are not experienced as pleasurable and are

intended to prevent or reduce distress and subjective anxiety.
ZZ If the person resists the compulsion, anxiety and subjective tension
usually increase.
ZZ Some people believe the compulsion can prevent some dreaded event
or situation that is experienced as an obsession, such as sexual or
horrific images.

XX Nonspecific
XX Dermatitis may be present related to excessive handwashing or overuse of caustic
cleaning agents.
XX Hypochondriasis and somatic fixation common

XX Thought content dominated by obsessions
XX Behavioral manifestations of rituals may be noted

XX Nonspecific
XX Body dysmorphic disorder
XX Eating disorders
XX Trichotillomania
XX Hypochondriasis
XX Obsessive–compulsive personality disorder

XX Tic or stereotypic movement disorder
Clinical Management
XX SSRIs (clients often need higher dosing range for adequate symptom control)
XX TCAs (clomipramine)
XX Second-generation antipsychotics such as risperidone are off-label but have data sup-
porting their adjunctive use with SSRI medication
XX CBT
XX Exposure therapy
XX Major depression
XX Eating disorders
XX Other anxiety disorders

XX Children
ZZ Common in childhood, usually with prepubertal onset
ZZ More common in boys than in girls
ZZ Washing, checking, and ordering are the most common behavioral
manifestations.
ZZ Common comorbidities in children:
XX Learning disorders
XX Disruptive behavioral disorders
XX Tourette’s syndrome
ZZ Associated in children with Group A beta-hemolytic streptococcal infections
(e.g., scarlet fever, strep throat)
XX Older adults
ZZ More obsessions than compulsions usually present
ZZ Obsessive content characteristically about dying
ZZ Compulsions characteristically about washing and cleaning
POSTTRAUMATIC STRESS DISORDER (PTSD)

Description
XX PTSD is the reexperiencing of an extremely traumatic event accompanied by symp-
toms of increased arousal and avoidance of stimuli associated with the trauma.
XX The traumatic event can be experienced directly or witnessed.
ZZ Common experienced trauma includes
XX Military combat
XX Violent personal assault such as robbery or rape
XX Kidnapping or hostage situation
XX Terrorist attack
XX Torture
XX Prolonged sexual abuse
XX Natural or human-made disasters
ZZ Common witnessed trauma includes
XX Observing the death of or significant injury to another
XX Unexpectedly witnessing of any of the above traumas
XX Learning of the sudden or unexpected death of or significant injury to family
member or close friend
XX A relationship exists between the person’s physical proximity to the traumatic event
and the likelihood of symptom onset.
Risk Factors
XX Experienced or witnessed trauma
ZZ Assumed to have strong genetic etiological component and tends to run in families
ZZ History of major depression in first-degree relative related to increased risk of
developing PTSD
Assessment
History
ZZ Symptoms cannot predate exposure to trauma.
ZZ Presenting symptoms and history can be delineated as one of three subtypes:
XX Acute: Duration of symptoms less than 3 months
XX Chronic: Symptoms lasting 3 months or longer
XX Delayed onset: At least 6 months between traumatic event and the onset
of symptoms

XX Nonspecific
XX Increased rates of somatic complaints
XX Insomnia frequently chief complaint on presentation for evaluation
XX Distractibility in motor tasks
XX Measurable increased autonomic symptoms
ZZ Tachycardia
ZZ Diaphoresis
ZZ Increased respiratory rates
ZZ Increased startle response

XX Thought content consistent with criteria for PTSD and often dominated by traumatic
experience
XX May demonstrate some psychotic findings during flashback episodes.

XX Diagnostic criteria (symptoms for 1 month or longer):
ZZ Exposure to a traumatic event
XX The person experienced, witnessed, or was confronted with an event
involving the actual or threatened death or serious injury, and the person’s
response involved intense fear, helplessness, or horror.
ZZ The traumatic event is persistently reexperienced in one or more of the
following ways:
XX Recurrent and intrusive, distressing recollection of the event, including
images, thoughts, and perceptions
XX May be experienced as flashbacks
XX Rare cases involve dissociative states lasting hours to days
XX Recurrent distressing dreams about the event
XX Acting or feeling as if the traumatic event were reoccurring
XX Intense psychological distress at exposure to cues that symbolize or
resemble aspects of the traumatic event
XX Physiological reactivity on exposure to cues that symbolize or resemble
aspects of the traumatic event
ZZ Three or more avoidance symptoms
XX Persistent avoidance of stimuli associated with the traumatic event and
numbing of responsiveness
XX Efforts to avoid talking about or thinking about traumatic event
XX Avoidance of activities, places, or people that arouse recollections of

traumatic event
XX Inability to recall important aspects of event
XX Marked decreased interest or participation in activities
XX Feelings of detachment or estrangement from others
XX Restricted range of affect
XX Sense of foreboding and of shortened future, premature death, or no
expectation for success or happiness
ZZ Two or more increased arousal symptoms
XX Persistent symptoms of increased arousal
ZZ Difficulty falling asleep
ZZ Irritability or outburst of anger
ZZ Difficulty concentrating
ZZ Hypervigilance
ZZ Exaggerated startle response
ZZ Symptoms causing significant distress or impairment in activities of daily

functioning
ZZ Symptoms usually occur within 3 months of trauma
ZZ Duration of symptoms highly variable
XX Symptoms remit within 3 months in one-half of cases
XX Common waxing and waning of symptoms related to internal and external
cues that resemble the trauma

XX Nonspecific
XX Adjustment disorder
XX Brief psychotic disorder
XX Acute stress disorder
XX Intrusive thoughts in OCD
Clinical Management
XX SSRIs
XX TCAs
XX BNZs are not recommended in the treatment of PTSD

XX Antipsychotics may be useful during episodes of flashbacks.
XX Alpha antagonists (e.g., Prazosin) may be used for treating nightmares (off-label use).
XX CBT
XX Exposure Therapy with Response Prevention (ERP)
XX Supportive group therapy
XX Eye movement desensitization and reprocessing
XX Major depression
XX Dysthymia
XX Substance abuse or dependence

XX Can occur at any age, including childhood
ZZ Children
XX Expression of fear and horror occurs in disorganized or agitated behavior.
XX Repetitive play behaviors show themes or aspects of trauma.
XX Frightening dreams, but without recognized content, are common.
XX In young children, learning that a traumatic event occurred to a parent or a
caregiver may be the precipitating factor.
DISSOCIATIVE DISORDERS
XX Dissociative amnesia, depersonalization or derealization, and dissociative identity
disorder (DID)
XX Dissociation is a defense mechanism that protects a person from overwhelming
anxiety by emotionally separating.
ZZ Dissociation causes gaps or interruption in the person’s memory
XX Depersonalization or derealization: A persistent feeling of oneself not being real, or
the environment not being real; reality testing remains intact
ZZ Depersonalization and derealization are generally perceived as uncomfortable.
ZZ Etiology of depersonalization and derealization can be physical or psychological.
ZZ Physical causes are seizures, migraine headaches, psychedelic drugs, and
alcohol.
ZZ Psychological causes are severe anxiety and traumatic stress.
XX DID is characterized by two or more distinct personality states (“alters”).

ZZ Personality states are generally split off from one another, leading to gaps in
recall of everyday events.
ZZ Symptoms cause significant distress and impaired functioning.
ZZ Comorbid with PTSD.
ZZ Etiology is a history of severe physical or sexual trauma, or both, in childhood.
BODY DYSMORPHIC DISORDER

XX Preoccupation with one or more perceived defects or flaws in physical appearance
XX Engages in repetitive behaviors (checking mirror, reassurance-seeking, etc.) in re-
sponse to appearance concerns
XX Preoccupation causes considerable distress
XX Insight ranges from good to poor to absent (fixed delusion)
HOARDING DISORDER
XX Persistent difficulty discarding possessions, regardless of actual value
XX Experiences marked distress in response to pressure to discard
XX Results in accumulation of possessions that compromise living space or ability to
function, including maintaining a safe environment for self or others
XX Insight ranges from good to poor to absent (fixed delusion)
TRICHOTILLOMANIA
XX Recurrent pulling out of one’s hair despite repeated attempts to stop
XX Causes significant distress or impairment in functioning
XX Hair-pulling is not an attempt to improve a perceived defect or flaw
EXCORIATION DISORDER
XX Recurrent skin picking that results in lesions despite attempts to stop
XX Results in significant distress or impairment
XX Behavior not better explained by physiologic response to substance (e.g., metham-
phetamine use) or intentional attempt at self-harm
Anxiety Disorders, Obsessive–Compulsive Disorder, and Trauma- and Stressor-Related Disorders 2 27
CASE STUDY
Mr. J. is a 47-year-old school custodian with a long history of GAD. He reports he had been doing
well until about 4 weeks ago, when he was traveling overseas with his church group for a car-
ing mission in South America. Mr. J. noted that he began feeling “depressed by seeing all the
poverty and despair in those places.” He began to have difficulty falling and staying asleep. He
experienced disturbing dreams about what he was seeing during the day. The sleep disturbances
persisted upon his return home, and he started feeling anxious and could not concentrate during
his work day.
One week ago, Mr. J. began to feel overwhelmed by anxiety. He was unable to go to work. He
experienced discreet “attacks” of rapid heart rate, sweating, and difficulty breathing. He went
to a local emergency department several times, was evaluated, and each time was given “a
shot” and sent home. The emergency department doctor also suggested he contact a therapist.
He was not convinced that his distress was due to anxiety. On the third visit to the emergency
department, the doctor gave Mr. J. a prescription for alprazolam 0.5 mg #30 with the directions
“take as needed for anxiety” and referred him back to his primary care provider. Although Mr.
J. initially felt the medication was helping, he has continued to have difficulty falling and staying
asleep and has continued to have “bad dreams.” He needed 4 tablets of alprazolam yesterday
before finally falling asleep until this morning. He now believes “the medicine isn’t working.
There is something really wrong with me and nobody believes me. My wife and the people
at the hospital think it’s all in my head. I know I’m anxious, but what if there’s also something
wrong with my heart? Doctors miss things all the time….” Mr. J. now presents to the PMHNP at
the hospital-based outpatient psychiatry department.
Mental Status Exam

XX Appearance: Well-nourished, well-dressed
XX Motor: Some motor restlessness
XX Speech: Some pressure
XX Affect: Anxious
XX Mood: Depressed
XX Thought process and content: Thematic for fear of serious cardiac etiology not being
adequately assessed or treated. There is no evidence of an overt delusional process.
XX Abstractive on proverbs
XX Memory: Impaired
XX Concentration: Impaired
Social History
XX Married and has 3 children
XX Works as high school custodian
XX Overweight at 280 lbs., with sedentary lifestyle
XX Smokes 2 packs a day
XX Does not drink alcohol for religious reasons
XX Wife very concerned and supportive
Past Psychiatric History

XX Hospitalized in 1998 for “nerves”
XX At that time started on paroxetine (Paxil) 20 mg/d
XX After 3 months, dose was raised to 40 mg q.d. and he remained on that dose for
the next 18 months, when he tapered off the drug under his primary care provider’s
supervision.
XX Has had no significant exacerbation of symptoms since initial treatment
Past Medical History

XX History of seizure disorder since childhood; well-controlled with levetiracetam
(Keppra)
Current Medications
XX Alprazolam 0.5 mg p.o. p.r.n. q 4 hrs.
Labs
XX Electrocardiogram (EKG), CBC, thyroid function tests, and chemistry panel done in
emergency department and all within normal limits
Screening Tools
XX Current level of anxiety: moderate–severe
In planning care for this client, the PMHNP has many issues to
consider:
1. What is the most likely diagnosis?
2. How will the PMHNP separate comorbidity from complications of current diagnosis?
3. What medication adjustments would the PMHNP make?
4. How will the PMHNP address the family issues?
5. How often will the PMHNP plan to see the client?

Given the level of Mr. J.’s initial distress, you decide to restart paroxetine and continue using al-
prazolam as a bridge medication while waiting for a therapeutic response to the antidepressant.
6. What considerations should be given to using a benzodiazepine in a client with panic
disorder?
Mr. J. has now been taking paroxetine 20 mg for the past 2 weeks. He has not had a panic attack
since beginning treatment with the scheduled dose of benzodiazepine that was started when
he started the paroxetine. He no longer worries that he has a heart condition. He falls asleep
quickly, but continues to have some mild middle-phase insomnia that lasts up to one hour. He
eventually falls back to sleep, but wakes up feeling anxious. He is tearful at times during the day,
and worries that the panic attacks will recur if he stops taking the benzodiazepine.
7. How should the PMHNP adjust the treatment plan?
8. Mr. J. has been taking paroxetine 40 mg q.d. for the past month. He is now taking
clonazepam 0.5 mg q.a.m. and q.h.s. for the past 2 weeks after he experienced
sedation while taking 0.5 mg q.a.m. and 1.0 mg q.h.s. He continues to experience
mild–moderate anxiety periodically most days. How should the PMHNP alter the
treatment plan?
9. At what point should the PMHNP begin to taper the client off the clonazepam?

1. Mr. J meets criteria for panic disorder. It is not unusual for people who have panic
attacks to misinterpret the symptoms as cardiac or other etiology. The PMHNP must
also assess for a mood disorder as symptoms anxiety and mood symptoms often
overlap.
2. The PMHNP should perform a complete assessment which includes a physical
examination, mental status examination, and lab studies. The client’s current medica-
tions should be evaluated and the chronology of symptoms should be compared to
any changes in his health status.
3. After assessing the efficacy of Mr. J’s treatment history, the PMHNP should con-
sider restarting paroxetine.
4. Several approaches might be appropriate, including using psychoeducation for the
family, providing supportive counseling, or involving the family in family therapy.
5. Mr. J. should be seen frequently until symptoms are stable. Weekly appointments
during the initial phase of treatment would be ideal.
6. Before starting a benzodiazepine, the PMHNP should assess the client’s history of
recent and remote substance use or abuse. Potential risks versus benefits of short-
term use must also be discussed along with the expectation that the medication will
be tapered once the antidepressant is therapeutic. The PMHNP should discuss the
expected therapeutic outcome of using an SSRI or other antidepressant. When using
a benzodiazepine, consider using scheduled dosing to prevent onset of panic symp-
toms. Clients who have severe anxiety often underdose or overdose medications
to address their symptoms. Discuss expectations that the client will not adjust his
dose of medication without direction. Short-acting benzodiazepines require dosing
more frequently than long-acting benzodiazepines and may contribute to the client
connecting the feeling of being anxious with taking a pill.
7. The PMHNP should consider switching to a long-acting benzodiazepine that may be
scheduled in the a.m. and h.s. to provide better nighttime and early morning cover-
age. The NP should discuss the expected outcome of each medication with the cli-
ent. The PMHNP should increase the paroxetine dose in increments back to the dose
that was previously therapeutic (40 mg).
8. As long as he is not having considerable side effects, increase the paroxetine to 50
mg q.d. Continue weekly psychotherapy. Continue clonazepam.
9. Although benzodiazepines should be used for as brief a period as possible, discon-
tinuing the medication too quickly may result in relapse. Unless otherwise indicated
by side effects, benzodiazepine taper should begin after the client is at an adequate
dose of antidepressant and he is no longer having significant anxiety symptoms


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meta-analysis. British J of Psychiatry, (2), 93-100.
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severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62, 617–627.
Lopez, I., Rivera, F., Ramirez, R., Guarnaccia, P., Canino, G., & Bird, H. (2009). Ataques de Nervios
and their psychiatric correlates in Puerto Rican children from two different contexts. Journal
of Nervous and Mental Disease, 197 (12), 923–929.
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Annual Review of Psychology, 51, 445–479.
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CHAPTER 11
SCHIZOPHRENIA SPECTRUM AND OTHER

PSYCHOTIC DISORDERS
This chapter describes a category of severe mental illnesses that have a researched biological
basis to the disorders. Schizophrenia, the prototypic disorder of this category of illnesses, is mul-
tifaceted and affects a person’s ability to function in many spheres of daily life. Of the psychotic
disorders, schizophrenia is the illness that has been heavily researched and the one we know the
most about.
The other disorders that compose this category of illnesses will be presented after the in-depth
discussion of schizophrenia. Almost all of the information provided for schizophrenia and for the
clinical management of this disorder will pertain to the other psychotic disorders presented in
this chapter.
GENERAL DESCRIPTION OF PSYCHOTIC DISORDERS

XX These brain-based psychiatric disorders are grouped together because of similarity in
frequent psychotic symptoms. Each disorder has a different etiology.
XX Psychotic disorders are some of the most debilitating classes of psychiatric disor-
ders, as determined by the degree of functional impairment and financial burden of
severe mental illness.
XX Psychotic implies inability to test reality.
ZZ Manifests in symptoms (see Table 11–1) such as
XX Hallucinations
XX Delusions
XX Disorganized thinking and speech
XX Referential thinking
XX Abnormal motor behavior
XX Negative symptoms
XX Psychotic disorders are generally known to have a strong genetic component.
2 3 4 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition
TABLE 11–1.
SYMPTOMS OF PSYCHOSIS
CLINICAL
MANIFESTATION DEFINITION TYPE
Hallucinations False sensory (Arranged in order of commonality)
experience without Auditory
stimuli being present
Visual
Tactile
Olfactory
Gustatory
Note: Hypnogogic* and hypnopompic*
experiences are considered normative
and do not fall under the true definition of
hallucinations.
Delusions A false belief firmly Persecutory
maintained despite Religious
evidence to the
contrary Grandiose
Somatic
Jealous
Erotomanic
Disorganized Problems with Loose association
thinking (often information organization Derailment
referred to as and interpretation that
formal thought is best assessed in Speaks tangentially
disturbance or the speech patterns of Word salad
disorder) clients
Disorganized Unusual behavior Silliness
behavior ranging from childlike Unpredictable anger
silliness to anger
Difficulties with activities of daily living
Disheveled
Odd or unusual dress
Inappropriate sexual activity
Stereotypic motor activities
Referential thinking Belief that events, Thought insertion
and delusions of actions, or situations in Thought withdrawal
control the environment hold
special significance or Thought control
meaning Thought broadcasting
Illusional Misperception of actual Auditory
environmental stimuli Visual
Tactile
Olfactory
Gustatory
*Hypnopompic hallucination = a false perception that occurs when one is waking up;
hypnogogic hallucination = a false perception that occurs when one is falling asleep; both are
not considered pathological hallucinations.
Schizophrenia Spectrum and Other Psychotic Disorders 2 35
SCHIZOPHRENIA
Description
XX Schizophrenia causes significant disturbance in many areas of functioning:
ZZ Cognition
ZZ Perception
ZZ Emotion
ZZ Behavior
ZZ Eye movement
ZZ Socialization
Etiology
XX Multiple theories exist, ranging from psychological to neurobiological.
XX The etiological profile is probably multifactorial.
XX Neurobiological theory
ZZ Implicates three areas of neurobiological functioning: genetics,
neurodevelopment, and neurobiological defects
XX Genetics
ZZ Studies of twins have identified schizophrenia as having a strong
genetic component.
ZZ Incidence increases from 1% risk of illness in general population to
50% risk in monozygotic twin of a person with schizophrenia.
ZZ 15% risk in dizygotic twin of a person with schizophrenia.
ZZ 40% risk in children if both parents have schizophrenia.
ZZ No one specific gene has yet been identified.
ZZ A polygenic SNIP defect is believed to exist.
ZZ Chromosomes 6p24–22 have been implicated (Sadock, Sadock, & Ruiz,
2015).
XX Neurodevelopment
ZZ Genetic defects are believed to cause abnormal neuronal cell
development, connection, organization, and migration.
XX These include inadequate synapse formation, excessive pruning of
synapses, and excitotoxic death of neurons.
ZZ Intrauterine insults may contribute to etiological picture:
XX Prenatal exposure to toxins, including viral agents
XX Oxygen deprivation
XX Maternal malnutrition, substance use, or other illness
XX Neurobiological defect
ZZ Several abnormal brain structures have been identified in people with
schizophrenia:
XX Enlarged ventricles
XX Smaller frontal and temporal lobes
ZZ Reduced symmetry in temporal, frontal and occipital lobes
XX Cortical atrophy
XX Decreased cerebral blood flow
XX Hippocampal and amygdala reduction (Sadock, Sadock, & Ruiz,
2015).
ZZ Abnormalities lead to suspected impaired neuronal communication:
XX Suspected alterations in chemical neuronal signal transmission
ZZ Excess dopamine in mesolimbic pathway
ZZ Decreased dopamine in the mesocortical pathway
ZZ Excess glutamate
ZZ Decreased gamma-aminobutyric acid (GABA)
ZZ Decreased serotonin

XX Geographic and historical variations in incidence give insight into etiological factors;
higher rates seen in:
ZZ Urban-born
ZZ First-born
ZZ Lower socioeconomic status
ZZ Born in winter and early spring
XX Schizophrenia tends to occur less often in women than in men.
ZZ Men: Onset ages 18–25 years
XX Tend to have more negative symptoms than women
XX Tend to have poorer prognosis, more hospitalizations, and less
responsiveness to medications than women
ZZ Women: Onset ages 25–35 years
XX Usually have less premorbid dysfunction than men
XX Usually experience more dysphoria than men
XX Tend to have paranoid delusions and more hallucinations than men
XX Age of onset has pathophysiological and prognostic significance.
ZZ Earlier age of onset
XX Tend to be men
Schizophrenia Spectrum and Other Psychotic Disorders 237
XX Have poorer premorbid functioning

XX Have more evidence of structural brain abnormalities
XX Have more prominent negative symptoms
XX Have more cognitive impairment
XX Have poorer prognosis
ZZ Later age of onset
XX Tend to be women
XX Have less evidence of structural abnormalities
XX Have less cognitive impairment
XX Have better prognosis
Possible Risk Factors

XX Genetic loading
ZZ First-order relative with schizophrenia
XX Prenatal exposure to flu or virus
XX Prenatal malnutrition
XX Obstetrical complications
XX Central nervous system (CNS) infection in early childhood

ZZ Stigma reduction
onset of illness
ZZ Usually mild manifestations of criteria symptoms:
XX Odd or unusual beliefs but not to delusional proportion
XX Feel unliked or picked on but not to delusional proportion
XX Odd speech patterns but not illogical
ZZ Digressions
ZZ Tangentiality
XX Overly concrete or abstractive

XX Odd behavior but not disorganized

ZZ Collects odd or worthless items
ZZ Mumbles to self
ZZ Isolates self and avoids interaction with others
Assessment
History
ZZ There exists no single pathognomonic symptom of schizophrenia, but rather a
constellation of symptoms.
ZZ Schizophrenia is a disease of information processing.
ZZ The symptoms are behavioral and cognitive.
ZZ The illness is associated with marked social or occupational functioning.
ZZ Prominent dysfunctions exist in many spheres of daily living.
XX Interpersonal relationships
ZZ 60% to 70% of clients do not marry
XX Social or occupational functioning

ZZ “Downdrift” functionality is noted over time.
XX Lower academic achievement compared to unaffected siblings
XX Difficulty holding a job
XX Underemployed relative to intellectual capacity
XX Self-care deficits
ZZ Poor hygiene
ZZ Difficulty with financial management
ZZ Limited independent living skills
ZZ Characteristic symptom clusters for the illness (see Table 11–2) include
XX Positive symptom cluster
XX Negative symptom cluster
XX Associated symptoms
XX DSM-5 (American Psychiatric Association, 2013) diagnostic criteria for schizophrenia:
ZZ Two or more of the following frequently are present during a 1-month period and
at least one must be delusions, hallucinations, or disorganized speech:
XX Delusions: Bizarre and unorganized type; examples include delusions that
manifest as loss of control over mind or body:
ZZ Thought withdrawal
ZZ Thought insertion
TABLE 11–2.
POSITIVE AND NEGATIVE SYMPTOM CLUSTERS OF SCHIZOPHRENIA
SYMPTOM
CLUSTER EXPLANATION CLINICAL MANIFESTATIONS
Positive symptoms Symptoms that respond positively Hallucinations
to and that can be controlled by Delusions
antipsychotic medications
Referential thinking
Reflect excesses or distortions of
normal brain functioning Disorganized behavior
Caused by increased dopamine in Hostility
the mesolimbic pathway Grandiosity
Mania
Suspiciousness
Negative Symptoms less responsive Affective flattening
symptoms to antipsychotic medications Alogia or poverty of speech
but respond better to atypical
antipsychotic medications Avolition
Represent a decrease or loss of Apathy
normal functioning Abstract-thinking problems
Caused by decreased dopamine in Anhedonia
the mesocortical pathway Attention deficits
Associated Symptoms not required to be Inappropriate affect
symptoms present to diagnose the disorder Dysphoric mood
but often are present and a focus of
treatment Depersonalization
Derealization
High anxiety
XX Hallucinations: Bizarre and unorganized type; examples include

hallucinations that are improbable or readily apparent as not likely to have
occurred
XX Disorganized speech
XX Grossly disorganized behavior
XX Negative symptoms
XX Significant impairment usually is evident by social or occupational
dysfunction.
XX Duration of symptoms lasts for at least 6 months.
ZZ The course of illness is variable.
XX Many clients have a fairly stable illness course.
XX Some clients have clear episodic remissions and exacerbation periods.
XX Negative symptoms tend to appear first as the illness develops.
XX Positive symptoms appear to decrease over time, but negative symptoms
persist.
XX Negative symptoms are more debilitating.
XX Factors predictive of good prognosis:

ZZ High level of premorbid functioning
ZZ Acute onset
ZZ Later age of onset
ZZ Clear precipitating event
ZZ Married or partnered
ZZ Good support system
ZZ Positive symptoms
ZZ Short interval between treatment and onset of first symptoms
XX The sooner the client is treated, the better the prognosis.
XX Longer untreated premorbid period is associated with a poorer
prognosis.
ZZ Absence of structural brain abnormalities
ZZ Family history of mood disorders
ZZ No family history of schizophrenia
XX Subtype identification is of limited clinical value, because illness course,

response to treatment, and prognosis appear unrelated to subtype (see
Table 11–3).

XX Abnormal smooth pursuit eye movements
XX Abnormal saccadic eye movement
XX Poor eye–hand coordination
ZZ Client identified as “clumsy” or “awkward”
TABLE 11–3.
SUBTYPES OF SCHIZOPHRENIA*
SUBTYPE CHARACTERISTIC
Paranoid Prominent delusions or auditory hallucinations
Lack of prominence of disorganized speech or behavior
Disorganized Prominence of disorganized speech, behavior, and flat or inappropriate affect
Catatonic Prominence of motor symptoms, including immobility as evidenced by
catalepsy or stupor, excessive motor movement that is purposeless and not
influenced by environmental stimuli, extreme negativity, mutism, oddities of
posturing, echolalia,* and echopraxia*
Undifferentiated Presence of symptoms consistent with schizophrenia but not a prominence
of symptoms consistent with any of the other subtypes
Residual Absence of prominent delusions, hallucinations, disorganized speech,
and disorganized or catatonic behavior, and the continued presence of
disturbance as indicated by presence of negative symptoms
*
Subtypes are no longer diagnosed in the DSM-5. Echolalia = repetition of the last-heard words
of other people; echopraxia = imitation of observed behavior or movements.
XX Presence of neurological nonlocalizing “soft signs”:

ZZ Astereognosis: Loss of ability to judge the form of an object by touch
ZZ Twitches, tics, or rapid eye blinking
ZZ Dysdiadochokinesia: Impairment of the ability to perform rapidly alternating
movements
ZZ Impaired fine-motor movement
ZZ Left–right confusion
ZZ Mirroring
XX Presence of neurological localizing “hard signs”:
ZZ Weakness
ZZ Decreased reflexes
XX Other abnormalities that may be noted:
ZZ Highly arched palate
ZZ Narrow or wide-set eyes
ZZ Subtle malformations of the ears

XX Appearance
ZZ Odd
ZZ Unusual
ZZ Peculiar
XX Speech
ZZ Bizarre content
ZZ Disorganized
ZZ Tangential
ZZ Loose association
XX Affect
ZZ Blunted
ZZ Flat
ZZ Inappropriate
XX Mood
ZZ Blandness
ZZ Impoverished
XX Thought process
ZZ Psychotic
XX Hallucination
XX Delusion
XX Referential
XX Thought control, insertion, or withdrawal
XX Thought content
XX Thematically matched to psychotic content
XX May be impoverished
XX Cognition
ZZ Illogical
ZZ Disorganized
XX Orientation
ZZ Usually intact
XX Memory
ZZ May have impaired short-term
XX Concentration
ZZ Impaired during acute episodes
XX Abstraction
ZZ Concrete on formal testing
XX Judgment
ZZ Impaired for self-welfare

XX No specific diagnostic lab findings exist.
XX Abnormalities noted in structural studies
ZZ Enlargement of lateral ventricles
ZZ Widened cortical sulci
ZZ Diffuse decrease in volume of white and gray matter
ZZ Decreased volume of temporal lobe
ZZ Decreased volume in hippocampus, amygdala, and thalamus (Sadock, Sadock, &
Ruiz, 2015)
XX Abnormalities noted in functional studies
ZZ Hypofrontality
ZZ Decreased cerebral blood flow and metabolism
ZZ Diffuse hypometabolic action in cortical–subcortical circuitry
XX Nonpsychiatric disorders
ZZ Epilepsy
ZZ CNS neoplasm
ZZ AIDS
ZZ Acute intermittent porphyria
ZZ B12 deficiency
ZZ Heavy-metal poisoning
ZZ Huntington’s disease
ZZ Neurosyphilis
ZZ Systemic lupus erythematosus
ZZ Wernicke-Korsakoff syndrome
ZZ Wilson’s disease
XX Psychiatric disorders
ZZ Bipolar affective disorder
ZZ Substance-induced psychotic disorder
XX Amphetamines
XX Hallucinogens
XX Alcoholic hallucinosis
XX Barbiturate withdrawal
XX Cocaine
XX PCP (phencyclidine or angel dust)
ZZ Mood disorders with psychotic features (see Chapter 9)
ZZ Schizoaffective disorder (see below)
ZZ Schizophreniform disorder (see below)
ZZ Brief psychotic disorder (see below)
ZZ Delusional disorder (see below)
ZZ Schizotypal personality disorder (see Chapter 14)
ZZ Schizoid personality disorder (see Chapter 14)
ZZ Paranoid personality disorder (see Chapter 14)
Clinical Management
XX Assess for acuity level
ZZ During acute psychotic episodes, client may require brief hospitalization to
XX Ensure client safety,
XX Rapidly stabilize client’s symptom level in a controlled environment, and/or
XX Monitor treatment adherence with the goal of stabilization and recovery.
settings.
244
TABLE 11–4.
ATYPICAL ANTIPSYCHOTICS
DOSAGE
FORMS;
BRAND DAILY
Clozapine Clozaril Tablet or oral Common: Only drug for treatment-resistant schizophrenia
disintegrated Tachycardia, Must be enrolled in a clozapine risk evaluation and management strategy program
tablet; 25–900 drowsiness, (clozapine REMS program)
mg/d dizziness,
hypersalivation Risk for neutropenia is monitored by the absolute neutrophil count (ANC) only ,not
(sialorrhea), weight in conjunction with the white blood cell count
gain, hyperlipidemia During first 6 months: weekly; during second 6 months: every 2 weeks; then
Rare: monthly if ANC normal
Agranulocytosis, ANC levels less than 500/μl suspend drug
myocarditis, Clients can be rechallenged if the prescriber determines benefits outweigh the risks
neuroleptic
Monitor for myocarditis
malignant
syndrome Dose-related seizure risk
Significant weight gain and risk of diabetes
Rare hyperprolactinemia
Monitor weight, body mass index (BMI), waist circumference
Monitor serum lipids and glucose
Assess family and personal history of cardiovascular disease
Quetiapine Seroquel Tablet; Common: Sedation Transient and asymptomatic elevated liver function tests (LFTs)
and 50–800 mg/d and hypotension Monitor for cataract development
Seroquel (orthostatic
XR hypotension), Divided doses: b.i.d. or t.i.d.

weight gain No prolactin elevation
Rare: Cataract Monitor weight, BMI, waist circumference
formation Monitor serum lipids and glucose
Olanzapine Zyprexa, Tablet and Sedation, Significant weight gain
Zyprexa intramuscular weight gain, Monitor weight, BMI, waist circumference
Zydis, injection hyperlipidemia,
Zyprexa (acute); elevated glucose, Monitor serum lipids and glucose
Relprevv 5–20 mg/d elevated LFTs, mild Assess family and personal history of cardiovascular disease
prolactin elevation
Injection;
150–405 mg Long-acting
every 2–4 preparation
weeks (Zyprexa Relprevv)
requires that clients
be monitored for 3
hours postinjection
due to risk of
postinjection
delirium sedation
syndrome
Risperidone Risperdal, Tablet, liquid, Hypotension, Doses >6 mg associated with a higher incidence of extrapyramidal symptoms
Risperdal and orally galactorrhea, Less weight gain than with clozapine or olanzapine
Consta disintegrated nausea, insomnia
tablets; 2–8 Greatest prolactin elevation among atypical psychotics
mg Monitor weight, BMI, waist circumference
Injectable; Assess family and personal history of cardiovascular disease
25–50 mg IM
every 2 weeks
Ziprasidone Geodon Tablets; Hypotension, Requires QTc monitoring
40–200 mg/d sedation, Avoid coadministration with other drugs known to prolong QTc
dizziness Taking with food increases absorption twofold
Injectable; Rare: Prolongation Use caution when administering with clients at risk for hypokalemia,
10–20 mg of QTc interval, hypomagnesemia, after myocardial infarction, or with congestive heart failure
IM (acute skin reaction,
treatment) drug reaction with Monitor weight, BMI, waist circumference
eosinophilia and Monitor serum lipids and glucose
Schizophrenia Spectrum and Other Psychotic Disorders
systemic symptoms Assess family and personal history of cardiovascular disease

(DRESS)
24 5
CONTINUED
246
DOSAGE
FORMS;
BRAND DAILY
Paliperidone Invega, Tablets; 3–12 Orthostatic Extended-release risperidone
Invega mg/d hypotension,
Sustenna hyperprolactinemia,
(monthly GI upset, dizziness,
injection) Injection; 39 headache
mg–234 IM
Invega
Trinza
(3-month Injection every
injection) three months;
273 mg, 410
mg, 546 mg,
or 819 mg IM
Aripiprizole Abilify Tablets; 5–30 Headache, agitation, Is a partial agonist of D2 receptors

mg/d anxiety, insomnia,
somnolence,
akathisia, Monitor weight, BMI, waist circumference
Injection gastrointestinal (GI) Monitor serum lipids and glucose
(acute problems
agitation); Assess family and personal history of cardiovascular disease
5.25–15 mg
IM, (long-
acting) or
200–400 mg
IM monthly
Iloperidone Fanapt 12–24 mg/ Orthostatic Titrate slowly due to the alpha 1 antagonist properties
day in divided hypotension, Might be helpful for posttraumatic stress disorder hyperarousal symptoms due to
doses sedation, dizziness alpha 1 blocking
Monitor weight, BMI, waist circumference
Asenapine Saphris 5–10 mg Akathisia, Monitor weight, BMI, waist circumference
p.o. b.i.d. somnolence Monitor serum lipids and glucose
sublingual
Lurasidone Latuda 40–160 mg Akathisia, sedation, Should be taken with food to increase absorption
daily and nausea Use with caution at lower doses in clients with renal and hepatic impairment
Monitor weight, BMI, waist circumference
Brexpiprazole Rexulti 2–4 mg p.o. Akathisia, weight Monitor serum lipids and glucose
once daily gain Assess family and personal history of cardiovascular disease (July 2015 approval)
Cariprazine Vraylar 1.5– 6 mg p.o. EPSE, akathesia, Monitor serum lipids and glucose
daily gI upset, Assess family and personal history of cardiovascular disease (September 2015
restlessness, approval)
somnolence
Aripiprazole Aristada Once a month Akathisia Monitor serum lipids and glucose
lauroxil IM injection; Assess family and personal history of cardiovascular disease (October 2015
441 mg, 662 approval)
mg, or 882
mg
Note. All atypical antipsychotic medications have a warning: increase in mortality in older adults with dementia-related psychosis
Schizophrenia Spectrum and Other Psychotic Disorders
247
XX Pharmacological therapy is the primary treatment modality, augmented by nonphar-
macological treatments.
XX Most clients will require lifelong medication.
XX Client and family education is important for treatment adherence.
XX Adjunctive medications may be used to achieve full symptom control:
ZZ Antidepressants
ZZ Anxiolytics
ZZ Anticonvulsants
XX Atypical antipsychotics (see Table 11–4)
ZZ Primary first-line treatment agents
ZZ First introduced in the 1990s
ZZ Have fewer significant neurological side effects compared to typical
antipsychotic medication
ZZ Effectively treat positive and negative symptoms
ZZ Function as serotonin-dopamine antagonists (SDAs)
XX D2 and 5HT2a blockade
ZZ Expensive (some generics now available)
ZZ Fewer clinically significant side effects related to EPS and TD compared to
typical antipsychotics
XX Can cause extrapyramidal side effects (EPSE; see five common types in
Table 11–5) but with lower risk compared to typical antipsychotics
XX Lower incidence of tardive dyskinesia (TD; see below).
ZZ Improved compliance
ZZ Mode of action:
XX In addition to the dopaminergic blockade found in first-generation
antipsychotics, second-generation drugs capitalize on the interplay between
dopamine and serotonin. Serotonin binds to 5HT2a heteroreceptors
on dopamine (DA) neurons, thus further shutting off release of DA. By
antagonizing (blocking) the 5HT2a heteroreceptors on DA neurons, DA
release in the nigrostriatal, tuberoinfundibular, and mesocortical pathways is
enhanced.
XX Dopamine pathways: These explain both the therapeutic effects and the
side effects of the atypical antipsychotics.
ZZ Mesolimbic pathway: SDAs block dopamine in this pathway, causing
decreased positive symptoms.
ZZ Mesocortical pathway: SDAs increase dopamine in this pathway,
causing decreased negative symptoms.
TABLE 11–5.
EXTRAPYRAMIDAL SIDE EFFECTS (EPSE)
SIDE EFFECT DEFINITION

Akathisia Motor restlessness; inability to remain still; rocking, pacing, or constant
motion of unilateral limb; also can manifest as a subjective sense of
restlessness without objective finding
Note: Often mistaken for increasing anxiety
Akinesia Absence of movement, difficulty initiating motion, subjective feeling of
lack of motivation to move
Note: Often mistaken for laziness or lack of interest
Dystonia Muscle spasm; spasticity of muscle group, especially back or neck
muscles; subjectively painful
Note: Often mistaken for agitation or unusual, stereotypic movements
characteristic of schizophrenia
Pseudo-Parkinson’s Presence of symptoms of Parkinson’s disease produced by D2 blockade;
includes shuffling gait, motor slowing, mask-like facial expression, pill-
rolling, tremors, and muscle rigidity
Note: Mask-like facial expression often confused as affective blunting or
flattening
Tardive dyskinesia Involuntary abnormal muscle movement of the mouth, tongue, face,
and jaw that may progress to limbs; can be irreversible; can occur as an
acute process at initiation of medications or as a chronic condition at any
point in treatment
ZZ Nigrostriatal pathway: Dopamine has a reciprocal relationship with

acetylcholine (ACh). When serotonin is blocked by the SDA, dopamine
increases; therefore, ACh decreases, which causes decreased EPSE.
(EPSE is caused by increased ACh.)
ZZ Tuberoinfundibular pathway: Dopamine inhibits prolactin. The blockade
of dopamine by SDAs cause prolactin to increase, causing galactorrhea
and gynecomastia.
XX Hyperprolactinemia associated with the antipsychotics may cause
sexual problems, galactorrhea, amenorrhea, gynecomastia, and
bone demineralization in postmenopausal women not on estrogen.
XX Typical antipsychotics (first-generation; see Table 11–6)

ZZ Cross-classified as neuroleptics because of significant side effects
ZZ First introduced in the 1950s
ZZ Useful for treating positive symptoms by blocking dopamine in the mesolimbic
pathway
ZZ Can make negative symptoms worse by blocking dopamine in the mesocortical
pathway
ZZ Therapeutic effect related primarily to D2 receptor blockade
ZZ Generic (inexpensive)
ZZ Can be used as sustained-released injectable agents
XX Decanoate long-acting injectable dose forms of typical antipsychotics:

ZZ Prolixin-D (limited availability due to low production)
ZZ Haldol-D
TABLE 11–6.
TYPICAL ANTIPSYCHOTICS
BRAND DOSAGE FORMS;
AGENT NAME DAILY DOSAGE SIDE EFFECTS COMMENTS
Chlorpromazine Thorazine Tablet, SR, liquid; High: Sedation, Allergic dermatitis
50–2,000 mg/d hypotension Photosensitivity
Moderate: EPSE, ECG changes—QTc
anticholinergic monitoring
Mesoridazine Serentil Tablet, liquid, High: Anticholinergic, ECG changes—QTc
injection; 100–400 sedation, hypotension monitoring
mg/d Low: EPSE
Thioridazine Mellaril Tablet, liquid; 50–800 High: Anticholinergic, ECG changes—QTc
mg/d sedation, monitoring
hypotension, Irreversible retinal
prolonged QT interval pigmentation at
Low: EPS doses >800 mg/d
Decreased libido
Retrograde
ejaculation
Fluphenazine Permitil Tablet, liquid, Very high: EPSE
Prolixin injection; 2–40 mg/d, Low: Anticholinergic,
12.5–75 mg/IM every sedation, hypotension
2 weeks (decanoate)
Perphenazine Trilafon Tablet, liquid, High: EPSE
injection; 8–64 mg/d Low: Anticholinergic,
sedation, hypotension
Trifluoperazine Stelazine Tablet, injection; 5–80 High: EPSE
mg/d Low: Anticholinergic,
Haloperidol Haldol Tablet, liquid, Very high: EPSE In older adults,
injection; 2–40 mg/d, High: Anticholinergic, monitor for oculogyric
50–300 mg IM, every sedation crisis and pneumonia
month
Low: Hypotension
(decanoate)
Loxapine Loxitane Capsule, liquid; High: EPSE
20–250/d Moderate: Sedation,
hypotension
Low: Anticholinergic
Molindone Moban Tablet, liquid; 50–225 High: EPSE Little or no weight
mg/d Low: Anticholinergic, gain
hypotension
Very low: sedation
Thiothixene Navane Capsule, liquid, High: EPSE
injection ; 5–60 mg/d Low: Anticholinergic,
ZZ High potency: Have a greater risk of EPSE but less risk of sedation and
anticholinergic symptoms
ZZ Low potency: Have a greater risk of sedation and anticholinergic side effects but
less risk of EPSE
ZZ Caffeine and nicotine cause diminished antipsychotic effect; dose may need to
be higher
TABLE 11–7.
MEDICATIONS USED TO TREAT EPSE
EFFECTIVE DRUG; PSEUDO- TARDIVE

CROSS-CLASSIFICATION AKINESIA AKATHISIA DYSTONIA PARKINSON’S DYSKINESIA
Cogentin X X X X
(benztropine) 0.5 mg–2 mg
p.o. t.i.d.;
Anticholinergic
Kemadrin X X X X
(procyclidine) 2.5 mg–5 mg
p.o. b.i.d.–q.i.d.;
Anticholinergic Best
Artane X X X X treatment
(trihexyphenidyl) 2–5 mg strategy is
p.o. t.i.d.; prevention
through
Anticholinergic careful
Benadryl X X X monitoring.
(diphenhydramine) 25 mg
p.o. q.i.d.;
Antihistamine
Symmetrel X X
(amantadine) 100–200 mg
p.o. b.i.d.;
Dopamine agonist
Inderal X
If present,
(propranolol) 20–40 mg p.o.
treat by
t.i.d.;
reducing
Beta blocker current dose,
Catapres X or change
client to
(clonidine) 0.1 mg p.o. t.i.d.; atypical
Alpha 2 agonist agent.
Klonopin X X
(clonazepam) 1 mg p.o.
b.i.d.;
Benzodiazepine
Ativan X X
(lorazepam) 1 mg p.o. t.i.d.;
Benzodiazepine
ZZ Because of multiple clinically significant side effects, are not considered first-line
treatment agents
XX Side effects leading to poor adherence
XX High client teaching needs
XX EPSE most common side effect (see Table 11–6)
ZZ Caused by D2 receptor antagonism (when dopamine receptors are
blocked, ACh increases, which causes EPSE; a reciprocal relationship
exists between ACh and dopamine)
ZZ Treated by use of anti-Parkinson drugs (cross-classified; see Table 11–7)
XX Anticholinergics
XX Antihistamines
XX Dopamine agonists
XX Benzodiazepines (BNZs)
ZZ Tardive dyskinesia (TD)
XX TD is a potentially irreversible movement disorder that may
occur in people who are treated for more than 1 year with typical
antipsychotics.
XX Symptoms consist of abnormal, involuntary movements such as
lip smacking, chewing, tongue protrusion, or twisting movements
of the trunk or limbs.
XX Perioral movements are most common.
XX Treatment involves discontinuation of the offending agent and
often starting an atypical antipsychotic.
ZZ Clients on typical antipsychotics should have routine abnormal involuntary

muscle movement screening (see below) every 6 months.
XX Client and family education on the detection of early signs and symptoms
of abnormal movements
XX If abnormal movements are noted, consider reducing the dosage or
switching to an atypical antipsychotic.
XX Risk factors include
ZZ Long-term treatment with neuroleptics
ZZ Older age
ZZ Female gender
ZZ Presence of mood or cognitive disorder
XX Assessment of abnormal movement rating scales

ZZ Abnormal Involuntary Movement Scale (AIMS)
ZZ Dyskinesia Identification System Condensed User Scale (DISCUS)
ZZ Simpson-Angus Rating Scale (SAS)
XX Neuroleptic malignant syndrome (NMS)

ZZ Rare but potentially life-threatening
ZZ Can occur at any point during treatment
ZZ Most common with typical but has been reported with atypical
antipsychotics
ZZ Risk factors include
XX Rapid dose escalation
XX Use of high-potency typical antipsychotic
XX Parenteral administration of antipsychotics
ZZ Assess for the following abnormal labs:
XX Elevated CPK (creatine phosphokinase)
XX Elevated WBCs (white blood cell count)
XX Elevated LFTs (liver function tests)
ZZ Assess for symptoms known to occur first:
XX Altered sensorium
XX Hyperthermia
XX Hyperreflexia
ZZ Assess for symptoms of autonomic instability:
XX Hypotension
XX Extreme muscular rigidity
XX Hyperthermia
XX Tachycardia
XX Diaphoresis
XX Tachypnea
XX Coma and potentially death
XX Treatment
ZZ Seek immediate medical care for treatment
ZZ Discontinue antipsychotic medication(s)
ZZ Administration of Dantrium (dantrolene) or Parlodel (bromocriptine) for
antipsychotic inducted dopamine receptor blockade
ZZ Antipyretic (Acetaminophen) and cooling blanket for hyperthermia
ZZ Intravenous hydration
ZZ Benzodiazepine for muscular rigidity (catatonic symptoms)
ZZ Other common side effects related to effects on receptors other than dopamine:
XX Alpha adrenergic blockade
ZZ Cardiovascular side effects
ZZ Orthostatic hypotension
XX Muscarinic cholinergic blockade

ZZ Dry mouth
ZZ Blurred vision
ZZ Constipation
ZZ Urinary retention
XX Endocrine side effects

ZZ Weight gain
ZZ Increased prolactin levels
XX Neurological side effects

ZZ Lowering of seizure threshold
XX Other side effects

ZZ Photosensitivity
ZZ Agranulocytosis
XX Individual therapy
ZZ Usually supportive rather than insight-oriented
XX Focuses on establishing reality testing
XX Builds daily-life skills
XX Assists client in establishing and meeting life goals
ZZ Cognitive behavioral therapy (CBT) for management of hallucinations and delusions.
XX Group therapy
ZZ Focuses on problem-solving
ZZ Focuses on education
XX Medication groups
XX Life skills groups
XX Proactive crisis management planning to deal with potential relapse needs
ZZ Identify symptom triggers.
ZZ Identify symptoms that indicate relapse.
ZZ Identify past pattern of relapse to help predict future relapses.
ZZ Identify self-care interventions.
ZZ Identify point at which professional intervention is required.
ZZ Identify support network of family and friends.
ZZ Identify other resources to be mobilized when symptom level increases.
XX Assertive community treatment (ACT)
ZZ Evidence-based case management program
ZZ Multidisciplinary treatment team
XX Illness management recovery (IMR)

ZZ Evidence-based recovery program
XX Education modules
ZZ Recovery strategies, information on mental illness, building supports, using
medication, drugs and alcohol, coping, reducing relapse, mental health system,
advocacy, and stress-vulnerability model (Whitley, Gingerick, Lutz, & Mueser, 2009).
XX Milieu therapy
ZZ Provides for structure and safety needs
ZZ Provides socialization and interpersonal support
ZZ Encourages independency
XX Client and family education
ZZ Explain underlying pathology of illness.
ZZ Discuss signs and symptoms.
ZZ Assist in identifying strategies for living with illness.
ZZ Assist in understanding and making decisions about care options.
ZZ Develop relapse prevention plan.
ZZ Promote overall health.
XX Rates of substance abuse and dependency are high.
ZZ 20% to 40% comorbidity
XX Nicotine dependence is especially high.
ZZ 80% to 90% comorbidity
ZZ Tend to use cigarettes with highest nicotine content
XX Drug interaction with antipsychotic medications
ZZ May need to reduce doses when client quits or cuts back.
XX Other common psychiatric comorbidities are anxiety disorders (see Chapter 10),
especially panic disorder and obsessive–compulsive disorder.

XX Schizophrenia is significantly associated with shorter-than-expected life span when
compared to the general population.
XX Persons with a severe mental illness (SMI) prematurely lose 10 to 25 years of life
compared to the general population.
ZZ Reasons are unclear but may include overall general lack of routine health care
and high levels of comorbidity (see below)
XX Suicide
ZZ Suicide rates are high; assess for suicidal ideations at every visit.
ZZ 10% commit suicide.
ZZ 20% to 40% attempt suicide.

ZZ Known risk factors for suicide include
XX Male gender
XX Ages 45 or younger
XX Presence of depressive symptoms
XX Hopelessness
XX Unemployed
XX Noncompliance
XX Recent hospitalization
XX Postpsychotic period
XX Comorbid substance abuse
XX General medical illnesses
ZZ Clients need access to ongoing primary care.
ZZ High rates of cardiometabolic illnesses
ZZ Monitor client for development of metabolic syndrome, diabetes, hypertension,
hyperlipidemia, respiratory illnesses, and cardiac illnesses.
XX Monitor weight gain, lipids, and blood glucose.
XX Provide weight management and nutritional assistance.
XX Use the body mass index (BMI) as the accepted standard for determining if a
client’s weight places him or her at risk of developing serious health problems.
XX BMI categories
ZZ Underweight: BMI 18.5 or less
ZZ Normal weight: BMI 18.5–24.9
ZZ Overweight: BMI 25.0–29.9
ZZ Obese: BMI 30.0–39.9
ZZ Severely obese: BMI 40 and higher.
XX Risks related to BMI

ZZ Clients who are overweight to obese as determined by BMI have
XX 2.9 times increased risk for diabetes
XX 2.9 times increased risk for hypertension
XX 2.1 times increased risk of coronary artery disease
XX 3.0 times increased risk for endometrial cancer
XX 2.7 times increased risk for colon cancer

XX Children
ZZ Hallucinatory and delusional content less rich, elaborate, and bizarre
ZZ Visual hallucinations more common than auditory
XX Older adults
ZZ More women than men with rare late onset
ZZ Although exhibiting prodromal social isolation, are more often married
ZZ Prognosis usually better; more responsive to medications due to dominance of
positive symptom cluster (see below)
ZZ Black box warning on all atypical antipsychotic medications: increase in mortality
in older adults with dementia-related psychosis
ZZ Risk factors
XX Postmenopausal states
XX Presence of human leukocyte antigen
XX Positive family history
ZZ Symptoms
XX Predominance of positive symptoms
XX High levels of persecutory delusions and hallucinations
XX Lower levels of disorganized behavior
XX Preservation of social and occupational interest
XX Fewer negative symptoms
Follow-up
XX Chronic illness
ZZ Usually requires lifelong treatment
ZZ Case management necessary to coordinate aspects of care.
XX Relapse periods
ZZ Develop relapse plan with client and family.
XX Multiple health needs
ZZ Perform frequent assessment of general health status.
ZZ Address comorbid nicotine addiction.
XX Preventative care
ZZ Monitor routine labs to screen for complications of treatment:
XX Serum glucose and lipid panels
XX Weight, BMI, and waist-to-hip ratio
XX Liver and kidney function (based on medication)
XX Complete blood count
XX American Diabetes Association, American Psychiatric Association, American
Association of Clinical Endocrinologists, & North American Association for
the Study of Obesity ADA APA SGA Guidelines (2004)
XX Perform annual eye exam if on typical antipsychotic agent or Seroquel
(quetiapine)
ZZ Clinical outcome measures

XX Standardized rating scales include:
ZZ Positive and Negative Syndrome Scale (PANNS)
ZZ Brief Psychiatric Rating Scale (BPRS)
ZZ Scale for Assessment of Positive Symptoms (SAPS)
ZZ Scale for Assessment of Negative Symptoms (SANS)
SCHIZOPHRENIFORM DISORDER
Description
XX Closely resembles schizophrenia
XX Two differences from schizophrenia:
ZZ Total duration of the illness is at least 1 month but less than 6 months, including
prodrome, active illness period, and residual symptom phase
ZZ Does not require impaired social or occupational functioning for diagnosis,
although these may be present
Etiology
XX Similar to schizophrenia
Demographics
XX Little is known
XX Fivefold increase in men than women
XX Lifetime prevalence rate of 0.11 percent
Risk Factors

XX Identification of individuals at high risk and monitoring
XX Relative with Schizophrenia and Bipolar Disorder
Assessment
History
ZZ Two or more of the following frequently present during a 1-month period

XX Delusions
XX Hallucinations
XX Presence of negative symptoms
ZZ Duration of symptoms for at least 1 month and for no longer than 6 months
ZZ Almost all information provided for schizophrenia pertains to this disorder,
except:
XX Occurs much less often than schizophrenia; incidence is 0.03% of general
U.S. population.
XX Approximately one-third recover completely within 6 months.
XX Remaining two-thirds develop schizophrenia or schizoaffective disorder (see
below).



ZZ Similar to schizophrenia
Clinical Management
XX Assess for acuity level.
XX During acute psychotic or affective episodes, client may require brief hospitalization
to
ZZ Ensure client safety.
ZZ Rapidly stabilize client’s symptom level in a controlled environment.
ZZ Ensure client compliance with treatment to reach stabilization.
settings.
Follow-up
SCHIZOAFFECTIVE DISORDER
Description
XX An uninterrupted period of illness in which the person experiences psychotic symp-
toms similar to those seen in schizophrenia as well as mood symptoms similar to
major depressive disorder (MDD) or bipolar (BP) disorder (see Chapter 9).
Etiology
XX Cause is unknown
XX The disorder may be a psychotic spectrum disorder, mood spectrum disorder, or both
Prevalence and Demographics

XX Less than 1%.
XX Equal number males and females.
XX Depressed type of the disorder is more common in older persons.
XX Men with the disorder tend to exhibit more antisocial behaviors.
Risk Factors
XX Family history of schizophrenia or bipolar disorder

XX Screening persons with a positive family history
Assessment
History
XX Symptoms of schizophrenia—two or more of the following frequently present during
a 1-month period:
ZZ Delusions
ZZ Hallucinations
ZZ Disorganized speech
ZZ Grossly disorganized behavior

ZZ Presence of negative symptoms but usually less severe than those in
schizophrenia
XX Symptoms of one or more of mood disorders (see Chapter 9):
ZZ Major depressive episode
ZZ Manic episode
ZZ Mixed-mood episode
XX Presence of delusions or hallucinations for at least 2 weeks in the absence of promi-
nent mood symptoms
XX Subtypes
ZZ Two subtypes differentiated by type of mood-related symptoms:
XX Depressive: When prominent mood symptoms are of the depressive type
only
XX Bipolar: When predominant mood symptoms are manic or mixed type



Clinical Management
XX Similar to MDD or BP disorder (see Chapter 9)
Follow-up
DELUSIONAL DISORDER
Description
XX Presence of one or more nonbizarre delusions lasting for at least 1 month
XX Psychosocial functioning and daily behavior not at all impaired except as they sur-
round content of delusion
XX Seldom any other symptoms; in rare cases may have hallucinations or mood
disturbances
Etiology
XX Cause is unknown

XX 0.2% to 0.3% of population in the United States
XX Mean onset is about 40 years of age
XX Men are more likely to have paranoid delusions
XX Women are more likely to have delusions of erotomania
Risk Factors
XX Person with disorders of the limbic system and basal ganglia

XX Unknown
Assessment
History
ZZ Presence of delusions
XX Well-organized and potentially believable
XX Any unusual behavior is explainable if content of delusion understood
ZZ Subtypes (categorized by thematic content of delusion)
XX Erotomanic
ZZ Delusional content focused on false belief that another person is in
love with the client
ZZ Usually focused on idealized or spiritual love and only infrequently has
strong sexual content
ZZ Focus of love usually a famous or powerful person who does not

usually know the client
XX In rare cases, person may know client
ZZ Leads to obsessive behaviors such as surveillance or stalking
XX Grandiose
ZZ Delusional content focuses on the client having some great talent, skill,
or knowledge
ZZ May have strong religious component, such as prophecy or deity
connections (special connection to God)
XX Jealous
ZZ Delusional content focuses on false belief that client’s spouse or
partner is being unfaithful with someone else.
ZZ Belief has no connection with realistic evidence.
ZZ Usually seen in men.
ZZ Client may try to control behavior of spouse or partner in an attempt to
prevent imagined infidelities.
XX Persecutory
ZZ Delusional content focuses on clients’ belief that others are out to
harm them, spy on them, or otherwise do them harm
ZZ Often angry and hostile at perceived persecution
XX Somatic
ZZ Delusional content focuses on bodily functions and sensations
ZZ Often belief that a body part is infected, absent, emits a strange odor,
or is misshapen or malformed.
XX Mixed
ZZ No clear predominant theme for the delusional content
ZZ Related symptoms that can be present but are not required for diagnosis include
XX May become depressed over protracted problems with thematic content
XX May become involved in legal difficulties related to behaviors based on
delusional content
XX May be subjected to or request unnecessary medical tests and procedures

XX Nonspecific

XX Normal except for delusions
ZZ Abstraction
XX May be concrete on proverbs during delusional episodes
ZZ Thought process
XX Presence of delusions
XX Perseveration on topics related to delusion
ZZ Thought content
XX Thematic for type of delusion

XX Nonspecific
Clinical Management
BRIEF PSYCHOTIC DISORDER

Description
XX Disorder with sudden onset of psychotic symptoms lasting at least 1 day but less
than a month
Etiology
XX Unknown cause

XX Unknown incidence
XX Occurs more in younger clients (20 to 30 years of age)
Risk Factors
XX Family history of psychotic disorder

XX Unknown
Assessment
History
ZZ Age of onset in adolescence or early adulthood
ZZ Positive-type psychotic symptoms:
XX Delusions
XX Hallucinations
ZZ Can occur with or without identified stressor
ZZ Person always returns to premorbid level of functioning

XX Nonspecific


XX Nonspecific
Clinical Management
XX Acute episode requires frequent monitoring for safety needs because of the
following:
ZZ Confusion
ZZ Rapid shifting in emotions
ZZ Impaired judgment
ZZ Inability to meet nutritional and hygiene needs
SHARED PSYCHOTIC DISORDER (FOLIE Á DEUX)

Description
XX Characterized by development of a delusion in a client who has a close relationship
with another person who already has a psychotic disorder with a prominent delusion
Etiology
XX Cause is unknown

XX Unknown
Risk Factors
XX Unknown

XX Unknown
Assessment
History
ZZ Client in close contact with a person who already has a delusion and
XX That person usually has schizophrenia.
XX That person usually is the dominant person in the relationship.
XX That person gradually imposes his or her delusion on the client.
XX Usually the relationship is long-term and very close.
ZZ Aside from the delusional content, the client’s behavior is otherwise normal.

XX Nonspecific


XX Nonspecific
Clinical Management
XX Chronic disease course

XX Poor prognosis if relationship continues, especially if person with delusion goes
untreated
XX Good prognosis if the client can be separated from person with the delusion
CASE STUDY
Casey is a 23-year-old client who has been recently diagnosed with schizophrenia. He experi-
enced his first psychotic break at age 22 while serving in the military. Casey lives at home with
his parents and is reluctant to accept his diagnosis, stating “I got bad weed” in the service and
“will be fine once the weed leaves my body.” He has been adherent with appointments but only
intermittently takes his Risperdal (3 mg p.o.) twice a day. His parents are threatening to kick him
out of the house if he does not start accepting treatment.
Casey has a history of juvenile-onset diabetes and has struggled to maintain a diabetic diet and
to control his weight. When asked to identify his current goals, Casey wishes to find a good wife,
have children, and settle down to a normal life. There are many issues to consider in planning
care with this client.
1. What is the top priority for the psychiatric–mental health nurse practitioner
(PMHNP)?
2. What medications changes would the PMHNP consider for Casey?
3. What is the relationship between his diabetes and schizophrenia?
4. How will his comorbid illness affect the PMHNP’s care planning?
5. What routine ongoing monitoring will he require?

1. The top priority for the PMHNP is to build a therapeutic alliance with Casey
2. Medication changes appropriate for Casey include switching to an alternative atypical
antipsychotic medication that has a lower risk for weight gain and elevated glucose
levels
3. The relationship between diabetes and schizophrenia is that individuals with schizo-
phrenia have a twofold increase of developing diabetes which is considered an
independent risk factor.
4. Because clients with schizophrenia are at high risk for developing cardiometabolic
illness as comorbidities, the care plan must address both his physical health, specifi-
cally his diabetes management, and his mental health.
5. The routine monitoring required for Casey includes ongoing monitoring for atypi-
cal antipsychotic medication should include serum glucose or A1c, lipid profile, and
complete blood count, weight, height, body mass index.

American Diabetes Association, American Psychiatric Association, American Association of
Clinical Endocrinologists, & North American Association for the Study of Obesity. (2004).
Consensus development conference on antipsychotic drugs and obesity and diabetes.
Diabetes Care, 27(2), 596–601.
Rector, N. A., & Beck, A. (2002). A clinical review of cognitive therapy for schizophrenia. Current
Psychiatric Reports, 4, 284–292.
Richardson, C., Faulkner, G., McDevitt, J., Skrinar, G., Hutchinson, D., & Piette, J. (2005).
Integrating physical activity into mental health services for persons with serious mental ill-
ness. Psychiatric Services, 56(3), 324–331.
Sable, J. A. (2002). Antipsychotic treatment for late-life schizophrenia. Current Psychiatric
Reports, 4, 299–306.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry:
Staal, W. G., Hulshoff Pol, H., Schnack, G., van Haren, N. E., Seifert, N., & Kahn, R. (2001).
Structural brain abnormalities in chronic schizophrenia at the extremes of the outcome spec-
trum. American Journal of Psychiatry, 158, 1140–1142.
Stahl, S. M. (2014). The prescriber’s guide Stahl’s essential psychopharmacology (5th ed.). New
York, NY: Cambridge University Press.
Tamminga, C. (2001). Treating schizophrenia now and developing strategies for the next decade.
CNS Spectrums, 6, 987–991.
Tandon, R., & Jibson, M. D. (2001). Pharmacologic treatment of schizophrenia: What the future
holds. CNS Spectrums, 6, 980–986.
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Safety Communication: FDA is investigating two deaths following injection of long-acting
antipsychotic Zyprexa Relprevv (olanzapine pamoate). Retrieved from www.fda.gov/Drugs/
DrugSafety/ucm356971.htm
Whitley, R., Gingerich, S., Lutz, W., & Mueser, K. (2009). Implementing the illness manage-
ment and recovery program in community mental health settings: Facilitators and barriers.
Psychiatric Services, 60(2), 202–209.
CHAPTER 12
NEUROCOGNITIVE DISORDERS
Cognitive disorders often are thought of as disorders of older adults. Although most common
in this population, cognitive disorders can occur at any age. Very young or very old people with
cognitive disorders have multiple health needs. Older adult clients usually have more than one
chronic illness, and psychiatric disorders can be accompanied by other comorbidities.
Psychiatric–mental health nurse practitioners (PMHNPs) must approach clients with cognitive
disorders by conducting a multisystem assessment.
COGNITIVE DISORDERS
Description
XX Cognitive disorders cause a clinically significant deficit in cognition that represents a
major change from the person’s previous baseline level of functioning.
XX Two common disorders are
ZZ Delirium
ZZ Dementia
Etiology
XX Cognitive disorders are a complex general medical condition resulting in changes
in multiple domains including memory, interpersonal relationships, and behavior.
Cognitive disorders can result from injury, medical condition, substance use or
abuse, a reaction to medications or other ingested agents, or a combination of some
or all of these factors.
DELIRIUM
Description
XX Delirium is a syndrome and not a disease, with an acute onset that causes short-
term changes in cognition.
XX The hallmark symptom is a disturbance of consciousness accompanied by changes

in cognition.
XX Subtypes of delirium
ZZ Hyperactive: Agitated, restless, hyperalert
ZZ Hypoactive: Lethargic, slowed, apathetic
ZZ Mixed: Cycles between hyperactive and hypoactive
Etiology
XX Due to changes in one of the following:
ZZ General medical condition
ZZ Substance induced
ZZ Multiple physical health problems
ZZ Medication, sleep deprivation, or other causes

XX Common, especially in older adults
XX Often overlooked and mistaken for other medical conditions or dementia
XX In persons with psychiatric disorders, often mistaken for worsening of psychotic
symptoms instead of a distinct condition
XX Prevalence varies based on age, client setting, and sample
ZZ Highest in hospitalized older adults
ZZ 0.4% in general U.S. population ages 18 years or older
ZZ 1% to 2% in those ages 65 or older
ZZ 6% to 56% of hospitalized clients
ZZ 15% to 53% in postoperative older adults
ZZ 70% to 87% of older adults in the intensive care unit
ZZ 60% in nursing home patients
ZZ 25% in clients with cancer
ZZ 80% in terminal clients nearing death
XX Poor prognosis
ZZ 1 year mortality rate of clients with delirium is up to 40%
Risk Factors
XX Advancing age
XX Multisystem medical illness
ZZ The more physically ill the client, the higher the risk.
Neurocognitive Disorders 273
XX Substance abuse
XX Visual or hearing impairment
XX Past episode of delirium or preexisting brain disorder or cognitive impairment

ZZ Stigma reduction
XX Use of the Confusion Assessment Method (CAM) instrument
ZZ Whenever a client’s clinical presentation changes rapidly from baseline, consider
delirium as one possible differential diagnosis.
Assessment
History
ZZ Key findings
XX Disturbance of consciousness develops over a short time, usually hours to
days.
XX This disturbance tends to fluctuate during the day.
ZZ Sleep–rest cycle disturbances
XX Reversal of the sleep–wake cycle is common: clients are awake at night and
sleep during the day.
ZZ Impaired recent and intermediate memory
ZZ Psychomotor agitation
XX The client exhibits purposeless, random actions.
ZZ Course of illness may resolve within hours to days
XX The more quickly the underlying physiological disturbance is recognized and
treated, the more rapidly the delirium will resolve.
XX Symptoms, when unrecognized, may persist for months.
XX Most symptoms resolve within 3 to 6 months.

XX Evidence that significant clinical symptoms are a consequence of direct physiological
processes, substance use or abuse, or general medical condition
XX Usually nonspecific neurological abnormalities

ZZ Tremors
ZZ Incoordination
ZZ Urinary incontinence
ZZ Myoclonus
ZZ Nystagmus
ZZ Asterixis—a flapping motion of the wrists
ZZ Increased muscle tone and reflex

XX General appearance
ZZ Unconcerned with appearance
ZZ Disheveled
ZZ Highly inattentive
XX Speech
ZZ Impaired
ZZ Disorganized
ZZ Rambling
ZZ Incoherent
ZZ Slurred
XX Affect
ZZ Rapid, unpredictable shifts in affective state without known precipitation
XX Lethargic
XX Agitated
XX Mood
ZZ Difficult to elicit from client
XX Thought process
ZZ Disorganized
ZZ Distractible
ZZ Perceptual disturbances
XX Illusions most common
XX Hallucinations are typically visual and accompanied by illusions
XX Thought content
ZZ Disorganized, distorted thought
ZZ Delusions and hallucinations are common.
XX Orientation
ZZ Disorientation is usually the first symptom to appear
ZZ Client usually disoriented to time and place

XX Memory
ZZ Impaired recent and immediate memory
XX Concentration
ZZ Grossly impaired
XX Abstraction
ZZ Grossly impaired
XX Judgment
ZZ Grossly impaired

XX Findings consistent with underlying physiological etiology
XX Workup includes standard tests
ZZ Blood chemistry
ZZ Complete blood count (CBC)
ZZ Thyroid function tests
ZZ Syphilis
ZZ Human immunodeficiency virus (HIV) antibody test
ZZ Urinalysis
ZZ Chest radiograph
ZZ Serum or urine drug screen
XX Electroencephalogram (EEG) abnormalities
ZZ Generalized slowing
ZZ Generalized increased activity if delirium is related to alcohol withdrawal
XX Dementia (see below)
XX Substance intoxication or withdrawal (see Chapter 13)
XX Schizophrenia (see Chapter 11)
XX Schizophreniform disorder (see Chapter 11)
XX Mood disorders with psychotic features (see Chapter 9)
Clinical Management
XX Undertake treatment of underlying condition or disorder.
XX Avoid the use of new medications whenever possible, because using them can
cloud the diagnostic picture.
XX Symptomatic treatment
XX Agitation and psychotic symptoms
ZZ Antipsychotic agents
XX Haloperidol (Haldol)
XX Atypical antipsychotic agents
XX Anxiolytic agents for insomnia
XX Monitor for safety needs.
XX Determine reality orientation frequently.
XX Pay attention to basic needs:
ZZ Hydration
ZZ Nutrition
XX Client should be neither sensory-deprived nor overstimulated.
XX It is helpful to have in the client’s room familiar people; familiar pictures or decora-
tions; a clock or calendar; and regular orientation to person, place, or time.

XX Delirium is associated with high morbidity and mortality.
XX High morbidity results from injury or its associated problems related to inactivity:
ZZ Pneumonia
ZZ Hydration and nutritional deficits
XX Safety concerns exist.
XX Mnemonic: DELIRIUM (Dick & Morency, 2011)
ZZ Drugs
ZZ Electrolyte abnormality
ZZ Low oxygen saturation
ZZ Infection
ZZ Reduced sensory input
ZZ Intracranial
ZZ Urinary or renal retention
ZZ Myocardial

XX Children
ZZ Especially susceptible
ZZ Related to immature brain development
Neurocognitive Disorders 27 7
ZZ Often mistaken for uncooperative behavior

XX If a child is not soothed by common methods (e.g., parental presence),
delirium is suspected.
ZZ Most common in febrile states
ZZ Medications known to affect cognition
XX Especially common with anticholinergic medications
XX Older adults
ZZ Susceptibility related to physiological changes of aging
ZZ Older men more prone than older women for unknown reasons
DEMENTIA
Description
XX Dementia is a group of disorders characterized by gradual development of multiple
cognitive deficits:
ZZ Impaired executive functioning
ZZ Impaired global intellect with preservation of level of consciousness
ZZ Impaired problem-solving
ZZ Impaired organizational skills
ZZ Altered memory
XX Various forms of dementia share common symptoms but have different underlying
pathology.
ZZ Dementia of Alzheimer’s type (DAT)
XX Most common type
XX Gradual onset and progressive decline without focal neurological deficits
XX Hallmark amyloid deposits and neurofibrillary tangles
ZZ Vascular dementia (VD)
XX Second most common type
XX Formerly called multi-infarct dementia
XX Primarily caused by cardiovascular disease and characterized by step-type
declines
XX Most common in men with preexisting high blood pressure and
cardiovascular risk factors
XX Hallmarks: carotid bruits, fundoscopic abnormalities, and enlarged cardiac
chambers
ZZ Dementia due to HIV disease
XX Classified as a subcortical dementia.
XX Parenchymal abnormalities visualized on magnetic resonance imaging (MRI)
scan.
XX HIV-associated neurocognitive disorder or HIV encephalopathy are less

severe forms.
XX HIV can cause many psychiatric symptoms.
XX Manifests by progressive cognitive decline, motor abnormalities, and
behavioral abnormalities.
XX Co-occurs with obsessive–compulsive disorder, posttraumatic stress
disorder, generalized anxiety disorder, depression, and mania.
XX Development of dementia in client with HIV is an indicator of poor
prognosis; death usually occurs within 6 months.
XX Psychotic symptoms usually occur in late-stage infection.
XX Clinical signs of late-stage HIV-related dementia include cognitive, motor,
behavioral, and affective impairment:
ZZ Global cognitive impairment
ZZ Mutism
ZZ Seizures
ZZ Hallucinations
ZZ Delusions
ZZ Apathy
ZZ Mania
XX Antiretrovirals and protease inhibitors can interact with psychotropic medications,

because many are metabolized by the P450 system or are CYP3A4 inhibitors.
Therefore, prescribing psychotropic medications in this client population should
be done with caution while monitoring for drug interactions.
ZZ Pick’s disease
XX Also known as frontotemporal dementia
XX Neuronal loss, gliosis, and Pick’s bodies present
XX More common in men
XX Personality and behavioral changes in early stage
XX Cognitive changes in later stages
XX Kluver-Bucy syndrome: hypersexuality, hyperorality, and placidity
ZZ Creutzfeldt-Jakob disease
XX Fatal and rapidly progressive disorder
XX Occurs mainly in adults in middle age or older
XX Initially manifests with fatigue, flulike symptoms, and cognitive impairment
XX Later manifests with aphasia, apraxia, emotional lability, depression, mania,
psychosis, marked personality changes, and dementia
XX Death usually occurs within 6 months.
ZZ Huntington’s disease
XX Subcortical type of dementia
XX Characterized mostly by motor abnormalities (e.g., choreoathetoid movements)

XX Psychomotor slowing and difficulty with complex tasks
XX Memory, language, and insight usually intact until late stages
XX High incidence of depression and psychosis
ZZ Lewy body disease
XX Caused by Lewy inclusion bodies in the cortex
XX Presents with recurrent visual hallucinations
XX Parkinson features (bradykinesia, cogwheel rigidity, tremor)
XX Adversely react to antipsychotics
Etiology
ZZ Probable multifactorial etiological profile
XX Primary cause mostly unknown
XX General medical condition, result of substance use or abuse, reaction to medications
or other ingested agents, or combination of some or all of these factors
XX Diffuse cerebral atrophy and enlarged ventricles in DAT
XX Decreased acetylcholine (ACh) and norepinephrine in DAT
XX Genetic loading
ZZ Genes on chromosomes 1, 14, and 21 have been identified in families with a
history of DAT.
ZZ Autosomal dominant trait.
ZZ Inherited alleles for apolipoprotein E4 (APOE4) on chromosome 19 are
suspected to be related to late-onset dementia.

XX Often misdiagnosed or unrecognized, especially in early stages and in young clients
XX Prevalence of 1.6% for people in the United States ages 65 or older
ZZ 16% to 25% in people ages 85 or older
XX DAT the most common
ZZ Affects an estimated 4 million in the United States
ZZ Duration of illness averages 8 to 10 years
Risk Factors
XX Age
XX Multisystem medical illnesses
XX Genetic loading
ZZ Family history of dementia in first-order relative
XX History of substance use or abuse

ZZ Stigma reduction
ZZ Allows for ruling out age-related memory changes or unidentified conditions
ZZ Cognitive and functional evaluation at least every 3 years for people ages 65 or older
ZZ Baseline and regular cognitive evaluation to monitor cognitive decline and
treatment response to medications in persons diagnosed with dementia
XX The U.S. Preventive Services Task Force concluded that there is insufficient evi-
dence to determine if the benefits of routine screening outweigh the harms (U.S.
Preventive Services Task Force, 2014).
Assessment
History
ZZ Detailed history of present illness, including time frame, progression, and
associated symptoms
ZZ Past medical history of hypertension, strokes, head trauma, and psychiatric illness
ZZ Psychiatric history of depression, anxiety, and schizophrenia
education; and alcohol, tobacco, or illicit drug use
ZZ Medications, including prescription, over-the-counter, herbals, supplements, and
home remedies
ZZ Validate history with family or caregiver.
ZZ Memory impairment—immediate and intermediate
XX Most prominent feature of disorder
XX Usually earliest symptom
XX Produces multiple deficits in daily functioning
ZZ Unable to learn new information
ZZ Forgets past information

ZZ Loses valuables
ZZ Forgets daily activities such as eating and dressing
ZZ Becomes easily lost
ZZ Has other cognitive deficits such as impaired executive functioning
ZZ Instruments for assessing level of impairment

XX Not in public domain
ZZ Mini-Mental State Examination (MMSE)
XX In public domain
ZZ Montreal Cognitive Assessment (MoCA)
ZZ Mini-Cog
ZZ St Louis University Mental Status Examination (SLUMS)
XX Remember to always consider visual, sensory, language, and physical

disabilities as well as education when administering mental status tests.

XX Amaurosis fugax: Unilateral transient vision loss, described as “curtain over eye”
XX Unilateral focal–motor weakness
XX Asymmetrical reflexes

XX General appearance
ZZ Apraxia
ZZ Decreased self-care activities of daily living
XX Speech
ZZ Deterioration of language skills
ZZ Aphasia
ZZ Circumlocutory phrases
ZZ Indefinite object recognition (such as calling items “things” and being unable to
find discrete name)
ZZ In advanced stages are
XX Mutism
XX Echolalia
XX Affect
ZZ Lability
XX Mood
ZZ Depressed
ZZ Often difficult to elicit from client
XX Thought process
ZZ Agnosia
XX Thought content
ZZ Difficult to elicit from client
XX Orientation
ZZ Disoriented to time and place
ZZ Disoriented to person in late stages of disorder
XX Memory
ZZ Impaired in many dimensions of memory:
XX Word registration
XX Recall
XX Retention
XX Recognition
XX Concentration
ZZ Distractible
XX Abstraction
ZZ Concrete on proverb testing
XX Judgment
ZZ Grossly impaired for self- and social judgment

XX CBC, chemistry profile, thyroid function tests, B12 level, and folate level to rule out
metabolic causes or unidentified conditions
XX Syphilis drug toxicity screening if indicated by history
XX Alcohol and illicit drug screen if suspected or indicated
XX Urinalysis if urinary tract infection suspected
XX Arterial oxygen or pulse oximetry if hypoxemia suspected
XX Computed tomography (CT) or magnetic resonance imaging (MRI) not routinely used
XX EEG not useful
XX Neuropsychological testing recommended to complete diagnostic assessment
Differential diagnosis
XX Nonpsychiatric
ZZ Parkinson’s disease
ZZ Hearing loss
ZZ B12 and folate deficiencies
ZZ Trauma, especially with history of falls
ZZ Hypothyroidism
ZZ Infection
ZZ Cerebrovascular accident
ZZ Polypharmacy
ZZ Alcohol intoxication
XX Psychiatric
ZZ Mood disorders (see Chapter 9)
ZZ Delirium (see above)
ZZ Anxiety disorders (see Chapter 10)
Clinical Management
General Considerations
XX Rule out or treat any conditions that may contribute to cognitive impairment.
XX Discontinue unnecessary medications, especially sedatives and hypnotics.
XX Cognitive symptoms
ZZ N-methyl D-aspartate glutamate receptor antagonists
XX Prevent overexcitation of glutamate receptors and stabilize the
neurodegenerative process
XX Memantine (Namenda; 10 to 20 mg b.i.d.)
ZZ Moderate to severe Alzheimer’s Dementia
ZZ May slow the degenerative process
ZZ Promotes synaptic plasticity
ZZ May be used in combination with cholinesterase inhibitors.
ZZ Memantine/Donepezil (Namzric) combination medication)
ZZ Cholinesterase inhibitors
XX May be initiated for mild to moderate Alzheimer’s disease
XX Can lead to modest clinical improvement in some clients, with studies
showing 2- to 3-point improvement in mental state exam (MSE) testing
XX Treat only symptoms, slow loss of function, and may improve agitated behaviors
XX Do not prevent pathological progression of disease
XX Not effective in severe, end-stage disease
XX Should stop if side effects, usually nausea and vomiting, develop
XX Commonly used agents:
ZZ Donepezil (Aricept; 5 to 10 mg/day; Stahl, 2014)
XX Approved for mild, moderate, and severe Alzheimer’s disease
XX Nausea, diarrhea, vomiting, appetite and weight loss, abnormal

dreams, insomnia, dizziness common
ZZ Rivastigmine tartrate (Exelon; 1.5 to 6 mg twice a day; increase
gradually to avoid nausea)
XX Indicated for mild to moderate Alzheimer’s disease and Parkinson’s
disease dementia (Stahl, 2014)
XX Transdermal: 4.5, 9.5, or 13.3 mg / 24 hours
XX Retitrate if a lapse in treatment occurs
XX Psychosis and agitation

ZZ Try nonpharmacological therapies first.
ZZ Use antipsychotic agents for agitation or psychotic symptoms regularly.
ZZ Use lowest effective dose and attempt to wean periodically.
ZZ Antipsychotics may cause many side effects of significance in the older adult:
XX Extrapyramidal symptoms
XX Sedation
XX Postural hypotension
XX Anticholinergic side effects
ZZ Benzodiazepines may be used for treating anxiety or infrequent agitation.
XX Depression
ZZ Treat clients with depressive symptoms:
XX Depressed mood
XX Insomnia
XX Fatigue
XX Irritability
XX Appetite loss
ZZ Use lowest effective dose.
ZZ Treat for 6 to 12 months, then attempt to taper; depression may reoccur and
need to be treated as a chronic condition.
ZZ Clients may have less depression as the dementia progresses and they become
less aware of their circumstances.
XX Educate client and family about the illness, treatment, and community resources.
XX Assist with long-term planning, including financial, legal, and advanced directives.
XX Assess home and driving safety.
XX Use behavioral therapy to identify causes of problem behaviors and changes to the
environment to reduce the behavior.
XX Use recreational therapy, art, and pet therapy to reduce agitation and promote nor-
malized behavior.
XX Use reminiscence therapy or life review to process through any unresolved issues
and recollect the past.
XX Maintain a simple daily routine for bathing, dressing, eating, toileting, and bedtime.
XX Integrate cultural beliefs into the management of all clients with dementia.
XX Psychotherapeutic approaches for HIV-related dementia
ZZ Major psychodynamic themes for people with HIV-related dementia are issues
of guilt, self-esteem, and fear of dying.
ZZ Because the client may not be able to give a complete and accurate history,
family or friends should be questioned about any unusual behavior or mental
status changes.
ZZ Changes in the level of activity, in interest in other people, or in personality are
clues to an acute central nervous system disturbance.
ZZ Some changes are directly due to brain dysfunction, while other changes are
due to psychological distress of a systemic problem—anxiety that the person is
dying.
ZZ The spectrum of neuropsychiatric and neurological manifestations depends on
the severity of immunosuppression.
ZZ Psychiatric disorders may preexist or result from HIV.
ZZ Even subtle neurocognitive impairment can affect psychological coping.
ZZ Neuropsychiatric disorders are much more prevalent in late-stage illness.

XX Primarily a disease of older adults but can occur in children
ZZ Diagnosis based on impaired cognition; diagnoses not applicable until ages 4 to
6 years, when cognition can be fully assessed
ZZ Dementia in children usually presents as deterioration in functioning, such as
school performance or delay in normal development.
MAJOR OR MINOR NEUROCOGNITIVE DISORDER DUE TO

TRAUMATIC BRAIN INJURY
Description
XX DSM-5 diagnostic criteria are not met for a major or minor neurocognitive disorder.
XX Evidence of a traumatic brain injury—an impact to the head or other mechanism of
rapid movement or displacement of the brain within the skull—with one or more of
the following:
ZZ Loss of consciousness
ZZ Posttraumatic amnesia
ZZ Disorientation and confusion
ZZ Neurological signs (neuroimaging demonstrating an injury; new onset of
seizures; worsening seizure disorder; visual field cuts; hemiparesis; anosmia)
XX The neurocognitive disorder presents immediately after the occurrence of the trau-
matic brain injury or immediately after recovery of consciousness and persists past
the acute postinjury period.
Etiology
XX Brain injury resulting when the head is hit or violently shaken, such as from a blast or
explosion.

XX About 2% of the population and estimated 30% of returning soldiers
Risk Factors
XX Combat duty exposing personnel to improvised explosive devices (IEDs) used by
opposing factions
Prevention and Screening for Military Personnel

XX Mandatory postdeployment screening for all veterans returning from combat
assignment
XX Traumatic brain injury screening
ZZ Exposure to events (such as blasts, vehicle accidents, falls) that may have
caused brain injury
ZZ Immediate symptoms (such as loss of consciousness, feeling dazed, head
injury, amnesia of event)
ZZ Onset or worsening of problems (such as with memory, balance, headaches,
dizziness, irritability, sensitivity to bright light, sleep problems) that may indicate
brain injury
ZZ Presence of symptoms in past week
XX Four factors complicate recovery from combat-related concussions compared with
mild TBI acquired in civilian settings.
1. The physically and emotionally traumatic environment in which they occur
2. The potentially repetitive and cumulative nature of concussions sustained over a
tour (or multiple tours) of combat duty
3. The high incidence of comorbid mental health conditions
4. The difficulty in following typical recommendations for postconcussion care,
such as rest (U.S. Department of Veteran Affairs, 2015)
TABLE 12–1.
SYMPTOMS OF TRAUMATIC BRAIN INJURY
MILD TBI MODERATE TO SEVERE TBI

Mental status changes: Symptoms in first column plus:
Poor concentration Chronic, worsening headaches
Memory difficulty Repeated nausea and vomiting
Intellectual impairment Seizures
Irritability Difficult to arouse from sleep
Depression Slurred speech
Anxiety Unequal pupils
Confusion
Physical findings: Restlessness and agitation
Dizziness Extreme weakness or numbness
Balance problems Loss of coordination
Headaches
Tinnitus (ringing in the ears)
Numbness and tingling
Vision changes
Sensitivity to light
Sensitivity to sound
Extreme fatigue
Sleep problems
Acute symptoms:
Dazed and confused
Assessment
Physical Findings and Mental Status
XX Symptoms of TBI (see Table 12–1)
XX Risk for suicide
ZZ Factors increasing risk for suicide attempt with TBI:
XX Males
XX Ages 18 and 19
XX Psychiatric disorder
XX Aggressive behavior
XX Substance use

XX No current diagnostic test can retrospectively diagnose mild TBI or determine that
current symptoms or problems are due to a past mild TBI. Conventional structural
neuroimaging studies are typically normal in mild TBI.
XX Posttraumatic stress disorder (PTSD)
XX Depression
XX Anxiety
XX Other mental health diagnosis
Clinical Management
XX No specific medications for TBI.
XX Treat related symptoms according to current evidence-based standards.
XX Increased sensitivity to side effects of medication (secondary to head injury).
ZZ Sedation
ZZ Anticholinergic side effects (decrease memory)
ZZ Seizures with tricyclic antidepressants (TCAs), buproprion, and amantadine
(lower seizure threshold)
ZZ Extrapyramidal symptoms, neuroleptic malignant syndrome, tardive dyskinesia
ZZ Neuroleptics: decrease neuronal recovery
ZZ Benzodiazepines: decrease memory, increase confusion, decrease coordination,
abuse potential
XX Cognitive disorders recommendations:
ZZ Methylphenidate: increase attention, processing speed, general cognitive
function, learning, and memory
ZZ Dextroamphetamine: increase attention, processing speed
ZZ Bromocriptine (off label, possibly helpful): increase executive function
ZZ Amantadine (off label, possibly helpful): increase general cognitive function,
attention, concentration
XX When using medications, start low and go slow.
XX Treat comorbidities (military personnel with TBI frequently have posttraumatic stress
disorder [PTSD], which makes treatment of TBI more difficult).
XX Safety plan for suicide risk; limit availability of means.
XX Teach family to identify signs of risk for suicide.
XX Follow up for 1 year after anyone with TBI makes a suicide attempt.
XX Treat vestibular dysfunction with physical therapy to reduce dizziness.
XX Treat traumatic vision syndrome with occupational therapy; scanning and accommo-
dation difficulties lead to headaches, irritability, and fatigue.
Neurocognitive Disorders 2 89
XX Treat memory impairment with occupational therapy to teach memory improvement

skills.
XX Teach about symptoms and implications for relationships, employment, etc.
XX Avoid alcohol.
XX Neuropsychological testing.
XX Psychotherapy
ZZ Supportive
XX Increase understanding of relationships between cognition and emotion
XX Target adjustment or development of new beliefs and assumptions (see
Table 12–2)
ZZ Behavioral therapy
ZZ Family therapy
XX Behavioral, affective, and personality changes are most difficult for families
to adjust to
XX Tips for families:
ZZ If concentration is an issue, ask the TBI survivor for one thing at a time.
Use of white noise machines may reduce distractions. May take longer
to complete tasks.
ZZ If memory is an issue, keep note pads near the phone for messages
and in other places throughout the house. Keep a “memory book.”
Make a calendar and keep in a central location.
ZZ If anger or irritability is an issue, leave the situation if possible and
wait for TBI survivor to calm down. Use a soft, calm voice. Keep your
distance and give the TBI survivor space.
ZZ Resources
XX Defense and Veterans Brain Injury Center: http://www.DVBIC.org
XX Brain Injury Association of America: http://www.biausa.org
XX U.S. Department of Veterans Affairs: www.VA.gov
TABLE 12–2.
COGNITIVE IMPAIRMENT AND ASSOCIATED CORE FEATURES OF COGNITIVE BEHAVIORAL
THERAPY
COGNITIVE IMPAIRMENT CORE FEATURE OF CBT

Impulsivity “Stop–think–reflect”
Decreased awareness, encoding, and recall Monitoring problems and successes
Memory Use of audiotapes of sessions
Executive impairment Develop independent problem-solving for
every day difficulties
XX Tips for the PMHNP for therapy with the client with TBI:
ZZ Determine what having a TBI means to the client.
ZZ Focus on “real life” difficulties in the here-and-now.
ZZ Monitor speed and complexity of comments.
ZZ Adjust session length according to level of attention and fatigue.
ZZ Reestablish an acceptable sense of self.
ZZ Instill hope without making predictions of a successful rehabilitation outcome.

XX Mild TBI
ZZ Most clients achieve full recovery within 3 months; if residual symptoms
continue, 80% to 85% will clear within 6 months
Follow-up
XX Symptoms may occur immediately but may also appear much later, which under-
scores the importance of screening for TBI
XX Resource for guidelines, conditions and concerns: Deployment Health Clinical Center
http://www.pdhealth.mil/main.asp
CASE STUDY
Mrs. Dean, a 59-year-old homemaker with a positive family history for Alzheimer’s disease, has
been very worried lately because she believes that she is losing her memory. She has hesitated
to go for an evaluation because of her concern and is very upset as she shares her beliefs with
the PMHNP. She gives a social history of being happily married for the past 35 years and of hav-
ing several children and two new grandchildren. She has had no recent stressors and has felt
a slow decline in her memory for the past 2 years. She believes no one else has noticed, but
recently it is harder to hide her deficit from her family.
She has been employed as a nurse for the past 25 years at the local hospital but has begun to no-
tice a decline in her ability to keep track of all of the information needed to do her job well. She has
a history of asthma and periodically uses a rescue inhaler and steroids to manage her asthma. She
routinely takes one aspirin a day and uses over-the-counter kava kava when she feels stressed. She
has been taking pravastatin (Pravachol) 20 mg/day for her cholesterol level for the past 2 years. She
has no significant physical findings but does show mild impairment in short-term memory testing
during the MSE. There are many issues to consider in planning care with this client:
1. What is the probable diagnosis at this time?
2. What further assessment is needed?
3. What does the PMHNP need to take into account when considering medication for
this client?
4. Would the PMHNP include the family in care planning at this time?
5. Are medications indicated at this time?

1. The correct diagnosis in this case is unspecified neurocognitive disorder.
2. Additional assessment information needed is to refer client for a complete medical
examination.
3. Before starting the client on medication the PMHNP needs to understand the cor-
rect diagnosis for the client’s symptoms and the stage of their illness, and discuss
the client’s preference for treatment.
4. In this case, yes, family should be involved as early as possible.
5. For this client, medication is not indicated at this time.

American Geriatric Society. (1999). Geriatric review syllabus. New York, NY: Kendall/Hunt.
Bickley, L. S. (2007). Bates’ guide to physical examination and history taking (9th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak A. (2000). The mini-cog: A cognitive
‘vital signs’ measure for dementia screening in multilingual elderly. International Journal of
Geriatric Psychiatry, 15, 1021–1027.
Burke, M., & Laramie, J. A. (2003). Primary care of older adults (2nd ed.). St. Louis, MO: Mosby.
Dick, K., & Morency, C. R. (2011). Delirium. In K. Devereaux & S. Crock (Eds.), Geropsychiatric
and mental health nursing (2nd ed., pp. 255–272). Sudbury, MA: Jones & Bartlett Learning.
Doornbos, M. M. (2002). Family caregivers and the mental health care system: Reality and
dreams. Archives of Psychiatric Nursing, 15(4), 39–46.
de Lange, E., Verhaak, P. F., & van der Meer, K. (2013). Prevalence, presentation and progno-
sis of delirium in older people in the population, at home and in long term care: A review.
International Journal of Geriatric Psychiatry, 28(2), 127–134.
Jacobson, S. (2014). Clinical manual of geriatric psychopharmacology (2nd ed.) Arlington, VA:
American Psychiatric Publication.
Melillo Devereaux, K., & Houde Crocker, S. (2011). Geropsychiatric and mental health nursing
(2nd ed.). Sudbury, MA: Jones & Bartlett Learning.
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic
brain deficit in elderly patients. Journal of American Geriatric Society, 23, 433–441.
Stahl, S. (2014). Essential psychopharmacology prescribers guide (5th ed.). New York, NY:
Cambridge University Press.
Steffens, D., Blazer, D., & Thakur, M. (2015). The American Psychiatric Publishing textbook of
geriatric psychiatry (5th ed.). Arlington, VA: American Psychiatric Publishing.
U.S. Department of Veterans Affairs. (2015). Polytrauma/TBI system of care. Retrieved from
http://www.polytrauma.va.gov/understanding-tbi/
U.S. Preventive Services Task Force. (2014). Screening for dementia: Recommendations and
rationale. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/
UpdateSummaryFinal/cognitive-impairment-in-older-adults-screening?ds=1&s=dementia
CHAPTER 13
SUBSTANCE-RELATED AND ADDICTIVE

DISORDERS
One of the most common but least well-addressed classes of disorders is substance use
disorders. Psychiatric–mental health nurse practitioners (PMHNPs) who work in primary psychi-
atric settings or integrated primary care settings commonly treat clients with substance-related
disorders. These disorders can stand alone or be part of complex co-occuring illness with either
general medical conditions or psychiatric disorders.
Many substances can be used and abused. No matter what the substance, the continuum of
use can range from mild to severe. Although the specific substances of abuse will determine
many of the physical, behavioral, and cognitive symptoms exhibited by the client, some com-
monalities exist for all drugs. New to the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; American Psychiatric Association, 2013) is the inclusion of gambling
as a behavioral addiction.
This chapter focuses on the PMHNP role in determining the severity of substance use and the
available clinical management and treatments. It also emphasizes alcohol use disorders as a
primary example. Alcohol is discussed because it is the most commonly abused substance, it
is well researched, and PMHNPs will most often encounter people in clinical settings with an
alcohol use disorder. Much of what is known about disorders of alcohol use is believed to be
transferable to other substances.
SUBSTANCE-RELATED DISORDERS
Description
XX Substance use disorders are a cluster of disorders in which cognitive, behavioral, and
physiological symptoms indicate that a person continues using a substance despite
significant substance-related problems (American Psychiatric Association, 2013).
XX Psychiatric symptom clusters may be related to substance use, discontinuation of
substance use, or withdrawal from habitual substance use.
XX Substance use disorders lead to changes in brain circuits and physiological functions
that lead to a need for detoxification and a possible need for long-term treatment.
XX The word substance can describe a drug of abuse, a medication, or a toxin that pro-
duces psychoactivation and alters cognitive, behavioral, and affective perceptions.
XX Dependence: repeated use of a substance with or without physical dependence
XX Abuse: use that is inconsistent with sociality use patterns
XX Misuse: usually applies to a prescribed substance
XX Intoxication: reversible syndrome caus ed by a specific substance affecting memory,
judgment, behavior, or social or occupational functioning
XX Withdrawal: substance-specific symptoms that occur after stopping or reducing use
XX Tolerance: needing more of the substance to get the desired effect
Etiology
XX Two common types of theories: psychodynamic and biological
ZZ Psychodynamic theory
XX Behaviors of abuse are seated in oral-stage fixation.
XX A person seeks gratification through oral behaviors.
XX Maladaptive regressive behaviors can become overlearned, fixed, and
reinforced through dysfunctional family patterns.
XX Sociocultural factors attempt to explain population-based differences in
substance abuse rates.
ZZ Biological theory
XX Genetic loading
ZZ People with a strong genetic vulnerability to addiction are thought to
have defects in the working of the reward center of the brain, which
predisposes them to stronger-than-normal positive rewards that draw
them to substance use.
ZZ Gender differences
ZZ Ethnic differences
ZZ A person is predisposed to stronger-than-normal negative rewards,
making it more difficult to stop abuse once it has begun.
XX Involves two neurobiological processes:

1. Reinforcement
XX Brain-based changes in structure and function can lead to addictive
behavior.
XX The process of positive and negative rewards is physiologically
linked to memory function.
XX Changes appear to occur with any drug of abuse.
Substance-Related and Addictive Disorders 2 95
XX Reinforcement results in “feel good” sensations when a drug of

abuse is used and in “feel bad” sensations when the drug exits
the body.
XX Positive rewards of reinforcement result in the social rewards
commonly associated with drug use, such as disinhibition,
euphoric mood, and anxiety reduction.
ZZ Mediated by dopamine (DA) pathways
XX Negative rewards are aversive, such as increased anxiety and
dysphoria.
ZZ Mediated by the gamma amino butyric acid (GABA) pathways
XX Reinforcement occurs in the ventral tegmental area and the
nucleus accumbens of the brain, collectively called the reward
center.
XX DA release within the reward center is enhanced further by
the release of natural morphine-like neurotransmitters called
neuropeptides (enkephalins, beta-endorphins).
XX Neuropeptides further enhance the reinforcing pleasure
experienced by the person.
XX With repeated drug use, the DA system becomes increasingly
sensitized.
XX Eventually, associated drug use stimuli (e.g., pictures of drug
paraphernalia) can cause DA release, leading to reinforcement of
use and often to increased drug use.
2. Neuroadaptation
XX Brain-based changes in structure and function can lead to
tolerance and withdrawal.
XX Drug-specific alterations in the normal level and function of
neurotransmitters occur as the body adapts to the chronic
presence of the substance of abuse.
XX Neuroadaptive processes become very significant when the
person stops substance use.
XX These processes become the basis for withdrawal symptoms,
because adaptive responses are unopposed when the substance
is no longer present.
XX Neuroadaptive changes may be more enduring in some persons,
possibly lasting for years, thus increasing their potential for
relapse.
XX This concept helps to explain why, after a long period of sobriety,
a person who returns to substance abuse often picks up at the
same level of tolerance and physical impact as experienced before
sobriety.

XX Persons age 18 to 24 years of age have high prevalence rates for using most
substances.
XX The United States has higher rates of substance use than any other developed
country.
XX More than 50% of U.S. clients with a psychiatric disorder have a comorbid sub-
stance use disorder.
ZZ Persons with schizophrenia are 4 times more likely to have a substance use
comorbidity than the general population.
ZZ Persons with bipolar affective disorder are 5 times more likely to have a
substance use comorbidity than the general population.
XX More than 2 million admissions annually are made to inpatient substance use treat-
ment facilities.
ZZ Though now legal in some states, marijuana is the most commonly abused
illegal substance.
XX Alcohol is the most commonly abused legal substance.
ZZ Rates are higher in men than in women.
XX 90% of men have used alcohol.
XX 70% of women have used alcohol.
XX Rates are highest in African Americans, Hispanic Americans, and Native
Americans; rates are lowest in Asian Americans.
ZZ 55% of fatal driving accidents in the United States occur with a driver
under the influence of alcohol.
ZZ 50% of crimes in the United Stated are committed under the influence
of alcohol.
ZZ The lifetime risk for alcohol use disorder is 15% in the general U.S.
population.
Risk Factors
XX Genetic loading
ZZ Family history of substance abuse or major depressive disorder (MDD)
XX Association with peer structure with heavy substance use
XX Co-occurring psychiatric disorder
XX Age and gender (younger, males)
XX Existence of chronic pain
XX Untreated chronic pathological-level anxiety
Substance-Related and Addictive Disorders 297

ZZ Stigma reduction
XX Early recognition, intervention, and initiation of treatment to prevent disease devel-
opment of complications of disorder
XX Implications of alcohol and other drugs of abuse during pregnancy:
ZZ Fetal alcohol syndrome (FAS)
XX Prevalence: one third of all infants born to females with alcohol use disorder
XX Signs: low birth weight and height, microphthalmia, short palpebral fissure,
midface hypoplasia, smooth or short philtrum, thin upper lip
ZZ Birth defects
XX Acute alcohol intoxication in nontolerant persons such as teenagers:
ZZ Coma
ZZ Respiratory depression
ZZ Death
ZZ Administered by asking the client four questions
ZZ Each positive answer scored as 1 point; negative answers receive no score
ZZ The more positive answers, the greater the likelihood of an alcohol abuse disorder.
ZZ Clients scoring 2 or greater are at mild to moderate risk for alcohol dependency,
and the score is considered clinically significant
ZZ Clients scoring 3 to 4 are considered at high risk for alcohol dependency
XX Other screening
ZZ AUDIT: Alcohol Use Disorders Identification Test
ZZ S-MAST: Short Michigan Alcoholism Screening Test (or Geriatric Version)
ZZ CRAFFT: Children and adolescents under 21 years of age
ZZ COWS: The Clinical Opiate Withdrawal Scale
CAGE SCREENING TEST IS THE MOST COMMONLY USED SCREENING TOOL FOR
ALCOHOL ABUSE (SAMHSA, 2016)
C: Have you ever felt the need to cut down on your drinking?
A: Have people annoyed you by mentioning your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had a drink the first thing in the morning to steady your nerves or
get rid of a hangover (eye-opener)?
Assessment
History
associated symptoms
education; and alcohol, tobacco, or illicit drug use
ZZ Validate history with a family member
ZZ Identify the category of drug abused by the client
XX Knowing category allows for anticipation of physical impact of drug and to
predict potential symptoms of withdrawal
XX Clients often abuse drugs from categories with similar pharmacological
properties.
XX Categories of abused agents:
ZZ Alcohol
ZZ Amphetamines or similar sympathomimetics
ZZ Caffeine
ZZ Cannabis
ZZ Cocaine
ZZ Hallucinogens
ZZ Inhalants
ZZ Nicotine
ZZ Opioids
ZZ Phencyclidine (PCP) or similar arylcyclohexylamines
ZZ Sedatives
ZZ Hypnotics
ZZ Anxiolytics
ZZ Assess for presence of substance abuse

XX Maladaptive pattern of substance use manifested by recurrent and
significant adverse consequences related to repeated use of a substance
XX Is not synonymous with use, misuse, or hazardous use
XX Specific criteria needed to identify substance use as abuse:
ZZ Maladaptive pattern of use occurring for at least a 12-month period of
sustained use
ZZ Must be accompanied by repeated failure to fulfill major role obligation

ZZ Must be accompanied by use in situation that presents as physically
hazardous, such as drinking and driving
ZZ Abuse continues despite multiple problems related to substance use
patterns, such as legal, interpersonal, or social problems
ZZ Assess for presence of substance use disorder

XX Cluster of cognitive, behavioral, and physiological symptoms indicating that
the person continues use of a substance despite significant substance-
related problems
XX Synonymous with addiction
XX Pattern of repeated use that leads to clinically significant impairment or
distress with three or more of the following symptoms within a 12-month
period:
ZZ Tolerance
ZZ Withdrawal
ZZ Using larger amounts than intended
ZZ Persistent craving or unsuccessful attempts to cut down
ZZ Large amount of time spent obtaining substance, using substance, or
recovering from its effects
ZZ Activities decreased or given up because of use
ZZ Using despite consequences
XX Physiological dependence implies tolerance and withdrawal

XX Degree of tolerance and withdrawal symptoms are substance-specific.
ZZ Can be physical, psychological, or both, depending on the substance
ZZ Withdrawal symptoms are almost always the opposite of the acute
action of the substance.
ZZ Categories of abused substances with pronounced, obvious withdrawal
symptoms:
XX Alcohol
XX Opioids
XX Sedatives
XX Hypnotics
XX Anxiolytics
ZZ Categories of abused substances with less pronounced, less obvious
withdrawal symptoms:
XX Stimulants
XX Nicotine
XX Cannabis
ZZ Categories of abused substances with little to no pronounced, obvious

withdrawal symptoms:
XX Hallucinogens
XX PCP
ZZ Assess for the presence of substance withdrawal or intoxication

XX Clients abusing substances present for assessment either under the
influence of the drug (intoxication) or experiencing problems related to
cessation of substance use (withdrawal)
ZZ Intoxication: Reversible substance-specific syndrome caused by recent
ingestion of a psychoactivating substance
ZZ Withdrawal: Potentially nonreversible substance-specific syndrome
caused by cessation or significant reduction in heavy, prolonged use of
a substance
XX Blood alcohol levels determine presence of alcohol in the body

ZZ Tolerant persons often have higher blood levels with less impairment
than nontolerant persons
ZZ Must interpret blood alcohol levels of a client based on his or her
degree of tolerance
XX Diagnostic criteria for substance withdrawal:

ZZ Cessation or reduction in substance use that has been heavy or
prolonged
ZZ Two or more of the following symptoms within several hours or days of
reduction or cessation of the substance:
XX Hand tremor
XX Insomnia
XX Autonomic hyperactivity (sweating, increased heart rate, and
increased blood pressure)
XX Nausea or vomiting
XX Hallucinations or illusions
XX Psychomotor agitation
XX Anxiety
XX Seizures
XX Structured interview allows for assessment of the use patterns and

consequences of a person’s substance use
ZZ Assess for all dimensions of the impact of substance abuse or
dependence in the person.
XX Current use
XX Pattern of use
XX Consequences (interpersonal, occupational, legal)
XX Physical health consequences

XX Substance abuse or dependence produces many physical symptoms.
ZZ Usually a result of sequelae of use or abuse rather than findings specific to
abuse or dependence
XX Generally nonspecific when viewed in isolation
XX Must be considered as a cluster of symptoms that raise an index of suspicion of
addiction potential
ZZ Abdominal pain and tenderness
ZZ Nausea
ZZ Weight loss
ZZ Gastrointestinal bleeding
ZZ Hypertension
ZZ Anxiety
ZZ First-episode seizure in adult
XX Physical findings related to alcohol use disorders (Domino, Baldor, Golding, &
Stephens, 2015; NIAAA, 2016).
ZZ Brain: mood changes, behavior changes
ZZ HEENT: poor oral health
ZZ Cardiovascular: hypertension, cardiomyopathy, tachycardia
ZZ Gastrointestinal: liver disease, cirrhosis, peptic ulcer, esophageal malignancies
ZZ Neurologic: tremor, cognitive deficits, peripheral neuropathy, Wernicke-Korsakoff
syndrome
ZZ Metabolic: hyperlipidemia
Mental Status Exam (MSE) Findings

XX Nature of findings depends heavily on whether the client is experiencing substance
intoxication or withdrawal, or is substance-free at the time of assessment.
ZZ Index of suspicion for substance-related disorder should be raised if client
presents differently during different periods of assessment (Sadock, Sadock, &
Ruiz, 2015).
XX Stimulants: agitation, anxiety, irritability, mood swings, elevated mood
XX Opioids: mood swings, aggression, disinhibition, impaired cognition, slurred
speech, psychomotor slowing
XX Hallucinogens: mood swings, hallucinations, paranoia, flashbacks, panic,
impaired judgement
XX Cannabis: confusion, paranoia, panic
XX Inhalants: agitation, irritability, confusion, hallucinations

XX Complete blood count (CBC), chemistry profile, thyroid function tests, and B12 level
to rule out metabolic causes or unidentified conditions
XX Alcohol dependence and abuse produce characteristic laboratory findings.
ZZ Blood alcohol level >100 mg/dL outpatient; >150 mg/dL anytime with sx; >300
mg/dL anytime
ZZ Aspartate transaminase (AST)/Alanine transaminase (ALT) ration >2.0
ZZ Elevated: glutamyltransferase, mean corpuscular volume, prothrombin time, uric
acid, total cholesterol, and triglycerides
ZZ Decreased: magnesium, calcium, potassium, blood urea nitrogen, hemoglobin,
hematocrit, platelet count and albumin (Domino et al., 2015).
XX Endocrine disorders
ZZ Cushing’s disease
XX Neurological disorders
ZZ Seizure disorders
XX Cardiovascular disorders
XX Mood disorders
ZZ MDD
ZZ Bipolar (BP) disorder
XX Anxiety disorders
XX Personality disorders
XX Differential diagnostic consideration for acute alcohol withdrawal:
ZZ Many acute general health conditions can mimic symptoms of alcohol
withdrawal.
Clinical Management
XX Rule out or treat any conditions that may contribute to clinical findings.
XX Note: 80% to 90% of people who require alcohol treatment do not get it.
ZZ Common reasons for failure to receive needed treatment:
XX Lack of diagnosis
XX Lack of referral
XX Lack of access to services
XX Resistance to treatment
XX The genetics of addiction vulnerability are becoming better known, which allows for
preventative and early intervention treatments.
XX The knowledge base of the pathophysiology of dependence has promoted new
somatic interventions.
ZZ Psychopharmacology offers the promise of a new era in the treatment of
addictions.
XX Clinical management differs depending on the substance-related syndrome exhibited
by the person.
ZZ Acute withdrawal
ZZ Acute intoxication
ZZ Long-term sobriety maintenance
ZZ Relapse prevention
XX Alcohol withdrawal carries a high risk of mortality.
XX Clinical management of alcohol withdrawal is a specialized treatment that requires
specific experience in this type of care.
XX Some clinical findings may assist in identification of clients at risk for severe alcohol
withdrawal:
ZZ Agitation
ZZ Decreased short-term memory
ZZ Disorientation
ZZ Hallucinations
ZZ Irregular pulse
ZZ Ophthalmoplegia
XX Clinical Institute Withdrawal Assessment for Alcohol
ZZ Used to determine likelihood of withdrawal and delirium tremens (DTs), which
usually occur within the first 24 to 72 hours after cessation of alcohol.
ZZ Assesses 10 common withdrawal symptoms:
XX Nausea and vomiting
XX Tremors
XX Paroxysmal sweats
XX Anxiety
XX Agitation
XX Tactile disturbances
XX Auditory disturbances
XX Visual disturbances
XX Headaches
XX Altered sensorium
ZZ Each symptom is graded on a 0- to 7-point scale with the exception of

orientation and sensorium, which are graded on a 0- to 4-point scale. The higher
the total score (maximum = 67), the more likely the person will experience
severe withdrawal and DTs: 0–9 = absent or very mild withdrawal, 10–15 = mild
withdrawal, 16–20 = moderate withdrawal, and 21–67 = severe withdrawal and
possible DTs.
XX Pharmacological treatments are symptom-specific
XX Clinical management of acute withdrawal
ZZ Detoxification (detox) agents replace uncontrolled use of substance with slow
tapering of controlled substance to minimize neuroadaptive rebound.
XX Multiple daily doses of benzodiazepines are used according to a fixed
schedule and gradually tapered down over several days.
XX Examples include:
ZZ Lorazepam (Ativan)
ZZ Chlordiazepoxide (Librium)
ZZ Diazepam (Valium)
ZZ Oxazepam (Serax)
XX Polytherapy is a newer approach that matches drugs required for safe and
effective withdrawal with neurotransmitter deficits created by substance
use.
ZZ Selective serotonin reuptake inhibitors
ZZ Opioid antagonists nalmefene hydrochloride (Revex), naltrexone (Revia),
or naltrexone for extended-release injectable suspension (Vivitrol)
ZZ N-methyl-D-aspartate (NMDA) agonists
XX Antiseizure medications such as carbamazepine (Tegretol) and valproic acid

(Depakene) are sometimes used to decrease the potential for seizures.
XX Adrenergic medications are sometimes used to decrease blood pressure
and pulse rate associated with withdrawal.
ZZ Clinical management of craving (see Table 13–1)
XX Use anticraving medication such as naltrexone (Revia), acamprosate
(Campral), ondansetron (Zofran), or buprenorphine (Buprenex).
XX Use behavior treatment to help client learn substitute behaviors.
ZZ Clinical management and maintenance of sobriety (see Table 13–1)
XX Person may require ongoing treatment for comorbid psychiatric disorder.
XX May use aversion treatment to avoid alcohol in persons with alcohol
dependence.
ZZ Disulfiram (Antabuse)
XX Do not administer until the person has been alcohol-free for at
least 12 hours.
TABLE 13–1.
PHARMACOLOGICAL AGENTS USEFUL IN TREATING CRAVING AND MAINTAINING (STAHL,
2014)
PHARMACOLOGICAL
AGENT CHEMICAL CATEGORY ACTION EFFECT
Citalopram (Celexa) Selective serotonin reuptake Decrease desire
inhibitor
Disulfiram (Antabuse) Aldehyde dehydrogenase Aversion therapy
inhibitor
Naloxone( Narcan) Opioid antagonist, antidote Blocks effects of opioids
Buprenorphine (buprenex) Opioid partial agonist, opioid Agonist and antagonist,
antagonist decrease cravings
Buprenorphine and Narcotic analgesic Opioid agonist/antagonist
naloxone (Suboxone)
Methadone (Dolophine) Narcotic analgesic Suppresses withdrawal
Nalmefene (Revex) Opioid antagonist Increases abstinence
IM (Revia; Vivitrol) Opioid antagonist Increases abstinence
Acamprosate (Campral) Homotaurine Decreases craving
XX Advise client to refrain from using anything that contains alcohol

(e.g., vinegar, aftershave lotion, perfumes, mouthwash, cough
medication) while taking disulfiram and up to 2 weeks after
discontinuing disulfiram.
XX Disulfiram can elevate liver function tests, so monitor.
XX Antabuse may potentially induce mania in people with BP disorder.
ZZ General health maintenance medication to treat vitamin deficiencies in persons

with alcohol dependence include thiamine, folic acid, and B-complex vitamins.
XX Multimodality treatment needed.
XX Lifetime treatment often required.
XX Inpatient treatment usually needed for safe and effective withdrawal from alcohol.
XX Indications for inpatient alcohol detoxification include history of severe withdrawal
symptoms, seizures, or delirium tremens; multiple past detoxifications; additional
medical or psychiatric illness; recent significant alcohol consumption; lack of reliable
support system; and pregnancy.
XX Reduce central nervous system stimulation by maintaining a quiet environment;
put client in room close to the nurses’ station to facilitate frequent observation
and monitoring; minimize abrupt changes in environment; decrease bright light and
sharp, sudden noises; decrease room clutter; and do not restrain.
XX Maintain hydration by monitoring intake and anticholinergic effects of benzodiaz-
epines. Frequently offer fluids.
XX Before discharge from acute-care setting, have a definite plan for follow-up treatment.
XX Connect client and family with support groups.

ZZ 12-step groups in community
ZZ Concrete plan for first week of support group attendance (may need daily)
XX Connect client with counseling or psychotherapy.
XX Identify a primary healthcare provider.
XX Note medical problems that will require further evaluation and potential treatment:
ZZ Neurological sequelae of chronic alcohol consumption
ZZ Nutritional deficiencies
ZZ Cardiomyopathy, hypertension, arrhythmias, ischemic heart disease
ZZ Blood dyscrasias
ZZ Gastrointestinal inflammations
ZZ Esophageal, liver, nasopharyngeal, and laryngeal cancers
XX Client care needs:
ZZ Substance abuse education classes
ZZ Substance abuse counseling program
ZZ Continued 12-step program involvement (e.g., Alcoholics Anonymous, Narcotics
Anonymous)
ZZ Halfway housing
ZZ Cognitive behavioral therapy
XX Family care needs:
ZZ Current and understandable information about condition, progress, and
treatment plan
ZZ Connect family to community support groups such as Al-Anon and Alateen
ZZ Management of feelings such as guilt and anger
ZZ Referrals to community resources
ZZ Specific considerations: relationship with treatment team; role strain; financial
stresses; social isolation and “code of silence”; family support systems; family
violence; marital and family strife; family members’ work and school functioning;
history of mental disorders, including substance-related disorders
ZZ Assist family in coping with difficulties incorporating drinking member back into
routines; encourage further counseling to resolve these difficulties
ZZ Refer for further treatment if family members report symptom clusters from
anxiety and mood disorders, eating disorders, and addiction

XX Children and adolescents
ZZ Most common period for starting drug use
ZZ Significant impact of peer pressure on substance use patterns
ZZ 30% to 40% of adolescents report drinking frequently
ZZ 15% report binge-drinking patterns

ZZ Approximately 50% of high school–age students report at least a one-time use
of illicit drugs
XX Older adults
ZZ Referral to specialized treatment program that emphasizes interventions to deal
with losses
ZZ Large-print psychoeducation materials
ZZ Transportation to service locations
ZZ Treatment with same-age peer group
ZZ Adaptations to home environment to cope with physical disabilities
ZZ Close collaboration with primary-care physician for follow-up
CASE STUDY
Mrs. Day is a 61-year-old widow who has multiple health problems. She had been diagnosed
with essential hypertension and chronic bronchitis and has non-insulin-dependent diabetes.
She has been coming to your primary care clinic for 6 months, and before that she had been
receiving her care from multiple other providers in the community. She receives Social Security
Disability Insurance.
Mrs. Day’s chief complaint for the past few months has been stasis ulcers on her lower left leg,
which have not healed well despite multiple approaches to care. She also complains of problems
with her “nerves.” She currently is taking
XX multivitamin daily
XX ranitidine (Zantac) 150 mg q 12 hrs
XX alprazolam (Xanax) 1 mg b.i.d.
XX glipizide (Glucotrol) 20 mg b.i.d.
Mrs. Day is in today, and this is the first time you see her. On initial approach, she is hostile and
difficult to get information from, stating, “You should know all this; you have my chart right there
in your hand.” She states that today she wants a refill of all of her prescriptions, and she wants
you to write a letter to her landlord to “stop harassing me.” She reports that her landlord is insist-
ing that she place her garbage in the containers in the parking lot of the complex. She feels that
is too far for her to walk, and she wants a letter supporting her current practice of leaving her
garbage bags in the hallway outside her apartment door.
She also is reporting that her nerves are worse, and the pain in her legs is worse as well. She
also believes that she has had a return of “chronic bronchitis,” and she is requesting an antibiotic.
She is requesting that you increase her alprazolam and add codeine or morphine or “any other
thing like that” for her “constant pain.” She states, “Just do this and get me out of here. I know
what I need.”
Mental Status Exam

XX Appearance: moderately obese, well-dressed with appropriate hygiene, poor eye
contact
XX Motor: mild psychomotor restlessness, slightly ataxic gait, tremulous
XX Speech: loud and pressured
XX Affect: angry
XX Mood: self-described as “cranky”; assessed as irritable
XX Thought processes: goal-directed and organized without evidence of psychotic pro-
cessing but does show some mild thought-blocking and tangentiality
XX Thought content: thematic for mistrust of health providers and for fear of pain
continuing
XX Memory: one-third of objects after 15 minutes
XX Concentration: refuses to do numbers testing, stating “I was never good with book
work or numbers”
XX Abstraction: is abstract on proverbs; asks, “You got any more dumb questions?”
XX Judgment: intact for self-welfare

XX Education: completed 12th grade and went to 2-year secretarial business school
XX Employment history: was a medical claims clerk for 32 years at the VA Medical
Center
XX Social history: no children; lives by herself; history of 2-pack-a-day smoker and “I
drink a six-pack or so at night to relax myself—wouldn’t you?”
Her physical exam is overall unremarkable. Her vital signs are within her documented baseline,
with BP 132/88, P 96, RR 26, Temp 98.5° F, Weight 209 lbs. Her lungs are overall clear. On her
left leg she has a stasis ulcer, which is circular and approximately 6 cm in circumference. It is
open and oozing white–yellow liquid drainage, with redness around the borders. She reports it
is painful to touch and increasingly painful when weight-bearing. She was ordered silver sulfa-
diazine treatments with cling wrap and hot soaks q 6 hours. She refuses to cover it because
“it hurts when I remove the bandage” and is not very clear about whether or not she is doing
the hot soaks. Recent labs are all within normal limits, including thyroid-stimulating hormone,
electrolytes, and CBC.
1. What is the primary healthcare concern of this client?
2. What method of interviewing would be useful for Mrs. Day?
3. What further laboratory testing should be considered?
4. If the client is unwilling to participate in further assessment, how will you deal with
her health needs?

1. Given her laboratory values are within normal limits and she has no physical signs of
a respiratory infection, the main concern is current or risk for addiction.
2. The method of interviewing Mrs. Day would be using the SBIRT technique.
3. Additional laboratory assessments should be obtained, which include liver function
tests, including ALT, AST, GGT, albumin, and possibly uric acid level.
4. If Mrs. Day is unwilling to engage in a further assessment, the use of motivational
interviewing techniques, building rapport, and keeping the client engaged would be
indicated.

Barbosa, C., Cowell, A., Bray, J., & Aldridge, A. (2015). The cost effectiveness of alcohol screen-
ing, brief intervention, and referral to treatment (SBIRT) in emergency and outpatient medi-
cal settings. Journal of Substance Abuse Treatment, 53, 1–8.
DiClemente, C., Bellino, L., & Neavins, T. (1999). Motivation for change and alcoholism treatment.
Alcohol Research and Health, 23(2), 86–92.
Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (2015). The 5-minute clinical consult
standard (24th ed.). Philadelphia, PA: Wolters Kluwer.
Dunn, K., Saulsgiver, K., Miller, M., Nuzzo, P., & Sigmon, S. (2015). Characterizing opioid with-
drawal during double blind buprenorphine detoxification. Drug and Alcohol Dependence,
151(1), 47–55.
Graham, A. W., & Schultz, T. K. (2007). Principles of addiction medicine (3rd ed.). Baltimore, MD:
American Society of Addiction Medicine.
Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcohol-
ism instrument. American Journal of Psychiatry, 131, 1121–1123.
Miller, N., Gold, M., & Smith, D. (1997). Manual of therapeutics for addictions. New York, NY:
Wiley-Liss.
National Institute on Alcohol Abuse and Alcoholism. (1997). Alcohol and health (DHHS Publication
No. 97-4017). Rockville, MD: Author.
National Institute on Alcohol Abuse and Alcoholism. (2016). Alcohol’s Effects on the body. http://
www.niaaa.nih.gov/alcohol-health/alcohols-effects-body
National Institute on Drug Abuse. (2012). Medical consequences of drug abuse: Mental health
effects. Bethesda, MD: National Institutes of Health. Retrieved from http://www.drugabuse.
gov/publications/medical-consequences-drug-abuse/mental-health-effects
Sadock, B., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry:
Stahl, S. (2014). Essential psychopharmacology prescribers guide (5th ed.). New York, NY:
Cambridge University Press.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Screening tools.
http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs
CHAPTER 14
PERSONALITY DISORDERS
This chapter reviews a category of illnesses called personality disorders, common disorders that
can affect the quality of the general health care that a person receives. Although these disorders
can create great difficulty for the given person, he or she remains able to perform routine daily
functions. Often the person does not recognize a problem or seek treatment.
This chapter briefly reviews the concept of personality and then its disorders. Assessment and
clinical management features of personality disorders are discussed.
PERSONALITY
Description
XX Personality is the sum total of all emotional, cognitive, and behavioral attributes of a
person.
XX Personality involves an enduring pattern of perceiving, relating to, and thinking about
the environment and one’s self that are exhibited in a wide array of social and per-
sonal contexts.
XX When healthy, personality structures allow for realistic, happy, and satisfying self-
perceptions and interpersonal interactions.
XX Characteristics
ZZ Personality is organized early in life and is dynamic and deeply ingrained;
however, it can be altered.
ZZ Patterns of behavior based on personality can be perceived by the person as
comfortable (ego-syntonic) or uncomfortable (ego-dystonic):
XX Ego-syntonic
ZZ Behavior consistent with personality
ZZ Causes little concern to the person
ZZ Person generally fails to recognize problem
ZZ Person does not seek treatment
XX Ego-dystonic
ZZ Behavior inconsistent with personality
ZZ Causes discomfort and concern to the person
ZZ Person generally recognizes problem
ZZ Person often seeks treatment
ZZ Personality is reflected in behavioral traits habitually displayed by the person:

XX Coping
ZZ Interpersonal or interactive style
ZZ Perceptions
ZZ Cognitive beliefs about events, people, and situations
PERSONALITY DISORDERS
Description
XX Personality disorders are chronically maladaptive patterns of behavior that cause
functional impairment in work, school, or relationships.
XX These disorders manifest as maladaptive patterns in four areas of functionality:
ZZ Maladaptive affective traits, such as overly affectual patterns of response
ZZ Maladaptive behavioral traits, such as poor impulse control patterns of response
ZZ Maladaptive cognitive traits, such as unrealistic perceptual patterns of response
ZZ Maladaptive social traits, such as maladaptive unsatisfying interpersonal patterns
of response
XX These disorders can cause subjective distress.
ZZ A person is unlikely to recognize the problem or seek help if maladaptive
patterns of behavior are ego-syntonic.
ZZ A person is more likely to recognize problem and seek help if maladaptive
patterns of behavior are ego-dystonic.
ZZ Maladaptive patterns are inflexible and pervasive across most personal and
social situations.
ZZ These disorders are coded in the DSM-5 (see Table 14–1).
ZZ Clients seldom fit neatly into one personality disorder diagnosis; rather, they
often exhibit features of several similar disorders.
ZZ For this reason, personality disorders often are referred to by the category of
commonly manifesting symptom clusters (A, B, or C).
Etiology
TABLE 14–1.
CATEGORIES OF PERSONALITY DISORDERS
CATEGORY CHARACTERISTIC BEHAVIOR DISORDERS

Cluster A Odd, unusual, eccentric, asocial Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Cluster B Dramatic, affective instability Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C Anxious Avoidant personality disorder
Dependent personality disorder
Obsessive–compulsive personality
disorder
XX Less empirical data available on neurobiological etiological factors

XX Borderline personality disorder is the most well researched.
XX Two common types of theories of personality disorders:
1. Psychodynamic theory (primarily borderline personality disorder)—based on two
etiological factors:
XX Early separation problems
ZZ Object relations theory
XX Internalized intrapsychic experiences of interpersonal relationships
XX Mental representation of the self in relation to others
XX Stability and depth of a person’s relationships
XX During development, child must accomplish two tasks: separation
and individuation.
ZZ Separation: Develop intrapsychic self-representation distinct
and separate from mother
ZZ Individuation: Form distinct identity with characteristics unique
to the person.
ZZ Failure in separation–individuation is etiologically linked to development
of personality disorders.
ZZ Different personality disorders linked to problems with different stages
of the separation–individuation process.
XX Disturbed parental interaction
XX Family background assumed to be dysfunctional:
ZZ Enmeshed family patterns
ZZ Role-reversal patterns of child–parent interaction
ZZ Restricted involvement of family with the rest of the
environment
ZZ Social isolation
ZZ Confusion of parental authority and nurturing roles
ZZ Blurred family boundaries
XX Dysfunctional family patterns block separation–individuation
processes; family rejection occurs if person attempts individuation.
2. Biological theory
XX Genetic factors
ZZ Familial tendency
ZZ Genetic overlap between loading for some Axis I disorders and
personality disorders
XX Structural abnormalities
ZZ Reduced gray-matter volume in prefrontal cortex
ZZ Limbic system deregulation
XX Neurotransmitter dysfunction
ZZ Decreased levels of serotonin
ZZ Elevated levels of norepinephrine
ZZ Dysregulation of dopamine receptors
XX Neurobiological impact of trauma

ZZ Most studied in borderline personality disorder
ZZ Assumes early childhood trauma alters basic brain patterns of response
ZZ In genetically susceptible people, may function as the environmental
vulnerability that causes expression of genetic load

XX Difficult to estimate, because people with personality disorders are rarely hospital-
ized and often receive no treatment
XX Incidence varies with disorder
XX Generally assumed to be 0.5% to 5.4% in the general U.S. population
Risk Factors
XX Genetic loading
XX Dysfunctional family of origin

ZZ Stigma reduction

XX Preventative work with young children in identified dysfunctional family
settings
Assessment
XX Symptoms of personality disorder are enduring maladaptive patterns of behavior,
generally seen as problems with living.
XX Often several interviews are needed to clarify the diagnostic picture.
History
associated symptoms
education; and alcohol, tobacco, and illicit drug use
ZZ Validate history with family member
XX Long-term patterns of functioning
ZZ Stability of traits over time and across situations
XX Cultural issues versus maladaptive personality traits
ZZ Issues of acculturation in new immigrants
ZZ Cultural expression of habitual behavior
ZZ Custom or religious practices
Assessment for Cluster A Disorders

XX Patterns of pervasive distrust and suspiciousness, with odd and unusual behavior
ZZ Present in a variety of contexts, even without supportive evidence
XX Distrust usually not at psychotic level but can display brief psychotic episodes under
stress
XX Significant history includes the following:
ZZ Limited social network
ZZ Poor interpersonal relationships
ZZ Limited disclosure or revealing of self to others, often refusing to answer
personal questions
ZZ Compliments often misinterpreted
ZZ Pathological jealousy common

ZZ Difficult to get along with
ZZ Appearing cold and lacking in feelings
ZZ High control needs
ZZ Rigid and critical of others
ZZ Often highly litigious
ZZ Negatively perceive others; often biased and prone to stereotypes
XX Differences in Cluster A disorders are in degree of suspiciousness and mistrust and
in behavioral manifestations of those traits (see Table 14–2).
Assessment for Cluster B Disorders

XX Patterns of pervasive affective and interpersonal disruption
XX Disturbance usually not at psychotic level but can display brief psychotic episodes
under stress
XX Of all clusters, disorders of Cluster B type may require hospitalization during period of
active symptom expression and when client is under significant levels of stress
ZZ Fluctuating emotional states
ZZ Dramatic qualities to how the person lives his or her life
TABLE 14–2.
CHARACTERISTICS OF CLUSTER A PERSONALITY DISORDERS
DISORDER CHARACTERISTIC
Schizoid personality disorder Neither desires nor enjoys close relationships
Chooses solitary activities
Shows little to no interest in sexual activity with another
person
Derives no pleasure in social activities
Lacks close friends or social supports
Is indifferent of opinion of others
Appears cold and detached
Exhibits affective flattening
Schizotypal personality disorder Ideas of reference
Odd beliefs
Magical thinking
Unusual perceptual experiences
Paranoid ideation
Inappropriate or constricted affect
Behavior overtly odd, eccentric, or peculiar
Few or no close friends
Excessive social anxiety
XX Antisocial personality disorder

ZZ Usually diagnosed by age 18
ZZ More common in men
ZZ High substance abuse comorbidity
ZZ High impulsivity
ZZ Often diagnosed with conduct disorder as children
XX Borderline personality disorder
ZZ Predominantly in women
ZZ Often with positive history of significant childhood physical abuse, sexual abuse,
neglect, or early parental separation or loss
XX Differences in Cluster B disorders are in degree of affective instability, type of inter-
personal disruption, and behavioral manifestations of those traits (see Table 14–3).
Assessment for Cluster C Disorders

XX Patterns of pervasive anxiety and fear
XX Disturbance usually not at psychotic level but can display brief psychotic episodes
under stress
ZZ Avoidant behavior
ZZ Procrastination
ZZ Difficulty in following through
ZZ Fearful of rejection and criticism
ZZ Difficulty relaxing
XX Avoidant personality disorder
ZZ Must consider cultural variable when looking at avoidant behavior
ZZ Disorder equal for both genders
XX Dependent personality disorder
ZZ Most frequently diagnosed personality disorder
ZZ Rates higher in women than in men
ZZ Commonly diagnosed in people with history of chronic physical illnesses
XX Obsessive–compulsive personality disorder
ZZ Predominantly in men
ZZ Symptoms similar to but less severe than obsessive–compulsive disorder
XX Differences in Cluster C disorders are in the degree of anxiety and fear and in behav-
ioral manifestations of those traits (see Table 14–4).

XX Nonspecific
TABLE 14–3.
CHARACTERISTICS OF CLUSTER B PERSONALITY DISORDERS
Antisocial personality Failure to conform to social norms
disorder Repeated acts that are grounds for arrest
Deceitfulness, lying, and use of aliases for profit or pleasure
Impulsivity and failure of future planning
Reckless disregard for the welfare of others
Consistent irresponsibility
Lack of remorse; indifference to the feelings of others
Borderline personality Frantic efforts to avoid real or imagined abandonment
disorder Pattern of unstable, intense interpersonal relationships
Identity disturbances
Impulsivity, often with self-damaging behavior
Recurrent suicidal behavior
Chronic feelings of emptiness
Inappropriate, intensified affective anger responses
Transient psychotic symptoms of paranoia and dissociation
Histrionic personality Uncomfortable in situations in which he or she is not center of
disorder attention
Interactions with others characterized by inappropriate
seductive or sexualized or provocative behavior, rapid shifting,
and shallow emotional responses
Consistent use of physical appearance to draw attention to self
Speech excessively impressionistic and lacking in detail
Suggestible and easily influenced
Relationships considered more intimate than they are
Narcissistic personality Grandiose sense of self-importance
disorder Preoccupation with fantasies of power, success, brilliance, and
beauty
Belief of self-importance and being special and unique
Excessive admiration required
Unreasonable expectations or sense of entitlement
Interpersonally exploitative
Empathy lacking
Envy of others and belief that others envy him or her
Arrogant and haughty behaviors

XX Complete blood count (CBC), chemistry profile, and thyroid function tests to rule out
metabolic causes or unidentified conditions
XX Drug toxicity screening if indicated by history
TABLE 14–4.
CHARACTERISTICS OF CLUSTER C PERSONALITY DISORDERS
Avoidant personality Avoidance of activities involving significant interpersonal contact
disorder Fear of criticism, disapproval, or rejection
Unwillingness to be involved with people unless sure of being
liked
Restraint in intimate relationships for fear of being shamed
Preoccupation with being criticized or rejected in social settings
View of self as socially inept, personally unappealing, or inferior
Unusual reluctance to take personal risks or engage in new
activities
Dependent personality Difficulty making everyday decisions without excessive advice
disorder Needing others to assume responsibility for most areas of life
Difficulty expressing disagreement
Difficulty initiating projects by himself or herself
Going to excessive lengths to obtain nurturing and support from
others
Urgent seeking of another relationship if a close relationship
ends
Unrealistic preoccupation with fears of being left alone
Obsessive–compulsive Preoccupation with details, rules, order, and organization
personality disorder Perfectionism that interferes with task completion
Excessive devotion to work and productivity
Overly conscientious, scrupulous, and inflexible on issues of
morality
Inability to discard worn-out or worthless objects
Reluctance to delegate tasks or work with others
Adoption of a miserly spending style toward self and others
Rigidity and stubbornness
XX Comorbidity is common
XX Mood disorders (see Chapter 9)
ZZ Affective instability of borderline personality disorder often mistaken for bipolar
affective disorder
XX Substance-induced disorders (see Chapter 13)
Clinical Management
XX Rule out or treat any conditions that may contribute to cognitive impairment.
XX Personality disorders are generally managed in a community setting.
XX In some cases, hospitalization may be required.
XX No specific class of pharmacological agents used to treat personality disorders
XX Individualized symptom control
ZZ Impulsivity
XX Selective serotonin reuptake inhibitors (SSRIs)
XX Anticonvulsant mood stabilizers
ZZ Affective instability
XX SSRIs
XX Anticonvulsant mood stabilizers
ZZ Anxiety
XX Non-benzodiazepine anxiolytics
XX SSRIs
XX Benzodiazepines are used with extreme caution
XX Most common form of treatment for personality disorders
XX Focus on issues of limit-setting, protection from self-harm, improved coping, and
enhanced interpersonal functioning
XX Multiple therapeutic interventions may be used, such as
ZZ Case management
ZZ Psychotherapy
XX Focus on the person gaining control
XX Improvement of interpersonal skill level
XX Enhanced coping
XX Alteration of problematic patterns of behavior
XX Forms of therapy:
ZZ Dialectical behavioral therapy
ZZ Psychodynamic therapy
ZZ Interpersonal therapy
ZZ Milieu therapy
XX Assist with realistic expectation formation

XX Structure environment
XX Improve realistic self-appraisal ability

XX Children
ZZ Before diagnosis is determined, sufficient life experiences must occur so that
chronicity of maladaptive patterns can be observed.
ZZ Features of personality disorder usually become apparent during adolescence to
early adulthood.
ZZ It is unusual for someone to be given personality disorder diagnosis before
ages 16 to 18 (an exception is antisocial personality disorder, which often is
observable by onset of puberty; however, diagnosis of antisocial personality
disorder is not made until age 18).
ZZ Separation anxiety and chronic physical illness often precede and predict onset
of dependent personality disorder.
Follow-up
XX These are chronic disorders, and clients may be resistant to change.
XX Relapse is common and frequent.
XX How long to treat and success rates vary with client characteristics and motivation.
XX Prognosis is poor without treatment.
XX Prognosis improves if treatment is started as early in life as possible.
CASE STUDY
Mr. Jevers is 42-year-old new client who seeks health care for a general physical exam. The fam-
ily nurse practitioner who examines Mr. Jevers asks the psychiatric–mental health nurse prac-
titioner (PMHNP) to speak with him because of his odd presentation. The client discusses with
the PMHNP an unusual, recurrent experience he has been having.
Mr. Jevers lives in an apartment building downtown and works as a bartender in the late eve-
ning. He tells the PMHNP that every night as he walks home from work he watches to see if
the wind “blows north to south or south to north.” He relates that, on the occasions that wind
goes north to south, he takes that as a sign that a woman will visit him. He tells of a woman
who rides a bicycle down the road and, as she passes him, he receives a blessing from her that
protects him from those who wish him harm. He believes the woman is a “spirit from the other
side” and that no one but he can see the woman.
As Mr. Jevers tells his story, his affect is inappropriate, his mood pleasant and happy, and he
exhibits some paranoid ideation as he worries that others will try to take away the spirit. His
mental status examination (MSE) shows ideas of reference and some magical thinking as he
shares his “blessing” with customers in the bar, and he describes odd, eccentric, and peculiar
behaviors. Mr. Jevers is not at all bothered by his unusual experience and seems to enjoy telling
it to others. He considers himself lucky to have “special powers” and to see and understand
things that other do not. Mr. Jevers denies the presence of any typical manifestations of halluci-
nations or delusions, any mood disturbance or anxiety, and alcohol or other drug use. He reports
having several close friends, a strong support network, and is in general good health but does
experience significant social anxiety. He does not believe his unusual experience is a symptom
of an illness and wishes no intervention or assistance at this time.
1. What is the most probable diagnosis for this client?
2. What further assessment should occur?
3. If the client desires no treatment, should the PMHNP attempt to follow up with him?
4. What treatment should be suggested at this time?

1. The most likely diagnosis for this client is schizotypal personality disorder.
2. Medical work-up including drug screen is indicated to complete a thorough
assessment.
3. If the client is unwilling to engage in treatment, the PMHNP should try to follow up
with the client at regular intervals and continue to build a therapeutic alliance.
4. If the client is willing to engage in treatment, treatment indicated is using a CBT ap-
proach would be helpful for the client to find “evidence” for his unusual thoughts and
beliefs.

Linehan, M., … Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dia-
lectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personal-
ity disorder. JAMA, 63(7), 757–766.
Neacsiu, A., Lungu, A., Harned, M., Rizvi, S., & Linehan, M. (2014). Impact of dialectical behav-
ioral therapy versus community treatment by experts on emotional experience, expression,
and acceptance in borderline personality disorder. Behaviour Research and Therapy, 53,
47–54.
Nelson, K., Zagoloff, A., Quinn, S., Swanson, H., Garber, C., & Schulz, C. (2014). Borderline per-
sonality disorder: Treatment approaches and perspectives. Clinical Practice, 11(3), 341–349.
Rees, C., & Prichard, R. (2015). Brief cognitive therapy for avoidant personality disorder.
Psychotherapy, 52(1), 45–55.
Reichborn-Kjennerud, T., Czajkowski, N., Ystrom, E., Orstavik, R., Aggen, S., & Kendler, K. (2015)
A longitudinal twin study of borderline and antisocial disorder traits in early to middle adult-
hood. Psychological Medicine, 45(14), 3121–1331.
Schmahl, C. G., McGlashan, T., & Bremner, J. D. (2002). Neurobiological correlates of borderline
personality disorder. Psychopharmacology Bulletin, 36(2), 69–78.
Tusaie, K., & Fitzpatrick, J. (2013). Advanced practice psychiatric nursing integrating psychother-
apy, psychopharmacology, and complementary and alternative approached. New York, NY:
Springer Publishing Company.
CHAPTER 15
DISORDERS OF CHILDHOOD AND ADOLESCENCE

Disorders first diagnosed in infancy, childhood, or adolescence, such as conduct disorder, oppo-
sitional defiant disorder, attention-deficit hyperactivity disorder, Rett syndrome, autism spectrum
disorder, eating disorders, and intellectual disabilities, are considered brain-based illnesses and
have many similarities to disorders diagnosed more commonly in adulthood. In addition, these
disorders often are missed during childhood and adolescent years and are therefore not identi-
fied until early adulthood.
The disorders diagnosed during childhood or in adolescent differ in presentation based on de-
velopmental context of the person, age of onset, and gender. Assessment, treatment planning,
and therapeutic interventions for these disorders must always occur within the context of the
family and assume a multimodal, systems-oriented approach to care. In addition, assessment of
children is different from assessment of adults. Prior to making a psychiatric diagnosis, all pos-
sible medical causes of the symptoms must be ruled out. Therefore, psychiatric–mental health
nurse practitioners (PMHNPs) must apply principles of child assessment to care and have a good
understanding of normal growth and development to detect what is disordered. Effective as-
sessment, diagnosis, and treatment is completed in the context of the family system, however
family is defined for the client.
ASSESSMENT AND CARE PLANNING FOR CHILDREN AND

ADOLESCENTS
XX Requires alteration in assessment process
ZZ Generally takes more time.
ZZ PMHNP must develop trusting relationship with the child to put him or her at
ease.
ZZ Interview the child and parent separately: child can provide information on
internal symptoms and family or care providers on external signs (Hamrin &
Gray Deering, 2012).
ZZ Must attend to developmental needs and interests of the child.
ZZ Must attend to the cognitive and language abilities of the child.
XX Mental status examination (Sadock, Sadock, & Ruiz, 2015).

ZZ Modified to reflect developmental and other age-related issues in children
ZZ Often requires establishment of a play environment to open communication
with the child
ZZ Appearance
XX Conclusions must consider age and developmental processes (e.g.,
physical appearance and dress for weather and age group).
XX Gait and motor skills are assessed on expected normative behaviors for
age.
XX Parent–child interaction
ZZ Observe interaction in waiting room
ZZ Examine way parent and child talk with one another and emotional overtones
ZZ Separation and reunion
XX Examine how child reacts to separation and reunion with parent
XX Speech and language
ZZ Assessed on expected normative and appropriate language use for age
ZZ Comprehension, word selection, and range of vocabulary
ZZ Rate, rhythm, latency, intonation, spontaneity
XX Mood and affect
ZZ Mood: Verbal admission of feelings or assessment based on themes, play, and
fantasy
ZZ Affect: Range of emotions expressed, appropriateness of affect to thought
content
XX Thought process and content
ZZ Thought process: Looseness of associations, magical thinking, preservation,
echolalia, ability to distinguish fantasy from reality (by age 4 children have some
understanding of what is real or made up), flight of ideas
ZZ Thought content: Suicidal or homicidal ideation, perceptual disturbances
(hallucinations)
XX Social relatedness
ZZ Child’s response to interviewer
XX Motor behavior
ZZ Coordination, activity level, involuntary movements, tremors, tics, unusual
asymmetries
XX Cognition
ZZ Intellectual functioning and problem-solving abilities
XX Memory
Disorders of Childhood and Adolescence 329
ZZ Test recall after 5 minutes (school-age children should be able to remember

three objects after 5 minutes)
XX Abstraction
ZZ Assessed on expected normative behaviors for age
ZZ Children ages 12 or younger not expected to have abstractive thought abilities
(young children have concrete thinking)
ZZ Proverb testing and similarity testing require prior exposure to concept, word
choices, and ability to think abstractly
XX Judgement and insight
ZZ Child’s view of problem
ZZ Child’s understanding of what he or she can do to help the problem
XX Therapeutic care planning
ZZ Variety of effective treatments commonly used with children and adolescents:
XX Play therapy
XX Art therapy
XX Bibliotherapy
XX Orative therapy (such as storytelling, family narrative therapy)
XX Interpersonal therapy
XX Cognitive therapy
XX Milieu therapy
XX Pharmacotherapy
OPPOSITIONAL DEFIANT DISORDER (ODD)

Description
XX Oppositional defiant disorder (ODD) is an enduring pattern of angry or irritable mood
and argumentative, defiant, or vindictive behavior lasting at least 6 months with at
least four of the associated symptoms:
ZZ Loses temper
ZZ Touchy or easily annoyed
ZZ Angry or resentful
ZZ Argues with authority
ZZ Actively defies or refuses to comply with request or rules from authority figures
ZZ Blames others
ZZ Deliberately annoys others
ZZ Spiteful or vindictive
Etiology
XX Temperament
XX Parents who model extreme ways of expressing emotions
XX Trauma
XX Unresolved conflicts

XX ODD is more common in children of parents with a history of ODD, conduct disor-
der, attention-deficit hyperactivity disorder (ADHD), antisocial personality disorder,
mood disorders, or substance abuse disorder.
XX It affects 1% to 11% of the general U.S. population, with an average of 3.3%.
XX More common in males (1.4:1).
XX About 30% of children with ODD develop conduct disorder.
Risk Factors
XX Genetic and physiological
XX Temperamental
XX Environmental

ZZ Stigma reduction
XX Well-child visit mental health screening
ZZ Secondary prevention important in younger clients
Assessment
History
associated symptoms
ZZ Social history, including present living situation; education; and alcohol, tobacco,
or illicit drug use

ZZ Substance or alcohol use

XX Nonspecific

XX Mood
ZZ Lability: Low frustration tolerance, angry, argue and lose temper
XX Concentration
ZZ Impaired
XX Thought content
ZZ Often blame others for mistakes

XX No specific laboratory tests
XX Complete blood count (CBC), chemistry profile, thyroid function tests, and B12 level
to rule out metabolic causes or unidentified conditions
ZZ Lead toxicity
ZZ Toxicology screen to rule out a substance abuse disorder
XX ADHD (see below)
XX Substance abuse disorders (see Chapter 13)
XX Intellectual disability (see below)
XX Conduct disorder (see below)
XX Psychotic disorders (see Chapter 11)
Clinical Management
XX Rule out or treat any conditions that may contribute to current symptom manifestation.
XX Nonspecific: not first-line treatment
XX Target symptoms: mood or aggression
XX Therapy is mainstay:
ZZ Individual therapy
ZZ Family therapy, with emphasis on child management skills
ZZ Evidence-based treatment: child and parent problem-solving skills training
(American Academy of Child and Adolescent Psychiatry [AACAP], 2007b).
XX Incredible Years (group intervention)
XX Parent–child interactional therapy (individual or family intervention)
XX Adolescent Transitions Program (ATP; individual or family and group
intervention)
CONDUCT DISORDER
Description
XX Conduct disorder is a repetitive and persistent pattern of behavior in which the rights
of others or societal norms or rules are violated. The presence of at least three of
the following criteria must be present in the past 12 months, with one in the past 6
months:
ZZ Aggression toward people or animals—bullies, threatens, intimidates, initiates
physical fights, uses a weapon to cause physical harm to others, physically cruel
to people or animals, stealing while confronting a victim, forced sexual activity
on someone
ZZ Destruction of property—engaged in fire-setting, destroyed others’ property
ZZ Deceit or theft—broke into house, building, or car; lies, steals items
ZZ Serious violation of rules—stays out late before age 13, runs away from home,
truant before age 13
ZZ Child onset before age 10 or adolescent onset after age 10
Etiology
XX No single factor accounts for presentation.
XX Etiology is largely unknown.
XX Many biopsychosocial factors contribute to the development.
Prevalence
XX Conduct disorder is more common in children of parents with antisocial personality
disorder, alcohol dependence, mood disorders, or schizophrenia than in the general
population.

XX Affects 2% to 10% of general U.S. population, 6% to 16% of boys and 2% to 9% of girls
XX Onset is earlier for boys (10 to 12 years) than for girls (16 years)
Risk Factors
XX Genetic loading
XX Temperamental: Lower than average IQ
XX Environmental: Family rejection and neglect, unsupervised, physical or sexual abuse,
substance use

ZZ Stigma reduction
ZZ Secondary prevention is important in younger clients
Assessment
History
associated symptoms
ZZ Social history, including present living situation; education; and alcohol, tobacco,
or illicit drug use
ZZ Developmental history

XX Nonspecific

XX Affect
ZZ Irritable
ZZ Angry
ZZ Uncooperative
XX Mood
ZZ Anger
XX Thought content
ZZ Lack of empathy or concern for others
XX Concentration
ZZ Distractible
XX Insight
ZZ Poor

XX Drug screening to rule out possible substance abuse
XX Attention-deficit hyperactivity disorder (ADHD; see below)
XX Oppositional defiant disorder (ODD; see above)
XX Posttraumatic stress disorder (see Chapter 10)
XX Substance abuse disorders (see Chapter 11)
XX Developmental disorders (see below)
Clinical Management
manifestation.
XX No specific pharmacological interventions
XX Aggression and agitation treated with antipsychotics, mood stabilizers, selective
serotonin reuptake inhibitors (SSRIs), and alpha agonists
XX Multimodality treatment programs that use all available family and community
resources
XX Behavioral therapy is mainstay:
ZZ Individual therapy
ZZ Family therapy

XX May be diagnosed in clients ages 18 years or older if criteria for antisocial personality
disorder are not met.
ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Description
XX Attention-deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention or
hyperactivity, impulsivity, or both, that interferes with functioning and development.
ZZ Inattention, six or more of the following:
XX Fails to give attention to details
XX Difficulty sustaining attention
XX Does not listen when spoken to
XX Does not follow through on instructions
XX Disorganized
XX Avoids or dislikes tasks requiring sustained mental effort
XX Loses things
XX Distracted
XX Forgetful
ZZ Hyperactive and impulsive, six or more of the following:
XX Fidgets
XX Leaves seat
XX Runs or climbs
XX Unable to engage in quiet activities
XX “On the go”
XX Talks excessively
XX Blurts out information
XX Difficulty waiting turn
XX Interrupts others
XX Several symptoms were present prior to age 12

ZZ Subtypes:
XX ADHD, inattentive type
ZZ Inattentive symptoms dominate
ZZ Lack of criterion symptoms for hyperactivity or impulsivity
XX ADHD, hyperactive type

ZZ Hyperactivity or impulsivity symptoms dominate
ZZ Lack of criterion symptoms for inattention
XX ADHD, combined type

ZZ Criterion symptoms met for inattention and hyperactivity or impulsivity
Etiology
XX Many biopsychosocial factors contribute to the development of ADHD.
XX Polygenic neurobiological deficits are associated with ADHD.
ZZ Problems with executive functioning
ZZ Abnormalities of fronto–subcortical pathways
XX Frontal cortex
XX Basal ganglia
ZZ Abnormalities of reticular activating system
ZZ Structural abnormalities producing neurotransmitter abnormalities
XX Dopamine dysfunction
XX Norepinephrine dysfunction

XX 5% of children and 2.5% of adults in the United States have ADHD.
XX Boys are more likely to be diagnosed (13.2%) than girls (5.6%; CDC, 2010).
XX Average age of onset is 3 years; mean age of diagnosis is 9 years.
XX Approximately 60% of clients have symptoms persisting into adulthood.
ZZ Inattention symptoms are more persistent than hyperactivity and impulsivity
symptoms.
Risk Factors
XX Genetic loading
ZZ Pregnancy and perinatal complications
ZZ Family conflict
XX Environmental
ZZ Low birth weight
ZZ Neglect, foster placement
ZZ Alcohol exposure in utero
XX Temperamental
ZZ Reduced behavioral inhibition

ZZ Stigma reduction
ZZ Secondary prevention is important in young clients.
Assessment
XX Nonspecific
XX Minor physical anomalies at higher rates in people with ADHD than in general
population:
ZZ Hypertelorism
ZZ Highly arched palate
ZZ Low-set ears
XX Higher-than-average accidental injury rates

XX Restlessness
XX Inattention
XX Distractible speech patterns
XX Overproductive speech patterns
XX Affective lability
XX Poor memory
XX Poor concentration

XX Nonspecific
XX Understimulated home environment
XX Substance abuse
XX Major depressive disorder (MDD)
XX Bipolar (BP) disorder
XX Stereotypic movement disorder
Clinical Management
XX Most commonly used agents (see Table 15–1) are stimulants (Schedule II)—
controlled substances that carry risk for abuse.
ZZ Monitor for side effects and adverse effects of stimulants:
XX Gastrointestinal (GI) upset
XX Cramps
XX Anorexia
TABLE 15–1.
MOST COMMONLY USED AGENTS FOR ADHD
DRUG DOSAGE
Ritalin (methylphenidate hydrochloride), Schedule II 5–40 mg/day
Ritalin LA/Ritalin SR (methylphenidate hydrochloride), Schedule II 10–60 mg/day
Metadate CD (methylphenidate hydrochloride), Schedule II 10–60 mg/day
Metadate ER (methylphenidate hydrochloride), Schedule II 10–60 mg/day
Concerta (methylphenidate hydrochloride), Schedule II 18–72 mg/day
Methylin (methylphenidate hydrochloride), Schedule II 5–60 mg/day
Methylin ER (methylphenidate hydrochloride), Schedule II 10–60 mg/day
Daytrana (methylphenidate transdermal patch), Schedule II 10 mg–30 mg/day
(9 hours)
Dexedrine (dextroamphetamine), Schedule II 2.5–20 mg/day
Adderall (amphetamine, dextroamphetamine), Schedule II 5–40 mg/day
Adderall XR (amphetamine, dextroamphetamine), Schedule II 5–60 mg/day
Focalin/Focalin XR (dexmethylphenidate), Schedule II 2.5–20 mg/day
Vyvanse (lisdexamfetamine dimesylate), Schedule II 30–70 mg/day
Strattera (atomoxetine hydrochloride), not a controlled substance 10–100 mg/day
Intuniv (guanfacine), alpha agonist; not a controlled substance; FDA- 1–4 mg/day
approved for ages 6–17
Catapres (clonidine), alpha agonist; not a controlled substance; not FDA- 0.1–0.4 mg/day
approved
Wellbutrin SR/XL (bupropion), norepinephrine dopamine reuptake 100–450 mg/day
inhibitor; not FDA-approved
XX Weight loss
XX Blood pressure changes
XX Increased pulse rate
XX Growth suppression (rare)
XX Headache, dizziness
XX Irritability
XX Psychosis (rare)
XX Patient and parent cognitive behavioral training program
XX Psychoeducation
XX Treatment of learning disorders
XX Family therapy and education
ZZ Parents of children with ADHD have many difficult emotions:
XX Stress
XX Self-blame
XX Social isolation
XX Embarrassment
XX Depressive reaction
XX Marital discord
ZZ Typical family concerns:
XX Stigma
XX Anger
XX Concerns over treatment options
XX Presence of controversial information in media
ZZ Claims of dietary causes of disorder
ZZ Belief in family etiological factors
ZZ Family educational needs:

XX Environmental structuring
XX Psychiatric comorbidities
XX School issues and concerns
XX Peer relationship-building
XX Smoking and substance abuse rates
XX Stress management
XX Common comorbidities
ZZ Major depressive disorder (see Chapter 9)
ZZ Bipolar disorder (see Chapter 9)

ZZ Oppositional defiant disorder (see above)
ZZ Substance abuse disorders (see Chapter 13)
ZZ Tic disorder
ZZ Learning disorders
Follow-up
XX Monitor clinical progress over time.
XX Use standardized rating scales such as:
ZZ Conners’ Parent and Teacher Rating Scales (copyrighted)
ZZ Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales (public domain)
XX Monitor attainment of growth and development milestones.
XX Symptoms may persist into adulthood.
ZZ Plan for long-term needs.
AUTISM SPECTRUM DISORDER

Description
XX Persistent deficits in social communication and social interaction across multiple set-
tings associated with deficits in:
ZZ Social reciprocity
ZZ Nonverbal communication
ZZ Developing, maintaining, and understanding relationships.
XX Restricted repetitive behavior:
ZZ Stereotyped or repetitive motor movements
ZZ Insistence on sameness
ZZ Highly restricted with fixed interests
ZZ Hyper- or hyposensory input
Etiology
XX No single factor can account for presentation.
XX Etiology is largely unknown.
XX Many biopsychosocial factors contribute to the development.
Prevalence
XX The disorder appears to be more common in families in which other members have
autism spectrum disorder (ASD).
XX Affects about 1% of U.S population, but the disorder is more common in boys.
XX Imbalances of glutamate, serotonin, and gamma-aminobutyric acid (GABA) are
thought to be implicated in causation.
XX Brain imaging studies of children with autism revealed microscopic and macroscopic
abnormalities of the amygdala, hippocampus, and cerebellum.
XX Decreased numbers of Purkinje cells in the cerebellum are thought to play a role in
the development.

XX ASD is more common in children with a family history of pervasive developmental
disorders.
XX The concordant rate for an identical twin with autism is 60%.
XX The incidence is 2 to 5 cases per 10,000 in the United States.
XX The male-to-female ratio is 4:1.
XX Onset of symptoms is before age 3 years.
XX About 10% of people with autism also have a genetic or chromosomal condition
such as Down syndrome or fragile X syndrome (CDC, 2015).
Risk Factors
XX Male
XX Intellectual disability
XX Genetic loading

ZZ Stigma reduction
Assessment
History
ZZ Impairment with social interaction, communications, and behavior
XX Impaired social interactions such as abnormal gaze, posture, and expression
in social interactions
ZZ Lack of peer relationships, emotional reciprocity, and spontaneous seeking of
enjoyment
ZZ Impaired communication, such as a delay or lack in the development of spoken
language, impaired ability to initiate and sustain conversations, repetitive and
stereotyped use of language, and inability to play with others
ZZ Restricted repetitive and stereotyped patterns of behavior, interests, and activities,
such as inflexible adherence to specific nonfunctional routines and repetitive,
stereotyped motor mannerisms (e.g., hand or finger flapping, rocking, swaying)
ZZ Parents may report any of the following symptoms:
XX No cooing by age 1 year, no single words by age 16 months, no two-word
phrases by age 24 months
XX Loss of language skills at any time
XX No imaginary play
XX Little interest in playing with other children
XX Extremely short attention span
XX No response when called by name
XX Little or no eye contact
XX Intense tantrums
XX Fixations on single objects
XX Unusually strong resistance to changes in routines
XX Oversensitivity to certain sounds, textures, or smells
XX Appetite or sleep–rest disturbance, or both
XX Self-injurious behavior

XX Nonspecific

XX Little or no eye contact
XX Flat or blunted affect
XX Lack of emotional reciprocity
XX Stereotyped or repetitive motor mannerisms
ZZ Expressive- and receptive-language impairment
Disorders of Childhood and Adolescence 34 3
Screening
XX Screened for developmental delays at well-child visit (CDC, 2015).
ZZ Modified Checklist for Autism in Toddlers (M-CHAT)
ZZ Autism Diagnostic Observation Schedule–Generic (ADOS-G)
ZZ Ages and Stages Questionnaires (ASQ)

XX Rett syndrome (see below)
XX Asperger syndrome
XX Childhood disintegrative disorder
XX Hearing impairment
XX Developmental language and speech disorders
XX Tic disorders
XX Cluster A personality disorders (see Chapter 14)
Clinical Management
XX No specific pharmacological interventions
XX Antipsychotics effective for symptoms such as tantrums; aggressive behavior; self-
injurious behavior; hyperactivity; and repetitive, stereotyped behaviors
XX Antidepressants, naltrexone, clonidine, and stimulants to diminish self-injurious and
hyperactive and obsessive behaviors
XX Behavioral therapy to improve cognitive functioning and reduce inappropriate
behavior
XX Occupational therapy to improve sensory integration and motor skills
XX Speech therapy to address communication and language barriers
XX Pivotal response training
XX Appropriate school placement with a highly structured approach
RETT SYNDROME
Description
XX Rett syndrome is the development of specific deficits following a period of normal
functioning after birth.
Etiology
XX Etiology is unknown.
XX There is a known, progressive, and deteriorating course after an initial period without
apparent disability.
XX It is compatible with probable metabolic disorder.
XX Genetic mutation is suspected.

XX The disorder occurs primarily in girls.
XX It is usually associated with an intellectual disability (see below).
Risk Factors
XX Seizure disorder

ZZ Stigma reduction
ZZ Secondary prevention is important in young clients
Assessment
XX Detailed history of present illness, including time frame, progression, and associated
symptoms
XX Social history, including present living situation and education
and home remedies
XX Validate all physical health findings with a family member.
History
ZZ Normal prenatal and perinatal development
ZZ Normal psychomotor development through the first 5 months after birth
ZZ Normal head circumference at birth
ZZ Onset of all of the following after the period of normal development:
XX Deceleration of head growth between the ages 5 to 48 months
XX Loss of previously acquired purposeful hand skills between ages 5 to
30 months, with the subsequent development of stereotyped hand
movements
XX Early loss of social engagement
XX Appearance of poorly coordinated gait or trunk movements
XX Severely impaired expressive- and receptive-language development with
severe psychomotor retardation.

XX Associated features:
ZZ Seizures
ZZ Irregular respirations
ZZ Scoliosis
ZZ Loss of purposeful hand skills
ZZ Stereotypic hand movements

XX Appearance
ZZ Stereotypic hand movements
XX Speech
ZZ Expressive- and receptive-language impairment
XX Affect
ZZ Flat or blunted affect
ZZ Diagnostic and laboratory findings
ZZ No specific laboratory or diagnostic findings
ZZ CBC, chemistry profile, thyroid function tests, and B12 level to rule out metabolic
ZZ Drug toxicity screening, if indicated by history
ZZ Electroencephalogram (EEG) and nonspecific abnormalities on brain imaging
XX Autism spectrum disorder (see above).
Clinical Management
manifestation.
XX Nonspecific
XX Multimodality treatment
XX Treatment aimed at symptomatic intervention
EATING DISORDERS
Description
XX Eating disorders are characterized by disordered patterns of eating, accompanied by
distress, disparagement, preoccupation, and a distorted perception of one’s body
shape.
XX Common forms of eating disorders:
ZZ Anorexia nervosa
XX Clients refuse to maintain a normal body weight.
XX Involves restricted caloric intake.
XX Clients have an intense fear of gaining weight because of a distorted body image.
ZZ Bulimia nervosa
XX Clients engage in binge eating, combined with inappropriate ways of
stopping weight gain
XX Associated with efforts made to lose weight
XX Usually normal or slightly overweight
ZZ Binge eating disorder
XX Recurrent episodes of binge eating with lack of control
XX Bingeing occurs at least 2 days weekly for 6 months
XX Not regularly associated with compensatory behaviors
Etiology
XX Etiology is multifactorial, with biological, social, and psychological factors implicated
in causation.
XX Neurobiological factors include decreased hypothalamic norepinephrine activation,

dysfunction of lateral hypothalamus, and decreased serotonin.

XX Incidence is more common in girls, with 85% to 95% of occurrences.
XX Anorexia nervosa affects approximately 0.28% of the general U.S. population.
XX Bulimia nervosa affects approximately 1.0% of the general U.S. population.
XX Onset is typically between ages 14 and 18 years.
Risk Factors
XX Genetic loading
XX Increased risk of eating disorders among first-degree biological relatives of people
with certain other psychiatric disorders:
ZZ Eating disorders
ZZ Mood disorders
ZZ Substance abuse disorders

ZZ Stigma reduction
Assessment
XX Detailed history of present illness, including time frame, progression, and associated
symptoms
XX Social history, including present living situation; marital status; occupation; education;
and alcohol, tobacco, or illicit drug use
and home remedies
XX Validate history with a family member.
History
ZZ Anorexia nervosa
XX Refusal to maintain a minimally normal body weight
XX Weight less than 85% of expected weight
XX Fear of gaining weight or becoming fat
XX Distorted body image
ZZ Restricting type: During the current episode, the person has not
regularly engaged in binge eating or purging behavior.
ZZ Binge eating or purging type: During the current episode, the person
has regularly engaged in binge eating or purging behavior.
ZZ Bulimia nervosa
XX Recurrent, episodic binge eating
XX Both binge eating and inappropriate compensatory behaviors occur at least
twice weekly for 3 months
XX Recurrent, inappropriate compensatory behaviors to prevent weight gain:
ZZ Self-induced vomiting
ZZ Laxatives
ZZ Enemas
ZZ Diuretics
ZZ Stimulants
ZZ Abuse of diet pills
ZZ Fasting
ZZ Excessive exercise
XX Self-evaluation unduly influenced by body shape and weight

ZZ Purging type: During the current episode, the person regularly has
engaged in purging or the misuse of laxatives, enemas, or diuretics.
ZZ Nonpurging type: During the current episode, the person has used
other inappropriate compensatory behaviors, such as fasting or
excessive exercise, but has not regularly engaged in purging or misuse
of laxatives, enemas, or diuretics.

XX Anorexia nervosa:
ZZ Low body mass index
ZZ Amenorrhea
ZZ Emaciation
ZZ Bradycardia
ZZ Hypotension
ZZ Electrocardiogram (ECG) changes

XX Inversion of T-waves
XX ST segment depression
XX Prolonged QT interval
ZZ Hypothermia
ZZ Yellow skin secondary to carotenemia
ZZ Dry skin
ZZ Brittle hair and nails
ZZ Lanugo growth on face, extremities, and trunk
ZZ Peripheral edema
ZZ Hypertrophy of the salivary glands
ZZ Erosion of dental enamel
ZZ Russell’s sign—scarring or calluses on the dorsum of the hand, secondary to
self-induced vomiting
XX Bulimia nervosa:
ZZ Weight usually within normal range
ZZ Erosion of dental enamel
ZZ Russell’s sign
ZZ Hypertrophy of salivary glands
ZZ Rectal prolapse

XX Appearance
ZZ Emaciated appearance with anorexia nervosa
XX Affect
ZZ Lability
ZZ Anxiety
ZZ Constricted and sad
XX Mood
ZZ Dysphoric mood
XX Thought content
ZZ Preoccupation with food and body weight
ZZ Suicidal ideation
ZZ Low self-esteem
XX Concentration
XX Judgment
ZZ Impaired for self-welfare
XX Insight
ZZ Impaired

XX Anorexia nervosa
ZZ No definitive laboratory test for diagnosis
ZZ Laboratory changes:
XX Normochromic, normocytic anemia
XX Leukopenia
XX Neutropenia
XX Anemia
XX Thrombocytopenia
XX Hypokalemia
XX Hypomagnesemia
XX Hypoglycemia
XX Decreased LH and FSH
XX Bulimia nervosa
ZZ No definitive laboratory tests
ZZ Laboratory changes:
XX Hypotension
XX Bradycardia
XX Hypokalemia
XX Hyponatremia
XX Hypochloremia
XX Hypomagnesemia
XX Metabolic acidosis or alkalosis
XX Elevated serum amylase
XX General medical condition
XX Cluster B personality disorders (see Chapter 14)
XX Obsessive–compulsive disorder (OCD; see Chapter 10)

Clinical Management
manifestation.
XX Medication management as adjunctive therapy to psychotherapy
XX No specific medication therapy for anorexia nervosa
XX Fluoxetine is FDA-approved for bulimia nervosa.
XX SSRIs and tricyclic antidepressants (TCAs) effective in reducing the frequency of
bingeing and purging
XX Treat associated symptoms, such as depression and anxiety, with appropriate phar-
macological therapy.
XX Multimodal treatment
ZZ Medical and nutritional stabilization
XX Weight restoration
XX Correction of electrolyte disturbance
XX Vitamin supplementation
XX Nutrition counseling
ZZ Dental care
ZZ Psychotherapeutic interventions
XX Individual psychotherapy
XX Cognitive behavioral therapy
XX Family therapy
XX Group therapy
ZZ Community resources
XX Eating disorder support groups
XX 12-step programs
Follow-up
XX Regular follow up with a multidisciplinary team is necessary
INTELLECTUAL DISABILITY
Description
XX Intellectual disability has an onset during the developmental period and includes low
intellect and adaptive functioning.
XX Onset must occur before age 18 years.
XX Mild, moderate, severe, or profound.
ZZ Based on adaptive functioning and not IQ scores
ZZ IQ scores are less valid on the lower end of IQ range
Etiology
XX Heredity accounts for 5% of cases:
ZZ Inborn errors of metabolism (e.g., Tay-Sachs disease)
ZZ Single-gene abnormalities (e.g., tuberous sclerosis)
ZZ Chromosomal aberrations (e.g., translocation of chromosome 21 [Down
syndrome] and X-linked gene of FMR-1 [fragile X syndrome]).
XX Early alterations of embryonic development account for 30% of cases.
ZZ Prenatal exposure to toxins (e.g., maternal alcohol consumption, infections)
XX Pregnancy and perinatal problems account for 10% of cases.
ZZ Fetal malnutrition
ZZ Premature birth
ZZ Fetal hypoxia
ZZ Birth trauma
XX General medical conditions acquired during infancy or childhood contribute to ap-
proximately 5% of cases.
ZZ Infections
ZZ Brain trauma
ZZ Exposure to toxins (e.g., lead poisoning)
XX No clear etiology can be found in 30% to 50% of cases.
XX The most preventable cause of intellectual disability is fetal alcohol syndrome.
ZZ Characteristics of fetal alcohol syndrome include:
XX Epicanthal skin folds
XX Low nasal bridge
XX Short nose
XX Indistinct philtrum
XX Small head circumference
XX Small eye openings
XX Wide-set eyes
XX Thin upper lip
Prevalence
XX 1% of the general population
Demographics
XX Highest rates are reported in school-age children (10–14 years of age).
XX 1.5 percent more males than females
Risk Factors
XX Genetic loading
XX Adverse birth events

XX At well-baby examinations
XX School screenings
Assessment
XX Oblique eye folds
XX Small, flattened skull
XX Large tongue
XX Broad hands with stumpy fingers
XX Single transverse palm crease
XX High cheekbones
XX Small height
XX Brushfield spots on iris
XX Abnormal finger and toe prints
XX Cryptorchidism
XX Congenital cardiac defects
XX Early dementia
XX Hypothyroidism

XX Communication deficits
XX Dependency
XX Passivity
XX Poor self-esteem
XX Low frustration tolerance
XX Aggressiveness
XX Stereotyped, repetitive motor movement
XX Self-injurious behavior

XX No specific laboratory findings
XX Some laboratory findings associated with a variety of causes of intellectual disability
(e.g., metabolic disturbances)
XX Borderline intellectual functioning
XX Learning and communication disorders
XX Pervasive developmental disorder (PDD)
ZZ 75% of people with a PDD have comorbid intellectual disability.
XX ADHD (see above)
XX General medical condition
Clinical Management
XX Pharmacological treatment is symptom-specific.
ZZ Treat concomitant psychopathology (e.g., ADHD, depressive disorder, anxiety
disorder, schizophrenia).
ZZ Aggressive or self-injurious behavior may be controlled with antipsychotics and
mood stabilizers.
XX Therapy
ZZ Group therapy
ZZ Family therapy
XX Community resources
ZZ Day care settings
ZZ Sheltered workshops
ZZ Group homes
Separation Anxiety Disorder (refer to Chapter 10)
DISRUPTIVE MOOD DYSREGULATION DISORDER

Description
XX Childhood depressive disorder that is diagnosed in children older than age 6 but
younger than age 18.
XX The features of this disorder are
ZZ chronic dysregulated mood,
ZZ frequent temper outbursts, and
ZZ severe irritability.
Etiology
XX Cause is unknown

XX Affects about 2% to 5% of children and adolescents
XX Higher incidence in boys and school-age children than girls and adolescents
Risk Factors
XX Complicated psychiatric history including comorbid ADD and ADHD.

XX Children and adolescents should be screened for a personal and family history of bi-
polar disorder as symptoms of disruptive mood dysregulation disorder can be similar
to bipolar disorder.
Assessment
XX Assess for comorbid conditions such as:
ZZ Bipolar disorder
ZZ ODD
ZZ ADHD
ZZ Depressive and anxiety disorders

ZZ Autism spectrum disorder
Clinical Management
Pharmacologic Management
XX Medications can be used to treat the target symptoms of the disorder.
XX Selective serotonin reuptake inhibitors, mood stabilizers, and atypical antipsychotics
can be helpful.
Nonpharmacologic Management
XX Individual, group, and family therapy are helpful.
Follow-Up
XX Regular follow-up is necessary, as is ongoing assessment for comorbid conditions
CASE STUDY
The parents of a 14-year-old with attention-deficit hyperactivity disorder (ADHD) ask to speak to
you privately after you complete your assessment of their child. They tell you they have several
questions that they want answered, and they want to ask you to keep the answers to yourself
and not tell their son what they ask. Their first question is about diet. They have read that ADHD
can be managed by dietary therapy instead of medications, and they want your opinion about
trying this strategy with their child. They also want to know how likely it is that he will “outgrow”
the disorder. You have many issues to consider before answering the parents’ questions.
1. What is the most accepted theory of etiology regarding ADHD?
2. What is the empirical database for dietary treatment in ADHD clients?
3. What is the natural course of this illness? Is it likely that the son’s symptoms will
improve as he ages?
4. What are the other issues to consider regarding the parents’ request to keep confi-
dential the concerns that they are expressing?

1. The accepted theory is that ADHD is a neurobiological disorder
2. The best-studied treatment for ADHD is stimulant medication. Elimination of food
allergens, sugar, and aspartame can be helpful to decrease hyperactivity. Limited
evidence exists about the use of herbal remedies; however, it is always best to
meet the client and parents where they are and if nonpharmacological treatments or
dietary alterations are requested, the PMHNP should provide evidence for treatment
of ADHD so the family can make an informed decision.
3. ADHD is a lifespan disorder; however, as children progress into adulthood, symp-
toms of inattention usually remain with a decrease in impulsive and hyperactive
symptoms.
4. Other issues of concern in a child with ADHD include a lack of involvement of the
child in treatment might lead to nonadherence by the child. Working in family therapy
would be beneficial.

American Academy of Child and Adolescent Psychiatry. (1997). Practice parameter for the treat-
ment of children and adolescents with conduct disorder. Journal of the American Academy
of Child and Adolescent Psychiatry, 36(10), 122S–139S.
American Academy of Child and Adolescent Psychiatry. (2007a). Practice parameter for the as-
sessment and treatment of children and adolescents with attention-deficit/hyperactivity dis-
order. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894–921.
American Academy of Child and Adolescent Psychiatry. (2007b). Practice parameter for the
assessment and treatment of children and adolescents with oppositional defiant disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 46(1), 126–141.
American Psychiatric Association. (2001). Practice parameters for the assessment and treatment
of children and adolescents with suicidal behavior. Journal of the American Academy of
Child and Adolescent Psychiatry, 4(Suppl. 7), 245–478.
American Psychiatric Association. (2009). Practice parameters on the use of psychotropic
medication in children and adolescents. Journal of the American Academy of Child and
Adolescent Psychiatry, 48(9), 961–973.
(5th ed.).Washington, DC: Author.
Centers for Disease Control and Prevention. (2010). Morbidity and mortality weekly report:
Increasing prevalence of parent reported attention-deficit/hyperactivity disorder among chil-
dren – United States, 2003 and 2007. Morbidity and Mortality Weekly Report, 59(44), 1–40.
Centers for Disease Control and Prevention. (2015). Facts about ASD. Retrieved from http://www.
cdc.gov/ncbddd/autism/facts.html
Hamrin, V., & Gray Deering, C. (2012). Mental health assessment of children and adoles-
cents. In M. Boyd (Ed.), Psychiatric nursing contemporary practice (5th ed., pp. 661–678).
Philadelphia, PA: Lippincott Williams & Wilkins.
Lock, J., LaVia, M., & The American Academy of Child and Adolescent Psychiatry Committee
on Quality Issues. (2015). Practice parameter for the assessment and treatment of children
and adolescents with eating disorders. Journal of the American Academy of Child and
Adolescent Psychiatry, 54(5), 412–425.
Murphy, T., Lewin, A., Storch, E., Stock, S., & The American Academy of Child and Adolescent
Psychiatry Committee on Quality Issues. (2013). Practice parameter for the assessment and
treatment of children and adolescents with tic disorders. Journal of the American Academy
of Child and Adolescent Psychiatry, 52(12), 1341–1359.
Nolan, E., Gadow, K., & Sprafkin, J. (2001). Teacher reports of DSM-IV ADHD, ODD, and CD
symptoms in school children. Journal of the American Academy of Child and Adolescent
Sadock, B. J., Sadock, A. V., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Baltimore, MD: Wolters Kluwer.
U. S. Department of Health and Human Services. (2000). Mental health: A report of the Surgeon
General. Washington, DC: Author.
Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., & The American Academy
of Child and Adolescent Psychiatry Committee on Quality Issues. (2014). Practice parameter
for the assessment and treatment of children and adolescents with autism spectrum disor-
der. Journal of the American Academy of Child and Adolescent Psychiatry, 53(2), 237–257.
CHAPTER 16
SLEEP
This chapter addresses sleep issues and disorders commonly encountered by the psychiatric–
mental health nurse practitioner (PMHNP). These conditions and clinical problems may co-occur
with the disorders already discussed or may present in clients with no other identifiable psychiat-
ric or mental health problems. They also may be frequent findings in primary care settings while
working with clients with general medical conditions.
GENERAL CONSIDERATIONS
XX Must be systematically assessed
XX Comparison of present level of sleep to historical baseline
XX Can be measured by polysomnography
XX Rapid eye movement (REM) alternating with four distinct nonrapid eye movement
stages (NREM).
ZZ Stage I
XX NREM
XX Transitional stage from wakefulness to sleep
XX 5% of total normal sleep cycle
ZZ Stage II
XX NREM
XX Specific electroencephalogram (EEG) waveforms
XX 50% of total sleep cycle
ZZ Stages III and IV
XX NREM
XX Slow-wave sleep period
XX Deepest level of sleep
XX 20% to 25% of total sleep cycle
ZZ Sleep stages are organized and sequential during sleep period.

XX Stages III and IV tend to occur in first one-third to one-half of sleep period
XX REM occurs cyclically throughout the night, alternating with NREM on
average every 80 to 100 minutes.
XX REM increases in duration toward morning.
ZZ Sleep patterns vary with age.
XX Children and adolescents have large amounts of slow-wave sleep.
XX Sleep continuity and depth decrease with age.
XX Consider age when assessing for sleep–rest problems.
ZZ Sleep patterns vary with medication use.
XX Many medications and agents of abuse affect sleep cycle.
XX Assess recent changes in medication or drug use in a person presenting
with sleep pattern disturbances.
INSOMNIA
XX Insomnia is the inability to get the amount of sleep needed to function efficiently
during the day.
XX Situational or acute insomnia lasts from days to weeks.
XX Insomnia disorder is characterized by a significant inability to initiate or maintain sleep,
or early morning awakening with inability to return to sleep and. Occurs at least 3
nights per week and is present for at least 1 month (episodic insomnia disorder) and
may persist for greater than 3 months (persistent insomnia disorder).
XX Insomnia disorder is associated with increased mortality, poor career performance,
overeating, and increased hospitalization.
XX Insomnia disorder is not better explained by or occurring exclusively during the course
of another sleep disorder, and is not attributable to the effects of a substance.
Etiology
XX Dysfunction in sleep–wake circuits of the brainstem
XX Neurochemical imbalances impinging on these circuits
XX May be stress-related in brief episodic insomnia

XX 33% of Americans have difficulty sleeping.
XX Up to 10% meet criteria for insomnia disorder.
XX Insomnia is highly comorbid with other psychiatric disorders.
Sleep 363
Risk Factors
XX Female gender and advancing age
XX Past history of insomnia
XX Significant stress
XX Forced pattern changes
ZZ Working alternating shifts
ZZ Swing-shift work patterns
ZZ Travel across time zones
ZZ Genetic (obstructive sleep apnea)
XX High-use patterns of medications, drugs, or substances known to affect sleep cycles
ZZ Caffeine, other stimulants
ZZ Alcohol
ZZ Benzodiazepines (BNZs)

XX At-risk family education for children and adolescents
XX Limits on shift work
XX Avoidance of medications known to affect sleep patterns
XX Good sleep hygiene patterns
XX Avoidance of stimulants late in the day
ZZ Routine screening at all healthcare settings
Assessment
XX Detailed history of present insomnia, including time frame, progression, and associ-
ated symptoms
XX Social history, including present living situation; marital status; occupation; educa-
tion; and alcohol, tobacco, or illicit drug use
and home remedies
XX Number of hours in usual sleep pattern
XX Initial- or middle-phase insomnia; early morning awakening
XX Use of sleep aids
XX Bed position, use of pillows
XX Environment: temperature, sound, light
Hypersomnolence Disorder
XX Self-reported excessive sleepiness despite adequate main sleep period
XX Difficulty being fully awake—“groggy” after abrupt awakening
XX Occurs at least 3 times per week and lasts for several months
XX Causes significant distress or impairment
XX Not better explained by another sleep disorder, viral infection, or physiologic affect of
a substance
XX May occur within 18 months of experiencing a head trauma
XX Comorbidity includes various depressive disorders (e.g., major depression with atypi-
cal features, seasonal affective disorder [SAD], bipolar disorder depressed state)
Obstructive Sleep Apnea (OSA)

XX Hallmark of disorder is snoring and repeated apnea during sleep
XX Daytime sleepiness or sense of feeling unrefreshed despite adequate sleep period is
prominent.
XX Headache upon awakening is common.
XX Consequences include panic attacks (waking up “gasping”), attention-deficit hyperac-
tivity disorder, depression, hypertension, and motor vehicle and workplace accidents
XX Affects up to 2% of children, up to 15% to 20% of adults
XX Etiology due to abnormally small nasopharynx, tonsillar tissue in children; obesity
Polysomnography to Make Definitive Diagnosis

XX Nonspecific
XX Sleep disturbance often a manifestation of an underlying disorder
XX Clients in whom a sleep disorder is suspected should have full exam

XX May have preoccupation or excessive worry about “not getting enough sleep”
XX Depending on duration of sleep deprivation, many areas of mental status exam
(MSE) may be affected

XX Complete blood count (CBC), chemistry profile, thyroid function tests, ferritin level (if
restless legs), and B12 level to rule out metabolic causes or unidentified conditions
Sleep 365
XX More than 50% of insomnia cases are related to primary psychiatric disorder.
ZZ Mood disorders (see Chapter 9)
ZZ Substance-related disorders (see Chapter 13).
ZZ Attention-deficit hyperactivity disorder (ADHD; see Chapter 15)
ZZ Early-morning wakefulness a possible sign of depression
ZZ Sudden, dramatic decrease in sleep a sign of possible mania or schizophrenia
ZZ Poor sleep a sign of possible obsessive–compulsive disorder (see Chapter 10)
ZZ Panic and anxiety episodes during sleep a sign of possible panic disorder
ZZ Alcohol may cause numerous awakenings during the night
ZZ Cardiac illnesses
ZZ Parasomnias
ZZ Gastrointestinal disorders
ZZ Chronic obstructive pulmonary disease
ZZ Medication side effects
ZZ Sleep apnea
ZZ Restless leg syndrome
ZZ Chronic pain
ZZ Stress reaction
ZZ Active substance abuse
ZZ Drug use
XX Caffeine
XX Stimulants
Clinical Management
XX Rule out or treat any conditions that may contribute to current symptom manifestation.
XX Weight loss and avoiding supine sleep position may alleviate sleep apnea
XX Positive airway pressure, continuous( CPAP) or bilevel (BPAP) for OSA
XX Melatonin is particularly useful to correct sleep onset issues and may be helpful for
the person with ADHD.
XX Benzodiazepine (BNZ) or hypnotics (should not be used in OSA)
XX Flurazepam (Dalmane)
ZZ Long-lasting agent
ZZ May cause excess drowsiness

ZZ Avoid in older adults
XX Temazepam (Restoril)
ZZ Intermediate acting agent
XX Triazolam (Halcion)
ZZ Short-acting agent
ZZ Little to no excess sedation
ZZ Common side effects:
XX Impaired memory
XX Efficacy decreases over time
XX Should not be used on a long-term basis
XX Nonbenzodiazepine hypnotics
ZZ Zaleplon (Sonata)
XX Ultra-short half-life makes this drug particularly useful for initial or middle-
phase insomnia
ZZ Zolpidem (Ambien, Ambien CR)
XX Short half-life drugs, but may affect person the next morning; must allow for
8 hours before planned awakening
XX Give on empty stomach
ZZ Eszopiclone (Lunesta)
XX Intermediate-acting agent
ZZ Rozerem
XX Melatonin receptor agonist
ZZ Suvorexant (Belsomra)
ZZ Orexin antagonist, suppresses wakefulness
XX Must consider long half-life
XX Antidepressants
ZZ Used for sedating properties
ZZ Amitriptyline (Elavil), doxepin (Sinequan, Silenor); generally avoid use in older
adults
ZZ Mirtazapine (Remeron)
ZZ Trazadone
XX Wake-promoting drugs
ZZ Armodafinil (Nuvigil) indicated for daytime sleepiness associated with OSA
XX Sleep hygiene practices
ZZ Establish a bedtime routine.
Sleep 367
ZZ Have a regular time to sleep and wake.

ZZ Avoid computer and other electronic device use 1 hour before bedtime.
ZZ Never lie in bed for more than 15 minutes if not able to sleep.
ZZ Reduce stress.
ZZ Do stress reduction activities before bedtime.
ZZ Avoid late-in-the-day exercise intensive.
ZZ Avoid late-in-the-day stimulant use, such as caffeine.
ZZ Use bed/bedroom for sleep or sex only.
ZZ Consider moving phone and other devices away from sleeping area; restrict
phone and computer use to 1 or more hours before bed time.
ZZ Psychotherapy.
ZZ Cognitive therapy for insomnia.
XX Relaxation and other therapies
ZZ Abdominal breathing
ZZ Progressive muscle relaxation
ZZ Meditation
ZZ Imaging
ZZ Hypnosis
ZZ Biofeedback
ZZ Stimulus control
ZZ Sleep curtailment
ZZ Light therapy
XX Somatic and other therapies
ZZ Exercise (during the day)
ZZ Warm bath
ZZ Warm milk
ZZ Change bedroom environment

ZZ Insomnia in children
XX Most commonly related to stress
XX Children with insomnia often have been poor sleepers since birth.
XX Pharmacological treatment is not recommended for most children.
ZZ Insomnia in older adults
XX If first presentation is in older years, insomnia often is the result of changes
in chronobiological rhythms. Older adults often become sleepier early in the
evening and wake up early.
XX Sleep latency, decreased REM sleep, and increased sleep fragmentation

are common.
XX Insomnia may be related to underlying psychiatric disorders:
ZZ Mood disorders
ZZ Anxiety disorders
ZZ Attention-deficit hyperactivity disorder
ZZ Alzheimer’s disease
XX Older adults often manifest confusion and restlessness as aspects of

insomnia.
XX A careful, complete assessment is necessary when pharmacological
interventions are planned.
Sleep 369
CASE STUDY 1
Ms. Jones, a 43-year-old receptionist, presents at the PMHNP’s clinic with a primary complaint
of insomnia. She reports lifelong problems with sleeping that “comes and goes” depending on
her stress level and general health. She has been experiencing a 4- to 5-day period of poor sleep-
ing, reporting only 3 to 4 hours of sleep and early morning awakening. She has tried over-the-
counter medication and has received no relief. She reports that her health is generally good but
states that she is a 2-pack-a-day smoker and has increased her recreational use of alcohol to 1
to 2 drinks a night in the past few weeks in order to get to sleep. Her insomnia is now beginning
to impair her daily functioning and her interest in social activities. She reports an irritable mood
since her sleep has been difficult and problems with memory and concentration in the morning
after she has slept poorly. She denies depression or any other mood problem and currently is
taking no routine medication. Her physical exam is unremarkable, and routine lab studies, includ-
ing thyroid-stimulating hormone (TSH), CBC, and electrolytes, are all normal.
1. What is the most likely diagnosis for this client at this time?
2. What further assessment should the PMHNP make?
3. What treatment should the PMHNP consider?
4. Is medication warranted at this time to induce sleep?
CASE STUDY 2
Mr. Smith is a 40-year-old married man who presents to the PMHNP with a chief complaint of “I
can’t fall asleep. I’ve tried everything. Nothing works! That medicine the doctor gave me made
me feel worse. It made me feel really anxious. I’m exhausted! I can’t function. I’m going to lose
my job.” Mr. Smith states his primary care provider has prescribed various sleeping medications,
“Ambien, Lunesta, and Ativan,” which have all caused a worsening of his insomnia. His physical
exam and routine labs performed by his primary care provider have all been within normal limits.
1. What further assessment should the PMHNP make at this time?
2. What treatment should the PMHNP consider?
3. Why might a person report feeling more anxious and have more trouble sleeping in
response to a hypnotic or anxiolytic medication?
4. Mr. Smith begins psychotherapy with the PMHNP and he begins to discuss growing
up in an alcoholic family in which his parents fought at night after the children went
to bed. In addition to continuing psychotherapy, should medication be considered?
CASE STUDY 3
Ms. Johnson, a 39-year-old single, obese woman is self-referred to the PMHNP for assess-
ment and treatment of “depression and exhaustion.” Ms. Johnson states “I sleep just fine, but
I’m always tired. My doctor did some blood work and said that everything was normal. I can’t
concentrate. I’m dragging at work. The other day I had to go out to my car and take a nap. I can’t
take this any more! This is really getting me down. Do you think an antidepressant would help?”
Ms. Johnson has had a CBC, comprehensive metabolic panel, serum iron, B12, folate levels, and
thyroid function tests which were all within normal limits.
1. What further assessment should be completed?
2. Should Ms. Johnson be started on medication?

Case Study 1
1. Ms. Jones is suffering from transient insomnia.
2. The PMHNP should identify life stressors, complete a full psychiatric assessment,
and identify any other mental health needs.
3. The PMHNP should assist Ms. Jones in managing her sleep by using effective sleep
hygiene strategies, encouraging diet changes, reducing smoking, and omitting the
use of alcohol for sleep induction.
4. Short-term use of sleep induction medications such as a low-dose sedating antide-
pressant would provide relief with little risk to this client and may help her reduce
current reliance on alcohol.
Case Study 2
1. The PMHNP should complete a comprehensive psychiatric evaluation exploring for
signs and symptoms of a mood or anxiety disorder. The history should include a
thorough evaluation of past sleep patterns and issues with insomnia. The PMHNP
should carefully assess for issues such as childhood or more recent trauma, alcohol,
or other related violence exposure. Clients who have experienced significant trauma
directed at them, or who have been raised in an environment of violence, may have
fear related to falling asleep.
2. The PMHNP should consider psychotherapy, which should include psychoeducation
about insomnia, the impact of anxiety on sleep, and sleep hygiene measures.
3. Children raised in traumatic environments commonly have difficulty falling and
staying asleep. Many children become hypervigilant. These patterns can persist into
adulthood. Adults may not be cognizant of the connection between current sleep
issues and childhood trauma. Any medication that prevents a person from being
hypervigilant could be experienced as a lack of control, thus causing an increase in
anxiety and insomnia.
4. The PMHNP should discuss the possibility of using a selective serotonin reuptake
inhibitor (SSRI) or perhaps another sedating antidepressant to address Mr. Smith’s
heightened arousal and insomnia.
Case Study 3
1. The PMHNP should complete a comprehensive psychiatric evaluation to rule out
a mood, anxiety, or substance abuse disorder. A careful sleep and energy history
should be taken and the PMHNP should screen for evidence of snoring or apnea.
Further assessment should be done by a sleep specialist to rule out obstructive
sleep apnea (OSA) or other sleep disorder.
2. The PMHNP should consider that medications may be indicated. If Ms. Johnson
does have OSA, she will be treated with a continuous or bilevel airway pressure
device (CPAP or BPAP). Wake-promoting medication such as armodafinil may also be
helpful in reducing Ms. Johnson’s excessive daytime sleepiness.
Sleep 37 1

(5th ed., text rev.). Washington, DC: Author.
Buysse, D. (2013). Insomnia. The Journal of the American Medical Association, 309(7), 706-716.
Redeker, N., & McEnany, G. P. (2011). Sleep disorders and sleep promotion in nursing practice.
New York, NY: Springer Publishing.
Rajput, V., & Johnson, R. (1999). Chronic insomnia: A practical review. American Family Practice,
11, 1–6.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology (4th ed.). New York, NY: Cambridge
University Press.
CHAPTER 17
VIOLENCE
This chapter deals with the psychiatric–mental health nurse practitioner’s (PMHNP’s) role in iden-
tifying and treating clients who are impacted by intimate partner violence (IPV), sexual assault,
homicide, and suicide. Assessment of lethality will also be reviewed. These issues may co-occur
with the disorders already discussed or may present in clients with no other identifiable psychiat-
ric or mental health problems. They also may be frequent findings in primary care settings while
working with clients with general medical conditions.
INTIMATE PARTNER VIOLENCE (IPV)

Description
XX IPV is physical, emotional, economic, or sexual pain and injury that is intentionally
inflicted by a person’s intimate partner.
XX The goal of the abuser is to:
ZZ Establish power
ZZ Manipulate the other person
ZZ Intimidate the other person
ZZ Control the other person
Etiology
XX Characteristics of abusers:
ZZ Personality disorders
XX Antisocial personality disorder
XX Narcissistic personality disorder
XX Borderline personality disorder
ZZ Environmental stressors
XX Financial difficulties
XX Ending of a relationship
XX Unemployment

XX IPV occurs among heterosexual and homosexual couples.
XX IPV is the leading cause of injury to women ages 15–44.
XX It is the leading cause of death among African-American women between the ages
of 15 and 24.
XX 1 in 10 female high school students in the United States have reported violence from
their dating partners.
XX 15% to 25% of pregnant women are physically abused.
XX 22% to 35% of all women seen in emergency rooms experienced injuries as a result
of IPV.
XX 1 in 3 women and 1 in 4 men are victims of IPV.
XX 50% of homeless women experience IPV.
XX 63% of men incarcerated for murder between the ages of 11 and 20 have murdered
their mother’s abuser.
XX 33% of male abusers are well educated and include men in professional jobs.
(National Coalition Against Domestic Violence, 2015)
Risk Factors
XX For abusers:
ZZ Exposure to violence at an early developmental age
ZZ Low self-esteem
ZZ Social isolation
ZZ Lack of support
ZZ Cognitive impairment
ZZ Physical or financial dependency

XX Public education and awareness beginning in high school
XX Social programs
ZZ Stigma reduction to allow victims to come forward
Violence 375
ZZ Signs and symptoms of being the victim of abuse

ZZ Prevention programs
ZZ Early recognition, intervention, and initiation of treatment for victims
ZZ Routine screening for victimization at all healthcare settings
Assessment
XX Interview the person who has experienced the violence alone.
XX Determine primary caregivers, living arrangements, legal custodian
History
ZZ Determine recurrent history of medical treatment consistent with abuse:
XX Accidents
XX Suspicious or repeated fractures
XX Physical injuries
XX Traumas
XX Refusal of ongoing treatment or follow-up
XX Missed medical appointments
ZZ Determine environmental, psychosocial, and financial stressors

XX Monitor nutritional status for dehydration and malnutrition.
XX Look for lacerations, bruises, wounds, burns, or fractures.
XX Look for poor skin and personal hygiene.

XX Findings of traits and behaviors suggestive of experiencing abuse:
ZZ Fearful
ZZ Evasive
ZZ Guarded
ZZ Depressed
ZZ Passive
ZZ Dependent

XX None specific to abuse
XX Determine general health and nutritional status
XX Accidental injuries
XX Anxiety disorders (see Chapter 10)
XX Substance use disorders (see Chapter 13)
Clinical Management
XX Most state laws mandate reporting of suspected abuse and neglect of vulnerable populations:
ZZ Older adults
ZZ People with disabilities
ZZ Children
XX None specific to condition
XX The safety and medical well-being of the person experiencing the abuse is most
important.
XX Refer the person to a domestic abuse shelter when feasible.
XX Help the person develop a safety plan.
ZZ Assist client in developing a “code word” for family or other support system as
an attempt to inform them that the person is in need of help.
ZZ Advise client to tell one person in his or her support system about the situation.
ZZ Advise client to pack an “emergency bag” and hide it in case of need to leave
quickly.
ZZ Advise client to keep the IPV hotline and other telephone numbers (e.g., police
department, counselor, shelter) in a secure place.
ZZ Monitor medical status as symptomology presents.
ZZ Monitor nutritional status and vital signs.
ZZ Suggest psychotherapy to assist in gaining insight and in developing new coping
skills.
ZZ Suggest hospitalization when in the best interest of the client.
SEXUAL ASSAULT AND ABUSE

Description
XX Sexual assault or abuse is any sexual act or penetration committed through coercion
or physical force.
ZZ This includes rape, incest, sodomy, oral and anal acts, and use of a foreign
object.
Violence 377
ZZ It is an act of violence and humiliation expressed through sexual means.

ZZ It is used to express power or anger.
Etiology
XX For abusers:
ZZ Character disorders
ZZ Behavioral act of violence is reinforcing
XX Once done, likely to repeat
ZZ Social exposure to violence in culture, media, and home

XX Women have a greater incidence of being assaulted than men.
XX Sexual assault is the most common form of abuse.
XX Perpetrators are more frequently men than women.
ZZ Sexual assaults are often committed by fathers and stepfathers, uncles, older
siblings, other family members, and men that women are dating.
XX Alcohol is involved in 34% of all rapes.
XX Only 1 in 4 rapes is reported.
Factors that Increase Incidence of Abusing

XX Substance abuse disorders
XX Psychiatric disorders
XX Divorce
XX Family or personal history of physical or sexual abuse
XX Long-term exposure to violence
XX Social isolation and lack of support systems
XX Environmental stressors such as unwanted pregnancy in an intimate partner, unem-
ployment, or financial difficulty
Prevention and Screening of Victims

XX Public education and awareness campaigns
XX Community resources and support
XX Community emergency shelters, help lines, and safe houses
XX Assertiveness training and self-defense
ZZ Routine screening at all healthcare settings
Assessment
XX Interview persons who have experienced the assault alone when possible.
XX Establish a safe, trusting relationship to promote sharing.
ZZ Routine inclusion of questions concerning sexual assault in medical history.
ZZ Interview alone and not in presence of family, friend, or partner.
ZZ Interview for social history, including history of living arrangements and
relationships.

XX Nonspecific
XX Presentation of traits and behaviors consistent with potential for having suffered
sexual assault or other abuse:
ZZ Withdrawn
ZZ Frightened appearance
ZZ Hyperreactive to touch
XX Associated findings:
ZZ Unexplained bruises, abrasions, cuts, laceration, burns, soft-tissue swellings,
and hematomas
ZZ Sexually transmitted diseases
ZZ Genital rash or discharge
ZZ Rectal tissue swelling or discharge
ZZ Physical signs that are strongly suggestive of sexual abuse in children:
XX Lacerations, ecchymosis, and newly healed scars of the hymen or posterior
fourchette
XX No hymenal tissue in 3- to 9-o’clock area
XX Healed hymenal transactions, especially in the above area
XX Perianal lacerations
Remember that any child presenting with concerning physical signs should be evaluated
by a sexual abuse expert. A complete history and a sexual abuse examination need to
take place.

XX Withdrawn
XX Frightened
XX Anxious
XX Scattered appearance
XX Hyperreactive to touch
XX Dissociative
Violence 379

XX Nonspecific
XX Assessment and documentation labs
ZZ Forensic specimens
ZZ Pregnancy tests
ZZ Rectal, throat, and vaginal cultures
ZZ Screening for sexually transmitted diseases: Syphilis, HIV, hepatitis B, herpes
simplex, human papillomavirus, trichomonas vaginalis
XX Accidental injuries
XX Consensual sexual activity
XX Lichen sclerosis
XX Posttraumatic stress disorder
XX Anxiety disorder (see Chapter 10)
Clinical Management
XX Use sensitivity and respectful care.
XX Be aware of legal reporting requirements.
XX Use available community resources.
XX Ensure safety and well-being.
XX Ensure confidentiality.
XX Complete accurate documentation.
XX Assess for potential suicidal ideation if the person is showing any depressive symptoms.
XX Suggest cognitive behavioral therapy (CBT).
XX Offer support groups and community resources.
XX Assist with access to criminal and legal supports.
LETHALITY ASSESSMENT
XX Lethality assessment: evaluation, screening, or testing.
XX Lethality refers to the likelihood that a person will commit suicide or homicide—
focused violence at the extreme.
XX Violence: the behavioral expression of anger, rage, and hostility that is demonstrated
by the use of physical force directed toward persons (in case of suicide, toward self)
or property.
VIOLENCE IN SCHOOL
XX Serious physical fighting with peers or family members
XX Severe destruction of property
XX Severe rage for seemingly minor reasons
XX Detailed threats of lethal violence
XX Possession, use, or both of firearms or other weapons
XX Self-injurious behaviors or threats of suicide
XX Bullying or being bullied
XX When warning signs indicate that danger is imminent, safety must always be the
first and foremost consideration. Action must be taken immediately. Immediate
intervention by school authorities and possibly law enforcement officers is needed
when a child:
ZZ Has presented a detailed plan (time, place, method) to harm or kill others,
particularly if the child has a history of aggression or has attempted to carry out
threats in the past
ZZ Is carrying a weapon, particularly a firearm, and has threatened to use it
SUICIDE ASSESSMENT
Risk Factors
XX Depression
XX All antidepressants have black box warnings about increased risk of suicide in chil-
dren, adolescents, and young adults under the age of 24.
XX Prior suicide attempt
XX Family history of mental disorder or substance abuse
XX Family history of suicide
XX Family violence
XX Firearms in the home
XX Incarceration
XX Males are 5 times more likely than females to commit suicide
XX White males over age 85 have highest rate of suicide
Signs of Imminent Danger

XX Threatening to hurt or kill oneself
XX Looking for ways to kill oneself (weapons, pills, or other means)
XX Talking or writing about death, dying, or suicide
XX Plans or preparations for a potentially serious attempt
XX Alcohol use increases the risk of suicide attempts in persons with ideation
Violence 381
HOMICIDE: EARLY WARNING SIGNS

XX Prior history of threatening or violent behavior
XX Paranoia or easily panicked behavior
XX A fascination or preoccupation with weapons, particularly weapons or explosives that
could be used for mass destruction, such as semi-automatic guns
XX Extreme stress from personal problems or a life crisis
XX Identifying with incidents of workplace violence reported in the media and either
condoning or sympathizing with the actions of the persons committing violence
XX Being a loner with little or no involvement with other employees
XX Engaging in frequent disputes with supervisors or coworkers
XX Persistent violation of company policy
XX Obsessive involvement with one’s job, particularly where it occurs with no apparent
outside interests
XX Volatile or violent home or other personal situation that has the potential to bring
violence into the workplace
THREATS OF VIOLENCE
XX Throwing objects
XX Making a verbal threat to harm another person or destroy property
XX Making menacing gestures or physical posturing without actually touching the
person
XX Displaying an intense or obsessive romantic interest that exceeds the normal
bounds of interpersonal interest
XX Attempting to intimidate or harass other persons
XX Behavior indicating that the person is significantly out of touch with reality and that
he or she may pose a danger to himself or herself or to others
XX Volatile or violent personal situations such as found in some custody battles
XX Alcohol use increases the risk for violence
Safety is the number one priority and any threatening behavior must be taken seriously.
CASE STUDY
Ms. Smith, a 24-year-old single Caucasian female is referred to the PMHNP for persistent in-
somnia and depression after being treated in the emergency department of her local hospital for
headaches, stomach pain, and various other physical complaints five times in the past 6 months.
The PMHNP suspects that Ms. Smith is a victim of IPV.
1. What should the PMHNP’s assessment include?
2. How should the PMHNP approach suspicions of IPV with Ms. Smith?
3. Should anyone beside Ms. Smith be interviewed?
4. If the PMHNP concludes that Ms. Smith meets criteria for major depression, should
medication be included as part of the treatment plan?
Assume Ms. Smith is an immigrant.
5. What other considerations must be included in the assessment?
6. How should the PMHNP approach the client with her suspicions of IPV?
7. What other considerations must be included in this woman’s treatment plan?

Assume Ms. Smith is an 80-year-old widowed woman.
8. What other considerations must be included in the assessment?
9. Who should be included in the assessment findings?
10. What other considerations must be included in the treatment plan for any person
suspected of being the victim of IPV?
Violence 383

1. Ms. Smith should undergo a complete physical assessment, labs as indicated (likely
working in conjunction with primary care providers) and a comprehensive psychiatric
evaluation. The PMHNP should also inquire about sexual partner(s), sexual behaviors,
birth control, and possibility of sexually transmitted infection.
2. The PMHNP should approach Ms. Smith privately (1:1). Questions should be posed
in a matter-of-fact manner, using language that is not stigmatizing, such as “Has
___________ ever threatened you or made you feel afraid?” or “Does _________’s
temper ever make you feel scared?”
3. Generally no one else besides the victim should be interviewed. Women often feel
reluctant to discuss being abused because they think if their partner finds out, things
will get worse. Women may feel embarrassed or judged if anyone else were to know
what is going on.
4. Possibly. Treating significant depression will allow Ms. Smith to be in a better posi-
tion to make decisions and take action.
5. The PMHNP must make sure the interview is done in the woman’s native language.
Interpreters must not be a family member or friend.
6. The PMHNP must consider that different cultures may have different perceptions
of IPV. The PMHNP must use culturally sensitive language. The PMHNP will need to
consider the woman’s concerns about legal issues related to immigration status.
7. The availability of culturally sensitive and relevant resources for therapy and medica-
tion management.
8. The client’s living situation and her ability to care for her own needs. Whether or not
she has caregivers, and whether or not her family member or other caregiver is pos-
sibly abusing her.
9. All states have mandatory reporting for suspected elder abuse.
10. A safety plan should be first and foremost. The victim should know where and how
to get help. Resources should include 24-hour hotlines, shelters, support groups,
and the like. The victim should have an escape plan that includes having some cloth-
ing and money packed and ready, in case she decides to leave.

Psychopharmacology, 14(Suppl. 1), 5–12.
Blunt, E., & Reinisch, C. (2013) The family nurse practitioner review manual (4th ed). Washington,
DC: American Nurses Credentialing Center.
National Coalition Against Domestic Violence. (2015). National statistics. Retrieved from http://
www.ncadv.org/learn/statistics
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Walters Kluwer.
Tusaie, K., & Fitzpatrick, J. (2013). Advanced practice psychiatric nursing: integrating psychother-
apy, psychopharmacology and complementary and alternative approaches. New York, NY:
Springer.
U. S. Department of Health and Human Services. (2000). Mental health: A report of the Surgeon
General. Washington, DC: Author.
APPENDIX A
REVIEW QUESTIONS
1. The purpose of the American Nurses Association’s Psychiatric–Mental Health Nursing:

Scope and Standards of Practice is to
a. Define the role and actions for the NP

b. Establish the legal authority for the prescription of psychotropic medications
c. Define the legal statutes of the role of the PMHNP
d. Define the differences between the physician role and the NP role
2. Primary prevention care practices are an essential aspect of the PMHNP role. Which of the
following is the best example of a primary prevention care strategy for community behav-
ioral health?
a. Aftercare program for chronically mentally ill clients recently discharged from the
hospital
b. Court-ordered counseling for abusive parents
c. 24-hour crisis hotlines
d. Parenting skills classes for pregnant adolescents
3. The trend in legal rulings on cases involving mental illness over the past 25 years has
been to
a. Encourage juries to find defendants not guilty by reason of insanity

b. Protect the person’s freedoms or rights when he or she is committed to a mental
hospital
c. Place increasing trust in mental health professionals to make good and ethical decisions
d. Decrease the “red tape” associated with commitments so that commitments are faster
and easier
4. Mr. Smithers, an involuntarily hospitalized patient experiencing psychotic symptoms, refuses

to take any of his ordered medication because he believes “Jesus Christ told me I am the
prophet and must fast for a year.” Your actions should be based on your knowledge of which
of the following?
a. Psychiatric clients cannot refuse treatment
b. Psychiatric clients do not always know what is good for them
c. Psychiatric clients can refuse treatment
d. Psychiatric clients cannot be trusted to make good healthcare decisions and, therefore,
the nurse’s best clinical judgment should guide actions
5. Which of the following statements best reflects the difference between the nurse–client
(N–C) relationship and a social relationship?
a. In the N–C relationship, the primary focus is on the client and the client’s needs.
b. Goals in the N–C relationship are deliberately left vague and unspoken so that the client
can work on any issue.
c. In the N–C relationship, the nurse is solely responsible for making the relationship work.
d. In the N–C relationship, there is no place for social interaction.
Review Questions 387
6. A community has an unusually high incidence of depression and drug use among the teen-
age population. The public health nurses decide to address this problem, in part, by modify-
ing the environment and strengthening the capacities of families to prevent the develop-
ment of new cases of depression and drug use. What is this is an example of?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Protective factorial prevention
7. Mrs. Kemp is voluntarily admitted to the hospital. After 24 hours, she states she wishes to
leave because “this place can’t help me.” The best nursing action that reflects the legal right
of this client is
a. Discharge the client

b. Explain that the client cannot leave until you can complete further assessment
c. Allow the client to leave but have her sign forms stating she is leaving against medical
advice
d. Immediately start the paperwork to commit the client and to allow you to treat her
against her wishes
8. In forming a therapeutic relationship with clients, the PMHNP must consider developing
many characteristics that are known to be helpful in relationship-building. Which of the fol-
lowing is an essential part of building a therapeutic relationship?
a. Collecting a family history

b. Like-mindedness
c. Authenticity
d. Accuracy in assessment
9. According to the DSM-5, which of the following is true? (Ch. 3)

a. A mental disorder is equivalent to the need for treatment.
b. Diagnostic criteria are used to inform clinical judgment.
c. Socially deviant behavior is considered a mental disorder.
d. A culturally expected response to a stressor is not a mental disorder.
10. Mrs. French has been in individual therapy for 3 months. She has shown much growth and
improvement in her functioning and insight and is to discontinue services within the next
few weeks. In the next session, after you discuss service termination, she suddenly begins
to demonstrate the original symptoms that had brought her to treatment initially. She is now
hesitant to discharge, wants to continue services, and is displaying an increase in regressive
defense mechanisms. What is the best explanation for Ms. French’s behavior?
a. An exacerbation of her symptoms related to stress

b. The normal cyclic nature of chronic mental health symptoms
c. A sign of normal resistance to termination seen in the termination phase of therapy
d. A sign of pathological attachment to the therapist that must be addressed
11. A client is displaying low self-esteem, poor self-control, self-doubt, and a high level of de-
pendency. These behaviors indicate developmental failure of which of the following stages
of development:
a. Infancy
b. Early childhood
c. Late childhood
d. School age
12. Mr. Thompson has been forgetful lately, for example, forgetting where he has placed his
keys or what time appointments are scheduled, and he has stated that he thinks these are
just random behaviors that have no particular meaning. Which Freudian-based psychodynam-
ic principle assumes that all behavior and actions are purposeful?
a. Pleasure principle
b. Psychic determinism principle
c. Reality principle
d. Unconsciousness principle
13. An example of a mature, healthy defense mechanism is
a. Denial
b. Rationalization
c. Repression
d. Suppression
14. Mr. Johnson is a 54-year-old client you have been seeing for several weeks in therapy. While
discussing his current concerns of marital stress, he lies on the floor and assumes the fetal
position. This is most likely an example of
a. Immature regressive defense mechanism

b. Denial of reality
c. Immature fantasy defense mechanism
d. Repressive behavior
15. Defense mechanisms are best viewed as a function of the ego
a. To alert us to harm and danger

b. To alert us to problems
c. Used to resolve a conflict
d. Used to protect the id
16. One of the health care changes that has occurred as a result of the affordable care act (ACA)
is that doctors/hospitals/clinic groups or health systems are coming together and assum-
ing the responsibility for quality care to large groups of individuals insured by Medicare. The
health care clinics/systems doctors or hospitals that join together are called which of the
following?
a. Health Maintenance Organization (HMO)

b. Preferred Provider Network (PPO)
c. Accountable Care Organization (ACO)
d. Individual Health Plan (IHP)
17. Health care economics is concerned with making decisions so the benefits outweigh the
cost of resource utilization. What are two concepts that healthcare economics is concerned
with in regard to fair distribution of resources and allocation?
a. Equity and efficiency

b. Cost and benefits
c. Opportunity and waste
d. Affordable and quality
18. What four elements need to be present for a malpractice lawsuit to be filed?
a. Beneficence, Non-Maleficence, Truthfulness, and Justice

b. Duty of care, Breach of standard of care, Injury, and Injury must be related to breach of
the standard of care
c. Abandonment, Breach of care, Violation of ethics, and Reimbursement for poor care
d. Breach of standard of care, Injury, Deceit, and Malpractice
19. Mary is a Psychiatric–Mental Health Nurse Practitioner (PMHNP) who is working in a

hospitalist role. Mary has encountered over five incidences in which attending psychiatrists
and medical residents have been demeaning to nursing staff and not answering calls in the
middle of the night or telling the nursing staff to write orders and the MD would sign off
in the a.m. Mary is concerned about errors and wants to improve quality, reduce errors to
promote safety. What concept is Mary employing?
a. Bullying
b. Abuse
c. Civil Disobedience
d. Just Culture
20. The role of neurotransmitters in the central nervous system is to function as
a. A communication medium
b. A gatekeeper for transmissions
c. A building block for amino acids
d. An agent to break down enzymes
21. Serotonin is produced in which of the following locations:
a. Locus ceruleus
b. Nucleus basalis
c. Raphe nuclei
d. Substantia nigra
22. Dopamine is produced in which of the following locations:
a. Locus ceruleus
b. Nucleus basalis
c. Raphe nuclei
d. Substantia nigra
23. A client presents with complaints of changes in appetite, feeling fatigued, problems with
sleep–rest cycle, and changes in libido. What is the neuroanatomical area of the brain that is
responsible for the normal regulation of these functions?
a. Thalamus
b. Hypothalamus
c. Limbic system
d. Hippocampus
24. In considering whether to order an MRI of the head for a client, which of the following
would be a contraindication to this diagnostic test?
a. Prosthetic limb
b. History of head trauma
c. Pacemaker
d. Pregnancy
25. The primary excitatory neurotransmitter is
a. GABA
b. Serotonin
c. Dopamine
d. Glutamate
26. A client who is experiencing difficulties with working memory, planning and prioritizing,
insight into his problems, and impulse control presents for assessment. In planning his care,
the PMHNP should apply his or her knowledge that these symptoms represent problems
with the
a. Frontal lobe
b. Temporal lobe
c. Parietal lobe
d. Occipital lobe
Review Questions 39 1
27. The concept of target symptom identification is best explained as
a. Identification of the major clinical presentation of the client

b. Identification of specific, precise, and individualized symptoms reasonably expected to
improve with medication
c. Identification of the secondary messenger system syndrome
d. Intentional modulation of synaptic pathways
28. The goal of the psychiatric assessment process performed by the PMHNP is to
a. Gain an understanding of the life experiences of the client

b. Correctly diagnose the client
c. Identify the mental health needs of the client
d. Be able to communicate with other staff about the client’s health needs
29. Mr. Johnson is a client newly admitted to an inpatient psychiatric hospital. The PMHNP on
call at the facility plans to perform the initial intake assessment and diagnostic process.
Mr. Johnson asks to please talk in his room because, he says, “People make me nervous.”
His room is at the end of the hallway and is the farthest away from the nursing station.
The PMHNP’s action should be based on awareness that the best location to do the
assessment is
a. In Mr. Johnson’s room, because it is least noisy and most comfortable for him, thus
facilitating data collection
b. In the dayroom, which is full of people, to observe his interactions with other people
c. In a quiet place, but public enough to get assistance with client care should it be re-
quired during the assessment
d. In the treatment room with the door closed, a neutral location
30. Which communication technique is the PMHNP using in the following situation? Client:
“Sorry I was late. I didn’t realize what time it was.” PMHNP: “This is the third time now that
you have been late for our sessions. I am wondering how committed you are to our working
on your problems.”
a. Theming
b. Recognizing
c. Validating
d. Sequencing
31. In assessing a client, you ask him the meaning of the proverb “People who live in glass
houses shouldn’t throw stones.” He replies, “Because it will break the windows.” The cor-
rect interpretation of this findings is
a. Client has a probable mood disorder

b. Client has a probable anxiety disorder
c. Client has limited intellectual ability
d. Unable to interpret the finding without knowing the client’s age
32. The PMHNP is planning to work with a client using an individual therapy model of care.
During the first session, the client makes the following statement: “This is the third time my
son has run away. I’ve grounded him, taken away his bike, even tried cutting off his allow-
ance and confining him to his room. What should I do now?” The most therapeutic response
for the PMHNP to make is
a. “I wonder if confining him to his room was abusive?”

b. “Maybe that depends on what you are trying to accomplish.”
c. “Perhaps talking to his friends and teachers would help.”
d. Remain silent
33. A client says to the PMHNP, “Some days life is just not worth it. All my wife and I ever do is
fight and scream. Things at home would be calmer and simpler if I just wasn’t there any-
more.” The most therapeutic response for the PMHNP to make is
a. “Do you mean that you are thinking about leaving your wife and moving out?”
b. “Tell me what you mean by ‘it would be simpler if you just weren’t there anymore.’”
c. “So you are thinking suicide might be an option for you?”
d. Remain silent
34. Mrs. Shea has come to the mental health center seeking treatment for depression. She has
a history of a suicide attempt by overdose 1 month ago. She was started on imipramine (tri-
cyclic antidepressant [TCA]) after that event but stopped taking the medication 1 week later
because it “did no good.” The PMHNP meets with Mrs. Shea to plan care with her. Which of
the following is the most appropriate initial action?
a. Asking Mrs. Shea how to help her

b. Providing client teaching about the long time frame for TCAs to work
c. Contracting with Mrs. Shea for 6 sessions of individual therapy
d. Providing Mrs. Shea with feedback about how suicide might affect her family
35. In completing the PMHNP assessment for the Mrs. Shea, the most appropriate lab test for
the PMHNP to order at this time is
a. CBC
b. TSH
c. Liver function tests
d. Electrolyte panel
36. A client comes into the clinic with a longstanding history of depression and chronic renal fail-
ure. He is on an antidepressant and a diuretic and complains of increased depression, mild
confusion, irritability, and overall apathy from being too tired to do anything. The best initial
PMHNP action to take at this time is
a. Increase his dose of antidepressant medication to better capture symptoms

b. Change him to another antidepressant for better symptom control
c. Augment his antidepressant with an atypical antipsychotic medication
d. Order a comprehensive metabolic panel
37. Sarah presents for her initial intake appointment with complaints of depression. She is be-
ing treated for hypertension and asthma by her primary care provider. Knowing that certain
medications can cause or exacerbate depression, you obtain a complete medication history.
Which of the following medications is known to exacerbate or cause depression?
a. Omeprazole
b. Propranolol
c. Levothyroxine
d. Clarithromycin
38. When treating older adults, you should keep in mind that they are more sensitive to issues
of drug toxicity because of which of the following reasons?
a. Decreased body fat

b. Increased liver capacity
c. Decreased protein binding
d. Increased muscle concentration
39. Which known teratogenic effects can be caused by the common psychotropic medications
divalproex and lithium?
a. Divalproex—Epstein anomaly; lithium—cleft palate

b. Divalproex—spina bifida; lithium—Epstein anomaly
c. Divalproex—limb malformations; lithium—seizure disorder
d. Divalproex—mental retardation; lithium—spina bifida
40. The study of what the body does to drugs is called
a. Pharmacodynamics
b. Pharmacology
c. Pharmacokinetics
d. Distribution
41. Your client Sam is being treated for panic disorder with agoraphobia. He currently is being
prescribed paroxetine (Paxil CR, 37.5 mg q.d.) and clonazepam (Klonopin, 0.5 mg q.d., p.r.n.).
He has been on clonazepam for 2 years and admits to needing 4 pills to achieve the same
effect that 1 pill initially produced. This is possibly an example of which process?
a. Kindling
b. Addiction
c. Tolerance
d. Potency
42. Why is group therapy beneficial?
a. It assists the client to focus on self

b. It lacks theoretical frameworks
c. It enables participants to acquire therapeutic factors

d. It is always time limited
43. Which of the following is the best rationale for using cognitive behavioral therapy?
a. Recognize and change his or her automatic thoughts

b. See reality as you see it
c. Change his or her reality by changing his or her environment
d. Recognize and accept that automatic thoughts suggest delusional thinking
44. When working with a dysfunctional family, you find that the father, Jim, worries excessively
and is resistant to change. You give Jim a paradoxical directive to worry extremely well for 1
hour per day, knowing that he will likely be noncompliant, and thus change will occur. With
this technique, you are using which type of therapy?
a. Experiential therapy
b. Structural therapy
c. Strategic therapy
d. Solution-focused therapy
45. Which of the following best describes homeostasis in a family system?
a. Choices a family makes to keep the peace

b. Balance or stability that the family returns to despite its dysfunction
c. Need for change and balance in a family
d. Calm in a family that returns after a crisis
46. In an attempt to bring the client toward the goal he or she is working on, you ask the client,
“If a miracle were to happen tonight while you slept, and you awoke in the morning and
the problem no longer existed, how would you know, and what would be different?” This
technique is used in which type of therapy?
a. Behavioral therapy
b. Solution-focused therapy
c. Adlerian therapy
d. Existential therapy
47. Ms. Thomas has been diagnosed with major depressive disorder (MDD) and is placed on
fluoxetine 20 mg for her depression. For the PMHNP to effectively monitor her use of the
medication, which of the following actions should be part of ongoing care?
a. Use of a standardized rating scale of depression

b. Monitoring for potential abuse of the medication
c. Monitoring of labs for renal functioning
d. Monitoring for potential cardiac side effects
48. Which of the following is the best reason for considering the SSRI among the first-line drug
choices for treating major depression?
a. Need to stair-step initial dosages

b. Sedating and calming effect of the medication
c. Safe use in suicidal overdose clients
d. Ability to obtain therapeutic serum drug levels
49. A 23-year-old woman is brought into the ER after attempting suicide by cutting her wrists.
Which nursing action by the PMHNP would be of highest priority initially?
a. Assess her coping behaviors

b. Assess her current level of suicidality
c. Take her vital signs
d. Assess her health history
50. Which of the following interventions by the PMHNP for a person experiencing ataque de
nervios demonstrates culturally informed care?
a. Offering brief supportive psychotherapy

b. Offering a brief hospitalization
c. Requesting a family member act as an interpreter
d. Offering low-dose, short-term anxiolytic medication
51. The PMHNP working at a student mental health clinic has now been working with a fresh-
man student for several weeks. The PMHNP learns that the student considers himself shy.
He tells the NP that he has always felt uncomfortable in social situations or when he has
to do oral presentations in class. He had few friends up until his senior year of high school
when he discovered he could enjoy himself if he “had a couple of drinks before going out.”
He has continued this pattern in college and now occasionally drinks “2 to 3 beers” on
weekends as well. According to the DSM-5, does the student have a mental disorder?
a. Yes, alcohol use disorder, mild
b. Yes, generalized anxiety disorder
c. No, at this point, the student does not meet criteria for a mental disorder.
d. Yes, adjustment disorder with mixed features
52. Jason misses several appointments. The PMHNP notes she feels resentful toward Jason
and is struggling with how to respond to Jason when he finally comes in for his appoint-
ment. Which of the following demonstrates a therapeutic response?
a. “Jason, since you have missed several appointments, we are closing your case.”
b. “Jason, it’s pretty clear to me that you don’t want to be here.”
c. “Jason, you are ambivalent about seeking treatment.”
d. “Jason, help me understand what’s going on so we can figure out how to proceed.”
53. Which is true about pharmacologic treatment of anxiety in older adults?
a. Course of treatment is generally shorter than for younger adults.

b. Drugs that are highly oxidized are more unpredictable than drugs that are mostly
conjugated.
c. The therapeutic dose of SSRIs is generally lower than for young adults.
d. Highly lipophilic drugs have a more linear elimination in older adults.
54. A client returns for a follow-up appointment 3 weeks after starting on fluoxetine 20 mg.
During this appointment you notice that her speech is a little rapid, in marked contrast to
the psychomotor retardation and paucity of spontaneous speech she displayed on her first
visit. Instead of looking at the floor, she now makes normal eye contact. Her affect has gone
from constricted to expansive. She continues to have difficulty sleeping, but her energy has
improved and she states she feels “so much better!” What should you conclude about the
shift in the client’s presentation?
a. She is experiencing the activating side effects of fluoxetine.

b. She is becoming euthymic.
c. She is becoming hypomanic.
d. She is in a mixed state.
55. Mr. D. is a 35-year-old, married, high-tech industry executive who is referred to the PMHNP
for “insomnia.” Mr. D. reports that he falls asleep quickly, but has difficulty staying asleep.
He wakes up several times during the night, and believes he tosses and turns even when he
is sleeping. He wakes up feeling exhausted and drinks “a pot of coffee” to stay awake and
concentrate during his long work day. He drinks 1 glass of wine most evenings. He denies
any illicit substance use. He denies any symptoms of a mood or anxiety disorder, but is feel-
ing increasingly frustrated and concerned about his sleep. Which of the following is the most
likely contributing factor to Mr. D.’s ongoing middle insomnia?
a. Obstructive sleep apnea (OSA)

b. Caffeine dependence
c. Alcohol withdrawal
d. Attention-deficit hyperactivity disorder (ADHD)
56. Tina is a 54-year-old single white woman who has been a Psychiatric–Mental Health Nurse
Practitioner for over 20 years. She is considering making application to a Doctor of Nursing
Practice (DNP) program but states “if a DNP is required to practice I’ll get grandfathered
in, no need for me to go back to school.” Following the 2008 License, Accreditation,
Certification, and Education (LACE) Consensus Model for Advanced Practice Registered
Nurse Regulation, which statement is correct?
a. Tina is correct: if the DNP becomes a requirement, she will be grandfathered in and
obtain a DNP degree.
b. The DNP is an academic terminal degree and there will not be an opportunity for Tina to
be grandfathered in a DNP.
c. Tina will be grandfathered in and obtain a DNP only if her state requires a DNP to prac-
tice as an APRN.
d. The DNP is a certification and Tina will have to take an examination to be grandfathered
in to obtain a DNP.
57. Tim is a board-certified Psychiatric–Mental Health Nurse Practitioner (PMHNP) working in

a busy community mental health center (CMHC). He is currently seeing a client diagnosed
with bipolar I disorder who has comorbid hypertension and diabetes. During the visit, Tim
takes the client’s blood pressure and her reading is 160/94 mm Hg. The client denies any
headaches, nausea, chest pain, or shortness of breath. The client states “I can’t afford all
these medications so I haven’t seen my doctor in 7 months and I am out of all my blood
pressure and sugar medications, can you give me some?” What is Tim’s most appropriate
action?
a. Call the pharmacy to find out what medications the client is taking and refill for 1 month
to cover until she can get in to see his primary care provider.
b. Tell the client he cannot refill her medications and inform her to go to the emergency
room should she develop any signs or symptoms of an elevated blood pressure or
hyperglycemia.
c. Call the client’s primary care provider, explain the situation, and coordinate the client
getting an appointment and medication refills.
d. Send the client to an urgent care clinic to get refills today.
58. The chief nursing officer of a large behavioral health system approached the PMHNP to dis-
cuss the new Healthcare Effectiveness Data and Information Set (HEDIS) behavioral health
measures and specifications. The PMHNP is asked to do a retrospective chart review of all
hospital discharge clients who received a follow-up visit within 7 days of discharge and with-
in 30 days of discharge. The PMHNP has been asked to engage in which of the following?
a. Needs assessment project

b. Plan, do, study, act project
c. A task that is outside of the PMHNP’s scope of practice
d. Quality improvement initiative
59. A PMHNP who is working on the consult liaison service is referred to a patient in the medi-
cal intensive care unit by the attending hospitalist. The consult note read “Evaluate the
patient for competency to make independent medical decisions and consent for a surgical
procedure.” Based on the scope of practice of a PMHNP, which response would be most
appropriate?
a. Complete the patient assessment and write up the findings in the patient’s medical
record.
b. Complete a patient assessment, including the mini mental status examination and fam-
ily collateral data to determine competency.
c. Call the hospitalist and provide education that competency is a legal concept and ex-
plain that you can assess the patient for the capacity to make medical decisions.
d. Refuse the consult and inform the hospitalist that this is outside your scope of practice.
60. You are asked by a church organization to work with members within your health system to
develop a flu vaccination program. According to public health principles, this is an example
of what level of prevention?
a. Secondary
b. Preventative
c. Tertiary
d. Primary
61. A client with bipolar I disorder presents to your PMHNP office for a follow-up visit. During
the visit the client informs you that he no longer wants to be treated with medication,
and he does not have bipolar disorder, that was a misdiagnosis. He further informs you he
stopped all his medication 2 months ago and is here to thank you for your care and tell you
that he no longer needs follow-up appointments. Understanding the ethical conflict, you use
which of the following ethical principles in working with this client?
a. Autonomy
b. Nonmaleficence
c. Justice
d. Beneficence
62. A new client reveals to the PMHNP that her boyfriend screams at her and has repeatedly
slapped and pushed her in front of her 3-year-old son. She goes on to say that the boyfriend
has thrown things at her and on one occasion threw a glass of water at her that hit her son
in the back. Should the PMHNP report this to child protective services (CPS)?
a. Yes, the client is issuing a cry for help for her son.
b. Yes, the PMHNP has a duty to report.
c. No, this does not constitute a reportable offense.
d. No, a report to CPS will escalate the violence.
63. Which of the following is a function of the psychiatric interview?

a. Understand the client’s psychosocial needs and communicate them to the treatment
team
b. Identify the mental health needs of the client
c. Review previous medical records
d. Evaluate a treatment plan
64. A 74-year-old married white woman was referred to you by her primary care provider for a
psychiatric evaluation. She had a normal medical and neurological examination in the last 2
months. The client presents with her husband of 45 years who states, “My wife is just not
the same anymore, she is irritable and asks the same question several times, even though
I’ve answered it many times.” The client responds, “Oh, Henry, you do the same thing, it’s
just a normal part of getting older, and the kids think everything is fine.” During the assess-
ment you compete the mini mental status examination (MMSE) and the client scores 18. As
the PMHNP treating the client, you know the results of her MMSE indicate which level of
cognitive impairment?
a. No cognitive impairment
b. Mild cognitive impairment
c. Moderate cognitive impairment
d. Severe cognitive impairment
65. You are the PMHNP treating Tim, a 10-year-old child, for ADHD and social anxiety disorder.
His mother presents with Tim for his scheduled individual therapy session. At the end of the
session his mother says, “I need to take Tim to see his pediatrician and at the last visit I was
told he needed some HPV shot. I don’t know, he’s a boy, why would he need that? What do
you think?” What is the PMHNP’s best response to her question?
a. “The Centers for Disease Control and Prevention (CDC) recommends the human papil-
lomavirus (HPV) vaccine for all boys and girls at age 10. HPV can cause cancer in both
men and women, and the vaccine is effective in protecting against the virus. Can you
tell me your concerns about Tim getting this vaccine?”
b. “While the Centers for Disease Control and Prevention (CDC) recommends the vaccine,
every parent has the right to choose and if you do not think Tim needs this vaccine, as
his parent you have the right to refuse.”
c. “The Centers for Disease Control and Prevention (CDC) recommends the human papil-
lomavirus (HPV) vaccine for older teenagers, starting at age 18, so you have time to
research and think about your decision.”
d. “My daughters received the vaccine, and I’m like you, I did not let my sons receive
the vaccine. They don’t need it. I agree, vaccines can be scary, can you tell me your
concerns?”
66. As a PMHNP working in a crisis evaluation center, you are aware that the initial focus of a
crisis assessment is on which of the following?
a. Client’s past diagnosis and medication trials

b. Psychosocial history and supports
c. Safety of the client and others
d. Current living situation and coping skills
67. When conducting a neurological examination on a client, the PMHNP asks the client to hold
out her arms and stick out her tongue while assessing for tremors. Which cranial nerve is
being assessed?
a. Glossopharyngeal
b. Vagus
c. Trigeminal
d. Hypoglossal
68. A 20-year-old Asian man who was recently diagnosed with schizophrenia comes to your
office for a follow-up appointment. During the assessment, he talks about his experience
in the group home, thinking that the television is sending him messages through news
anchors during the 10 p.m. evening news. What symptom is the client describing?
a. Paranoia
b. Illusions
c. Ideas of reference
d. Neologisms
69. You are working with a family: mother, father, and two biological children. Sam, the father,
is very rigid and controlling, which seems to be out of fear that something might happen to
his family. He worries daily and it affects his family relationships. You give Sam a paradoxical
directive and instruct him to intensely worry about everything he can think of for 1 hour a
day. Using a paradoxical directive is part of which therapy?
a. Experimental
b. Structural
c. Strategic
d. Cognitive
70. As a PMHNP working in an outpatient addiction clinic, you often refer your clients to com-
munity AA and NA meetings. Using Yalom’s therapeutic factors, you are aware that peer-
led groups can inspire and encourage other group participants. Which therapeutic factor is
instilled in AA and NA group members?
a. Hope
b. Altruism
c. Catharsis
d. Existential factors
71. Which of the following client statements best describes imitative behavior as a therapeutic
factor in group therapy?
a. Group members talk over one another so the loudest person is heard
b. Group members begin to model aspects of other members of the group and group
leaders
c. Group members discuss past situations when they were bullied and felt ashamed
d. Group leaders take charge of the group and redirect members when they monopolize
the group
72. Dialectical behavioral therapy (DBT) draws on cognitive theory and behavioral theory, along
with other theories. Elements of behavioral theory in DBT include which of the following?
a. Skills training and exposure

b. Examination of feelings and relating feelings to visceral sensations
c. Working through the transference with the therapist
d. Cognitive interpretation of past traumatic experiences
73. Dialectical behavioral therapy (DBT) affirms dialectical thinking, which involves examining
and discussing opposing ideas to find the truth. This philosophy is a supportive principle
of DBT training. The central dialectical pattern emphasized in DBT involves the tension
between:
a. Radical acceptance and change

b. Cue exposure and block avoidance
c. Problem avoidance and problem-solving
d. Crisis survival and acceptance
74. Samantha is a 26-year-old partnered woman who works full time as a teacher. She is in a
long-term relationship with Mary and they are getting along well, and doing well financially.
They have two children, ages 2 and 6. Samantha is seeing the PMHNP to address her
concerns that she is feeling down and sad for no reason and states, “I know my life is going
well but I just don’t feel happy. I have always worried a lot and have been sad most of my
life.” As a PMHNP trained in transactional analysis (TA), you understand that personality
is multifaceted and wonder if which of the following is affecting her ability to experience
happiness:
a. She had long periods of separation from her primary caregiver as a child and now has a
difficult time accepting and receiving love and experiencing happiness
b. She likely had a traumatic event in her childhood and her thoughts and feelings related
to the event are locked together in her brain and cannot be accessed
c. Her unhappiness is likely related to distorted thoughts and feelings about her
relationship
d. As an adolescent she experienced an event that was processed in an ego state as an
older sibling
75. You have been working with a 54-year-old man who has been treated for schizophrenia since
age 19. He has limited social interactions, likes to be alone, and has never dated nor had a
desire to date. His symptoms are best explained by which of the following?
a. Antisocial personality disorder

b. Lack of personal hygiene
c. Negative symptoms
d. Positive symptoms
76. Following evidence-based (EB) practice, which laboratory screening tests and assessments
should be completed prior to placing a person on a second-generation (“atypical”) antipsy-
chotic medication?
a. Serum glucose, lipid profile, weight, blood pressure, waist circumference, and family
history of cardiovascular disease
b. Comprehensive metabolic panel, body mass index, complete blood count, and thyroid
panel
c. Serum glucose or hemoglobin A1c, lipid profile, weight, body mass index, blood pres-
sure, waist circumference, and family history of cardiovascular disease
d. Serum glucose, complete blood count, assessment of family history of cardiovascular
disease and cancer
77. Which type of hallucination is rare in persons with psychotic illnesses and is often associ-
ated with an organic etiology?
a. Auditory hallucinations
b. Gustatory hallucinations
c. Visual hallucinations
d. Combination hallucinations
78. What differentiates atypical antipsychotic medications from first-generation or typical anti-
psychotic medications?
a. 5HT2a receptor antagonist properties

b. 5HT2a receptor agonist properties
c. Specific dopamine receptor 3 and 5HT2a blockade
d. Dopamine receptor 2 antagonist properties
79. You are treating a client with schizophrenia who takes clozapine. What laboratory values will
indicate the client needs to discontinue treatment?
a. White blood cell count of less than 1,800/mm3 and absolute neutrophil count of less
than 1,200/mm3
b. Absolute neutrophil count of less than 1,000/uL
c. White blood cell count of less than 1,200/mm3
d. Absolute neutrophil count of less than 2,000/uL
80. Sean is a 47-year-old Gulf War veteran who was in combat during Operation Desert Storm.
Sean has been treated by the PMHNP for major depressive disorder and associated anxiety
symptoms. During the most recent visit, the PMHNP learns that Sean sustained a traumatic
brain injury during his service, which was recently diagnosed at the TBI clinic in the Veterans
Affairs clinic. What is the rationale for the PMHNP to taper Sean off clonazepam?
a. Benzodiazepines causes memory problems and confusion in clients with a history of a

TBI.
b. Benzodiazepines lower the seizure threshold in clients with a history of a TBI.
c. Veterans Affairs has banned benzodiazepines from the medication formulary.
d. Benzodiazepines place clients with a TBI at risk for a second head injury.
81. Alice is a 68-year-old woman who presents to you with concerns about her memory. She
explains that her mother and grandmother both experienced dementia and she wants to do
what she can to prevent this terrible disease. Alice is treated for hypertension, which is well
controlled; other than that she is in good health. She is socially and physically active and
participates in a monthly cooking class, volunteers at her church, and plays bridge twice a
week at the senior center. She says, “I understand that I am losing brain cells at my age, but
I would still like to keep my mind and body active.” Which is the best response to Alice?
a. “You are correct that you cannot form new brain cells at your age but you should
continue with your activities because they offer excellent physical and mental health
benefits and in turn will lower your risk for dementia.”
b. “Although most brain development occurs early in life, we still form some new brain
cells in a couple of areas of the brain during adulthood. You should continue with your
activities because they offer excellent physical and mental health benefits and are
neuroprotective.”
c. “Scientists now know that we do continue to form new brain cells throughout the
entire brain during adulthood. Continue with your activities because you are producing
new brain cells in the frontal lobe and this will decrease your risk of dementia.”
d. “You should continue the social activities such as bridge, volunteering, and the book
club but should consider the risks and benefits of physical activities such as dancing.
If you were to fall and break a hip, this could lead to prolonged hospitalization, loss of
independence, and ultimately increase your risk of dementia.”
82. What is the best treatment for AIDS dementia complex?
a. Acetylcholinesterase inhibitors
b. Symptom-targeted pharmacologic treatments
c. Nonpharmacologic supportive care
d. Antiretroviral therapy
83. As a PMHNP working on the consult liaison team, you know the importance of preventing
delirium due to which of the following?
a. Risk of 1-year mortality rate

b. Risk of harm to the client and staff
c. Risk of unremitting psychosis
d. Risk of aspiration
84. When working with a 26-year-old, Mike, who presents for treatment of cannabis use and
gambling, you use motivational interviewing techniques. As a PMHNP, you are familiar with
the core counseling skills used in motivational interviewing. Mike made the following state-
ment: “I don’t know why I came here in the first place but I thought maybe some medica-
tion would help me.” You respond by saying, “You’re feeling confused about the process”
and Mike replies, “I never thought I’d need to come to a place like this.” You respond, “You
kept your appointment today and I appreciate the courage it took for you to come here.”
What two motivational interviewing techniques are used in this interaction?
a. Interrupting and reassurance

b. Affirming and reflecting
c. Open-ended questions and summarizing
d. Clarification and data collection
85. You are a PMHNP working in a hospitalist role on an acute inpatient psychiatric unit at a lo-
cal hospital. As you make rounds, the registered nurse informs you that a 32-year-old client
who was admitted for alcohol detox has a score of 17 on the Clinical Institute Withdrawal
Assessment for Alcohol. What phase of withdrawal is this client in?
a. Mild withdrawal
b. Moderate withdrawal
c. Severe withdrawal
d. Delirium tremens
86. A client who has been addicted to opioids has not used in 15 days. During your medication
management visit, the client states, “I’m going to die from not having my Opanas. You need
to give me something now.” The PMHNP’s best response is:
a. “I know you are feeling very uncomfortable and we need to get you to the emergency
room immediately to prevent a seizure.”
b. “I know you are feeling very uncomfortable, let’s take your vital signs and talk about a
trial on Catapres to treat your withdrawal symptoms.”
c. “You have been using Opana for a long time and it is going to take several months for
the withdrawal to end. In the meantime, I will see you weekly.”
d. “There is no treatment for opioid withdrawal; you will have to wait it out.”
87. Signs and symptoms of cannabis intoxication include:
a. Increase sensitivity to external stimuli

b. Enhanced motor skills
c. Fast passage of time
d. Lower heart rate
88. Which defense mechanisms are commonly used by persons with obsessive–compulsive
personality disorder?
a. Rationalization, isolation, and intellectualization
b. Projection, distortion, and hypochondriasis
c. Regression, somatization, and dissociation
d. Sexualization, displacement, and reaction formation
89. You have been working with Cody, a 30-year-old single man, in weekly individual psychother-
apy for 3 weeks. At the start of session 4 he says, “I noticed when I came in that your usual
parking spot has a new car in it with temporary tags, and it’s a BMW. Nice car.” What is the
best response from the PMHNP psychotherapist to Cody?
a. “Thanks for noticing, it is a nice car.”

b. “How do you know what spot I park in?”
c. “I noticed you drive a BMW as well, how do you like your car?”
d. “Sounds like having expensive things is important to you.”
90. When working in individual psychotherapy with a client who has a personality disorder, what
are the primary treatment goals?
a. Change the client’s personality structure and make him or her more adaptable in every-
day life.
b. Reparent the client, following Bowlby’s theoretical framework.
c. Allow the client to reprocess his or her childhood trauma because all clients with per-
sonality disorders have a history of severe abuse.
d. Assist the client in changing dysfunctional interpersonal relationships and use of imma-
ture defense mechanisms.
91. For a client who has paranoid personality disorder, what are the best treatment strategies?
a. Confront negative and misinterpreted thoughts and feelings.

b. Deflate grandiose thoughts.
c. Engage the client in detailed and emotional responses and dialog.
d. Do not challenge negative views or recollections of events.
92. John, a client with paranoid personality disorder, states the following: “I noticed there is a
red light in the upper corner of your door and it has been going on and off during our ses-
sions. Are you recording me?” What is the PMHNP best response?
a. “No, it would be illegal for me to record you, and that is not a camera it’s just a red
light.”
b. “John, thank you for asking the question. The light you see in the upper corner of my
door tells me when a client has arrived and is in the waiting room. The client turns on
the light, as you do, when they arrive in the waiting room, alerting me their arrival, and I
turn off the light when we get into the office using the switch by my desk.”
c. “Come on John, do you think I would record your sessions? You are not that interesting.
I’m just kidding, no John, it is not a recorder or camera.”
d. “John, it takes courage to ask me the question. Tell me a time in your life when you had
a similar experience.”
93. As a PMHNP, you understand the genetic factors that contribute to psychiatric and personal-
ity disorders. Persons who develop antisocial personality disorder often are raised in families
with high rates of which of the following?
a. Psychotic disorders
b. Alcohol use disorders
c. Anxiety disorders
d. Mood disorders
94. Persons with obsessive–compulsive personality disorder often use isolation as a de-
fense mechanism. Which of the following examples best describes isolation as a defense
mechanism?
a. Staying in the house for days or weeks to clean

b. Declining invites by friends or family to attend social gatherings
c. Describing information with very little affect variation

d. Being an introvert in the work setting to prevent talking with coworkers
95. In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), how
should a personality disorder be coded?
a. Coded with the major psychiatric disorder

b. Coded on Axis II
c. Coded on Axis III
d. Coded on Axis IV
96. When prescribing a selective serotonin reuptake inhibitor (SSRI) for a child or young adult up
to age 24, what education must be included?
a. Black box warning about increased suicidality in this population

b. Black box warning about increased risk of mania in this population
c. Risk of sexual side effects on this class of medication
d. Risk of stomach upset and headaches, to prevent unnecessary primary care visits
97. Tommy is an 8 year-old who presents to the PMHNP for evaluation of attention-deficit hyper-
activity disorder. His mother completed the Vanderbilt ADHD rating scale and brought in the
Vanderbilt teaching rating scale. Both your clinical interview and the rating scales indicate
Tommy has ADHD. What assessment indicator(s) need to be completed prior to starting a
stimulant mediation?
a. Get a copy of the rating scale completed by his grandparents.

b. Assess for family history of cardiovascular disease and, if positive for conduction prob-
lems, order an electrocardiogram before prescribing medication.
c. Obtain blood pressure, and pulse, and begin the stimulant medication.
d. Assess for a family history of bipolar disorder.
98. A mother brings in her 7-year-old son for a psychiatric follow-up visit with the PMHNP. This
is the fourth visit the PMHNP has had with the client, his mother, and his younger sister,
Renee, now 7 months old. You notice that she has a decrease in head growth, along with
stereotypic motions of the hands, often licking and slapping. Renee has also lost her lan-
guage skills. What medical condition do you suspect Renee has developed?
a. Autism spectrum disorder

b. Rett syndrome
c. Selective mutism
d. Childhood onset diabetes
99. You are treating Timothy, a 16-year-old boy, for an eating disorder. Timothy is of normal
weight and socially extroverted, at times appearing to seek attention when in a peer group
or class. Timothy’s symptoms are most consistent with which eating disorder?
a. Anorexia nervosa
b. Bulimia nervosa
c. Binge eating disorder

d. Anxiety-induced eating disorder
100. You are treating a 14-year-old female for attention-deficit hyperactivity disorder (ADHD) who
has a family history of bipolar disorder. As a PMHNP familiar with symptoms of both ADHD
and pediatric bipolar disorder, you know the following are overlapping symptoms of both
disorders:
a. Excessive talking, increased activity, and distractibility

b. Irritability, sleep problems, and mood swings
c. Excessive talking, irritability, and sleep problems
d. Sleep problems, mood swings, and distractibility
APPENDIX B
REVIEW QUESTION
ANSWERS
1. Correct Answer: A. The ANA’s Psychiatric–Mental Health Nursing: Scope and

Standards of Practice defines the role and actions of the nurse practitioner.
2. Correct Answer: D. Information reduces incidence of disease.
3. Correct Answer: B. Identifies the trend of ensuring the protection of individual civil
liberties for psychiatric clients.
4. Correct Answer: C. As with any client, psychiatric clients can refuse treatment un-
less a legal process resulting in involuntary commitment or mandatory court order
for treatment has been obtained.
5. Correct Answer: A. Social relationships are mutual interpersonal relationships in
which the needs of both parties are addressed. The N–C relationship is most con-
cerned with meeting the needs of the client.
6. Correct Answer: A. This action focuses on interventions designed to reduce the
incidence of new cases of disease.
7. Correct Answer: B. Almost every state allows for a brief period of detainment to as-
sess a client for dangerousness to self or others before allowing the client to leave a
hospital setting, even if the admission was voluntary.
8. Correct Answer: C. Authenticity. Being genuine, honest, and respectful are essential
elements in establishing a working relationship with any client. Like-mindedness
is not a part of the therapeutic relationship. Although an important aspect of the
PMHNP role, collecting a family history and accuracy in assessment does not in and
of itself facilitate relationship-building.
9. Correct Answer: D. All DSM-5 disorders need to be made taking a person’s culture
into account. A cultural expression of a response to grief, loss, or stress is not con-
sidered a DSM-5 diagnosis.
10. Correct Answer: C. Clients frequently display resistance and regression at the termi-
nation of a meaningful therapeutic process. The PMHNP is responsible for planning
an effective termination and monitoring clients during the termination period.
11. Correct Answer: B. These signs indicate developmental failure of early childhood.
12. Correct Answer: B. The psychic determinism principle states that all behavior has
purpose and meaning, often unconscious in nature, and that no behaviors occur
randomly or by coincidence.
13. Correct Answer: D. Suppression is the only defense mechanism listed in which the
client channels conflicting energies into growth-promoting activities.
14. Correct Answer: A. Immature regressive defense mechanism is a return to a behav-
ior common to an earlier stage of development.
15. Correct Answer: C. Defense mechanisms are a function of the ego used to resolve a
conflict.
16. Correct Answer: C. ACO’s are groups of doctors or other health care providers who
voluntarily come together and assume the care provided to Medicare patients.
17. Correct Answer: A. Health care efficiency is making risk and benefit decision about
how care resources are allocated and equity is ensuring that there is a fair distribu-
tion of the resources.
Review Question Answers 411
18. Correct Answer: B. The four elements that must be satisfied for malpractice to have
occurred are a duty of care between clinician and patient, breach of standard of care,
an injury to the patient, and the patient’s injury must be related to the clinician’s
breach of care.
19. Correct Answer: D. The ANA has a position statement that nurses are responsible for
developing health care settings that include just culture initiatives understanding that
human error can cause error and harm by creating an open and fair environment.
20. Correct Answer: A. Neurotransmitters in the central nervous system function as a
communication medium.
21. Correct Answer: C. Serotonin is produced in the raphe nuclei.
22. Correct Answer: D. Dopamine is produced in the substantia nigra.
23. Correct Answer: B. Appetite, sleep, and libido are regulated by the hypothalamus.
24. Correct Answer: C. A client with a pacemaker should not receive an MRI of the
head.
25. Correct Answer: D. Glutamate is the primary excitatory neurotransmitter.
26. Correct Answer: A. Problems with working memory, planning and prioritizing, insight
into problems, and impulse control indicate a problem in the frontal lobe.
27. Correct Answer: B. Target symptom identification is the identification of specific,
precise, and individualized symptoms reasonably expected to improve with a given
medication.
28. Correct Answer: C. Although diagnosis is an important aspect of the assessment
process, the assessment ultimately should identify the needs of the client.
29. Correct Answer: C. One PMHNP role is to control the milieu as an aspect of as-
sessment, so the PMHNP should choose a quiet place that is public enough to get
assistance with client care should it be required during the assessment.
30. Correct Answer: B. This exchange is an illustration of the technique of recognizing.
31. Correct Answer: D. The answer demonstrates concrete thought processes, which
are normal in persons younger than age 12 but are abnormal after age 12. To inter-
pret the finding, the PMHNP must know the age of the client.
32. Correct Answer: B. This response will be the most therapeutic in moving forward
with the client.
33. Correct Answer: B. This response is the most therapeutic, allowing the client to
further clarify and express feelings.
34. Correct Answer: A. Asking the client how to help is an aspect of assessment—all
other answers are aspects of interventions, which are not initial actions of the
PMHNP.
35. Correct Answer: C. Client overdosed and then was placed on a medication that af-
fects the liver. The PMHNP needs to assess the client’s liver function as an aspect of
care planning for her.
36. Correct Answer: D. Client symptoms are consistent with electrolyte imbalance and a
physical cause of his symptoms must be ruled out first.
37. Correct Answer: B. Beta blockers can cause or exacerbate depression.
38. Correct Answer: C. Older adults usually have decreased protein levels. Most psycho-
tropic medications are highly protein-bound. It is the unbound (free) concentration
of the drug that is active; the bound concentration of the drug is inert. Thus, with
decreased protein available for binding, more free (active) drug remains in the body,
which then predisposes older adults to toxicity.
39. Correct Answer: B. Divalproex can cause spina bifida and lithium can cause Epstein’s
anomaly.
40. Correct Answer: C. Pharmacokinetics is the study of what the body does to drugs.
41. Correct Answer: C. Tolerance means needing more to achieve the same effect.
42. Correct Answer: D. Group therapy is beneficial because it increases social skills, is
cost-effective, and enables participants to acquire the curative factors.
43. Correct Answer: A. Cognitive behavioral therapy helps clients recognize and change
their automatic thoughts.
44. Correct Answer: C. Paradoxical directives are used in strategic therapy.
45. Correct Answer: B. Homeostasis is balance or stability that the family returns to
despite its dysfunction.
46. Correct Answer: B. Miracle questions are used in solution-focused therapy.
47. Correct Answer: A. The use of a standardized rating scale will allow the PMHNP to
monitor the level of client symptoms and to evaluate the efficacy of the medication.
48. Correct Answer: C. SSRIs are considered among the first-line medications used to
treat depression because of safety in suicidal overdose clients.
49. Correct Answer: C. The PMHNP needs to ensure that her suicide attempt has not led
to medical instability.
50. Correct Answer: A. The literature suggests that although short-term anxiolytic
medication may be offered in an emergency room setting, ataque de nervios is best
treated by brief supportive therapy by a Spanish-speaking Latino therapist.
51. Correct Answer: C. The student does not meet criteria for alcohol use or other
disorder at this point, but if he does not learn alternative coping skills to deal with his
shyness, he is at risk of developing an alcohol use disorder.
52. Correct Answer: D. Although the PMHNP’s resentment is in response to actual
behavior by Jason (his missing several appointments), clarifiying what is going on for
him, his expectations for treatment and the PMHNP’s (and the clinic’s) expectations
in a non-judgemental manner will help to develop a therapeutic alliance.
53. Correct Answer: B. Liver enzyme functioning (among other things) diminishes as we
age. All of the other statements are false.
54. Correct Answer: C. In this case, you see a shifting set of symptoms, the most impor-
tant being her expansive mood and statement “so much better” that indicates she
has gone beyond euthymia.
55. Correct Answer: A. OSA is the only plausible possibility if the rest of the information
given by the client is accurate. OSA causes clients to have frequent awakenings and
a sense that they are not sleeping deeply (“tossing and turning”) that is caused by
apnea. The client should be assessed further for snoring and awareness of apnea.
Although the client states he drinks a lot of coffee, this is driven by his sleep issues.
Drinking 1 glass of wine in the evening would not cause the degree of sleep pathol-
ogy he is exhibiting. Other than diminishing concentration that is consistent with
sleep deprivation, there are no other signs and symptoms of ADHD.
56. Correct Answer: B. APRNs are not grandfathered into an academic degree; degrees
must be earned from accredited academic institutions.
57. Correct Answer: C. It is not within the scope of practice of a PMHNP to treat hyper-
tension. Coordination of care to ensure the client does not run out of medication is
the appropriate course of action.
58. Correct Answer: D. Engaging in a project to assess whether a standard of care was
met is a quality improvement project.
59. Correct Answer: C. The legal system makes determination whether a person is com-
petent; practitioners can assess and make a determination about a person’s capacity
to make medical decisions.
60. Correct Answer: D. Prevention of illness is primary prevention and administration of
flu vaccinations in a community is intended to prevent a flu outbreak.
61. Correct Answer: A. Clients who are legally competent have the ability to make medi-
cal decisions and maintain individual autonomy.
62. Correct Answer: B. PMHNPs are mandated reporters of child abuse. The 3-year-old
is being exposed to violence and although not the target, could have been injured
when the boyfriend threw the glass of water.
63. Correct Answer: B. During a psychiatric interview, the PMHNP is responsible to iden-
tify symptoms and needs of a client to develop an appropriate treatment plan.
64. Correct Answer: C. Cut points on the MMSE are as follows: total score 30, 25–30
questionable significance, 20–25 mild impairment, 10–20 moderate impairment, and
10 or lower severe impairment.
65. Correct Answer: A. When family members or clients ask questions about illnesses
and treatment, it is the PMHNP’s responsibility to provide data and then assess
understanding and meaning.
66. Correct Answer: C. In a crisis, the first assessment should be safety of the client and
those near the client.
67. Correct Answer: D. The tongue is controlled by the hypoglossal cranial nerve.
68. Correct Answer: C. Ideas of reference are misinterpretations of incidents and events
that one believes have a direct personal reference to oneself.
69. Correct Answer: C. Paradoxical directives may be used in strategic family therapy.
70. Correct Answer: A. Working in support groups such as AA and NA, hearing stories of
others who had similar struggles, instills hope.
71. Correct Answer: B. As group progresses the leader is less active and the members
of the group take over and begin to model other members and the leaders.
72. Correct Answer: A. DBT focuses on cognitive and behavioral techniques, mindful-
ness including meditation, and emotional regulation.
73. Correct Answer: A. DBT emphasis acceptance of the current reality of what is and
the ability to engage in personal change.
74. Correct Answer: B. According to TA, when a person is traumatized the thoughts and
feelings get tied together and the process of therapy is to unlock the two.
75. Correct Answer: C. Negative symptoms include flat affect, alogia, avolition, poor
attention, and anhedonia. In the case study, the symptoms are avolition and
anhedonia.
76. Correct Answer: C. EB practice guidelines indicate that all clients should have the fol-
lowing prior to starting antipsychotic medication: fasting glucose or A1c, lipid profile,
weight, body mass index, blood pressure, waist circumference, and family history of
cardiovascular disease.
77. Correct Answer: B. The most common type of hallucinations in persons with psy-
chotic illnesses are auditory and visual. Tactile and gustatory hallucinations are less
common and more likely related to an organic illness.
78. Correct Answer: A. Typical antipsychotic medications block D2 receptors; atypical
antipsychotic medications block D2 receptors and have 5HT2a antagonist properties.
79. Correct Answer: B. The recent change in monitoring clozapine clients using the risk
evaluation and mitigation strategy (REMS) indicates persons treated on clozapine
need to have absolute neutrophil count monitored and, if it drops below 1,000/uL,
treatment must be interrupted and can be resumed once the absolute neutrophil
count normalizes above 1,000/uL.
80. Correct Answer: A. Benzodiazepines are contraindicated in clients with a TBI due to
increase rates of confusion and memory problems.
81. Correct Answer: B. While it was once thought that brain neurons did not regenerate,
we now known that while most brain development occurs early in life, we continue
to form some new brain cells throughout life. As we age, we need to engage in
activities that keep our brains healthy by encouraging this growth. Examples are diet,
exercise, socialization, and cognitive stimulation.
82. Correct Answer: D. All persons with AIDS should be treated with antiretroviral
therapy. Those who develop dementia complex should have those symptoms treated
with appropriate pharmacological or nonpharmacological interventions.
83. Correct Answer: A. Studies have identified high rates of mortality post hospitalization
for delirium so the best treatment is prevention.
84. Correct Answer: B. When a person is in contemplation stage, interventions should
be affirming and reflecting.
85. Correct Answer: B. CIWA cut off scores are as follows: 0–9, absent or very mild
withdrawal; 10–15, mild withdrawal; 16–20, moderate withdrawal; and 21–67, severe
withdrawal.
86. Correct Answer: B. Opioid withdrawal symptoms can be treated with central alpha
agonists.
87. Correct Answer: A. Persons intoxicated on cannabis exhibit distorted perceptions,
increase relaxation and sensitivity, and loss of coordination.
88. Correct Answer: A. Persons with obsessive–compulsive personality disorder use
defense mechanisms of rationalization, isolation of affect, and intellectualization to
make sense of their behavior.
89. Correct Answer: D. In a therapy relationship, the therapist should try to understand
the meaning of a client’s statement rather than engage in social conversations.
90. Correct Answer: D. Persons with personality disorders have a pervasive maladaptive
pattern of behavior and the goal of therapy is to slowly shift how they relate in the
world and begin to use higher-order defenses.
91. Correct Answer: D. Persons with fixed false beliefs should not be challenged.
92. Correct Answer: B. When working with a paranoid client, help the person find proof
of meaning and explain any questions in a matter-of-fact manner.
93. Correct Answer: B. Being raised in an alcoholic family increases the likelihood of
chaos, unpredictability, and lack of rules and order, leading to higher rates of develop-
ing antisocial personality disorder.
94. Correct Answer: C. Isolation is a defense mechanism often used by people with
obsessive–compulsive personality disorder and has to do with affect and emotion
rather than getting out and being social.
95. Correct Answer: A. DSM-5 no longer uses the axial system.
96. Correct Answer: A. The SSRIs all carry a black box warning for increased suicidal
ideation for this age group.
97. Correct Answer: B. American Academy of Child and Adolescent Psychiatry practice
parameters require physical exam, pulse, weight, height, and blood pressure workup
prior to the start of stimulant medication. Because his grandfather had a cardiac
conduction problem, an electrocardiogram (ECG) should also be obtained prior to the
start of medication.
98. Correct Answer: B. Girls with Rett’s syndrome develop normally and around the 7th
month regress, with a decrease in head size and language loss.
99. Correct Answer: B. Clients with bulimia are often of normal weight or overweight
and are outgoing.
100. Correct Answer: A. Clients with ADHD and bipolar disorder often have excessive
talking, increased activity, and distractibility.
INDEX
A Antidepressants 158–159, 161

Abdomen 85–86 classes of 152–154
Absorption 111 target symptons of treatment 152
of drugs 111 tricyclic 154
Abuse 294 Antihistaminergic 156
Access to care 56 Antipsychotics 115
Acetylcholine atypical 244–247
explanation of 69 typical 249–250, 250
function of 72 Anxiety
psychiactric disorders and 70 certification examination and 1
Acupressure 132–133 description of 195–196
Acupuncture 132–133 levels of 195, 196
Addiction. See Substance-related disorders pathological levels of 200
Addictive disorders. See Substance-related tips for dealing with 6
disorders Anxiety disorders 196–207, 197
Adolescent Transitions Program (ATP) 332 agoraphobia as 210–211
Advance directives 23 assessment of 200–202
Affect 328 clinical management of 202
Affordable Care Act (2010) 57 comorbidities of 206
Aggression-turned-inward theory 140–141 demographics for 199
Agonist effect 113 description of 196–197
Agoraphobia 210–211. See also Anxiety diagnostic and laboratory findings 202
disorders differential diagnosis of 202, 203
assessment of 210–211 etiology for 197–199
clinical management of 211 follow-up for 206–207
comorbidities of 211 generalized anxiety disorder as 215–218
description of 210 health considerations for 206
diagnostic and laboratory findings and 211 history of 200–201
history of 210 incidence of 199
mental status exams for 210 life span considerations for 205
nonpharmacological management of 211 mental status exams for 201–202
pharmacological management of 211 nonpharmacological management of 205
physical exams for 210 obsessive–compulsive disorder as 218–221
Alanine aminotransferase 95 panic disorder as 207–210
Alcohol use disorders identification test pharmacological management of 203–205,
(AUDIT) 297 205
Alzheimer’s dementia 283 physical exams for 201
Amaurosis fugax 281 posttraumatic stress disorder as 222–225
Amino acids 69 prevention of 199–200
Amygdala 66 risk factors for 199
Anal stage 42 screening for 199–200
Analysis of variance (ANOVA) 54 separation anxiety disorder as 218
Anhedonia 146 social anxiety disorder as 214–215
Anorexia nervosa 348 specific phobias as 211–214
Antagonist effect 113 Anxiolytics 116, 205
Antiadrenergic 156 Arbitration 52
Anticholinergic 156 Aromatherapy 132, 133
Anticipatory guidance 98–99 Aspartate 69
Anticonvulsants 182–183 aminotransferase 95–96
INDEX 419
Assessment description of 340

gender-based 99–101 diagnostic and laboratory findings 343
health behavior guidelines and 101–103 differential diagnosis of 343
Assessment components etiology of 340
abdomen as 85–86 history of 342
back as 84–85 incidence of 341
breasts as 85 mental status exams for 342
coordination and fine-motor skills as 82 nonpharmacological management
ears as 84 of 343–344
eyes as 83 pharmacological management of 343
head, skin, and nails as 83 physical exams for 342
heart as 85 prevalence 341
indicators of child abuse as 86 prevention of 341
motor functions as 82 risk factors for 341
musculoskeletal system as 86 screening for 341, 343
neck as 84 symptons of 342
neurological exam as 80–86 Autonomic nervous system 64
neurological soft signs as 82–83 Aversion treatment 304
nose and sinuses as 84 Axon 64, 68
physical exam as 79–86
sensory functions as 82 B
thorax and lungs as 85 Back 84–85
vital signs as 83 Bandura, Albert 46
Attention deficit disorder 117 Basal Ganglia 67
Attention-deficit hyperactivity disorder Beck, Aaron 125, 141
(ADHD) 117, 335–340 Beck depression inventory (BDI) 145
agents for treatment of 338 Becker, Marshall 46
assessment of 337 Behavioral therapy 289
clinical management of 338–339 explanation of 126
comorbidities of 339–340 Belladonna 135
demographics of 336 Benzodiazepines (BNZs) 116, 204
description of 335–336 Bereavement. See Grief and bereavement
diagnostic and laboratory findings 337–338 Berg, Insoo 131
differential diagnosis of 338 Binge eating 348
etiology of 336 Biofeedback 132, 133
follow-up for 340 Biological
incidence of 336 based therapies 132
mental status exams for 337 preventative factors 104
nonpharmacological management risk factors 103
of 339–340 theories of personality disorders 316
pharmacological management of 338–339 theories of substance-related
physical exams for 337 disorders 294–296
prevention of 337 Biopsychosocial framework of care, recovery
risk factors for 336–337 and 37
screening for 337 Bipolar (BP) disorder 173–184
Autism spectrum disorder 340–343 anticonvulsants and 182–183
assessment of 342 assessment of 175–177
clinical management of 343–344 clinical management of 179–180
demographics of 341 demographics of 174
Bipolar (BP) disorder (continued) screening for 264

description of 173–174 Brief therapy 162
diagnostic and laboratory findings for 179 Bright Futures 98–99
differential diagnosis of 179 Bulimia nervosa 348
drugs for 182–183
etiology of 174 C
history of 175–177 CAGE alcohol screening test 297
incidence of 174 Calcium 89–90
lithium for treatment of 180 Cardiac disorders 150
medications for 179 Caring theory 47
mental status exam for 177–178 Carrier proteins 113
pharmacological management of 180–182 Case management 22
phycial exam for 177 Catecholamine. See Dopamine (DA)
prevention of 175 Catnip 135
rapid cycling and 177 Cell body and neurons 64, 68
risk factors for 175 Central nervous system (CNS) 64
screening for 175 Cerebellum 67
symptoms of 176, 179 Cerebral cortex 66
types of 177 Cerebrum
Black cohosh 134 basal ganglia in 67
Body dysmorphic disorder 226 brainstem and 67–68
Body mass index (BMI) 83 cerebral cortex in 66
Bowen, Murray 130 function of 65
Brain/brain function limbic system in 66
brainstem and 67–68 lobes in 65–66
cerebrum and 65–67 Certification 15–16
depression and 143 Certification examination 1–10
gray matter and 64 anxiety 1
neuroanatomy and 64–68 current knowledge about 2
neurophysiology and 68–70 depth of knowledge required 3
outermost surface of 64–65 expectations for 2
white matter and 64 facts about 8–9
Brainstem 67–68 general content 2
Breasts 85 instituting a study plan for 3–5
Brief psychotic disorder 264–265 internet resources for 9
assessment of 265 mentally preparing for 2
clinical management of 265 physically preparing for 2
demographics of 264 preparing for 1–8
description of 264 review courses for 2
diagnostic and laboratory findings 265 strategies prior to 5–6
etiology of 264 test-taking strategies for 6–8
history of 265 Chamomile 135
incidence of 264 Child abuse 86
mental status exams for 265 Childhood and adolescence
nonpharmacological management of 265 disorders 327–360
pharmacological management of 265 assessment and care planning for 327–329
physical exams for 265 attention-deficit hyperactivity disorder
prevention of 264 (ADHD) 335–340
risk factors for 264 autism spectrum disorder 340–342
INDEX 4 21
conduct disorder 332–334 differential diagnosis of 334

disruptive mood dysregulation etiology of 332
disorder 355–356 history of 333
eating disorders 346–351 incidence of 333
intellectual disability 352–355 life span considerations for 335
oppositional defiant disorder mental status exams for 334
(ODD) 329–332 nonpharmacological management of 335
Rett syndrome 344–346 pharmacological management of 334
Children and adolescents under 21 years of physical exams for 333
age test (CRAFT) 297 prevalence of 332
Chloride 92–93 prevention of 333
Cholinergics 69 risk factors for 333
Chronic fatigue syndrome 150 screening for 333
Chronobiological theory 143–144 Confidentiality 16
Circadian rhythms 143 exceptions to guaranteed 17
Circular causality 129 Conflict 52
Client advocacy 22 defense mechanisms and 43
Clinical Opiate Withdrawal Scale of interest (COI) 57–58
(COWS) 297 resolution 52
Cluster A personality disorders 317–318 Confusion Assessment Method (CAM) 273
characteristics of 318 Conservation 44
Cluster B personality disorders 318–319 Coordination 82
characteristics of 320 Corpus striatum 67
Cluster C personality disorders 319 Corticotropin-releasing hormone (CRH) 142
characteristics of 321 Countertransference 38–39
Cognitive behavioral therapy (CBT) 162, 289, Cranial nerves 80–82
379 Credentialing 15
Cognitive disorders 271 Creutzfeldt-Jakob disease 278
description 271 Critical thinking 52
etiology 271 Cultural differences and health influences and
Cognitive theory 43–45, 141 determinants 24
Cognitive therapy 125–126 Culturally competent care 23–24
Combined structural and functional forensics and corrections and 27–28
imaging 73 homeless individuals and 24–25
Commitment, involuntary 21 migrant and seasonal farm workers and 25
Competency, elements of 21 sexual orientation and 26–27
Complementary and alternative therapies Culture 23
(CATs) Culture-bound syndromes 23
origins of 132 Cyclothymic disorder 186–187
types of 132–135 assessment of 187–188
Complete blood count (CBC) 149 clinical management of 188
Computed tomography (CT) 72 demographics of 186–187
Concrete operations stage 44 description of 186–187
Conduct disorder 332–335 diagnostic and laboratory findings 188
assessment of 333 differential diagnosis of 188
clinical management of 334 etiology of 186–187
demographics of 333 follow-up for 188
description of 332 history of 187
diagnostic and laboratory findings 334 indicence of 186–187
Cyclothymic disorder (continued) physical exam for 263

life span considerations for 188 prevalence of 262
mental status exams for 187–188 prevention of 262
nonpharmacological management of 188 risk factors for 262
pharmacological management of 188 screening for 262
physical exams for 187 somatic 263
prevention of 187 subtypes 262–263
risk factors for 187 Dementia 277–285
screening for 187 assessment of 280–281
Cytochrome P450 clinical management of 283
inhibitors and inducers 112 demographics of 279
description of 277–279
D diagnostic and laboratory findings 282
Defense mechanisms 43, 44 differential diagnosis of 282–283
Delirium 271–277 etiology of 279
assessment of 273 history of 280–281
clinical management of 275 incidence of 279
demographics of 272 life span considerations for 285
description of 271 mental status exams for 281
diagnostic and laboratory findings 275 nonpharmacological management of 284
differential diagnosis of 275 pharmacological management of 283–284
etiology of 272 physical exams for 281
health considerations for 276 prevention of 280
history of 273 risk factors for 279
incidence of 272 Dendrites 64, 68
life span considerations for 276–277 Deontological theory 19
mental status exams for 274 Dependence 294
nonpharmacological management of 276 Depolarization 68
pharmacological management of 276 Depression. See also Cyclothymic disorder;
physical exam for 273 See also Persistent depressive disorder
prevention of 273 (Dysthymia); See also Premenstrual
risk factors for 272–273 dysphoric disorder; See also Stevens
screening for 273 Johnson syndrome (SJS)
subtypes of 272 aggression-turned-inward theory 140–141
Delusional disorder 262–265 anhedonia during 146
assessment of 262–263 biological theories of 142–144
clinical management of 264 chronobiological theory of 143–144
demographics of 262 circadian rhythms and 143
description of 262 cognitive theory 141
diagnostic and laboratory findings 264 corticotropin-releasing hormone (CRH)
erotomanic 262–263 and 142
etiology of 262 diagnostic and laboratory findings 149
grandiose 263 dysphoria and 142
history of 262–263 endocrine dysfunction and 142–143
jealous 263 etiology of 140–146
mental status exam for 263–264 genetic predisposition to 142
nonpharmacological management of 264 hypothalamic–pituitary–adrenal axis deregu-
persecutory 263 lation and 142
pharmacological management of 264
INDEX 4 23
learned helplessness-hopelessness nonpharmacological management of 356

theory 141–142 pharmacological management of 356
major depressive disorder (MDD) 140–166 prevalence of 355
medications that induce 119 prevention of 355
menses and 146 risk factors for 355
mental status exams for 147 screening for 355
mood and 146 Dissociative disorders 225–226
neurotransmitter abnormalities and 143 body dysmorphic disorder as 226
object loss theory 140 excoriation disorder as 226
physical exams for 147 hoarding disorder as 226
psychodynamic theories of 140–142 trichotillomania as 226
versus sadness 139 Distribution 111
sex steroid hormones and 173 of drugs 111
sleep disruption and 146 DNA 74
structural brain changes causing 143 Donabedian model 55
weight loss from 146 Dopamine (DA) 295
Descriptive statistics 54 explanation of 69
deShazer, Steve 131 function of 71
Developmental stages 99–101 pathways 248–249
Developmental theories 40–41 psychiatric disorders and 70
Dexamethasone suppression test (DST) 143 Double depression 168
Diagnostic and laboratory testing 86–97 Drug Enforcement Administration (DEA) 115
Diagnostic and Statistical Manual of Mental Drug screening and false positives 119
Disorders 293 Dysphoria 142
Dialectical behavioral therapy 126 Dysthymia. See Persistent depressive disorder
Differential diagnosis (Dysthymia)
anxiety disorders and 202, 203
obsessive–compulsive disorder and 220–221 E
panic disorder and 208–209 Ears 84
posttraumatic stress disorder and 224 Eating disorders 346–351
specific phobias and 213 assessment of 347
Disclosure clinical management of 351
benefits of 20 description of 346
of disability 20 diagnostic and laboratory findings 350
ethics of provider 19–20 differential diagnosis of 350–351
risk of 20 etiology of 346–347
Discontinuation syndrome 165 follow-up for 351
symptoms of 165–166 history of 348
Disease prevention strategies incidence of 347
immunization and 97–98 mental status exams for 349–350
implementation of 98–99 nonpharmacological management of 351
Disruptive mood dysregulation pharmacological management of 351
disorder 355–356 physical exams for 348–349
assessment of 355–356 prevention of 347
clinical management of 356 risk factors for 347
demographics of 355 screening for 347
description of 355 Edinburgh Postnatal Depression Scale
etiology of 355 (EPDS) 145
follow-up for 356 EEG 73
Ego 43 Fetal alcohol syndrome (FAS) 297, 352–353

Electrocardiogram (EKG) 156 Fibromyalgia 150
Electroconvulsive therapy (ECT) 159 Fine-motor skills 82
Electrolytes 89 First-pass metabolism 112
Electronic health records, function of 17 Fish oil 134
Elimination 112 Fissures in the brain 65
of drugs 112 Folie á Deux. See Shared psychotic disorder
Emancipated minors 18 Forensics
Endocrine corrections and 27–28
disorders 150 knowledge base of 28
dysfunction 142–143 Formal operations stage 45
Enzymatic destruction 70 Frankl, Viktor 126
Epinephrine 69 Free thyroxine T4 87
Erikson, Erik 40 Freud, Sigmund 41, 42, 125, 140–141, 197
Ethical issues Frontal lobe 65
in decision-making 19 Functional imaging 73
disclosure by providers as 19–20
for nurse practitioners 18–19 G
in research 54–55 GABA
Evidence-based practice 53 explanation of 69
Evoked potentials testing 73 function of 72
Excitatory response 113 psychiatric disorders and 70
Excoriation disorder 226 Gamma amino butyric acid (GABA) 295
Exercise Gamma glutamyl transpeptidase 96–97
benefits of 101 Gender
client teaching regarding 101–102 based screening 99–101
monitoring intenstity of 102 dysphoria 26
recommendations for 102 identity 26
Existential therapy 126 Generalized anxiety disorder (GAD) 215–218
Experiential therapy 130–131 assessment of 216–217
External validity 54 comorbidities of 218
Extrapyramidal side effects (EPSE) 249 description of 215–216
medications used to treat 251 history of 216
side effects of 252 life span considerations for 218
Eye movement desensitization and reprocess- mental status exams for 217
ing (EMDR) 127 nonpharmacological management of 217
Eyes 80, 83 pharmacological management of 217
physical exams for 216–217
F Genes 74–75
Family history, explanation of 73–74 Gene therapy 74
Family homeostasis 129 Genetic
Family structure 130 counseling 74
Family systems theory 129–130 loading 294
Family systems therapy 130 predisposition to depression 142
Family therapy 162, 289 terms 74
family system concepts in 129–130 testing 75
types of 130–132 Genital stage 42
Federal Drug Administration (FDA) Genomics 73–75
pregnancy ratings for medications from 118 Ginkgo 135
INDEX 4 25
Ginseng 135 Health Information Technology for Economic

Glia 68 and Clinical Health Act (HITECH) of
Glutamate 2009 17
explanation of 69 Heart 85
function of 72 Herbal products/supplements 132, 133–135
psychiatric disorders and 70 Hierarchy of needs theory 45–46
Glycine 69 HIPAA, privacy protections under 16–17
Gray matter 64 Hippocampus 66
Grief and bereavement 150, 169–173 Hoarding disorder 226
assessment of 171 Homelessness 24–25
clinical management of 172 strategies for reducing 25
demographics of 170 Homicide 381
description of 169–170 early warning signs of 381
diagnostic and laboratory findings 172 Human Genome Project 74
differential diagnosis of 172 Humanistic therapy 126–127
etiology of 170 Huntington’s disease 278
follow-up for 173 Hypercalcemia 90
history of 171 Hyperkalemia 94
indidence of 170 Hypermagnesemia 92
life span considerations for 172 Hypernatremia 91
mental status exams for 171 Hypersomnia. See Sleep disorders
nonpharamacological management of 172 Hypersomnolence disorder 364
pharamacological management of 172 Hypertensive crisis 157
physical exams for 171 Hyperthyroidism 88
prevention of 171 Hypocalcemia 90
psychotherapy and 172 Hypokalemia 94
risk factors for 171 Hypomagnesemia 92
screening for 171 Hypomania 177
Group therapy 162 Hyponatremia 91
explanation of 127–128 Hypothalamic–pituitary–adrenal axis 142
phases in 128–129 Hypothalamus 66
Gyri 65 Hypothyroidism 88
Hypovolemic hippocampus 143
H Hypovolemic prefrontal cortex 143
Haley, Jay 131
Half-life 112 I
Hamilton Depression Rating Scale Id 42
(HAM-D) 145 Illness management recovery (IMR) 255
Health Immunization 97–98
behavior guidelines 101–103 Improvised explosive devices (IEDs) 286
belief model 46 Incredible years 332
cultural influences on 24 Individual therapy 162
delivery systems 56 Indole. See Serotonin
policy and nurse practitioners 22–23 Infectious and inflammatory states 150
policy development 58 Inferential statistics 54
promotion 103 Informed consent 17–18
Health care home 57 Inhibitory response 113
Insomnia 362–367. See also Sleep disorders
assessment of 363–364
Insomnia (continued) differential diagnosis of 376

in children 367 etiology of 373–374
clinical management of 365 history of 375
demographics of 362 incidence of 374
diagnostic and laboratory findings 364 mental status exams for 375
differential diagnosis of 365 nonpharmacological management of 376
etiology of 362 pharmacological management of 376
hypersomnolence disorder and 364 physical exams for 375
incidence of 362 prevention of 374–375
life span considerations for 367–368 risk factors for 374
mental status exams for 364 screening for 374–375
nonpharmacological management Intoxication 294, 300
of 366–367 Inverse agonist effect 113
obstructive sleep apnea (OSA) and 364 Involuntary admission 21
in older adults 367–368 Involuntary commitment 21
pharmacological management of 365–366
physical exams for 364 J
polysomnography and diagnosis of 364 Just culture of safety 55–56
prevention of 363
risk factors for 363 K
screening for 363 Kidney disease 113
Institutional review boards (IRBs) 54–55 Kindling 174
Intellectual disability 352–354 Klerman, Gerald L. 127
assessment of 353–354
clinical management of 354 L
demographics of 353 Laboratory testing, diagnostic and 86–97
description of 352 Latency stage 42
diagnostic and laboratory findings 354 Lazarus, Arnold 126
differential diagnosis of 354 Leadership, nurse practitioners and 51
etiology of 352–353 Learned helplessness-hopelessness
and fetal alcohol syndrome 352–353 theory 141–142
mental status exams for 354 Left hemisphere (of brain) 65
nonpharmacological management Leininger, Madeline 47
of 354–355 Lethality assessment 379
pharmacological management of 354 Lewy body disease 279
physical exams for 353–354 Licensure 15
prevalence of 353 Limbic system 66
prevention of 353 Linehan, Marsha 126
risk factors for 353 Lithium 180
screening for 353 side effects of 181
Internal validity 54 Stevens Johnson syndrome (SJS) and 186
Interpersonal theory 45, 47, 198 Liver disease 113
Interpersonal therapy 127 Liver function tests (LFTs) 95, 181
Intimate partner violence (IPV) 373–376 Living wills 23
assessment of 375 Lungs 85
clinical management of 376
demographics of 374 M
description of 373 Macrobiotics 135
diagnostic and laboratory findings 375 Magnesium 91–92
INDEX 4 27
Magnetic resonance imaging (MRI) 73–74 antipsychotics 115

Magnetoencephalography (MEG) 73 for anxiety disorders 116
Major depressive disorder (MDD) 140–166. anxiolytics 116
See also Depression for attention deficit disorder 117
adults and 163–164 for attention deficit hyperactivity
age and 142 disorder 117
assessment of 145 benzodiazepines (BNZs) 116
brain damage and 143 for bipolar affective disorders 115
children and 163 for bipolar (BP) disorder 179, 182–183
clinical management of 151 depression inducing 119
demographics of 144–145 for depressive disorders 116
description of 140 distribution in organs 111
diagnostic and laboratory findings and drug screening results 119
for 149–151 enzyme inducers and 112
electroconvulsive therapy (ECT) treatment enzyme inhibitors and 113
for 159 FDA pregnancy ratings for 118
etiology of 140–146 first-pass metabolism and 112
expected course of 166 half-life of 112
follow-up for 164–166 kidney disease from 113
history of 145–146 liver disease from 113
hospitalization for 151 mania inducing 119
HPA dysregulation causing 142 median effective dose 114
incidence of 144–145 median toxic dose 114
individual therapy 162 metabolism and 112
life span considerations for 163–164 monoamine oxidase inhibitors
mental status exams for 147–149 (MAOIs) 113, 116, 152, 156
nonpharmacological management mood altered states as side effects 151
of 159–162 for mood disorders 115, 153
pharmacological management of 151–155 mood stabilizers 115
phototherapy 162 norepinephrine dopamine reuptake inhibi-
prevention of 145 tors (NDRIs) 154
risk factors for 145 pharmacodynamics and 113
screening for 145 pharmacokinetics and 111–113
transcranial magnetic stimulation (TMS) potency of 113
treatment for 160 for psychiatric disorders 115
vagal nerve stimulation (VNS) treatment for psychotic disorders 115
for 160 schedules for controlled substances 118
Malpractice for schizophrenia 115
insurance 20–21 selective serotonin reuptake inhibitors
negligence as proof of 21 (SSRIs) 113, 116, 152, 156
Mania 177 serotonin agonist and reuptake inhibitors
medications inducing 119 (SARIs) 154
Manipulative and body-based therapies 132 serotonin norepinephrine reuptake inhibi-
Maslow, Abraham 45 tors (SNRIs) 152–153, 159
Massage 132, 135 steady state of 112
Mean 54 stimulants 117
Mediation 52 tachyphylaxis 114
Medications teratogenic nature of 118–119
absorption of 111 therapeutic index for 114
Medications (continued) Metabolism 112

tolerance to 114 of drugs 112
tricyclic antidepressants (TCAs) 152, 156 Midbrain 67
for unipolar affective disorders 116 Migrant workers 25
Meditation 132, 135 Mind–body interventions 132
Medulla 67 Mini-cog 281
Melatonin 134 Mini-Mental State Examination (MMSE) 281
Mental state exam (MSE) 283 Minuchin, Salvador 130
Mental status exams Misuse (of substances) 294
for agoraphobia 210 Monoamine oxidase inhibitors (MAOIs) 69,
for anxiety disorders 201 113, 116, 152, 155, 156
for attention-deficit hyperactivity disorder hypertensive crisis from 157
(ADHD) 337 side effects of 158
for autism spectrum disorder 342 Montreal Cognitive Assessment (MoCA) 281
for bipolar (BP) disorder 177–178 Mood 328
for brief psychotic disorder 265 depression and 146
for conduct disorder 334 stabilizers 115
for cyclothymic disorder 187–188 Morphogenesis 130
for delirium 274 Morphostasis 130
for delusional disorder 263–264 Motivational interviewing 46
for dementia 281 Motor functions 82
for depression 147 Musculoskeletal system 86
for eating disorders 349–350
for generalized anxiety disorder (GAD) 217 N
for grief and bereavement 171 Neck 84
for insomnia 364 Negotiation 52
for intellectual disability 354 Nervous system
for intimate partner violence (IPV) 375 central 64
for major depressive disorder components of 64
(MDD) 147–149 function of 63
for obsessive–compulsive disorder peripheral 64
(OCD) 220 Neuroadaptation 295
for oppositional defiant disorder (ODD) 331 Neuroanatomy 64–68
for panic disorder 208 Neurobiological theory 198–199
for persistent depressive disorder of schizophrenia 235
(Dysthymia) 168 Neurocognitive disorders 271–292
for phobias 213 cognitive disorders 271
for posttraumatic stress disorder delirium 271–277
(PTSD) 223 dementia 277–285
for Rett syndrome 345 traumatic brain injuries and 285–290
for schizoaffective disorder 261 Neuroimaging 72–74
for schizophrenia 241–242 Neuroleptic malignant syndrome (NMS) 253
for schizophreniform disorder 259 Neurological
for sexual assault and abuse 378 disorders 150
for shared psychotic disorder 266 examinations 80–86
for social anxiety disorder 215 soft signs 82–83
for substance-related disorders 301 Neurons 63–64, 68
Mentoring 22 Neuropeptides 70, 70–71
Messenger RNA (mRNA) 74 Neurophysiology 68–70
INDEX 4 29
Neurotransmitters 113 regulatory dimensions of 14–16

abnormalities of 143 research utilization and 52–53
categories of 68–70 role responsibilities of 16–19
classification requirements for 69 scholarly activities of 22
function of 68, 71–72 specialty competencies of 12–13
psychiatric disorders and 70 statutory dimensions of 14–16
recovery and degradation of 70 Nursing theories 47
Nonpharmacological management Nutritional disorders 150
of agoraphobia 211
of anxiety disorders 205 O
of generalized anxiety disorder 217 Object loss theory 140
of obsessive–compulsive disorder 221 Obsessive–compulsive disorder
of panic disorder 209–210 (OCD) 218–221
of personality disorders 322 assessment of 219–220
of posttraumatic stress disorder 225 clinical management of 221
of social anxiety disorder 215 comorbidities of 221
of specific phobias 214 description of 218
Nonpharmacological treatment differential diagnosis of 220–221
complementary and alternative therapies history of 219–220
as 132–135 life span considerations for 221
family therapy as 129–132 mental status exams for 220
group therapy as 127–129 nonpharmacological management of 221
individual therapy as 125–127 pharmacological management of 221
issues related to 125 physical exams for 220
Nonrapid eye movement stages (NREM) 361 risk factors for 219
Norepinephrine Obstructive sleep apnea (OSA) 364
explanation of 69 Occipital lobe 66
function of 71 O’Hanlon, Bill 131
psychiatric disorders and 70 Omega-3 fatty acids 134
Norepinephrine dopamine reuptake inhibitors Opioid neuropeptides 70, 72
(NDRIs) 154 Oppositional defiant disorder
Nose 84 (ODD) 329–332
Nurse practitioners. See also Psychiatric– assessment of 330–331
mental health nurse practitioners clinical management of 331
(PMHNPs) demographics of 330
admissions criteria and 21 description of 329–330
client advocacy and 22 diagnostic and laboratory findings 331
commitment process and criteria and 21–22 differential diagnosis of 331
competency issues and 21 etiology of 330
core competencies of 11–12 history of 330–331
disclosure issues and 19–20 mental status exams for 331
ethical behavior for 18–19 nonpharmacological management of 332
growth of 14 pharmacological management of 331–332
health policy and 22–23 physical exams for 331
historical background of 13–14 prevalence of 330
leadership and 51 prevention of 330
legal considerations for 20–21 risk factors for 330
mentoring of 22 screening for 330
public health principles and 103–104 Oral stage 42
Orem, Dorothy 47 mental status exams for 168

Organization of practices 56 nonpharmacological management of 168
personality disorders and 169
P pharmacological management of 168
Panic disorder 207–210. See also Anxiety physical exams for 168
disorders polysomnographic findings for 168
assessment of 207–208 prevention of 167
clinical management of 209 risk factors for 167
comorbidities of 210 screening for 167
description of 207 symptoms of 167–168
diagnostic and laboratory findings 208 Personality 313–314
differential diagnosis of 208–209 Personality disorders 314–323. See
history of 207–208 also Cluster A, B, and C personality
mental status exams for 208 disorders
nonpharmacological management assessment of 317–320
of 209–210 categories of 315
pharmacological management of 209 client history and 317
physical exams for 208 clinical management of 321
Parasympathetic nervous system 64 demographics of 316
Parietal lobe 66 description of 314
Partial agonist effect 113 diagnostic and laboratory findings 320
Pathways differential diagnosis of 321
mesocortical 248 etiology of 314–316
mesolimbic 248 follow-up for 323
nigrostriatal 249 history of 317
tuberoinfundbular 249 incidence of 316
Patient-centered care model (PCC) 56 life span considerations for 323
Patient Health Questionnaire 9 (PHQ-9) 145 nonpharmacological management of 322
Pearson’s r correlation 54 pharmacological management of 322
Peplau, Hildegard 47 physical exams for 319–320
Peptides 72. See also Opioid neuropeptides prevention of 316–317
Peripheral nervous system (PNS) 64 risk factors for 316
Persistent depressive disorder screening for 316–317
(Dysthymia) 166–194 Person-centered therapy. See Humanistic
assessment of 167–168 therapy
clinical management of 168–169 Phallic stage 42
comorbities of 168–169 Pharmacodynamics 111, 113
demographics of 166–167 agonist effect 113
description of 166 antagonist effect 113
diagnostic and laboratory findings for 168 excitatory response 113
differential diagnosis of 168 inhibitory response 113
double depression and 168–169 inverse agonist effect 113
etiology of 166 monoamine oxidase inhibitors (MAOIs) 113
follow-up for 169 neurotransmitters and 113
history of 167–168 partial agonist effect 113
indicence of 166–167 selective serotonin reuptake inhibitors
life span considerations for 169 (SSRIs) 113
and major depressive disorder target sites and 113
(MDD) 168–169 Pharmacogenomics 75
INDEX 4 31
Pharmacokinetics 111–113 for intimate partner violence (IPV) 375

absorption of 111 for major depressive disorder (MDD) 147
alterations in 112–113 for obsessive–compulsive disorder
distribution of 111 (OCD) 220
elements of 111–113 for oppositional defiant disorder (ODD) 331
elimination and 112 for panic disorder 208
explanation of 111 for persistent depressive disorder
first-pass metabolism and 112 (Dysthymia) 168
half-life of medications 112 for personality disorders 319–320
metabolism and 112 for phobias 213
steady state 112 for posttraumatic stress disorder
Pharmacological management (PTSD) 223
concepts in 111–114 for Rett syndrome 345
of agoraphobia 211 for schizoaffective disorder 261
of anxiety disorders 203–205, 205 for schizophrenia 240–241
of generalized anxiety disorder 217 for schizophreniform disorder 259
of obsessive–compulsive disorder 221 for sexual assault and abuse 378
of panic disorder 209 for shared psychotic disorder 266
of personality disorders 322 for social anxiety disorder 215
of posttraumatic stress disorder 224–225 for substance-related disorders 301
of social anxiety disorder 215 Piaget, Jean 43
of specific phobias 214 Pick’s disease 278
psychiatric–mental health nurse practitio- PICO method 53
ners (PMHNPs) role in 114–120 Polygenic single nucleotide polymorphism
Pharmacology 111. See (SNP) disorder 142
also Psychopharmacology Polysomnography 364
considerations related to 118–119 Pons (of brainstem) 67
explanation of 111 Population genetics 75–76
Phenotype 74 Positron emission tomography (PET) 73
Phototherapy 162 Posttraumatic stress disorder (PTSD) 222–225
Physical exams 79–86 assessment of 222–224
for agoraphobia 210 clinical management of 224
for anxiety disorders 201 comorbidities of 225
for attention-deficit hyperactivity disorder description of 222
(ADHD) 337 diagnostic and laboratory findings 223–224
for autism spectrum disorder 342 differential diagnosis of 224
for bipolar (BP) disorder 177 history of 222
for brief psychotic disorder 265 life span considerations for 225
for conduct disorder 333 mental status exams for 223
for cyclothymic disorder 187–188 nonpharmacological management of 225
for delirium 273 pharmacological management of 224–225
for delusional disorder 263 physical exams for 223
for dementia 281 risk factors for 222
for depression 147 Potassium 93–94
for eating disorders 348–349 Potency 113
for generalized anxiety disorder (GAD) 217 Premenstrual dysphoric disorder 173
for grief and bereavement 171 description of 173
for insomnia 364 symptoms of 173
for intellectual disability 353–354 Preoperational stage 44
Preventative factors 104 Psychological risk factors 104

Primary prevention of mental disorders 103 Psychopharmacology 111–124
Probability 54 management concepts 111–112
Professional civility 52 pharmacological considerations in 118–119
Psychiatric principles of 111
nursing 11 Psychosexual stages of development 42
research in psychotropic medications 111 Psychosis, symtoms of 234
Psychiatric disorders 151 Psychotic 233
age of onset for 41 Psychotic disorders 233–270
among incarcerated individuals 27–28 delusional disorder 262–265
classification of 38 schizoaffective disorder 260–261
neurotransmitters and 70 schizophrenia 235–257
schizophreniform 258–260 schizophreniform disorder 258–260
Psychiatric–mental health nurse practi- shared psychotic disorder 265–267
tioners (PMHNPs). See also Nurse Psychotropic medications
practitioners older adults and 113
assessment of childhood and adolescent pregnancy and 118
disorders 327–329 risks of 118–119
bipolar disorders treatment of and 139–194 teratogenic nature of 118–119
and childhood disorders 327–360 weight gain and 83
culturally competent care and 23–24 Public health principles 103–104
depressive disorders treatment of Purging 348
and 139–194 p value 54
foundational theories supporting role
of 41–47 Q
and grief and bereavement 170 Qualitative hierarchy 53
health policy of 22–23 Quality improvement 55
major depressive disorder (MDD) follow-up Quality of care 56
care practices from 164 Quantitative hierarchy 53
nursing theories and 47
origins of 11 R
pharmacological management role Rapid cycling 177
of 114–120 Rapid eye movement (REM) 361
psychopharmacology and 111–124 Reflective practice 52
research utilization by 52–53 Reflexes 80
roles of 22 Reflexology 132, 135
specialized content for 12–13 Reminiscence therapy 129
Psychiatry 19 Repolarization 68
Psychic determinism 41 Research
Psychoanalytic dissemination of 53–54
theory 41 donabedian model 55
therapy 125 ethical considerations in 54–55
Psychodynamic theories interpretation of 54
anxiety disorders and 197–198 quality improvement 55
explanation of 41–43 utilization of 52–53
of personality disorders 315–316 Reticular formation system (of brain) 67–68
of substance-related disorders 294 Rett syndrome 344–346
psychotherapy 162 assessment of 344
Psychological preventative factors 104 clinical management of 346
INDEX 4 33
demographics of 344 atypical antipsychotics for 248–249

description of 344 clinical management of 243
differential diagnosis of 346 comorbidities of 255
etiology of 344 delusions and 238
history of 345 demographics of 236–237
incidence of 344 description of 235
mental status exams for 345 diagnostic and laboratory findings 242
nonpharmacological management of 346 differential diagnosis of 242–243
pharmacological management of 346 dopamine pathways and 248–249
physical exams for 345 downdrift and 238
prevention of 344 DSM-5 diagnostic criteria for 238–240
risk factors for 344 etiology of 235–236
screening for 344 extrapyramidal side effects (EPSE) of 249
Reuptake pumps 71, 113 follow-up for 257–258
Reversibility 44 genetics and 235
Right hemisphere (of brain) 65 group therapy for 254–255
Rights of clients 58 hallucinations and 239
Risk assessment 23, 28 health considerations of 255–256
Risk factors 103–104 history of 238–240
Risk management 23 illness management recovery (IMR) for 255
Rogers, Carl 126 incidence of 236–237
individual therapy for 254–255
S life span considerations for 256–257
Sadness 139–140. See also Depression mental status exams for 241–242
Sam-e 134 milieu therapy for 255
Satir, Virginia 130 neurobiological defect and 236
Schedules for controlled substances 118 neurobiological theory of 235
Schizoaffective disorder 260–261 neurodevelopment and 235–236
assessment of 260–261 nonpharmacological management
clinical management of 261 of 254–255
demographics of 260 pharmacological management of 248–254
description of 260 physical exams for 240–241
diagnostic and laboratory findings 261 prevention of 237–238
etiology of 260 proactice crisis management planning
follow-up for 261 for 254–255
mental status exams for 261 risk factors for 237
nonpharmacological management of 261 screening for 237–238
pharmacological management of 261 subtypes of 240
physical exams for 261 suicide and 255–256
prevalence of 260 symptom of 239
prevention of 260 typical antipsychotics for 249–250
risk factors for 260 Schizophreniform disorder 258–260
screening for 260 assessment of 258–259
symptoms of 261 clinical management of 259
Schizophrenia 233, 235–257 demographics for 258
abnormalities and 236 description of 258
assertive community treatment (ACT) diagnostic and laboratory findings 259
for 254–255 etiology of 258
assessment of 238–240 follow-up for 260
Schizophreniform disorder (continued) incidence of 377

history of 258–259 mental status exams for 378
mental status exams for 259 nonpharmacological management
nonpharmacological management of 259 of 379–380
pharmacological management of 259 pharmacological management of 379
physical exams for 259 physical exams for 378
prevention of 258 prevention of 377–378
risk factors for 258 screening for 377–378
screening for 258 Sexually transmitted infections (STIs) 185
Scholarly activities 22 Shapiro, Francine 127
Scope of practice 16 Shared psychotic disorder
Seasonal farm workers 25 assessment of 266
Secondary prevention of mental disorders 103 clinical management of 266
Selective serotonin reuptake inhibitors demographics of 266
(SSRIs) 113, 116, 152, 156, 203 description of 265
discontinuation syndrome 165–166 diagnostic and laboratory findings 266
Self etiology 266
awareness 102 history of 266
disclosure 102 incidence of 266
efficacy and social learning theory 46–47 mental status exams for 266
system 45 nonpharmacological management of 266,
Seligman, Martin 141 266–267
Sensorimotor stage 44 pharmacological management of 266
Sensory functions 82 physical exams for 266
Separation anxiety disorder 218 prevention of 266
Serotonin risk factors for 266
explanation of 69 screening for 266
function of 71 Short Michigan alcoholism screening test
psychiatric disorders and 70 (S-MAST) 297
Serotonin agonist and reuptake inhibitors Single nucleotide polymorphism (SNP)
(SARIs) 154 disorder 142
Serotonin norepinephrine reuptake inhibitors Single photon emission computed tomography
(SNRIs) 152–153, 159 (SPECT) 73
Serotonin syndrome 165 Sinuses 84
symptoms of 165 Sleep disorders 361–368
Sex steroid hormones 173 considerations of 361–362
Sexual disturbances 146
behavior 27 insomnia 362–367
identity 26 Social anxiety disorder 214–215
orientation 26–27 assessment of 214–215
Sexual assault and abuse clinical management of 215
assessment of 378 description of 214–215
clinical management of 379 history of 214–215
demographics of 377 mental status exams for 215
description of 376–377 nonpharmacological management of 215
diagnostic and laboratory findings 379 pharmacological management of 215
differential diagnosis of 379 physical exams for 215
etiology 377 Social preventative factors 104
factors of 377 Social risk factors 104
INDEX 4 35
Sodium 90–91 Substance-related disorders 293–312

Solution-focused therapy 131–132 abused agents list 298
Somatic nervous system 64 assessment of 298–300
Special populations, culturally competent care biological theories of 294–296
and. See Culturally competent care clinical management of 302–304
Specific phobias 211–214 demographics of 296
assessment of 212–213 description of 293–294
client history and 212–213 diagnostic and laboratory findings 302
clinical management of 213 differential diagnosis of 302
description of 211 etiology of 294–296
diagnostic and laboratory findings 213 history of 298–300
differential diagnosis of 213 incidence of 296
mental status exams for 213 intoxication 300
nonpharmacological management of 214 life span considerations for 306–307
pharmacological management of 214 mental status exams for 301–302
physical exams for 213 nonpharmacological management
risk factors for 211–212 of 305–306
Stages of human development (Erikson) 40 pharmacological management of 304–305
Stages of interpersonal development physical exams for 301
(Sullivan) 45 prevention of 297–298
Standard deviation 54 psychodynamic theory of 294
Standards of practice 16 risk factors for 296
State legislative statutes 14–15 screening for 297–298
Statistics withdrawal 300
descriptive 54 Substance use disorders. See Substance-related
inferential 54 disorders
Statutory law 15 Suicide 143, 148–149
Steady state 112 assessing for 149, 379–381
Stem (of neuron) 64 clinical management of 162
Stevens Johnson syndrome (SJS) 83, risk factors for 163, 380–381
184–186 schizophrenia and 255–256
clinical management of 184–185 signs of imminent danger 380
comorbidities of 185 traumatic brain injury and 287–288
description of 184 Sulci 65
follow-up for 185–186 Sullivan, Harry Stack 45, 198
health considerations for 185 Superego 43
life span considerations for 185 Sympathetic nervous system 64
lithium and 186 Synapse 68, 70
nonpharmacological management Synaptic cleft 68, 69
of 184–185
symptoms of 184 T
Stimulants 117 Tachyphylaxis 114
St Louis University Mental Status Examination Tardive dyskinesia (TD) 248, 252
(SLUMS) 281 Target sites 113
Strategic therapy 131 Team leadership model 51–52
Structural family therapy 130 Telehealth 17
Structural imaging 72–73 Teleological theory 19
Structural mapping (genogram) 130 Temporal lobe 65–66
Substance 294 Tertiary prevention of mental disorders 103
Tests etiology of 286

alcohol use disorders identification test follow-up for 290
(AUDIT) 297 incidence of 286
CAGE alcohol screening test 297 life span considerations for 290
children and adolescents under 21 years of mental status of 287
age test (CRAFT) 297 military personnel and 286
clinical opiate withdrawal scale (COWS) 297 nonpharmacological management
dexamethasone suppression test (DST) 143 of 288–289
liver function tests (LFTs) 181 pharmacological management of 288
short Michigan alcoholism screening test physical findings for 287
(S-MAST) 297 prevention of 286
Thalamus 66 psychotherapies for 289
Theory of cultural care 47 risk factors for 286
Theory of self-care 47 screening for 286
Therapeutic index 114 suicide and 287–288
Therapeutic nurse–client relationship 38–39, symptoms of 287
39 Trichotillomania 226
theory or interpersonal theory 47 Tricyclic antidepressants (TCAs) 116, 152,
Therapies 156, 204
behavioral 126 Tryptophan 134
cognitive 125–126 t test 54
complementary and alternative 132–135
dialectical behavioral 126 V
existential 126 Vagal nerve stimulation (VNS) 160
eye movement desensitization and reprocess- Valerian 135
ing (EMDR) 127 Variance 54
family 129–132 Violence 382–384
group 127–129 homicide 381
humanistic 126–127 intimate partner violence (IPV) 373–376
individual 125–127 and lethality assessment 380
interpersonal 127 in school 380
psychoanalytic 125 sexual assault and abuse 376–379
reminiscence 129 suicide assessment 380–381
Thorax 85 threats of 381
Thought content 328 Virtue ethics 19
Thought process 328 Vital signs 83
Thyroid function tests 86 Vitamin E 134
Thyroid-stimulating hormone 87–88 Voluntary admission 21–22
Tolerance 294
to drugs 114 W
Transcranial magnetic stimulation (TMS) 160 Watson, Jean 47
Transference 38 Weight loss 146
Transtheoretical model of change 46 Weissman, Myrna M. 127
Traumatic brain injury White matter 64
assessment of 287 Withdrawal 294, 300
clinical management of 288
demographics of 286 Y
description of 285 Yalom, Irvin 128
diagnostic and laboratory findings 287–288 Yoga 132, 135
differential diagnosis of 288 Young Mania Rating Scale (YMRS) 186
4TH
EDITION
PSYCHIATRIC-MENTAL HEALTH

Nurse Practitioner
Psychiatric-Mental Health
NURSE PRACTITIONER PSYCHIATRIC-
MENTAL HEALTH
Review and Resource Manual, 4th Edition
Are you looking into how to advance your professional development through
NURSE
certification? Need a reliable and credible reference resource? No matter where you
are in the process, make sure you have the most valuable review and resource tool
at your disposal.
The Nursing Knowledge Center’s Psychiatric-Mental Health Nurse Practitioner

Review and Resource Manual is a must-have tool for nurses planning to take the
American Nurses Credentialing Center’s (ANCC’s) Psychiatric-Mental Health
PRACTITIONER
Nurse Practitioner certification exam.
4th Edition
Based on the official ANCC certification exam test content outline, this
review and resource manual will help you:
n S
tudy and analyze comprehensive material and concepts written by
nursing experts.
n D
evelop a recommended seven-step plan to equip you for the exam
and map out what to do on the day of the exam.
n P
repare for and familiarize yourself with psychological-mental health practitioner
standards of practice.
n A
nd much more ... Nursing Certification Review Manual
Make the Psychiatric-Mental Health Nurse Practitioner Review Continuing Education Resource
and Resource Manual a key resource in your certification preparation. Clinical Practice Resource

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4TH

Review and Resource Manual

The Nursing Knowledge Center’s Psychiatric-Mental Health Nurse Practitioner

Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC

AMERICAN NURSES ASSOCIATION

©2016 American Nurses Association. All rights reserved.

Published by American Nurses Credentialing Center

Names: Johnson, Kathryn, 1947-, author. | Vanderhoef, Dawn, author. |

© 2016 American Nurses Association

INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION

Chapter 1. Taking The Certification Examination. . . . . . . . . . . . . 1

Chapter 2. Psychiatric–Mental Health Nurse Practitioner Role,

Chapter 3. Theoretical Basis of Care. . . . . . . . . . . . . . . . . . . . . . 37

Chapter 4. Psychiatric–Mental Health Nurse Practitioner

Chapter 5. Neuroanatomy, Neurophysiology, and Behavior . . 63

Chapter 6. Advanced Health and Physical Health Assessment. . 79

Chapter 7. Pharmacological Principles. . . . . . . . . . . . . . . . . . . . 111

Chapter 8. Nonpharmacological Treatment . . . . . . . . . . . . . . . 125

Family Therapies 129

Chapter 9. Depressive Disorders and Bipolar Disorders. . . . . 139

Chapter 10. Anxiety Disorders, Obsessive–Compulsive Disorder,

Dissociative Disorders 225

Chapter 11. Schizophrenia Spectrum and Other Psychotic

Chapter 12. Neurocognitive Disorders. . . . . . . . . . . . . . . . . . . . 271

Chapter 13. Substance-Related and Addictive Disorders . . . . . 293

Chapter 14. Personality Disorders. . . . . . . . . . . . . . . . . . . . . . . . 313

Chapter 15. Disorders of Childhood and Adolescence . . . . . . . 327

Chapter 16. Sleep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Case Study 1 369

Chapter 17. Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Appendix A. Review Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 385

Appendix B. Review Question Answers. . . . . . . . . . . . . . . . . . . . 409

INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION

Nursing Knowledge Center

ANCC Provider Number 0023.

TAKING THE CERTIFICATION EXAMINATION

GENERAL SUGGESTIONS FOR PREPARING FOR THE EXAM

Step Two: Do Not Listen to Gossip About the Exam

Step Three: Set Reasonable Expectations for Yourself

Step Four: Prepare Mentally and Physically

Step Five: Access Current Knowledge

Take a Review Course

Step Six: Institute a Systematic Study Plan

Personalize Your Study Plan

Implement Your Study Plan

Focus on General Material

Pace Your Studying

Work With Others

Consider a Study Group

Step Seven: Strategies Immediately Before the Exam

The Night Before the Exam

ZZ Get a good night’s sleep.

The Day of the Exam

Specific Tips for Dealing With Anxiety

Focus on Specific Test-Taking Skills

All Certification Exams Are Multiple Choice

Analyze the Information Given

What Kind of Question Is Asked?

Read All of the Answers

avoid initial most