Mental Health Exam #1

Question 1

What are the three attributes of nursing?

Answer 1

Caring
Attending
Patient advocacy

Question 2

Explain what “caring” means for the nurse.

Answer 2

Caring includes

• Giving of self
• Leads to happiness
• Is evidenced by empathetic understanding, actions, and patience
• Is the most natural and fundamental aspect of human existence

Question 3

How is a nurse a “patient advocate”?

Answer 3

A patient advocate

• Speaks up for another’s cause
• Helps another by defending and comforting

Advocacy in nursing includes…

• Committing to the patient’s health
• Alleviating suffering
• Promoting a dignified death
• *Advise patients of their rights
• Provide accurate and current information

Question 4

How is the DSM-5 used in practice?

Answer 4

DSM-5 = Diagnostic and Statistical Manual of Mental Health Disorders (Edition 5)

Is the current guidebook for categorizing and diagnosing psychiatric mental health disorders in the US
Prior to the fifth edition, an ‘axial system’ was used

Question 5

What is the purpose of a mental status examination (MSE)?

Answer 5

MSE is fundamental to overall patient assessment
Evaluates CURRENT cognitive processes
Aids in collecting objective data

Question 6

List the parts of a mental status examination (MSE).

Answer 6

Personal information
Appearance
Behavior
Speech
Affect and mood
Thought
Perceptual disturbances
Cognition

Question 7

What is a psychosocial assessment? How does it differ from a MSE?

Answer 7

Psychosocial assessment provides additional information to develop a plan of care beyond the MSE
Helps obtain the following
-Chief complaint
-History of violence, suicidal ideation, self-mutilating behaviors
-Alcohol and substance abuse
-Family psychiatric history
-Personal psychiatric treatment (includes meds and complementary therapies)
-Stressors and coping methods
-Quality of ADLs
-Personal background
-Support system
-Weaknesses, strengths, and goals for treatment

Spiritual/religious assessment
Cultural/social assessment

Question 8

Describe the three personality structures of Freud’s psychoanalytic theory.

Answer 8

Id: pleasure principle, reflex action, primary process (develops when born; ex: crying for what we want)
Ego: problem solver, reality tester (in the middle; result of id + superego)
Superego: moral component (morals taught by others)

Question 9

What are the three levels of awareness in Freud’s psychoanalytic theory?

Answer 9

Levels of awareness:
Conscious
Preconscious
Unconscious

Question 10

What are the defence mechanisms involved in the psychoanalytic theory?

Answer 10

Ways that we cope:
Develop anxiety
Operate on an unconscious level
Deny, falsify, or distort reality to make it less threatening

Question 11

How does the Freudian theory apply to nursing?

Answer 11

Formation of personality
Conscious and unconscious influences
Importance of individual talk sessions
Attentive listening
Transference: patient transfers feelings onto you
Countertransference: you transfer feelings onto your patient

Question 12

What is the goal of psychoanalytic therapy?

Answer 12

Goal: reveal unconscious mind and repressed memories
Free association used
Psychodynamic therapy (is a shorter form of psychoanalytic therapy)

Question 13

According to Sullivan’s interpersonal theory, what is the purpose behind our behavior?

Answer 13

“The purpose of all behavior is to get needs met through interpersonal interaction and to decrease or avoid anxiety”

Question 14

List several behavioral theories, including who founded them.

Answer 14

Pavlov’s classical conditioning
Watson’s behaviorism
Skinner’s operant conditioning

Question 15

What are some types of behavioral therapy, used in accordance with the behavioral theories?

Answer 15

Behavioral modification
Systematic desensitization (adjusting to something slowly, through several exposures; opposite of “flooding” technique)
Aversion therapy (ex: Antabuse)
Biofeedback (changes your physiological reaction to fear)

Question 16

How are needs divided into two categories in humanism/Maslow’s hierarchy of needs?

Answer 16

“D-motives” – basic needs, based on DEFICIENCY
Ex: air, water, food
“B-motives” – self-actualization, based on BEING
Ex: self-esteem, community

Question 17

What are the two cognitive theories?

Answer 17

Rational-Emotive-Behavior Therapy (Ellis): aims to eradicate irrational beliefs, recognizes that thoughts are not accurate
Cognitive-Behaviors Therapy (Beck): tests distorted beliefs, changes ways of thinking to reduce symptoms

Question 18

What is the focus of the biological theories?

Answer 18

Focus on
	Neurologic
	Chemical
	Biological
	Genetics

Question 19

How do the biological theories influence nursing?

Answer 19

Consider other influences that play a role in the development and treatment of mental disorders (social, environmental, cultural, economic)
Focus on the qualities of a therapeutic relationship
Apply the newest findings of the biological models in nursing practice

Question 20

Describe Piaget’s stages of cognitive development.

Answer 20

Cognitive development explains the progression from primitive awareness –> complex thought
Sensorimotor (birth – 2 years): object permanence
Preoperational (2 – 7 years): language egocentric thinking
Concrete operational (7 – 11 years): conservation, logic, abstract problem solving, patterns
Formal operational (11 – adult): conceptual reasoning, problem solving like an adult

Question 21

List Erikson’s eight stages of development.

Answer 21

Personality continues to develop through old age
Failure at one stage can be rectified at another stage
Infant: Trust vs. Mistrust
Toddler: Autonomy vs. Shame/Doubt
Preschooler: Initiative vs. Guilt
School-Aged Child: Industry vs. Inferiority
Adolescent: Identity vs. Role Confusion
Young Adult: Intimacy vs. Isolation
Middle-Aged Adult: Generativity vs. Stagnation
Older Adult: Integrity vs. Despair

Question 22

What overall influence do these psychological theories have on nursing care?

Answer 22

Behavioral: promoting adaptive behaviors through reinforcement
Cognitive: helping patients identify negative thought patterns
Psychosocial development: providing structure for understanding
Hierarchy of need: prioritizing nursing care

Question 23

List and define some of nursing’s legal and ethical concepts.

Answer 23

Ethics: wrongs vs. right (personal to each individual)
Bioethics: ethics pertaining to life (ex: euthanasia, abortion)
Beneficence: doing good for the patient
Autonomy: decisions made for self
Justice: fairness
Fidelity: being faithful (keeping promises)
Veracity: being truthful

Question 24

What are the two main types of psychiatric admissions?

Answer 24

Voluntary admission (202): come to facility willingly
May sign an AMA (Against Medical Advice), requesting to leave
Doctor has 72 hours to approve of AMA

Involuntary admission (302 OR 303): commitment; against their will
Once brought in initially, they are a “302”.
If found to need an extended stay (against their will), they will be “303’d”
Who determines this?
Judicial determination (court hearing)
Administrative determination
Agency determination
Specified number of physicians must certify that the person’s mental health status justifies detention and treatment

Question 25

What rights do patients have to REFUSE treatment?

Answer 25

Right to withhold consent
Right to withdraw consent at any time
Right to retract consent; must be honored, whether verbal or written

The right of a patient who is mentally ill to refuse treatment with psychotropic drugs has been debated in the courts
A patient can refuse meds - UNLESS two doctors approve of “forced meds”

Question 26

Explain the right to informed consent.

Answer 26

Canterbury v. Spence (1972): right to self-determination

An adult with sound mind has a right to determine what shall be done with his or her own body

Question 27

What is the difference between informed consent and implied consent?

Answer 27

If the clinician approached the patient with medication in hand and the patient indicates a willingness to receive the medication, then implied consent ha occurred.
State psychiatric hospitals generally require informed consent for every medication given
General rule to follow: the more intrusive or risky the procedure, the higher the likelihood informed consent must be obtained

Question 28

What rights does the patient have, after death?

Answer 28

The Dead Man’s Statue
Legal privilege of confidentiality exists after death in some states (ex: nurse-patient, physician-patient, attorney-patient)
Duty to report: you may be required to divulge private information shared by the patient (ex: murder trial)
Different states have varying laws

Question 29

Explain patient privilege and HIV status.

Answer 29

Some states mandate health care providers to warn spouse if a partner tests positive for HIV
Nurses must understand the laws in their jurisdiction regarding privileged communications and warnings of infectious disease exposures

Question 30

Can a release of information be given to a patient’s employer?

Answer 30

Release of information to a patient’s employer about a patient’s condition without the patient’s consent is a(n)
Breach of confidentiality
Invasion of privacy
Violation of HIPAA

Question 31

Under what circumstances does the nurse have the duty to break confidentiality?

Answer 31

Duty to Warn
Tarasoff v. Regents of University of California (1974): California supreme court case
Ruled that a psychotherapist has the duty to warn a patient’s potential victim
-University student in counseling at a -California university becomes despondent over a rejection by Tatiana Tarasoff
-Psychologist notifies police verbally and in writing that the young man may be dangerous to Tarasoff
-Police question the student, find him to be rational, and secure a promise to stay away from Tarasoff
-The student kills Tarasoff 2 months later

Question 32

What is the duty to protect third parties?

Answer 32

Duty to Protect Third Parties
California supreme court issued a second ruling in the Tarasoff case (1976)
It now includes the duty to protect
Duty to protect usually includes the following:
-Assessing and predicting a patient’s danger of violence toward another
-Identifying specific individual(s) being threatened
-Identifying appropriate actions to protect victim(s)

Question 33

What are the nursing implications for the Duty to Warn and Protect Third Parties?

Answer 33

Nursing implications
In jurisdictions that have adopted the Tarasoff doctrine…
Duty to warn third parties is applied to advance practice registered nurses (APRNs) and psychiatric mental health nurses
Staff nurses and members of the mental health team should report threats of harm
Failure to communication and record relevant information from police and relatives may result in patient’s old records being deemed as negligent

Question 34

Today, what are the restrictions/instructions regarding use of restraints?

Answer 34

• Original order may be extended after a review and reauthorization (typically conducted every 24 hours)
• Must specify the type of restraint
• In an emergency, the nurse may place the patient in seclusion and/or restraints, but must first obtain a written or verbal order
• A telephone order is acceptable, but must be followed by a written order in the chart with a physician follow-up and physician signature (this must happen within 24 hours)
• For emergency restraints, the situation must have immediate risk of harm to the patient or others (Exception: patient may request seclusion)
• Patient must be protected from harm
• Must be documented (behavior leading to restraint, time patient is placed in and released from restraint or seclusion)

Question 35

How is patient safety maintained during restraint use?

Answer 35

Patient must be:

• Assessed at regular and frequent intervals for physical needs (ex: food, hydration, toileting), safety, and comfort every 15-30 minutes
• Removed from restraint when safer and quieter behavior is observed
• Observations must be documented every 15-30 minutes

Question 36

Are nurses liable for reporting child abuse?

Answer 36

Child Abuse Reporting Statues
Established in all 50 states and Washington, DC.
Statutes differ from state-to-state
Most statutes include civil penalties for the failure to report
Many states require nurses to report cases of suspected abuse

Question 37

How is there a conflict between federal and state laws in reporting child abuse?

Answer 37

When health care professionals discover child abuse or neglect during a suspected abuser’s alcohol and drug treatment
Federal laws govern confidentiality apply to most providers of drug abuse and alcohol treatment
Prohibit any disclosure without a court order
Federal law supersedes state laws, although compliance with state law may be maintained under the following
If a court order is obtained pursuant to the regulations
If a report can be made without identifying the abuser as a patient in an alcohol and drug treatment program
If the report is made anonymously (though some states do not allow anonymous reporting)

Question 38

Are nurses liable for reporting elder abuse?

Answer 38

Elder Abuse Reporting Statutes
Apply to older adults – 65 years of age and older
Many states require RNs to report abuse
Federally funded agencies (Medicare, Medicaid) have strict guidelines for reporting and preventing elder abuse

Question 39

What is a projective question?

Answer 39

Start with a what if question to help people articulate, explore, and identify thoughts and feelings.
Examples:
If you had three wishes, what would you wish for?
What if you could go back and change how you acted in [X situation] or [significant life event]? What would you do differently now?
What would you do if you were given $1 million, no strings attached?
Projective questions can help people imagine thoughts, feelings, and behaviors they might have in certain situations.

Question 40

What is a presupposition question (The “Miracle Question”)?

Answer 40

Suppose you woke up in the morning and a miracle happened, and this problem had gone away:
What would be different?
How would it change your life?
These two questions can reveal a lot about a person, which can be used in identifying goals that the patient might be motivated to work on. These questions often get to the crux of what might be among the mostimportant issues in a person’s thinking and life.

Question 41

List some of the therapeutic communication techniques used by nurses.

Answer 41

Using silence
Accepting
Giving recognition
Offering self
Offering general leads (“I read you came here because…”)
Giving broad openings (“How are you feeling today?”)
Placing the events in time and sequence
Making observations (“I noticed you didn’t come to group.”)
Encouraging description of perception
Encouraging comparison
Restating
Reflecting
Exploring
Giving information (patient education, resources)
Seeking clarification
Presenting reality (correcting altered perceptions)
Voicing doubt (“I don’t think they hate you are much as you seem to think.”)
Seeking consensual validation
Verbalizing the implied (“It seems you’re upset with…”)
Encouraging evaluation
Attempting to translate into feelings
Suggesting collaboration
Summarizing
Encouraging formulation of plan
Focusing (bringing them back to the topic at hand)

Question 42

Give examples of some nontherapeutic communication techniques.

Answer 42

Asking excessive questions
Giving approval (agreeing)
Disapproving (disagreeing)
Giving premature advice
*ASKING “WHY” QUESTIONS
Minimizing feelings
Being falsely reassuring
Making value judgements
Changing the subject

Question 43

What is a “therapeutic relationship”? How does it differ from a “nontherapeutic relationship”?

Answer 43

Therapeutic relationship
Facilitating (therapeutic communication)
Assisting patient in: alternative problem solving, new coping skills
Helping
Promoting independence
Focusing on patient’s problems
Encouraging behavioral changes

Nontherapeutic relationship
	Blocking (nontherapeutic communication)
	Does not assist patient in: alternative problem solving, coping skills
	Controlling
	Promoting dependence
	Focusing on nurse’s needs
	Enabling negative behaviors

Question 44

Explain what transference and countertransference are. How/why do they occur?

Answer 44

Transference
Person unconsciously and inappropriately displaces (transfers) those emotional reactions that originated from significant figures in childhood onto another individual
Example: “You remind me of _____.”

Countertransference
Tendency of the nurse to displace feelings related to people in his or her past onto a patient
Frequently, the patient’s transference to the nurse evokes countertransference feelings in the nurse
Example: shown as favoritism on the nurse’s part

Although the boundaries of the nurse-patient relationship are generally clearly defined, they can become blurred. This burring can be insidious and may occur at an unconscious level.
Usually, the transference and countertransference phenomena are operating when boundaries are blurred.

Question 45

List the types of benzodiazepines used for psychiatric patients.

Answer 45

Anxiety
	Diazepam (Valium)
	Clonazepam (Klonopin)
	Alprazolam (Xanax)
	Lorazepam (Ativan)

Lorazepam and alprazolam reduce anxiety without being as soporific (sleep-producing) at lower therapeutic doses

Insomnia
Flurazepam (Dalmane)
Triazolam (Halcion)

Question 46

How is stress involved in mental health? What are the different types of stress?

Answer 46

Stress: our responses to it are central to psychiatric disorders and the provision of mental health care
Eustress “good stress” (graduation, wedding day, etc.)
Distress “bad stress” (death in the family, failing a test, etc.)

Question 47

What symptoms do people experience when they are stressed?

Answer 47

Troubles with eating or sleeping (either too much or too little)
Experience headache or back pain
Lose interest in favorite activities
Feel tense and become irritable
Feel powerless

Question 48

What is PTSD?

Answer 48

PTSD = Posttraumatic Stress Disorder
Usually occurs after a traumatic event outside the range of usual human experience
HPA system is abnormal (Hypothalamic-pituitary-adrenal axis)
Major depression frequently occurs
If left untreated or undertreated, painful repercussion can result

Question 49

What are some examples of traumatic events (that may cause PTSD)?

Answer 49

Childhood physical abuse, kidnapping, sexual assault
Natural disasters, human disasters
Crime-related events (terror attack, muggings, taken hostage)
Diagnosis of a life-threatening illness

Question 50

What are some symptoms of PTSD?

Answer 50

Flashbacks
Avoidance of stimuli associated with trauma
Persistent negative alterations in mood and cognition; guilt, detachment
Persistent symptoms of increased arousal (angry outbursts, self-destructive behavior, startling, sleep difficulties)

Question 51

Explain what acute stress disorder is.

Answer 51

Acute Stress Disorder occurs as a result of
Witnessing a violent or gruesome death or experience
Repeated exposure to aversive details of the event
Example: first responders who collect body parts, police officers exposed to details of child abuse, etc.
If acute stress disorder continues after 30 days, it becomes PTSD.

Question 52

What are some symptoms of acute stress disorder?

Answer 52

Intrusive symptoms: experience keeps coming into mind, interrupts daily life
Dissociative symptoms: ignores situation that could be triggering (tries to distract self by putting mind elsewhere)
Avoidance symptoms: avoiding situations that could be triggering altogether
Arousal symptoms: hyperactive, anxiety

By definition, acute stress disorder should resolve in about a month.

Question 53

What is anxiety?

Answer 53

Anxiety is the most basic emotion; it is a universal human experience
Dysfunctional behavior is often a defense against anxiety
When behavior is recognized as dysfunctional, interventions can be initiated by the nurse to reduce anxiety
As anxiety decreases, dysfunctional behavior will frequently decrease

Question 54

What is the difference between anxiety and fear?

Answer 54

Anxiety and fear are indistinguishable, except for the cause
FEAR = a reaction to a specific danger
ANXIETY = a feeling of apprehension, uneasiness, uncertainty, or dread, resulting from a real or perceived threat whose actual source is unknown or unrecognized

Question 55

What are some different types of anxiety?

Answer 55

Normal anxiety: healthy life force necessary for survival
Acute anxiety: precipitated by imminent loss or threat
Pathological anxiety: differs from normal anxiety in terms of duration, intensity, and disturbance of a person’s ability to function (ex: dysfunction behaviors or extreme withdrawal)
Chronic anxiety: long-term; thought to be associated with increased risk for cardiovascular morbidity, usually begins at a young age

Question 56

Explain the different levels of anxiety.

Answer 56

Mild (normal “worry”)
Moderate (more stressed than usual)
Severe (debilitating; interferes with ability to function)
Panic (lost all touch with all reality, not able to think straight)

Question 57

What behaviors and characteristics are altered during anxious states?

Answer 57

Perceptual fields become narrowed
Ability to learn impaired
Physical characteristics sympathetic NS (chest pain, heart attack symptoms, trouble breathing, etc.)

Question 58

What are defense mechanisms?

Answer 58

Defense mechanisms are
	Major means of managing conflict
	Relatively unconscious
	Discrete from one another
	Hallmarks of major psychiatric syndromes, which are reversible (if finding new ways of coping)
	Adaptive, as well as pathologic

Question 59

What is “projection”?

Answer 59

Attribute feelings/thoughts onto someone else

Ex: I don’t like a boy named Mike, and I say “I know that dude hates me, I know it.”

Question 60

What is “regression”?

Answer 60

Return to earlier stage of development

Ex: “My 7 year old is wetting the bed again, since he found out he’s going to have a little sister.”

Question 61

What is “undoing”?

Answer 61

The action of “reaction formation”. Acting out the reverse of unacceptable behavior.
Ex: Pyromaniac putting out fire

Question 62

What is “sublimation”?

Answer 62

Using an unacceptable impulse for good.

Ex: Pyromaniac starts working for a special effects company.

Question 63

What is the prevalence of anxiety with other disorders?

Answer 63

Highly co-occurring
	Substance abuse
	Major depressive disorder (MDD)
Frequently co-occurring 
	Eating disorders
	Bipolar disorder
	Dysrhythmias 
Co-occurring medical conditions
	Cancer, heart disease, HTN, IBS, renal/liver dysfunction, reduced immunity
Chronic anxiety
	Associated with increased risk for cardiovascular morbidity and mortality

Question 64

What are panic disorders (PD)? What symptoms occur with them?

Answer 64

Panic Disorders (PD)
Panic attack
Sudden onset of extreme apprehension or fear, usually with a feeling of doom
(not necessarily in response to a stressor)
Terror so severe that normal function is suspended
Signs similar to a heart attack
Severely limited perceptual field
Increased rate of suicidal and suicide attempts

Physical manifestations: chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, chills, hot flashes, GI symptoms

Panic Disorder with Agoraphobia
Agoraphobia
An intense and excessive level of anxiety; fever of being in places and situation from which escape is impossible (open spaces, large crowds, airplanes, etc.)
Feared places are avoided to control anxiety
Avoidance behaviors can be debilitating

Question 65

What is a phobia? What are the types of phobias?

Answer 65

Phobia
Persistent, irrational fear of something
Usually specific objects of situations (dogs, spiders, heights, storms, blood, closed spaces, open spaces)
Are common, but usually do not cause much difficulty

Social anxiety disorder (SADs)
Severe anxiety produced by exposure to a social or performance situation
Fear of saying something foolish, not be able to answer questions in a classroom, eating in the presence of others, performing onstage
Fear of public speaking is most common

Question 66

What is general anxiety disorder?

Answer 66

General Anxiety Disorder (GAD)
Severe distress with pervasive cognitive dysfunction and impaired functioning
No specific triggers

Question 67

Define obsessive compulsive disorder.

Answer 67

Obsessions (thoughts) – unwanted and persistent, ideas, thoughts, or impulses that cause significant anxiety
Compulsions (behaviors) – unwanted and ritualistic behavior the individual feels driven to perform (in order to reduce anxiety)

Question 68

What are the symptoms of OCD?

Answer 68

Obsessive Compulsive Disorder (OCD)
OCD behavior exists along a continuum
“Normal” individuals may experience mild obsessive-compulsive behaviors
Mild compulsions can even be valued traits in U.S. society
More severe symptoms: center around dirtiness, contamination, and germs (occur with corresponding compulsions, such as cleaning or hand-washing)
Most severe symptoms: include persistent thoughts of sexuality, violence, illness, and death

Question 69

What other diagnoses are closely related to OCD?

Answer 69

Body Dysmorphic Disorder (BDD)
Preoccupation with an imagined “defective body part”
Obsessional thinking about the body
Impairment of normal social activities, related to academic or occupational functioning

Compulsive Hoarding
Excessive collection of items considered worthless
Individual is ashamed of failure to discard items
Extreme life disruption and distress
Social isolation
Unsafe living conditions

Question 70

What behavior modification therapies can be used to treat anxiety?

Answer 70

Modeling – mimicking appropriate behaviors in situations
Systematic desensitization – gradually exposing a person to a feared object or situation until the person is free of incapacitating anxiety
Response prevention – starts with the therapist preventing the compulsion, such as handwashing, and gradually helps the patient limit the time between rituals, until the urge dissipates
Thought stopping – snapping a rubber band on wrist to stop an obsession or negative thought

Question 71

Define somatic symptom disorders.

Answer 71

Somatic Symptom Disorders
Characterized by the presence of multiple, real, and/or physical symptoms for which no evidence of medical illness is revealed
Accompanied by abnormal thoughts, feelings, and reactions to symptoms
Associated with increased health care use, functional impairment, provider dissatisfaction, psychiatric co-morbidity, and failure treatment responses
May be exacerbated by other physical disorders
Symptoms: impaired functioning, obsession with health concerns, actively seeks medical relief; pain is predominant symptoms (cause not always identifiable)
Persistent (>6 months) – can be mild, moderate, or severe

Question 72

What is the difference between somatic symptom disorder and illness anxiety disorder?

Answer 72

Illness Anxiety Disorder (aka, hypochondria)
Illness preoccupation, with or without mild symptoms
Persistent (>6 months)
Symptoms: high anxiety over health, alarmed by body sensations, may or may not seek help

Question 73

What is conversion disorder?

Answer 73

Conversion Disorder
Presents with impaired motor or sensory function compliant
Findings inconsistent with known neurologic conditions
Symptoms are not voluntarily controlled or created
Exhibits either la belle indifference (lack of concern) OR high distress over symptoms
Current theories: dispute purely psychologic origin; think patients may have smaller hippocampal volume
Co-morbidities: childhood abuse, depression, anxiety, personality disorder

Question 74

What is factitious disorder?

Answer 74

Factitious disorder
Imposed on self (Munchausen)
Deliberate symptom fabrication or self-injury without obvious potential reward (attention presume to be possible motivation)
Patient identifies self as ill
Single or recurrent episodes
Different from malingering (faking injuring for obvious, often monetary, gain)
Imposed on another (Munchausen by-proxy)
Offender is usually parent or caregiver, motivation is attention or nurturing for self at expense of a dependent victim

Question 75

How can the nursing process be used for somatic symptom disorders?

Answer 75

Nursing assessment
History and course of past symptoms
Current physical/mental status
No voluntary control over symptoms (with exception of factitious disorders)
Assess for secondary gains (benefits derived from symptoms)
Cognitive style

Misinterpretation of physical stimuli
Reality distortion regarding symptoms Ability to communicate emotional needs Dependence on medications  patients often seek prescription renewal, and seek treatment from many physicians (go “doctor shopping”); nurse must evaluate the importance of each med 
Anxiolytics, such as benzos (rebound anxiety occurs on withdrawal), pain meds, and sleep meds

Question 76

What are some “hallmark” characteristics of dissociative disorders?

Answer 76

Disturbance in a normally well-integrated continuum of consciousness, memory, identity, and perception
Dissociation = the unconscious defense mechanisms to protect an individual against overwhelming anxiety
Intact reality testing (is not delusional or hallucinating)
Includes amnesiac states

Question 77

Explain the difference types of dissociative disorders.

Answer 77

Depersonalization/Derealization Disorder
Recurrent periods of feeling unreal, detached, outside the body, dreamlike, numb, or with a distorted sense of time or perception
Reality testing remains intact
Symptoms are not related to medical conditions or substance use

Dissociative Amnesia
Psychologically induced memory loss and inability to recall important personal information after a severe stressor

Dissociative Amnesia with Fugue
Sudden, unexpected travel from a customary location, and the inability to recall one’s identity after a traumatic event

Dissociative Identity Disorder (DID) – very rare
	Formerly known as “Multiple Personality Disorder” 
	Presence of two or more personality states that control behavior
	Each alternate personality (alter) has its own pattern of perceiving, affect, cognition, behavior, and memories
	Severe sexual, physical, psychologic trauma in childhood predisposes an individual to DID

Question 78

How can the nursing process be used for dissociative disorders?

Answer 78

Patient history
	Recent injuries, seizure history, early trauma, memory/identity questions, history of similar episodes
Mood
	Depressed, anxious, unconcerned, suicidal 
	Frequent shifts in mood
	Erratic behavior
Use of alcohol or other drugs
Effect on patient and family