NCLEX: Caring for the Client with Psychiatric Disorders

Terms you’ll need to understand:
Anorexia nervosa
Attention deficit hyperactive disorder
Bipolar disorder
Bulimia nervosa
Conduct disorder
Conversion
Delusion
DSM-IV-TR
Dysthymic disorder
Electroconvulsive therapy
Extrapyramidal side effect
Hallucination
Hypertensive crisis
Hypochondriasis
Neuroleptic malignant syndrome
Neurosis
Neurotransmitter
Pain disorder
Personality disorder
Psychosis
Schizophrenia
Somatization disorder

Nursing skills you’ll need to master:
Administering medication
Performing mental status assessment
Maintaining a therapeutic mileau
Obtaining vital signs
Assessing for side effects of psychotropic drugs
Assisting with alternative therapies

The past decade has been an exciting time for psychiatric nursing. Technological advances have given us the ability to study not only the physical structure of the brain, but also how chemical messengers (known as neurotransmitters) affect our mood and behavior. The depiction of the hopelessness of mental illness has been partly done away with by the release of movies like A Beautiful Mind. Finally, the discovery of newer and more effective drugs has made it possible for many of those with mental illness to lead more normal lives.
Although it is not possible to cover all the psychiatric disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV–TR), we will review the most commonly diagnosed disorders: anxiety-related disorders, personality disorders, the psychotic disorders of schizophrenia and bipolar disorder, substance abuse, and the disorders of childhood and adolescence.
Alzheimer’s disease and other degenerative neurological disorders are discussed previously.

Anxiety-Related Disorders
These types of disorders are sometimes referred to as neurotic disorders and include the following categories:
- Dissociative identity disorder
- Generalized anxiety disorder
- Obsessive compulsive disorder
- Panic disorder
- Phobic disorder
- Post-traumatic disorder
- Somatoform disorder

Anxiety disorders are characterized by feelings of fear and apprehension accompanied by a sense of powerlessness. Anxiety-related disorders are listed on Axis I of the DSM-IV-TR.

Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is the most common form of anxiety disorder and frequently is accompanied by depression and somatization or the development of phobias.
The client with GAD worries excessively over everything, and the stress this creates eventually affects every aspect of life. The client with GAD might try to gain a sense of control by retreating from anxiety-producing situations or by self-medication with drugs or alcohol.
Genetics and alterations in neurotransmitters seem to be the primary causes for GAD. Studies show a higher occurrence in those with an affected twin.
Neurophysiology research suggests that alterations in serotonin, norepinephrine, and gamma – aminobutyric acid can account for some cases of generalized anxiety disorder.

Post-traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) develops after exposure to a clearly identifiable threat. The nature of the threat is so extreme that it overwhelms the individual’s usual means of coping.
PTSD is characterized according to the onset as either acute or delayed. Acute PTSD occurs within 6 months of the event, whereas delayed PTSD occurs 6 months or more after the event. Symptoms of PTSD include
- Blunted emotions
- Feelings of detachment
- Flashbacks
- Moral guilt
- Numbing of responsiveness
- Survivor guilt

Additional symptoms include increased arousal, anxiety, restlessness, irritability, sleep disturbances, and problems with memory and concentration.
Individuals with PTSD frequently have problems with depression and impulsive self-destructive behaviors, including suicide attempts and substance abuse.
Posttraumatic stress disorder is common in those who are survivors of combat, natural disasters, sexual assault, or catastrophic events.

Clients with PTSD who use cocaine or amphetamines are more vulnerable to paranoia and psychosis than those who do not use stimulants.

Dissociative Identity Disorder
Dissociative identity disorder (DID), formerly referred to as multiple personality disorder, is characterized by the existence of two or more identities or alter personalities that control the individual’s behavior.
The traditional view of DID is that dissociation acts as a defense against an overwhelming sense of anxiety that is both painful and emotionally traumatic. The alter personality contains feelings associated with the trauma, which is often related to physical, emotional, or sexual abuse.
Each alter personality is different from the other, having its own name, ways of behaving, memories, emotional characteristics, and social relationships.
Overwhelming psychological stress can cause the onset of a dissociative fugue. The major feature of a dissociative fugue is unexpected travel from home with the appearance of one of the alter personalities. The travel and behavior might seem normal to the casual observer who is unfamiliar with the client’s history.
The following films offer good depictions of dissociative identity disorder: The Three Faces of Eve, Sybil, and Identity.

Somatoform Disorder
Somatoform disorder is characterized by the appearance of physical symptoms for which there is no apparent organic or physiological cause. The client with a somatoform disorder continuously seeks medical treatment for a physical complaint even though he has been told there is no evidence of physical illness. Somatoform disorders include
- Conversion disorder
- Hypochondriasis
- Pain disorder
- Somatization disorder

Panic Disorder
Panic disorder is characterized by sudden attacks of intense fear or discomfort that peaks within 10–15 minutes. Clients with panic disorder might complain of not being able to breathe, of feeling they are having a heart attack, or that they are 'going crazy.' Panic attacks can occur during sleep or in anticipation of some event. In some instances, clients with panic disorder develop agoraphobia, or fear of having a panic attack in a place where they cannot escape. As a result, they restrict activities outside the safety of their home.
Panic attacks can be brought on by caffeine, carbon dioxide, and sodium lactate.

Genetic and environmental factors appear to be involved in the development of panic disorder. Other findings suggest that there are alterations in the benzodiazepine receptor sites.

Phobic Disorders
Phobic disorders are expressed as intense, irrational fears of some object, situation, or activity. A persons with a phobic disorder experiences anxiety when he comes in contact with the situation or feared object. Although the client recognizes that the fear is irrational, the phobia persists. According to the DSM-IV–TR the three major categories of phobic disorders are
- Agoraphobia
- Social phobia
- Specific phobia

There are no clearly identifiable factors in the development of phobic disorders.

Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is characterized by the presence of recurrent persistent thoughts, ideas, or impulses and the repetitive rituals that are carried out in response to the obsession. Persons with OCD know that their actions are ridiculous; still they must carry them out to avoid overwhelming anxiety. Unfortunately, this continual preoccupation interferes with normal relationships. The client with OCD is viewed by others as rigid, controlling, and lacking spontaneity.
The main character in the movie As Good As It Gets is an excellent example of the client with OCD. Remember what happened when his schedule was upset.

There is some evidence that OCD, like other anxiety disorders, is related to genetic transmissions or alterations in the serotonin regulation.
Treatment of anxiety disorders depends on the diagnosis and severity of symptoms. Some disorders, such as panic disorder and obsessive-compulsive disorder, respond to treatment with antidepressant medication. Others, such as post-traumatic stress disorder and phobic disorder, benefit from cognitive behavioral therapy and desensitization.
Nursing interventions in caring for the client with an anxiety disorder include administering antidepressant medication, helping the client become aware of situations that increase anxiety, helping the client recognize the overuse of certain defense mechanisms, and teaching cognitive behavioral methods for reducing anxiety.
You should read up on nursing topics that cover discussion of the most commonly used defense mechanisms.

Personality Disorders
The second major category of reality-based disorders focuses on the client with faulty personality development.
Unlike clients with an anxiety disorder, who believe that everything is wrong with them, clients with personality disorders seldom seek treatment. They see nothing wrong with their behavior and therefore see no need to change.
Personality disorders are listed on Axis II of the DSM-IV-TR.
Personality disorders refer to pervasive maladaptive patterns of behavior that are evident in the perceptions, communication, and thinking of an individual. The DSM-IV–TR divides personality disorders into three clusters according to the predominant behaviors:
- Cluster A—Includes odd, eccentric behavior
- Cluster B—Includes dramatic, erratic, emotional behavior
- Cluster C—Includes anxious, fearful behavior

Of these three clusters, those with dramatic, erratic behavior pose the greatest threat to others.
Each cluster contains from three to four identifiable personality disorders.
The clusters and identified personality disorders of each are outlined in the following sections.

Cluster A
Cluster A disorders include paranoid, schizoid, and schizotypal personality disorders. Although these represent different personalities, they all involve behavior that is odd or eccentric in nature.

Paranoid Personality Disorder
Paranoid personality disorder is characterized by rigid, suspicious, and hypersensitive behavior. Persons with paranoid personality disorder spend a great deal of time and energy validating their suspicions. Unlike those with paranoid schizophrenia, the client with paranoid personality does not have fixed delusions or hallucinations. However, transient psychotic features can appear when the client experiences extreme stress, and the client might be hospitalized because of uncontrollable anger toward others.

Schizoid Personality Disorder
This disorder is characterized by shy, aloof, and withdrawn behavior. The client with schizoid personality disorder prefers solitary activities and is often described by others as a hermit. This client might be quite successful in situations where little interaction with others is required. Although the client with schizoid personality disorder is reality oriented, she often fantasizes or daydreams.

Schizotypal Personality Disorder
Like schizoid personality disorder, this disorder is found more often in relatives of those with schizophrenia. Their behaviors are similar to those of the client with schizoid personality—that is, they are shy, aloof, and withdrawn.
However, clients with schizotypal personality disorder display a more bizarre way of thinking. They often appear similar to clients with schizophrenia but with less frequent and less severe psychotic symptoms. Because they are sensitive to the reactions of and possible rejection by others, clients with schizotypal and schizoid behavior avoid social situations.

Cluster B
This disorder set includes the histrionic, narcissistic, antisocial, and borderline personality disorders. Persons with these identified disorders tend to be overly dramatic, attention seeking, and manipulative with little regard for others.

Histrionic Personality Disorder
This disorder is diagnosed most often in females. Sometimes referred to as southern belle syndrome, the picture of the histrionic female is one who is overly seductive, excitable, immature, and theatrical in her emotions. These behaviors are not genuine but are used to manipulate others. The client with histrionic personality disorder tends to form many shallow relationships that are always short lived.

Narcissistic Personality Disorder
This disorder is summarized by the expression 'It’s all about me.'
Characterized by self-absorption, persons with narcissistic personality have grandiose ideas about their wealth, power, and intelligence. They believe that they are superior to others and that, because they are superior, they are entitled to certain privileges and special treatment. Although they appear nonchalant or indifferent to the criticism of others, it is only a coverup for deep feelings of resentment and rage. Clients with narcissistic personality tend to rationalize or blame others for their self-centered behavior.

Antisocial Personality Disorder
This is characterized by a pattern of disregard for the rights of others and a failure to learn from past mistakes. These clients frequently have a history of law violations, which usually begin before age 15. Common behaviors in early childhood include cruelty to animals and people, starting fires, running away from home, truancy, breaking and entering, and early substance abuse.
Persons with antisocial personality disorder are often described as charming, smooth talking, and extremely intelligent—characteristics which allow them to take advantage of others and escape prosecution when caught.
Persons with antisocial personality disorder do not feel remorse for wrongs committed and respond to confrontation by using the defense mechanisms of denial and rationalization.
You might want to check out a number of movies that depict the features of those with antisocial personality disorder. Primal Fear and Monster are good examples.

Borderline Personality Disorder
Borderline personality disorder, the most commonly treated personality disorder, is seen most often in females who have been victims of sexual abuse.
These clients have many of the same traits as those with histrionic, narcissistic, and antisocial personality disorder; thus, they have a difficult time identifying their feelings. Like many victims of sexual abuse, this client relies on dissociation as a means of coping with stress. This dissociation results in splitting, a very primitive defense mechanism that creates an inability to see self and others as having both good and bad qualities. Clients with borderline personality disorder tend to see themselves and others as all good or all bad.
Feelings of abandonment and depression can escalate to the point of selfmutilation and suicidal behavior. These clients usually require hospitalization and treatment with antidepressant medication as well as counseling for post-traumatic stress disorder.
Fatal Attraction is an excellent movie for reviewing the characteristics of borderline personality disorder.

Cluster C
Cluster C disorders include the avoidant, dependent, and obsessivecompulsive personality disorders, which are characterized by anxious, fearful behavior.

Avoidant Personality Disorder
Avoidant personality disorder is used to describe clients who are timid, withdrawn, and hypersensitive to criticism. Although they desire relationships and challenges, clients with this disorder feel socially inadequate, so they avoid situations in which they might be rejected. They tend to lack the selfconfidence needed to speak up for what they want and so are seen as helpless.

Dependent Personality Disorder
Dependent personality disorder is characterized by an extreme need to be taken care of by someone else. This dependency on others leads to clinging behavior and fear of separation from the perceived caretaker. Clients with dependent personality disorder see themselves as inferior and incompetent, and they frequently become involved in abusive relationships. These abusive relationships are usually maintained because of a fear of being left alone.

Obsessive-Compulsive Personality Disorder
This disorder describes the individual who is a perfectionist, overly inhibited, and inflexible. Clients with obsessive-compulsive personality disorder are preoccupied with rules, trivial details, and procedures. They are cold and rigid with no expression of tenderness or warmth. They often set standards too high for themselves or others to make and, because they are fearful of making mistakes, tend to procrastinate. Clients with obsessive-compulsive personality disorder put off making decisions until all the facts are in; thus, they might do good work but not be very productive.
Although they share some common traits, obsessive-compulsive anxiety disorder and obsessive-compulsive personality disorder are two different diagnoses.

Managing Clients with Personality Disorders
The management of the client with a personality disorder depends on the diagnosis. Pharmacological interventions are generally not appropriate for these clients. However, if there is a coexisting diagnosis such as depression or anxiety, medication will be ordered. The nurse caring for the client with a personality disorder should set limits on the client’s behavior while at the same time conveying a sense of acceptance of the individual. Many clients with personality disorders have disturbed personal boundaries; therefore, it is important to maintain a professional rather than friendly relationship.

Psychotic Disorders
Psychotic disorders involve alterations in perceptions in reality. Common symptoms include hallucinations, delusions, and difficulty organizing thoughts. Psychotic symptoms are present in clients with schizophrenia, bipolar disorder, dementia, and drug intoxication or withdrawal. This section reviews two of the most common psychotic disorders: schizophrenia and bipolar disorder. Psychosis associated with drug use and withdrawal is covered later in the chapter.

Schizophrenia
This disorder is most often diagnosed in late adolescence or early adulthood, although symptoms might have been present at a much earlier age. The disorder equally affects both males and females; however, males seem to have an earlier onset of symptoms. Theories offered regarding the cause of schizophrenia include genetics, environmental factors, and biological alterations in the neurotransmitters serotonin and dopamine.
Clients with schizophrenia are best known for their odd appearance and behavior, which are sometimes summarized by the 4 A’s. The 4 A’s include
- Affect—Described as flat, blunted, or inappropriate
- Autism—Preoccupation with self and a retreat into fantasy
- Association—Loosely joined unrelated topics
- Ambivalence—Having simultaneous opposing feelings

The DSM-IV-TR classifies schizophrenia into subtypes based on the history and presenting symptoms:
- Catatonic
- Disorganized
- Paranoid
- Residual
- Undifferentiated

In addition to the subtypes, schizophrenia is classified as having either positive or negative symptoms. Positive symptoms of schizophrenia are those such as delusions and hallucinations; negative symptoms are those such as social withdrawal and failure to communicate with others. One of the main differences in the newer antipsychotic medications is that they work on both the negative as well as the positive symptoms of schizophrenia. The older medications worked primarily on clearing the hallucinations and delusions.
You might want to refer to your nursing textbook for a more complete description of the subtypes and symptoms associated with positive and negative schizophrenia.
Although there are overlapping symptoms, some have unique features. For instance, the client with catatonic schizophrenia exhibits waxy flexibility or stupor.

Nursing interventions in the care of the client with schizophrenia include
- Providing a quiet, supportive environment
- Establishing a trusting relationship
- Administering antipsychotic medication
- Assisting with the activities of daily living
- Attending to the client’s physical needs, including nutrition and hydra- tion
Instead of allowing the client to retreat to his room, the nurse should provide simple recreational activities such as painting.
It is best to avoid challenging activities that can confuse and overwhelm the client.

The nurse shouldn’t argue or try to change the client’s delusional thinking; instead, redirecting the client to a reality-based subject will be more effective and less upsetting. In instances where the client is having hallucinations, the nurse should respond to the client’s feelings while at the same time reinforce what is real. For example, the nurse should acknowledge the client’s fear at hearing voices when no one is there but then point out that the voices are not real and that the medication will soon help eliminate the voices.
The discovery of newer, more effective medications in the past decade has enabled many persons with schizophrenia to remain in their homes and communities for longer periods of time than the older medications. These medications are often referred to as atypical or novel antipsychotics. Atypical antipsychotics, such as risperidone, can be given in smaller doses, produce fewer side effects, and help manage the negative symptoms of schizophrenia more effectively than the older antipsychotics (such as chloropromazine).
The mainstay in the management of the client with schizophrenia is medication. Refer to the chapter on psychopharmacology in your psychiatric nursing textbook for more information on the typical and atypical antipsychotics.

Antipsychotic medication carries the risk of neuroleptic malignant syndrome, a potentially fatal adverse reaction. Symptoms of neuroleptic malignant syndrome include malignant hyperthermia or temperature elevation as high as 107° F. The medication should be immediately discontinued and an antiparkinsonian medication given.
Older antipsychotic medications have many side effects and adverse reactions associated with their use, including extrapyramidal effects. Some of these are severe enough to warrant discontinuing the drug and administering medication to reverse their effects.

Schizophrenia is a chronic illness and, although the medications improve the client’s quality of life, they do not cure the disease. The prognosis for the client with schizophrenia is based on the subtype, the severity of symptoms, and compliance with treatment.

Bipolar Disorders
This refers to a group of psychotic disorders that are evident in extreme changes in mood or affect. These disorders, like schizophrenia, are believed to be caused by alterations in serotonin, dopamine, and norepinephrine.
Most clients with bipolar disorder have the type known as bipolar I, in which the client experiences periods of acute mania and major depression.

Acute Mania
Manic episodes are essential to a diagnosis of bipolar I disorder. During a manic episode, the client experiences profound changes in mood. These mood changes are described as elevated, expansive, or irritable. Additional symptoms associated with acute mania include
- Delusions of grandeur
- Flight of ideas
- Increased motor activity
- Increased risk taking and promiscuity
- Use of profanity
- Uncontrolled spending
- Failing to sleep or eat for long periods of time

When limitations are placed on the client’s behavior, he typically reacts with sarcasm and belligerence.
Nursing interventions for clients with acute mania include providing a quiet, nonstimulating environment and protecting them from physical exhaustion.
Most will have weight loss due to their excessive activity; therefore, nutritional needs can best be met by providing high-calorie, high-protein finger foods and snacks that can be eaten while moving about. Nursing interventions also include the administering of medications to stabilize the mood.
Medications commonly used as mood stabilizers include lithium, valproic acid, and carbamezepine. Olanzapine, an atypical antipsychotic, has also been shown to be effective in treating clients with acute mania.

Lithium is not a drug, but a mineral that stabilizes the mood of the client with acute mania. During the initiation of lithium therapy, lithium levels should be drawn twice weekly and then every 2–3 months during long-term therapy.
The therapeutic range for lithium is 0.5–1.5 mEq /liter. Lithium levels greater than 1.5 mEq/liter can produce signs of toxicity that can be fatal. Symptoms of lithium toxicity include muscle weakness, confusion, ataxia, seizures, cardio-respiratory changes, and multiple organ failure. A standard treatment for lithium toxicity is the administration of intravenous normal saline.

Major Depression
Major depression, the other side of bipolar I disorder, is characterized by a depressed mood lasting at least two weeks. Symptoms of major depression include feelings of worthlessness, diminished ability to concentrate, anorexia, sleep disturbances, and recurrent thoughts of death or suicide. A diagnosis of mental disorder or substance abuse is among the most significant risk factors for suicide.
The depressed client should be assessed for the presence of suicidal ideation and suicidal plan. Harmful objects should be removed from the client’s environment, and the client should be placed on basic suicide precautions with constant observation by the nursing staff. The nurse must remember that the greatest risk for suicide exists when the client seems to be improving.

Nursing interventions for the client with major depression include providing a safe environment, meeting the client’s physiological needs, reinforcing the client’s sense of worth, assisting with electroconvulsive therapy, and administering antidepressant medications. Currently, the most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). Less frequently prescribed medications include monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs).
The use of SSRIs with MAOIs, selective MAOIs, trytophan, and St. John’s wort is contraindicated. Serotonin syndrome, a potentially fatal condition, can occur as a result of drug interaction. Symptoms of serotonin reaction include confusion, hypomania, agitation, hyperthermia, hyperreflexia, tremors, rigidity, and gastrointestinal upset. The medication should be discontinued immediately. The physician will order medication to block the serotonin receptors, and artificial ventilation might be required. Most clients show improvement within 24 hours of discontinuing the SSRI.

Substance Abuse
Substance abuse is defined as the excessive use of a drug that is different from societal norms. These drugs can be illegal, as in the case of heroin, or legal, as in the case of alcohol or prescription drugs. Symptoms of substance abuse include

- Absenteeism
- Decline in school or work performance
- Frequent accidents
- Increased isolation
- Slurred speech
- Tremors

The primary substance abuse problem in the United States is alcohol addiction.

Alcoholism
Alcoholism is responsible for more than 100,000 deaths each year in the United States. Many of these deaths are the result of accidents. Premature death from cirrhosis, cardiovascular disease, esophageal varices, or cancer has also been linked to heavy alcohol consumption. It is important for the nurse to recognize the stages of alcohol withdrawal to keep the client safe.
Symptoms of withdrawal usually begin about 6–8 hours after the client’s last drink, or when the amount consumed is less than usual. Four stages of alcohol withdrawal are generally recognized.
The stages of withdrawal and the symptoms associated with each stage are as follows:
- Stage 1 (6–8 hours after last use)—Symptoms include anxiety, anorex- ia, tremors, nausea and vomiting, depression, headache, increased blood pressure, tachycardia, and profuse sweating.
- Stage 2 (8–12 hours after last use)—Symptoms include confusion, dis- orientation, hallucinations hyperactivity, and gross tremors.
- Stage 3 (12–48 hours after last use)—Symptoms include severe anxi- ety, increased blood pressure, profuse sweating, severe hallucinations, and grand mal seizures.
- Stage 4 (3–5 days after last use)—Symptoms of delirium tremens include confusion, insomnia, agitation, hallucinations, and uncontrolled tachycardia. In spite of treatment, the client might die from cardiac complications.



Although each stage has an expected timeframe and behaviors during the withdrawal, you should keep in mind that withdrawal is highly individual.

The Addiction Research Foundation Chemical Institute Withdrawal AssessmentAlcohol (CIWA-Ar) is a useful instrument for quickly assessing the client’s withdrawal status. You can find a copy of the CIWA-Ar scale at www.chce. research.med.va.gov. Click the section for alcohol, and you should be able to read and download it from there.

Nursing interventions for the client with alcohol withdrawal include maintaining a safe environment, providing nutritional supplements, providing additional fluids to prevent dehydration, and administering pharmacological agents to prevent delirium tremens.
The nurse should teach the client taking disulfiram to avoid alcohol or substances containing alcohol. Contact with alcohol while taking disulfiram can produce headache, nausea and vomiting, tachycardia, chest pain, convulsions, cardiorespiratory collapse, and death.

Other Commonly Abused Substances
Other commonly abused substances include sedative-hypnotics, opiates, stimulants, hallucinogens, and cannabis.

Sedative-Hypnotics
Sedative-hypnotics are potent central nervous system depressants. This group, which includes barbiturates and benzodiazepines, is capable of producing both physiological and psychological dependence. Drugs in this category are regulated by the Controlled Substances Act.

The important signs of use, signs of withdrawal, signs of overdose, and treatments for several of these substances:

Signs and Treatments Related to Sedative-hypnotic Abuse


Signs and Treatments Related to Stimulant Abuse


Signs and Treatments Related to Hallucinogens Abuse


Signs and Treatments Related to Cannabis Abuse


Signs and Treatments Related to Opiate Abuse


Disorders of Childhood and Adolescence
These disorders refer to the emotional and behavioral alterations that become evident in the early years of life. In this section, we review four of these disorders:
- Conduct disorder
- Oppositional defiant disorder
- Attention deficit hyperactive disorder
- Eating disorders

Other emotional disorders, such as major depression and schizophrenia, were covered previously.

Conduct Disorder
Conduct disorder is characterized by persistent patterns of behavior in which the rights of others are violated. Early in life, some say by the age of 3, the child with conduct disorder is observed to be cruel and physically aggressive with people and animals. The child later develops antisocial behavior that includes destruction of property, truancy, and substance abuse. When confronted with their behavior, children with conduct disorder show a lack of guilt or remorse and frequently blame others for their acts. Conduct disorder gives way to an adult diagnosis of antisocial personality disorder.

Oppositional Defiant Disorder
Oppositional defiant disorder is characterized by persistent patterns of negativistic, hostile, and defiant behavior. Unlike the child with conduct disorder, the child with oppositional defiant disorder does not violate the rights of others. The behaviors of the child diagnosed with oppositional defiance are more likely to be argumentative, uncooperative, annoying, and spiteful.

Attention Deficit Hyperactive Disorder
Attention deficit hyperactive disorder (ADHD) is characterized by persistent patterns of hyperactivity, impulsivity, and inattention. The disorder, which is more common in boys, often goes unrecognized until the child enters school.
The child with ADHD typically has problems following directions and lacks the attention necessary to complete assigned tasks. Theories as to the cause of ADHD include genetics, exposure to environmental lead, dietary influences, and alterations in dopamine and norepinephrine levels. Impairments in social, academic, and occupational functioning are common in those with ADHD.
The approach to the treatment of ADHD is threefold. Children with ADHD need counseling to help them develop positive self esteem and gain the social skills necessary for making and keeping friends. These children also need educational interventions to help them succeed in school. Finally, children with ADHD can benefit from medication that helps control the symptoms of the disorder.

Eating Disorders
Eating disorders refer to the separate disorders of anorexia nervosa and bulimia nervosa. Both disorders, which are more common in females, have increased in incidence in the past three decades.

Anorexia Nervosa
Anorexia nervosa is defined as a morbid fear of obesity characterized by a preoccupation with food while refusing to eat. The client with anorexia nervosa sustains significant weight loss through strict dieting, excessive exercising, self-induced vomiting, and the abuse of laxatives and diuretics.

Bulimia Nervosa
Bulimia nervosa is characterized by the uncontrolled compulsive ingestion of enormous amounts of food in a short period of time. High-calorie, highcarbohydrate snacks that can be ingested quickly are preferred. The binging episode, which occurs in secret, is followed by feelings of guilt, which are relieved only by a period of purging.
Nursing interventions for the client with an eating disorder include stabilizing the client’s physical condition. Complications from fluid and electrolyte imbalance and muscle wasting are often life threatening. When the client’s physical condition is stable, treatment modalities using behavior modification, individual therapy, and family therapy are begun. Although there are no specific medications to treat eating disorders, selective serotonin reuptake inhibitors have been effective in treating bulimia nervosa.

Diagnostic Tests for Review
The diagnostic tests for a client admitted with a psychiatric diagnosis include many of the tests used for clients with any hospital admission. Other tests are necessary for monitoring the client’s response to certain medications. For example, the client with lithium will continue to show signs of mania until a therapeutic level is reached. Some of the diagnostics requested for the client on a behavioral health unit include
- CBC
- Complete metabolic panel
- Lithium level
- Urinalysis

Pharmacology Categories for Review
The client with a psychiatric diagnosis usually receives one or more of the psychotropic medications. Some conditions, such as ADHD, are treated with central nervous system stimulants or antidepressants. The categories of psychotropic medications commonly prescribed are
- Anticonvulsants
- Antidepressants
- Antipsychotics
- Mood stabilizers