NEUROCOGNITIVE

DISORDERS

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Cognitive Disorder ● Personality changes
- also known as neurocognitive disorder ● Impaired ability to perform motor activities despite
- are a category of mental health disorder that intact motor abilities (apraxia)
primarily affect cognitive abilities including: ● Disorientation
a. learning, memory, perception and ● Wandering
problem-solving ● Delusions (particularly delusions of persecution)

- neurocognitive disorders include: Major Neurocognitive Disorder

a. delirium - is a syndrome that progresses with significant
b. mild neurocognitive disorder deterioration of cognitive domains as compared to
c. major neurocognitive disorder (previously previous levels of cognitive performance in
known as dementia) memory, speech, reasoning, intellectual function
and/or spatiotemporal perception and may also be
- They are defined by deficits in cognitive abilities associated with changes in emotional behavior
that are acquired (as opposed to developmental), and difficulties at the functional level.
typically represent decline and may have an - The cognitive decline is initially noticed by the
underlying brain pathology. individual, the family or the general
practitioner/doctor who is usually responsible for
The DSM-5 defines six key domains of cognitive the early diagnosis.
functions: - The cognitive deficits interfere with daily life and
1. executive function require assistance from others to maintain
2. learning and memory everyday activities
3. perceptual-motor function - The decline in functioning is not caused by
4. language delirium or another mental disorder.
5. complex attention
6. social cognition Mild neurocognitive disorder
- is similar to major neurocognitive disorder, but is
Neurocognitive Disorders characterized by a less extreme cognitive decline
- generally refer to severely impaired judgment, in one or more areas, such as attention, memory,
memory or problem-solving ability language, social cognition, etc.
- It can occur before old age and is not an inevitable - Generally, people with mild neurocognitive
development even among the very old disorder can still live independently, but still
- Dementia can be caused by numerous diseases struggle in some cognitive areas.
and circumstances, all of which result in similar
general symptoms of impaired judgment, memory Delirium
and problem-solving ability. - is caused by an acute organic process, which is a
- Alzheimer’s disease is the most common form of physically identifiable structural, functional, or
neurocognitive disorder and is incurable, but there chemical problem in the brain that may arise from
are also non organic causes of neurocognitive a disease process outside the brain that
disorders that can be prevented. nonetheless affects the brain.
- Malnutrition, alcoholism, depression and mixing - may result from an underlying disease process
medications can also result into symptoms of (e.g., infection or hypoxia), a side effect of a
dementia medication, withdrawal from drugs,
- If causes of the symptoms of dementia are over-consumption of alcohol, usage of
properly identified, they can be treated. hallucinogenic deliriants, or from any number of
factors affecting one's overall health (e.g.,
Symptoms that have been identified with the malnutrition, pain, etc.).
symptoms of NCD include: - also known as acute confusional state, is an
● Memory impairment (impaired ability to learn new organically caused decline from a previous
information or to recall previously learned baseline mental functioning that develops over a
information) short period of time, typically hours to days.
● Impairment in abstract thinking, judgment and - Delirium is a syndrome encompassing
impulse control disturbances in
● Impairment in language ability, such as difficulty a. attention
naming objects. In some instances, the individual b. consciousness
may not speak at all (aphasia). c. cognition.

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 - may also involve other neurological deficits, such - sedatives (benzodiazepines, opioids),
as anticholinergics, dopaminergics,
a. psychomotor disturbances (e.g., corticosteroids, polypharmacy
hyperactive, hypoactive, or mixed) - general anesthetic
b. impaired sleep-wake cycle, emotional - substance intoxication or withdrawal
disturbances ● primary neurologic diseases
c. perceptual disturbances (e.g., - severe drop in blood pressure, relative to
hallucinations and delusions), although the patient's normal blood pressure
these features are not required for (orthostatic hypotension) resulting in
diagnosis. inadequate blood flow to the brain
(cerebral hypoperfusion)
Notes: Fluctuations in mental status/function due to - stroke/Transient ischemic attack (TIA)
changes in primarily psychiatric processes or diseases - intracranial bleeding
(e.g., schizophrenia or bipolar disorder) do not, by - brain inflammation from meningitis or
definition, meet the criteria for delirium. encephalitis
● Concurrent illness
The most important predisposing factors of delirium - Infections - especially respiratory (e.g.
are pneumonia) and urinary tract infections
● older age (> 65 years old) - Iatrogenic complications (complications
● male sex include adverse drug effects (eg,
● cognitive impairment / dementia interactions), falls, nosocomial infections,
● physical comorbidity (biventricular failure, cancer, pressure ulcers, delirium, and
and cerebrovascular disease) complications related to surgery.)
● psychiatric comorbidity (e.g., depression) - Hypoxia, hypercapnia, anemia
● sensory impairment (vision, hearing) - Poor nutritional status, dehydration,
● functional dependence (e.g., requiring assistance electrolyte imbalances, hypoglycemia
for self-care or mobility) - Cardiac shock, heart attacks, heart failure
● dehydration/malnutrition - Metabolic derangements (e.g. SIADH,
● drugs and drug-dependence Addison's disease, hyperthyroidism)
● alcohol dependence - Chronic or terminal illness (e.g. cancer)
- Post-traumatic event (e.g. fall, fracture)
Notes:
● Individuals with multiple and/or significant ● Surgery
predisposing factors are highly at risk for suffering - Cardiac, orthopedic, prolonged
an episode of delirium with a single and/or mild cardiopulmonary bypass, thoracic
precipitating factor. surgeries.
● Conversely, delirium may only result in healthy
individuals if they suffer serious or multiple Treatment
precipitating factors. ● Treatment of delirium requires identifying and
● The factors affecting an individual may change managing the underlying causes, managing
over time, thus an individual's risk of delirium is delirium symptoms, and reducing the risk of
dynamic. complications.
● In some cases, temporary or symptomatic
Some of the most common precipitating factors of treatments are used to comfort the person or to
delirium are: facilitate other care (e.g., preventing people from
● prolonged sleep deprivation pulling out a breathing tube).
● environmental or physical/psychological stress ● Antipsychotics are not supported for the treatment
- inadequately controlled pain or prevention of delirium among those who are in
- admission to an intensive care unit. hospital.
- immobilization or use of physical restraints ● When delirium is caused by alcohol or
urinary retention or use of a bladder sedative-hypnotic withdrawal, benzodiazepines
catheter are typically used.
- emotional stress
- severe constipation and/or fecal impaction Prevention
● medications ● Delirium may be prevented and treated by using
non-pharmacologic approaches focused on risk

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 factors, such as constipation, dehydration, low Specifiers
oxygen levels, immobility, visual or hearing 1. Due to Alzheimer's disease, frontotemporal lobar
impairment, sleep deprivation, functional decline, degeneration, Lewy body disease, vascular
and removing or minimizing problematic disease, traumatic brain injury,
medications. substance/medication use, HIV infection, prion
● Ensuring a therapeutic environment disease, Parkinson's disease, Huntington's
- individualized care disease, other medical conditions, multiple
- clear communication etiologies, or unspecified.
- adequate reorientation and lighting during 2. Accompanied by a clinically significant behavioral
daytime disturbance (e.g., psychotic symptoms, mood
- promoting uninterrupted sleep hygiene disturbance, agitation, apathy, or other behavioral
with minimal noise and light at night symptoms
- minimizing bed relocation 3. Current severity: Mild: Difficulties with instrumental
- having familiar objects like family pictures activities of daily living (e.g., housework,
- providing earplugs managing money). Moderate: Difficulties with
- providing adequate nutrition, pain control, basic activities of daily living (e.g., feeding,
and assistance toward early mobilization. dressing). Severe: Fully dependent.
● Research into pharmacologic prevention and
treatment is weak and insufficient to make proper Major etiological categories for the syndrome of NCD:
recommendations. 1. NCD Due to Alzheimer's Disease
2. Vascular NCD
DSM-5 CRITERIA FOR MILD AND MAJOR 3. Frontotemporal NCD
NEUROCOGNITIVE DISORDERS 4. NCD With Lewy Bodies
- Evidence of cognitive decline from a previous level 5. NCD Due to Traumatic Brain Injury
of performance in one or more cognitive domains 6. NCD Due to HIV Infection
(complex attention, executive function, learning 7. NCD Due to Prion Disease
and memory, language, perceptual-motor, or 8. NCD Due to Parkinson's Disease
social cognition) based on: 9. NCD Due to Huntington's Disease
1. Concem of the individual, a 10. NCD Due to Another Medical Condition
knowledgeable informant, or the clinician 11. Substance/Medication-Induced NCD
that there has been a significant decline in
cognitive function, and NCD Due to Alzheimer's Disease
2. Impairment in it in cognitive performance, ● It's the most common cause of dementia, affecting
preferably documented by standardized over 40 million people worldwide, and yet finding a
neuropsychological testing or, another cure is something that still eludes researchers
quantified clinical assessment. today.
● The exact cause of Alzheimer's disease is
A. (Major) The cognitive deficits interfere with unknown, but several theories have been
independence in everyday activities (i.e., at a proposed,
minimum, requiring assistance with complex - such as reduction in brain acetylcholine,
instrum complex instrumental activities al activities - the formation of plaques and tangles,
of daily living such as paying bills or managing serious head trauma,
medications). - genetic factors.
B. (Minor) The cognitive de cognitive deficits do not ● Pathological changes in the brain include atrophy,
interfere with capacity for independence in enlarged ventricles, and the presence of
everyday activities (i.e. complex instrumental numerous neurofibrillary plaques and tangles.
activities of daily living such as paying bills or ● Definitive diagnosis is by biopsy or autopsy
managing medications are preserved, but greater examination of brain tissue,
effort, compensatory strategies, or - Although refinement of diagnostic criteria
accommodation may be required). and discriminating diagnostic instruments
C. The cognitive deficits do not occur exclusively in now enable clinicians to use specific
the context of a delirium. clinical features to identify the disease at a
D. The cognitive deficits are not better explained by high rate of accuracy.
another mental disorder (e.g., major depressive
disorder, schizophrenia).

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Discovery ● Lewy body dementia is a neurodegenerative
● Dr. Alois Alzheimer, a German psychiatrist, first disease, meaning that it worsens over time, and
described the symptoms in 1901 when he noticed it's the disease that afflicted comedian and actor
that a particular hospital patient had some peculiar Robin Williams.
problems, including difficulty sleeping, disturbed
memory, drastic mood changes, and increasing Anaphy review
confusion. ● The brain is made up of billions of neurons that
● When the patient passed away, Dr. Alzheimer was communicate with each other by releasing
able to do an autopsy and test his idea that neurotransmitters.
perhaps her symptoms were caused by ● Most neurons in the cerebral cortex are called
irregularities in the brain's structure. cholinergic neurons because they produce
● Alzheimer's disease is not simply part of the aging acetylcholine.
process. It is a disease with physiological ● In contrast, neurons in a section of the midbrain
symptoms and decay in the brain. called the substantia nigra are in charge of
initiating movement and other motor functions.
Pathology These neurons are called dopaminergic because
● In Alzheimer's disease, neurofibrillary tangles are they produce dopamine.
built from a protein known as tau. The brain's ● The underlying cause of Lewy body dementia isn't
nerve cells contain a network of tubes that act like well understood.
a highway for food molecules among other things.
Usually, the tau protein ensures that these tubes Pathology
are straight, allowing molecules to pass through ● Normally, neurons contain a protein called alpha
freely. synuclein, and in Lewy body dementia, this protein
● But in Alzheimer's disease, the protein collapses gets misfolded within the neurons.
into twisted strands or tangles, making the tubes ● The misfolded alpha-synuclein aggregates to form
disintegrate, obstructing nutrients from reaching Lewy bodies that deposit inside neurons,
the nerve cell and leading to cell death. particularly in the cortex and the substantia nigra.
● The destructive pairing of plaques and tangles ● Under a microscope, Lewy bodies look like dark,
starts in a region called the hippocampus, which is eosinophilic inclusions inside the affected
responsible for forming memories. neurons.
● That's why short-term memory loss is usually the ● As the disease progresses, more and more
first symptom of Alzheimer's. neurons accumulate Lewy bodies and die.

Treatment Symptoms
● Currently the focus of management is on slowing ● The significance of Lewy bodies, however, is
its progression. unknown, but they're seen in other diseases like
● One temporary treatment helps reduce the Parkinson's disease and multiple system atrophy.
breakdown of acetylcholine, an important chemical ● In Lewy body dementia, the early symptoms are
messenger in the brain which is decreased in typically cognitive ones, like:
Alzheimer's patients due to the death of the nerve - difficulty focusing, poor memory,
cells that make it. - visual hallucinations,
- disorganized speech,
● Another possible solution is a vaccine that trains - depression, similar to Alzheimer's
the body's immune system to attack beta-amyloid disease.
plaques before they can form clumps. ● Later symptoms are typically motor ones, like
● But there is no actual cure yet discovered. resting tremors, stiff and slow movements, and
● Alzheimer's disease was discovered more than a reduced facial expressions, similar to Parkinson's
century ago, and yet still it is not well understood. disease. But usually these motor symptoms are a
bit milder than what's seen in Parkinson's disease.
NCD With Lewy Bodies
● Lewy body dementia is a type of dementia, where Diagnosis
individuals lose their memory and have difficulty ● A diagnosis of Lewy body dementia is based on
learning new information. the pattern of symptoms but can only be
● Lewy bodies refers to protein deposits found confirmed with a brain autopsy that shows Lewy
inside neurons, and they're named after Frederic bodies in neurons.
Lewy, the neurologist who discovered them.

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Treatment ● Symptoms may include
● Treatment is aimed at alleviating symptoms. - behavioral and personality changes,
● Motor symptoms respond to drugs used to treat - speech and language problems,
Parkinson's disease like levodopa, a dopamine - Or both.
analogue ● Apathy, a decline in social cognition, and
● Cognitive symptoms may improve with drugs for compulsive/ ritualistic behaviors are common.
Alzheimer's disease like donepezil, which ● The disease progresses steadily and often rapidly,
increases acetylcholine availability. ranging from less than 2 years in some individuals
to more than 10 years in others.
NCD Due to Parkinson's Disease:
● Parkinson's is the second most common Treatment
neurodegenerative disease after Alzheimer's. ● Currently, there is no cure or treatments that slow
● The most visible features of this disease are: or stop the progression of frontotemporal
- a slowness of movement, disorders.
- muscle rigidity and
- tremors at rest. Vascular NCD:
● There are also many often-debilitating non-motor ● This type of NCD is caused by significant
symptoms, some of which may present before the cerebrovascular disease.
motor problems. ● The client suffers the equivalent of small strokes
● Parkinson's affects many areas of the nervous caused by
system and different types of neurons. - arterial hypertension or cerebral emboli or
thrombi, which destroy many areas of the
Pathology brain.
● Neurons in brain regions associated with the overt ● The onset of symptoms is more abrupt than in
motor symptoms, notably a region of the midbrain Alzheimer's disease and runs a highly variable
called the substantia nigra pars compacta, forms course, progressing in steps rather than as a
part of a major pathway in the brain that's critical gradual deterioration.
for facilitating movements.
● In Parkinson's, dopaminergic neurons in the Symptoms and progression
substantia nigra gradually die, leading to the ● People with vascular neurocognitive disorder
malfunction of this pathway and the characteristic present with progressive cognitive impairment,
motor problems. acutely or sub-acutely as in mild cognitive
● A distinctive pathology in most cases of impairment, frequently step-wise, after multiple
Parkinson's is clumps of misfolded proteins within cerebrovascular events (strokes).
neurons. Lewy bodies are the most common type. ● Some people may appear to improve between
A characteristic component of these is a misfolded events and decline after further silent strokes.
protein called alpha synuclein. ● A rapidly deteriorating condition may lead to death
● the multifactorial nature of Parkinson's disease from a stroke, heart disease, or infection.
progression might make it hard to fully understand
Signs and symptoms are
Treatment ● cognitive, motor, behavioral, and a significant
● Drugs that replace or mimic dopamine are often proportion of patients also show affective
used to treat these modes of deficits, but they symptoms.
grow less effective over time. ● The signs and symptoms typically occur over a
● Deep brain stimulation may also be used to treat period of five to 10 years.
symptoms ● Signs of vascular neurocognitive disorder are
● No current treatment slows the neurodegeneration typically the same as other dementias,
- primarily include cognitive decline and
Neurocognitive Disorder Due to Other Neurological memory impairment of sufficient severity
Disorders that these impairments interfere with a
Frontotemporal NCD person's ability to complete activities of
● Symptoms from frontotemporal NCD occur as a daily living.
result of shrinking of the frontal and temporal
anterior lobes of the brain.
● The cause is unknown, but a genetic factor
appears to be involved.

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Treatment - kuru (a rare, incurable, and fatal
● Currently, there are no medications that have neurodegenerative disorder that was
been approved specifically for the prevention or formerly common among the Fore people
treatment of vascular dementia. of Papua New Guinea).
● Smoking cessation and the Mediterranean diet
have not been found to help patients with ● The most common type is Creutzfeldt-Jakob
cognitive impairment disease (CJD).
● Physical activity was consistently the most ● Variant CJD is much rarer and is associated with
effective method of preventing cognitive decline. bovine spongiform encephalopathy (BSE) or "mad
cow disease," and is transmitted through infected
Neurocognitive disorder due to prion disease meat.
● is a rare neurological disorder that researchers
believe is caused by an infectious agent that Treatment
results in abnormal protein accumulations in the ● The duration of the disease varies greatly, but
brain, known as prions. sporadic (non-inherited) CJD can be fatal within
● Prions are misfolded proteins with the ability to months or even weeks.
transmit their misfolded shape onto normal ● Most victims die six months after initial symptoms
variants of the same protein. appear, often of pneumonia due to impaired
● Prions characterize several fatal and transmissible coughing reflexes. About 15% of people with CJD
neurodegenerative diseases in humans and many survive for two or more years, though there is
other animals. currently no cure.
● Some of the symptoms like twitching can be
NCD Due to Prion Disease: managed, but otherwise, treatment is palliative
● This disorder is identified by its insidious onset, care.
rapid progression, and manifestations of motor ● Psychiatric symptoms like anxiety and depression
features of prion disease, such as myoclonus or can be treated with sedatives and
ataxia, or biomarker evidence antidepressants.
● The clinical presentation is typical of the syndrome ● Myoclonic jerks can be handled with clonazepam
of mild or major NCD, along with involuntary or sodium valproate.
movements, muscle rigidity, and ataxia. ● Opiates can help in pain.
● The clinical course is extremely rapid, with ● Seizures are very uncommon and can be treated
progression from diagnosis to death in less than 2 with antiepileptic drugs.
years.
NCD Due to Huntington's Disease:
Cause ● This disease is transmitted as a Mendelian
● Prion variants of the prion protein (PrP), whose dominant gene, and damage occurs in the areas
specific function is uncertain, are hypothesized as of the basal ganglia and the cerebral cortex.
the cause of transmissible spongiform ● The onset of symptoms (i.e., involuntary twitching
encephalopathies (meaning that large holes of the limbs or facial muscles, mild cognitive
develop in brain tissue), changes, depression, and apathy) usually occurs
- including scrapie in sheep, chronic between age 30 and 50 years.
wasting disease (CWD) in deer, bovine ● The client usually declines into a profound state of
spongiform encephalopathy (BSE) in cognitive impairment and ataxia (muscular
cattle (commonly known as mad cow incoordination).
disease) and Creutzfeldt-Jakob disease ● The average duration of the disease is 10 to 20
(CJD) in humans. years depending on the severity of symptoms
● All known prion diseases in mammals affect the (Huntington's Disease Society of America, 2016).
structure of the brain or other neural tissue;
- all are progressive, have no known Prognosis
effective treatment, and are always fatal. ● Huntington's disease causes disability that gets
● In humans, prions are believed to be the cause of worse over time. Currently, no treatment is
- Creutzfeldt-Jakob disease (CJD), CJD available to slow, stop, or reverse the course of
variant (vCJD), HD.
- Gerstmann-Sträussler-Scheinker ● Life expectancy in HD is generally around 20
syndrome (GSS), years following the onset of visible symptoms.
- fatal familial insomnia (FFI),

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 ● Most life-threatening complications result from ● TBI causes immediate disorientation or loss of
muscle coordination and, to a lesser extent, consciousness, along with headaches, dizziness,
behavioral changes induced by declining cognitive nausea, and sensitivity to light (Alla, Sullivan, &
function. McCrory, 2012).
● The largest risk is pneumonia, which causes death ● Symptoms of a concussion are usually temporary,
in one-third of those with HD. there can be more permanent damage due to
repeated concussions, particularly if they are
Treatment within close time periods.
● There is no treatment that can stop or reverse the ● Chronic traumatic encephalopathy (CTE) is a
course of HD. progressive, degenerative condition due to
● Tetrabenazine and deutetrabenazine can treat repeated head trauma.
chorea associated with HD.
● Antipsychotic drugs may ease chorea and help to Chronic traumatic encephalopathy (CTE) due to TBI
control hallucinations, delusions, and violent ● Chronic traumatic encephalopathy (CTE) is a
outbursts. distinctive tau-protein associated
● Drugs may be prescribed to treat depression and neurodegenerative disease.
anxiety. ● There has been a rise of chronic traumatic
● Side effects of drugs used to treat the symptoms encephalopathy (CTE) diagnosis in athletes.
of HD may include fatigue, sedation, decreased ● TBI was first described as "punch drunk"
concentration, restlessness, or hyperexcitability, syndrome in a classic article by Martland et al.
and should be only used when symptoms create ● The report was focused on a number of boxers
problems for the individual. who had suffered repetitive head blows throughout
● There have been relatively few studies of their careers and were presented with both
exercises and therapies that help rehabilitate psychiatric symptoms as well as severe memory
cognitive symptoms of HD, there is some and neurocognitive deficits that were analogous to
evidence for the usefulness of physical therapy, typical dementia patients.
occupational therapy, and speech therapy. ● In addition to the neurological symptoms,
● An association between caffeine intake and earlier psychological symptoms such as depression and
age of onset in Huntington's disease has been poor impulse control have been observed in
found, but, since this finding was based on individuals with CTE. Individuals with CTE also
retrospective questionnaire data rather than a appear to be at greater risk for development of
blinded, randomized trial or case-control study, dementia (McKee et al., 2013).
this association is a poor basis for guiding lifestyle
decisions. Prevention
● Providing education for safe practice techniques,
NCD Due to Traumatic Brain Injury: such as safe tackling and hitting.
● DSM-5 criteria states that this disorder "is caused ● Providing ready access to full neuropsychiatric
by an impact to the head or other mechanisms of assessment by team physicians.
rapid movement or displacement of the brain
within the skull, with one or more of the following: Treatment
- loss of consciousness, ● It is important to begin emergency treatment within
- posttraumatic amnesia, the so-called "golden hour" following the injury.
- disorientation and confusion, ● People with moderate to severe injuries are likely
● neurological signs (e.g., positive neuroimaging to receive treatment in an intensive care unit
demonstrating injury, a new onset of seizures or a followed by a neurosurgical ward.
marked worsening of a preexisting seizure ● Treatment depends on the recovery stage of the
disorder, visual field cuts, anosmia, hemiparesis)" patient.
● Depending on the severity of the injury, the ● In the acute stage, the primary aim is to stabilize
symptoms may eventually subside or may become the patient and focus on preventing further injury.
permanent. This is done because the initial damage caused by
trauma cannot be reversed.
Symptoms ● Rehabilitation is the main treatment for the
● The most common type of TBI is a concussion. subacute and chronic stages of recovery.
● A concussion occurs when there is a significant
blow to the head, followed by changes in brain International clinical guidelines 4th editing
functioning. ● Scope of the Guidelines

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 ● The guidelines address treatment interventions, Treatment
monitoring, and treatment thresholds that are ● If the symptoms of alcohol dementia are caught
specific to TBI or that address a risk that is greater early enough, the effects may be reversed.
in patients with TBI. The guidelines are not ● The person must stop drinking and start on a
intended to cover all topics relevant to the care of healthy diet, replacing the lost vitamins, including,
patients with severe TBI. but not limited to, thiamine.
● https://braintrauma.org/coma/guidelines/guidelines ● Recovery is more easily achievable for women
-for-the-management-of-severe-tbi-4th-ed than men, but in all cases, it is necessary that they
have the support of family and friends and abstain
Neurocognitive disorder due to HIV (HAND) from alcohol.
● The immune dysfunction associated with HIV
disease can lead to brain infections by other Predictive Factors of MND
organisms. ● Previous studies have identified predictive factors
● HIV also appears to cause NCD directly. of MND, which can be grouped into the following:
● Antiretroviral therapy may prevent or delay the - sociodemographic factors (e.g., sex, age,
onset of HAND in people with HIV infection, and and years spent in education and social
may also improve mental function in people who isolation)
already have HAND. - health factors (e.g., hearing loss,
cardiovascular diseases, hypertension,
NCD Due to Another Medical Condition: diabetes, handgrip strength, and
● A number of other general medical conditions can nutritional status)
cause NCD. Some of these include - bio-behavioral factors (e.g., smoke,
- hypothyroidism, alcohol, and physical activity)
- hyperparathyroidism,
- pituitary insufficiency, uremia, Note
- encephalitis, ● Given that most of these factors are all potentially
- brain tumor, modifiable (e.g., diabetes, cholesterol, depression,
- pernicious anemia, thiamine deficiency, or malnutrition; Chen et al., 2017),
- pellagra, ● the individual can play an active role in the
- uncontrolled epilepsy. prevention or management of MND, which creates
- cardiopulmonary insufficiency the opportunity to allow for more efficient
- fluid and electrolyte imbalances, intervention.
- central nervous system and systemic ● Primary prevention in the primary health care
infections context is important for the course of MND and
- systemic lupus erythematosus, multiple should focus on the identification of situations that
sclerosis increase the likelihood of occurrence or worsening
of symptoms.
Substance/Medication-Induced NCD: ● However, few studies identify predictive factors
● NCD can occur as the result of substance associated with the severe stage of MND
reactions, overuse, or abuse. (Eshkoor et al., 2016).
● Symptoms are consistent with major or mild NCD
and persist beyond the usual duration of Treating Neurocognitive Disorders
intoxication and acute withdrawal (ΑΡΑ, 2013). ● There is no cure for neurocognitive disorders or
● Substances that have been associated with the the diseases that cause them.
development of NCDs include ● Pharmacological approaches combined with
- alcohol behavioral and environmental interventions are
- sedatives most successful in treating neurocognitive
- hypnotics disorders.
- anxiolytics
- inhalants Pharmacological Interventions
● Drugs that cause anticholinergic side effects and ● Targets for pharmacological treatment include
toxins such as lead and mercury have also been - cognitive impairment (e.g., memory loss,
implicated. disorientation, and decrease in attention
and problem-solving).
- behavioral symptoms (e.g., agitation and
aggression).

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 - psychological symptoms (e.g., - [Purposeless, thrashing movements;
depression, anxiety, and psychosis). hyperactivity that is out of touch with the
environment]
Nonpharmacological Interventions
● Cognitive stimulation therapy has been shown Goals/Objectives
to be cost-effective for people with Short-term Goals
mild-to-moderate dementia when delivered 1. Client will call for assistance when ambulating or
biweekly over seven weeks carrying out other activities.
● Deep brain stimulation (DBS) is a neurosurgical 2. Client will not experience physical injury
procedure involving the placement of a medical Long-term Goal
device called a neurostimulator (sometimes 1. Client will not experience physical injury
referred to as a brain pacemaker), which sends
electrical impulses, through implanted electrodes, Interventions With Selected Rationales
to specific targets in the brain (brain nuclei) for the ● Assess the client's level of disorientation and
treatment of movement and some neurocognitive confusion to determine specific requirements for
disorders, including Parkinson's disease and safety. Knowledge of the client's level of
epilepsy. Deep brain stimulation (DBS) is used to functioning is necessary to formulate an
manage some of the symptoms of Parkinson's appropriate plan of care.
disease that cannot be adequately controlled with ● Institute appropriate safety measures, such as the
medications. following.
a. Place furniture in the room in an
Common Nursing Diagnoses and Interventions for arrangement that best accommodates the
NCD client's disabilities.
RISK FOR PHYSICAL TRAUMA b. Observe client behaviors frequently,
● Definition: susceptible to physical injury of sudden assign staff on one-to-one basis if
onset and severity which require immediate. condition warrants, accompany and assist
Risk Factors ("related to") client when ambulating, and use
● Chronic alteration in structure or function of brain wheelchairs for transporting long
tissue, secondary to the aging process, multiple distances.
infarcts, HIV disease, head trauma, chronic c. Store items that client uses frequently
substance abuse, or progressively dysfunctional within easy access
physical condition resulting in the following d. Remove potentially harmful articles from
symptoms: client's room: cigarettes, matches,
- Disorientation; confusion lighters, and sharp objects
- Weakness e. Remain with client when he or she
- Muscular incoordination smokes
- [Seizures] f. Pad side rails and headboard of client with
- Memory impairment seizure disorder Institute seizure
- Poor vision precautions as described in procedure
- [Extreme psychomotor agitation observed manual of individual institution gif client is
in the late stages of delirium] prone to wander, provide an area within
- [Frequent shuffling of feet and stumbling] which wandering can be carried out safely
[Falls, caused by muscular incoordination ● Frequently orient clients to reality and
or seizures] surroundings. Disorientation may endanger client
- [Bumping into furniture] safety if he or she unknowingly wanders. away
- [Exposing self to frigid conditions with from a safe environment.
insufficient protective clothing] ● Use tranquilizing medications and soft restraints,
- [Cutting self when using sharp as prescribed by physician, for client's protection
instruments] during periods of excessive hyperactivity. Use
- [History of attempting to light burner or restraints judiciously, because they can increase
oven and leaving gas on in house] agitation. They may be required, however, to
[Smoking and leaving burning cigarettes provide for client safety
in various places; smoking in bed; falling ● Teach prospective caregivers methods that have
asleep sitting on couch or with lighted been successful in preventing client injury. These
cigarette hand) caregivers will be responsible for the client's safety

10 MCAES
 after discharge from the hospital. Sharing decor, low noise level). Anxiety increases in a
successful interventions may be helpful. highly stimulating environment
4. Remove all potentially dangerous objects from the
RISK FOR SELF DIRECTED OR OTHER-DIRECTED client's environment. in a disoriented, confused
VIOLENCE state, the client may use these objects to harm
● Definition: Susceptible to behaviors in which an self or others.
individual demonstrates that he or she can be 5. Have sufficient staff available to execute a
physically, emotionally, and/or sexually harmful physical confrontation, If necessary. Assistance
[either to self or to others] (NANDA-1, 2018, pp. may be required from others to provide for the
416-417) physical safety of the client or primary nurse or
Risk Factors ("related to") both.
● [Chronic alteration in structure or function of brain 6. Maintain a calm manner with client. Attempt to
tissue, secondary to the aging process, multiple prevent frightening the client unnecessarily.
infarcts, HIV disease, head trauma, chronic Provide continual reassurance and support.
substance abuse, or progressively dysfunctional Anxiety is contagious and can be transferred to
physical condition resulting in the following the client.
symptoms: 7. Reorient to surroundings as needed. Client safety
- Delusional thinking is jeopardized during periods of disorientation.
- Suspiciousness of others 8. Use tranquillizing medications and soft restraints,
- Hallucinations as prescribed by physician, for protection of client
- Illusions and others during periods of elevated anxiety.
- Disorientation or confusion 9. Sit with client and provide one-to-one observation
- Impairment of impulse control if assessed to be actively suicidal. Client safety is
- [Inaccurate perception of the environment] a nursing priority, and one-to-one observation may
- Negative body language-rigid posture, be necessary to prevent a a suicidal attempt.
clenching of fists and jaw, 10. Teach relaxation exercises to intervene in times of
- hyperactivity, pacing, breathlessness, and increasing anxiety.
threatening stances. 11. Teach prospective caregivers to recognize client
- Suicidal ideation, plan, available means behaviors that indicate anxiety is increasing and
- Cognitive impairment [Depressed mood] ways to intervene before violence occurs.

Goals/Objectives CHRONIC CONFUSION

Short-term Goals - Definition: Irreversible, progressive, insidious, and
1. Client will maintain agitation at manageable level long-term alteration of intellect, behavior, and
so as not to become violent personality, manifested by impairment in cognitive
2. Client will not harm self or others. functions (memory, speech, language,
Long-term Goal decision-making, and executive function), and
1. Client will not harm self or others.environment dependency in execution of daily activities
(NANDA-I, 2018, p. 256)
Interventions With Selected Rationales
1. Assess the client's level of anxiety and behaviors Possible Contributing Factors ("related to")
that indicate the anxiety is increasing. Recognizing ● [Alteration in structure/function of brain tissue,
these behaviors, the nurse may be able to secondary to the following conditions:
intervene before violence occurs. - Vascular disease
2. Assess the client's level of orientation. Client's - Hypertension
level of orientation may be variable, so ongoing - Cerebral hypoxia
assessment is important in protecting client safety. - Long-term abuse of mood- or
This assessment is also valuable in differentiating behavior-altering substances
pseudodementia (depression) in the older adult - Exposure to environmental toxins
clients with pseudodominant symptoms of - Various other physical disorders that
depression and more insight into their symptoms, predispose to cerebral abnormalities (see
and they improve with treatment for depression Predisposing Factors)]
(APA, 2013; Sadock et al 2015).
3. Maintain a level of stimuli in the client's Defining Characteristics ("evidenced by")
environment (low lighting, few people, simple ● Altered interpretation
● Altered personality

11 MCAES
 ● Altered response to stimuli
● Clinical evidence of organic impairment
● Impaired long-term memory
● Impaired short-term memory
● Impaired socialization
● Long-standing cognitive impairment
● No change in level of consciousness
● Progressive cognitive impairment

Goals/Objectives
Short-term Goal:
1. Clients will accept explanations of inaccurate
interpretations within the environment.
Long-term Goal:
2. With assistance from a caregiver, the client will be
able to interrupt non reality-based thinking.

Interventions With Selected Rationales

1. Frequently orient client to reality and
surroundings. Allow client to have familiar objects
around him or her. Use other items such as clock,
calendar and daily schedules to assist in
maintaining reality orientation. Client safety is
jeopardized during periods of disorientation.
Maintaining reality orientation enhances cognitive
function (Alzheimer's Australia. 2017) and may
enhance client's sense of self-worth and personal
dignity.
2. Teach prospective caregivers how to orient client
to time. person, place, and circumstances as
required. These caregivers will be responsible for
client safety after discharge from the hospital.
Sharing successful interventions may be helpful.
3. Give positive feedback and validation when
thinking and behavior are appropriate or when the
client verbalizes that certain ideas expressed are
not based in reality. Positive feedback increases
self-esteem and enhances desire to repeat
appropriate behaviors.
4. Use simple explanations and face-to-face
interaction when communicating with clients. Do
not shout messages into the client's ear. Speaking
slowly and in a face-to-face position is most
effective when communicating with an elderly
individual experiencing a

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TREATMENT
MODALITIES

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The various treatment modalities in psychiatry are broadly feelings of calm and safety, such as
divided as: special people and places

➤ Somatic therapies Different Types of Somatic Therapy

➤ Psychological therapies Somatic Experiencing
➤ Milieu Therapy - Somatic experiencing is a type of therapy that
focuses on the body's natural ability to heal itself.
SOMATIC THERAPY: Treatment Modalities - This type of therapy uses techniques such as
What is somatic therapy? massage, acupuncture, yoga to help the body
- Somatic therapy explores how the body expresses reach a state of balance and well-being.
deeply painful experiences, applying mind-body - The goal of somatic experiencing is to help the
healing to aid with trauma recovery. body heal itself by using techniques that promote
- "It's a treatment focusing on the body and how relaxation and stress relief.
emotions appear within the body,"
- "Somatic therapies posit that our body holds and Hellerwork
expresses experiences and emotions, and - Hellerwork is a type of somatic therapy that
traumatic events or unresolved emotional issues combines massage, movement, and education to
can become 'trapped' inside." help the body heal itself.
- Hellerwork is based on the belief that the body has
Who might benefit from somatic therapy? an innate ability to heal itself.
Disturbing feelings often show up in the body in debilitating - Hellerwork can be used to treat a wide range of
ways, somatic therapy aims to drain those emotions of conditions, including pain, anxiety, depression,
their power, relieving pain and other manifestations of and chronic stress.
stress, such as disrupted sleep or an inability to - By working with the body's natural healing
concentrate. process, Hellerwork can help to improve overall
health and well-being.
Conditions and circumstances that somatic therapy - The goal of Hellerwork is to help the body reach a
may potentially help alleviate. state of balance and well-being.
- post-traumatic stress disorder (PTSD)
- complicated grief Rolfing
- depression - Rolfing is a form of structural integration that was
- anxiety developed by Ida Rolf in the 1940s.
- trust and intimacy issues - It is based on the belief that the human body is a
- self-esteem problem three-dimensional structure and that this structure
can be manipulated to improve overall health and
How is somatic therapy carried out? well-being.
● A somatic therapist helps people release - Rolfing practitioners use their hands to apply deep
damaging, pent-up emotions in their body by using pressure and release restrictions in the connective
various mind-body techniques. These can vary tissues, muscles, and fascia.
widely, ranging from acupressure and hypnosis to - This therapy can be used to treat pain, improve
breathwork and dance. range of motion, and increase circulation.
- There may be some discomfort during the
● Other techniques include: treatment, but it is generally considered to be safe
- body awareness, which helps people and effective.
recognize tension spots in the body as
well as conjure calming thoughts Craniosacral Therapy
- pendulation, which guides people from a - Craniosacral therapy is a gentle yet powerful type
relaxed state to emotions similar to their of bodywork that can be used to treat a variety of
traumatic experiences and then back to a conditions.
relaxed state - It is based on the belief that the craniosacral
- titration, which guides people through a system, which includes the bones of the skull,
traumatic memory while noting any spine, and pelvis, is connected to the nervous
accompanying physical sensations and system and can be used to treat dysfunction in the
addressing them in real time body.
- resourcing, which helps people recall
resources in their lives that promote

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 - Craniosacral therapists use gentle touch to Behavior therapy.
release restrictions in the craniosacral system and - This approach focuses on learning's role in
Improve overall health and well-being. developing both normal and abnormal behaviors
- This therapy is safe for all ages and can be used - Ivan Pavlov made important contributions to
to treat a wide variety of conditions. behavior therapy by discovering classical
conditioning, or associative learning. Pavlov's
Polarity Therapy famous dogs, for example, began drooling when
- Polarity therapy is a holistic approach to health they heard their dinner bell, because they
that uses the five elements of nature: fire, water, associated the sound with food.
earth, air, and ether to balance the energy field - "Desensitizing" is classical conditioning in action:
within the body. A therapist might help a client with a phobia
- Practitioners believe that this balancing of energy through repeated exposure to whatever it is that
helps to promote healing. and wellbeing. causes anxiety.
- Polarity therapy treatments may include massage, - Another important thinker was E.L. Thorndike,
energy work, and exercises. who discovered operant conditioning. This type of
- This therapy is safe for all ages and can be used learning relies on rewards and punishments to
to treat a wide variety of conditions. shape people's behavior.
- Several variations have developed since behavior
Neurosomatic Therapy therapy's emergence in the 1950s. One variation
- Neurosomatic therapy is a type of manual therapy is cognitive-behavioral therapy, which focuses on
that uses gentle pressure and stretching to both thoughts and behaviors.
release restrictions in the nervous system.
- This type of therapy can be used to treat a variety Cognitive therapy
of conditions such as headaches, back pain, TMJ - Cognitive therapy emphasizes what people think
disorders, carpal tunnel syndrome, and rather than what they do.
fibromyalgia. - Cognitive therapists believe that it's dysfunctional
- Neurosomatic Therapy is safe for all ages and can thinking that leads to dysfunctional émotions or
be performed by a trained therapist or behaviors. By changing their thoughts, people can
self-administered. change how they feel and what they do,
- It can also be used in conjunction with other forms
of therapy such as massage, chiropractic, and Major figures in cognitive therapy include Albert. Ellis
acupuncture. and Aaron Beck.
Albert Ellis
Psychological therapies - Rational emotive behavioral therapy (REBT),
Approaches to psychotherapy fall into five broad developed by Albert Ellis in 1955 and originally
categories: called rational therapy, laid the foundation for what
- Psychoanalysis and psychodynamic therapies. is now known as cognitive behavioral therapy.
- Behavior therapy. - REBT is built on the idea that how we feel is
- Cognitive therapy. largely influenced by how we think.
- Humanistic therapy - As is implied by the name, this form of therapy
- Integrative or holistic therapy encourages the development of rational thinking to
facilitate healthy emotional expression and
Psychoanalysis and psychodynamic therapies behavior.
- This approach focuses on changing problematic
behaviors, feelings, and thoughts by discovering Aaron Temkin Beck
their unconscious meanings and motivations. - an American psychiatrist pioneered research on
- Psychoanalytically oriented therapies are psychotherapy, psychopathology, suicide, and
characterized by a close working partnership psychometrics, and developed the cognitive
between therapist and patient. therapy.
- Patients learn about themselves by exploring their - He became interested in psychiatry during an
interactions in the therapeutic relationship. internship at the Rhode Island hospital, where he
- While psychoanalysis is closely identified with studied neurology as a specialty.
Sigmund Freud, it has been extended and - Aaron Beck is considered as the father of
modified since his early formulations. cognitive behavior therapy.
- According to Beck, "If beliefs do not change, there
is no improvement. If beliefs change. symptoms

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 change. Beliefs function as little operational units," psychological health and functioning of the
which means that one's thoughts and beliefs individual.
(schema) affect one's behavior and subsequent
action BASIC ASSUMPTIONS
- He believed that dysfunctional behavior is caused Skinner outlined seven basic assumptions on which a
due to dysfunctional thinking, and that thinking is therapeutic community is based:
shaped by our beliefs. 1. The health in each individual is to be realized and
encouraged to grow:
Humanistic therapy. - all individuals are considered to have
- This approach emphasizes people's capacity to strengths as well as limitations. These
make rational choices and develop to their healthy aspects of the individual are
maximum potential. Concern and respect for identified and serve as a foundation for
others are also important themes. growth in the personality and in the ability
- Humanistic philosophers like Jean-Paul Sartre, to function more adaptively and
Martin Buber and Søren Kierkegaard influenced productively in all aspects of life
this type of therapy.
- Three types of humanistic therapy are especially 2. Every interaction is an opportunity for therapeutic
influential. Client-centered therapy rejects the idea intervention:
of therapists as authorities on their clients' inner - Within this structured setting, it is virtually
experiences. Instead, therapists help clients impossible to avoid interpersonal
change by emphasizing their concern, care and interaction. The ideal situation exists for
interest. clients to improve communication and
- Gestalt therapy emphasizes what it calls development relationship skills. Learning
"organismic holism," the importance of being occurs from immediate feedback of
aware of the here and now and accepting personal perceptions.
responsibility for yourself.
- Existential therapy focuses on free will, 3. The client owns his or her own environment:
self-determination and the search for meaning. - The client makes decisions and solves
problems related to the government of the
Integrative or holistic therapy. unit. In this way personal needs for
- Integrative therapy is an individualized, holistic autonomy as well as needs that pertain to
approach to therapy that combines ideas and the group as a whole are fulfilled.
techniques from different therapeutic schools of
thought depending on the unique needs of a given 4. Each client owns his or her behavior:
client. - Each individual within the therapeutic
- Many therapists don't tie themselves to any one community is expected to take
approach. responsibility for his or her own behavior,
- Instead, they blend elements from different
approaches and tailor their treatment according to 5. Peer pressure is a useful and a powerful tool:
each client's needs. - Behavioral group norms are established
- Integrative therapy is sometimes referred to as through peer pressure. Feedback is direct
holistic therapy because it aspires to consider an and frequent, so that behaving in a
individual's mental, physical, and emotional health manner acceptable to the other members
in a unified way. of the community becomes essential
- Ideally, therapist and client will work together to
understand the sources of the latter's anxiety, 6. Inappropriate behaviors are dealt with as they
unhappiness, physical discomfort, or unhealthy occur:
behavior patterns. - Individuals examine the significance of
Milieu therapy their behavior, look at how it affects other
● The word milieu is French for "middle". The people, and discuss more appropriate
English translation of the word is surroundings or ways of behaving în certain situations.
environment.
● Milieu therapy is the scientific planning of an 7. Restrictions and punishment are to be avoided:
environment for therapeutic purposes. - Destructive behaviors can usually be
● A scientific structuring of the environment in order controlled with group discussion.
to affect behavioral changes and to improve the However, if an Individual requires external

16 MCAES
 controls, temporary isolation is preferred Distribution of power
over lengthy restriction or other harsh ● The milieu therapy approach involves "flattening"
punishment. the control hierarchy, so all participants have a
voice in decision making.
GOALS OF MILIEU THERAPY ● This process may include the whole population of
● Manipulate the environment so that all aspects of the treatment unit, or a governing council may
a client's hospital experience are considered take the final decisions based on input from
therapeutic. various smaller groups of clients and staff
● Client is expected to learn adaptive coping, members.
interaction and relationship skills that can be ● The ultimate goal of any treatment program is
generalized to other aspects of his or her life. client autonomy.
● Achieving client autonomy ● This may be achieved through a stepwise
progression through a number of treatment
PRINCIPLES OF MILIEU THERAPY programs or by gradually increasing
● To promote a fundamental respect for individuals independence within a given program.
(both clients and staff). Consciously incorporating a plan for increasing
● To use opportunities for communication between independence is a means to achieve client
client and staff for maximum therapeutic benefit. autonomy.
● To encourage clients to act at a level equal to their
ability and to enhance their self esteem( autonomy Open communication:
is reinforced) ● The importance of open communication has been
● To promote socialization. widely recognized in literature, but it is still not a
● To provide opportunities for clients to be part of reality in many settings.
unit management. ● One reason for this may be the insecurity of
● Individuals are held responsible for their own persons in authority.
actions. ● Open communication requires risk taking.
● Peer pressure is utilized to reinforce rules and Questioning and criticism may be threatening,
regulations. whereas there is little to risk if no feedback is
● Team approach is used. allowed.
● Group discussions and temporary seclusions are ● Cultural norms, personal defenses and
favored approaches for acting out behavior. established communication patterns may block the
● The nurse's function is to act in ways that communications.
consistently promote these goals. ● In the therapeutic milieu, treatment decisions are
often made by the clients themselves, who
Characteristics of milieu therapy therefore need information to make effective
● The concept of milieu therapy developed from a decisions.
desire to counteract the negative, regressive ● It is not necessary to communicate personal
effects of institutionalization: information but clients and staff need to be aware
- reduced ability to think and act of individual treatment goals to ensure everyone is
independently. working towards the same goal. In this
- an adoption of institutional values and atmosphere, exclusive confidentiality is replaced
attitudes, and by mutual trust, honesty and open communication.
- loss of commitments in the outside world.
● Several strategies have been developed to Structured interactions
counter these negative effects. They include ● K.A Menninger pioneered the concept of
- Distribution of power structured interaction patterns in the form of
- Open communication attitude therapy.
- Structured interactions ● An advantage of the structured interaction
- Work-related activities. approach is that all staff members approach the
- Community and family involvement in the client in a consistent manner, acknowledging
treatment process specific diagnostic areas, thereby shortening
- Adaptation of the environment to meet treatment time.
developmental needs. ● The difficulty with this approach is that once a
diagnosis is made and an attitude prescribed there
is little flexibility in the interaction pattern.

17 MCAES
 ● Day- to day fluctuations in the client's condition other clients benefit from a program that promotes
may not be accounted for, and some staff autonomy and responsibility.
members sometimes seem stilted in their ● A program that provides a stepwise increase in
response to clients. responsibility would be an effective solution.
Progressive levels of responsibility according to
Work related activities: client's self care capacity:
● The focus of these activities is on benefits to the Level 1:
client rather than to the agency. ● Displays destructive behavior to self, others, or the
● Work under realistic circumstances and for environment.
appropriate rewards is probably the best central ● Disoriented to time, place and person.
activity for all clients. ● Unable to function in group therapy.
● Several factors contribute to effective work ● Exhibits poor personal hygiene.
therapy programs:
● First, clients need to choose the type of work they Level II:
wish to perform ● Does not display destructive behavior.
● Second, work activities should be geared toward ● Know the current time, date and place.
developing skills that will be useful in actual job ● Attends at least one therapeutic group daily.
situations. The current trend is to place clients on ● Attempts to maintain good personal hygiene
the job and provide funds for staff support in the
work environment. Level III:
● Third, a variety of activities provides the ● Attends All Therapeutic Activities.
opportunity to test different areas for future job ● Participates actively in the Community Meetings
interests. and serves on at least one client committee.
● Develops a self-directed behavior plans to change
Community and family involvement: or resolve a personal problem.
● Effective medications and humane treatment ● Knows the names of all medications and the times
philosophies, had resulted in community mental they are to be taken.
health centers emerging. ● Participates in a family session.
● Hospitalization is considered desirable only for
acute illnesses. For easy accessibility, mental Level IV:
health centers are placed conveniently within a ● Takes an active role in assisting other clients to
neighborhood. gain level changes.
● According to the milieu therapy approach, clients ● Demonstrates willingness to serve as an officer on
are kept in their usual environment, for example, a the client committee.
day treatment center or halfway house, and ● Assumes a leadership role in the community, acts
continue most of their routine activities while as a positive role model, and ensures that other
receiving treatment. clients are prompt in their attendance of regularly
● If one family member is hospitalized, an attempt is scheduled activities and group meetings.
made to continue family involvement. ● Initiates discussions with the mental health team
● This is an effective way to improve family concerning discharge planning.
interaction and minimize the isolation resulting
from hospitalizing one family member. Note:
● One approach to differing levels of responsibilities
Adaptation of the environment to meet the is to divide the clients into small groups according
developmental needs: to their developmental needs.
● To develop the client's full potential, an individual ● More regressed clients focus on physical and
must have an environment adapted to his current safety needs
needs. ● More advanced individuals concentrate on social,
● Adapting the environment to meet these multiple esteem and self- actualizing needs.
needs is challenging due to the extension of milieu ● Individuals progress to more advanced levels as
therapy to all age groups and the inclusion of their needs indicate.
family members with individuals of varying ages
within the treatment milieu.
● Clients who are regressed or who are
overwhelmed need more structure and support;

18 MCAES
SUBSTANCE
ABUSE

19 MCAES
Substance abuse ● Some becomes aggressive or display
- Using a drug in a way that is inconsistent with inappropriate sexual behavior
medical or social norms and despite negative ● Intoxication can lead to BLACKOUT
consequences.
- 50% of people with substance abuse disorder to OVERDOSE OR EXCESSIVE ALCOHOL
have a mental health diagnosis ”DUAL - People die of alcohol because it depresses the
DIAGNOSIS” CNS Vital centers becomes anesthetized
- DM: Denial - Compromising the HR and leading to a comatose
- DETOXIFICATION is the initial priority state
- Vomiting unconsciousness respiratory depression
Polysubstance abuse - More than one substance - Respiratory depression + vomiting = aspiration
Intoxication - is use of substance that results in pneumonia
maladaptive behavior - Alcohol-induced hypotension GI bleeding or
Withdrawal syndrome - refers to the negative hemorrhage
psychological and physical reactions that occur when use - Heat loss due to vasodilating effect
of a substance ceases or dramatically decreases
Detoxification - process of safely withdrawing from a Treatment
substance. ● Gastric lavage
Substance dependence - abuse of substances even ● Dialysis
when significant problems related to their use have ● Supportive care
developed
PHYSIOLOGIC EFFECTS OF LONG TERM ALCOHOL
ALCOHOL USE
- Is a primary substance problem ● Cardiomyopathy
- Is a central nervous system depressant that is ● Wernicke’s
absorbed rapidly into the bloodstream. ● Encephalopathy
- Ethanol ● Korsakoff’s Psychosis
● Pancreatitis
ETIOLOGY ● Esophagitis
Psychoanalytical theories ● Hepatitis
- Due to fixation in the oral stage of development ● Cirrhosis
Learning theories ● Peripheral neuritis
- Due to learned behaviors ● Leukopenia
Biological theories ● Thrombocytopenia
- Due to inherited traits
Socio cultural theories CBQ
- Effects of mass media KORSAKOFF’S Psychosis
- Thiamine and Niacin deficiency
Physiologic Effects - Memory Disturbance – essential feature
- Initially, RELAXATION and DISINHIBITIONS - Retrograde amnesia
- Anxiety is relief - Anterograde amnesia
- Increase psychomotor activity as a consequence - Confabulation
of alcohol is called “alcohol withdrawal syndrome” - Korsakoff’s Psychosis
- As the CNS becomes more irritated.
- the normal drinkers feel sick and irritable WERNICKE’S Encephalopathy
“HANGOVER” but live through it, perhaps vowing - Thiamine Deficiency
“never again” - Confusion
- For the alcoholic/heavy drinker they have to drink - Ophthalmoplegia
again to RESEDATE. - Ataxia
- Alcohol dependent – large amount – “normal” - Thiamine deficiency
INTOXICATION
● Slurred speech WITHDRAWAL AND DETOXIFICATION
● Unsteady gait - Symptoms usually begin 4 – 12 hours
● Lack of coordination - Peaks on the second day and is over by day 5
● Impaired attention, concentration, memory and - Withdrawal is life-threatening, detoxification needs
judgment. to be accomplished under medical supervision

20 MCAES
 - hypotension
- pulse and BP - Confusion
- Insomnia - Coma
- Coarse hand tremors - Death
- Sweating
- Elevated Anxiety AVOID Products that contain alcohol
- Nausea and vomiting - M-outhwash
- Delirium Tremens – severe withdrawal or if - V-inegar
untreated. The ultimate level of CNS irritability - C-ough syrup
- Hallucinations become visual and the sufferer is - L-otions
tremulous and terrified. - A-ftershaves
- Tonic-clonic seizure “grand mal” occurs - P-erfume

BENZODIAZEPINES Ondansetron (ZOFRAN)

- Dosaging will be based on an assessment tool like - A 5HT3 antagonist that blocks the vagal
the Clinical Institute Withdrawal Assessment of stimulation effects of serotonin in the small
Alcohol Scale intestine is used as an antiemetic.
- Less than 8 – mild withdrawal 8 to 15 – moderate - Used in young males at high risk for alcohol
withdrawal over 15 - severe dependence or early onset alcohol dependence
- Treatment for methamphetamine
To suppress the withdrawal symptoms
● Lorazepam (ativan) Acamprosate (CAMPRAL)
● Diazepam (valium) - Decreases alcohol cravings and to maintain
abstinence
TREATMENT AND PROGNOSIS
AA (ALCOHOL ANONYMOUS) SEDATIVES, HYPNOTICS, AND ANXIOLYTICS
- Was founded in the 1930’s by alcoholics Barbiturates - Relieve anxiety or to produce sleep
- Developed the 12 step program - Thiopental (anesthesia)
- Philosophy: “Total abstinence is essential and that - Phenobarbital (epilepsy)
alcoholics need the help and support of others to
maintain sobriety” Non Barbiturates hypnotics
Anxiolytics (benzodiazepines)
PHARMACOLOGIC TREATMENT
TWO main Purposes: INTOXICATION
1. to permit safe withdrawal from alcohol, - S-lurred speech
sedatives/hypnotics, benzodiazepines - U-nsteady gait
2. to prevent relapse - S-tupor or coma
- I-mpaired attention
Vitamin B1 (thiamine) - L-ack of coordination
- To prevent or to treat Wernicke’s syndrome and - L-abile mood
Korsakoff’s syndrome ; neurologic conditions that
can result from heavy alcohol use. OVERDOSE
Vitamin B12 (cyanocobalamin) and Folic acid Benzodiazepines (Rarely fatal)
- For nutritional deficiencies - Lethargy and confusion
Management
Disulfiram (ANTABUSE) - Gastric lavage followed by ingestion of activated
- To help deter clients from drinking charcoal and a saline cathartic
- Inhibits breakdown of acetaldehyde by the - Dialysis if severe
enzyme aldehyde dehydrogenase
Barbiturates (Fatal)
If taken with alcohol a severe adverse reaction occurs: - Coma
- Flushing - Respiratory arrest Cardiac failure Death
- A throbbing headache Management
- Sweating - ICU
- Nausea and vomiting - Lavage or dialysis
- Severe hypotension - Support respiratory and cardiovascular function

21 MCAES
 - Nausea
WITHDRAWAL AND DETOXIFICATION - Chest pain
● Depends on the half life of the drug - Confusion
● Like lorazepam, actions typically last after 10 - Cardiac dysrhythmia
hrs.produces withdrawal symptoms in 6 to 8
hours. OVERDOSE
● Longer medications such as diazepam may not ● Arrhythmia and Respiratory Collapse
produce withdrawal symptoms for 1 week. ● Seizure
● Coma
WITHDRAWAL SYNDROME ● Death (rare)
● Autonomic hyperactivity
- Increased PR, BP, RR and TEMP MANAGEMENT
● Hand tremors ● Induction of vomiting
● Insomnia ● Forced diuresis
● Anxiety ● Chlorpromazine
● Nausea ● Antagonize the amphetamine effect
● Psychomotor agitation
● Seizures and hallucination (severe withdrawal of Ondansetron (ZOFRAN)
benzodiazepine) - A 5HT3 antagonist that blocks the vagal
stimulation effects of serotonin in the small
DETOXIFICATION intestine is used as an antiemetic.
- Tapering the amount of the drug. 10% each day - Used in young males at high risk for alcohol
dependence or early onset alcohol dependence
STIMULANTS (Amphetamines, Cocaine, Others) - Treatment for methamphetamine
Amphetamines
- “uppers” “speed” or “Crank” for losing weight and CANNABIS SATIVA
staying awake, ADHD - Is an Indian hemp plant
- Widely known for its psychoactive resin
Cocaine - Refers to the upper leaves, flowering tops, stems
- illegal drug, no clinical use in medicine, highly of the plant
addictive and popular recreational drug because - Hashish – is the dried resinous exudate from
of the intense and immediate feeling of leaves of female plants.
EUPHORIA it produces. - Most often smoked in cigarettes “joints”
- Used as a mild tea - Known to decrease the IOP
- Snorting best way “NASAL SEPTUM - Relieving nausea & vomiting associated with
PERFORATION” cancer chemotherapy and the anorexia of weight
loss of AIDS
Methamphetamines
- dangerous, highly addictive and causes psychotic Tetrahydrocannabinol
behavior. Brain damage - Changed into metabolites and stored in fatty
tissues
INTOXICATION (develops rapidly) - Remains in the body up to 6 weeks
- High or euphoric feeling - Acts less than 1 minute after inhalation
- Hyperactivity - PEAK is 20 – 30 minutes and lasts at least 2 – 3
- Hypervigilance hours.
- Talkativeness - Ingested – 12 hours
- Anxiety - Effects similar to your alcohol, lowered inhibition,
- Grandiosity relaxation, euphoria, increased appetite
- Hallucinations “munchies”, conjunctival injection (bloodshot
- Stereotypic or repetitive behavior eyes), dry mouth, hypotension and tachycardia.
- Anger - Excessive use: delirium, psychotic disorder (rare)
- Impaired judgment - 2 cannabinoids Dronabinol (marinol) Nabilone
- Physiologic effects (Cesamet)
- Increase HR, BP, - For nausea and vomiting from cancer
- Dilated pupils - chemotherapy
- Perspiration or chills

22 MCAES
INTOXICATION
- Yawning - Muscle spasm
- Impaired motor coordination
- Tearing - Fever
- Inappropriate laughter
- Rhinorrhea - Nausea and
- Impaired judgment
- Sweating vomiting
- Short term memory
- Repetitive
- Distortions of time and perception
Intermediate sneezing
- Others: anxiety, dysphoria and social withdrawal
- Flushing - Abdominal cramps
- Piloerection - backache
OVERDOSES
- Tachycardia
- Do not occur
- Tremor
- Restlessness
- irritability
WITHDRAWAL
- No clinically withdrawal syndrome
- Muscle aches MANAGEMENT
- Sweating Naloxone (NARCAN) – antagonists
- Anxiety - Given every few hours until the level drops to non
- Tremors toxic; may take for days
- Nalorphine (nalline)
OPIOIDS
- Popular drug abuse because they desensitize the Clonidine (CATAPRES)
user to both physiologic and psychological pain - Is an alpha 2 adrenergic agonist used to treat
and induce a sense of euphoria and well being. HYPERTENSION
- Relieve pain by increasing the pain threshold and - For opiate dependence to suppress some effects
by reducing anxiety and fear of withdrawal or abstinence

- Meperidine (Demerol) METHADONE (Dolophine)

- Codeine - A potent synthetic opiate
- hydromorphone - To prevent withdrawal symptoms
- Morphine - Which meets the physical needs for opiates but
- hydrocodone does not produce cravings for more.
- oxycodone
- methadone oxymorphone LEVOMETHADYL
- hydrocodone - Treatment of opiate dependence
- Propoxyphene HEROIN
- NORMETHADONE
- Cocaine + heroin = speed balling HALLUCINOGENS “psychosis like reaction”
- “Psychotomimetics” or “psychedelics”
INTOXICATION - Distorts the user’s perception of reality and
- Apathy Lethargy Restlessness produces symptoms similar to psychosis including
- Impaired judgment hallucinations (visual and depersonalization)
- Psychomotor agitation or retardation
- Constricted pupils
- Drowsiness 2 basic groups
- Slurred speech 1. Natural
- Impaired attention and memory - Mescaline (peyote) from cactus
- Psilocybin from mushrooms Marijuana
OVERDOSE
- Coma 2. Synthetic
- Respiratory depression – primary effect - Lysergic acid diethylamide (LSD)
- Pupillary constriction - “Designer drugs”
- Unconsciousness - ecstasy
- Death - phencyclidine (PCP), anesthetic

- Increased PR, BP and TEMP,

Early Late
- Dilated pupils

23 MCAES
 - Hyperreflexia - Acute toxicity: anoxia, respiratory depression,
- sweating vagal stimulation, dysrhythmia, death from
- Tachycardia bronchospasm, cardiac arrest, suffocation,
- palpitations aspiration of the compound or vomitus.
- blurred vision, tremors and lack coordination - NO MEDS
- NO WITHDRAWAL AND DETOX
INTOXICATION
- Anxiety Depression Paranoid ideation Ideas of PSYCHOTHERAPEUTIC MANAGEMENT
reference Education
- Fear of losing one’s mind - The nurse must dispel the following myths and
- Jumping out of the window misconception
- PCP: belligerence, aggression, impulsivity and - “it’s a matter of will power”
unpredictable behavior. - I can’t be an Alcoholic if I only drink beer on
- Overdose: none weekends
- I can learn to use drugs socially
MANAGEMENT - I’m okay now; I could handle using it once in a
- psychotic reactions – isolation from while.
- external stimuli restraints - Education about relapse
- Any alcohol can be abused
PCP TOXICITY - Prescribed medications can be an abused
- seizures substance
- hypertension - Feedback from family is vital
- hyperthermia - Continued participation in an aftercare program is
- Respiratory depression important
- Addressing family issues
WITHDRAWAL AND DETOXIFICATION ➔ Alcoholism and other substance often is
- None called a FAMILY ILLNESS
➔ CODEPENDENCE is a maladaptive
INHALANTS coping pattern on the part of the family
- CNS depressants members or others that results from
- Most common substances in this category are prolonged relationship with the person
ALIPHATIC and AROMATIC hydrocarbons who uses substance
- Can cause significant brain damage, peripheral - Promoting coping skills
nervous system damage and liver disease. - Role play potentially difficult situations
- Inhalant crosses the blood brain barrier quickly - Focus on here and now with clients
- Set realistic goals such as staying sober today
3 Basic forms of Inhalants
1. Solvents (gasoline, glues) MILIEU
2. Aerosol propellants (spray cans) ● Safety
3. Anesthetic (chloroform, nitrous oxide) - Drug free environment
● Structure
- Active meaningful schedule provides for
INTOXICATION less downtime
- Dizziness ● Norms
- Nystagmus - Non-violent behavior
- Lack of coordination - Openness feedback
- Slurred speech ● Limit setting
- Unsteady gait ● Balance and Environmental Modification
- Tremor
- Muscle weakness CBQ
- Blurred vision ● Short term Goal for Alcoholism
- Stupor and coma - Cut off denial
- Belligerence ● Long term
- Aggression - Abstinence
- Apathy ● Number 1 sign of Cocaine withdrawal
- Impaired judgment Inability to function - Goosebumps

24 MCAES
 ● Heroine
- CAT’S eye phenomenon

Hallucinogen cardinal sign

● BAD TRIP
- Nightmares and flashbacks
● Number sign of Marijuana user
- RED eyes
● Signs of withdrawal
- Opposite of the effects

DOWNER’s
- Alcohol Barbiturates
- Opiates Narcotics
- Marijuana
- Morph
- Code Heroine
Uppers “CHA ’’
- Cocaine
- Heroin
- Amphetamines

OVERDOSE
UPPERS
- Tachypnea/cardia
- Dry mouth Dilated
- pupils Hypertension
- Euphoria
- Seizure Weight loss
DOWNERS
- Brady
- Moist mouth
- Constriction of pupil
- Urinary retention
- Hypotension
- Sleep Coma
- Hungry – eats – weight gain

25 MCAES
EATING
DISORDERS

26 MCAES
Eating Disorders Anorexia nervosa
- The Diagnostic and Statistical Manual of - Anorexia nervosa is a condition where people
Mental Disorders, Fifth Edition (DSM-5) avoid food, severely restrict food, or eat very small
(American Psychiatric Association [APA], quantities of only certain foods.
2013), states that eating disorders are - Anorexia nervosa is a clinical syndrome in which
characterized by "a persistent disturbance of the person has a morbid fear of obesity.
eating or eating-related behavior that results in the - It is characterized by the individual's:
altered consumption or absorption of food and that a. gross distortion of body image,
significantly impairs physical health or b. preoccupation with food, and
psychosocial functioning" (p. 329). c. refusal to eat.
- Three such disorders that are described in the - The disorder occurs predominantly in females 12
DSM-5 Include to 30 years of age.
1. anorexia nervosa, - Without intervention, death from starvation can
2. bulimia nervosa, occur.
3. binge-eating disorder. - There are two subtypes of anorexia nervosa:
1. "restrictive" subtype
- Obesity is not classified as a psychiatric disorder 2. "binge-purge" subtype.
per se: however, because of the strong emotional - In the binge-purge subtype of anorexia nervosa,
factors associated with it, it is suggested that people also greatly restrict the amount and type of
obesity may be considered within the category of food they consume.
Psychological Factors Affecting Medical Condition. - In addition, they may have binge-eating and
- Obesity is also considered as a factor associated purging episodes eating large amounts of food in
with binge-eating disorder a short time followed by vomiting or using
laxatives or diuretics to get rid of what was
Definition according to National Institute of Mental consumed..
Health - In the restrictive subtype of anorexia nervosa,
- Eating disorders are commonly misconceived as a people severely limit the amount and type of food
lifestyle choice. they consume.
- In fact it is a serious and often fatal illnesses that - Anorexia nervosa can be fatal. It has an extremely
are associated with severe disturbances in high death (mortality) rate compared with other
people's eating behaviors and related thoughts mental disorders.
and emotions. - People with anorexia are at risk of dying from
- Preoccupation with food, body weight, and shape medical complications associated with starvation.
may signal possibilities of eating disorder. - Suicide is the second leading cause of death for
people diagnosed with anorexia nervosa.
Definition according to American Psychological
Association (APA) Symptomatology (Subjective and Objective Data)
- An eating disorder is any disorder characterized 1. Morbid fear of obesity. Preoccupied with body
primarily by a pathological disturbance of attitudes size. Reports "feeling fat" even when in an
and behaviors related to food emaciated condition.
a. anorexia nervosa 2. Refusal to eat. Reports "not being hungry,"
b. bulimia nervosa, although it is thought that the actual feelings of
c. binge-eating disorder. hunger do not cease until late in the disorder.
d. Pica 3. Preoccupation with food. Thinks and talks about
e. rumination, (which are usually diagnosed food at great length. Prepares enormous amounts
in infancy or early childhood) of food for friends and family members but refuses
to eat any of it.
4. Amenorrhea is common, often appearing even
before noticeable weight loss has occurred.

27 MCAES
 5. Delayed psychosexual development. ● After the binge has begun, there is often a feeling
6. Compulsive behavior, such as excessive hand of loss of control or inability to stop eating.
washing, may be present. ● Following the binge, the individual engages in
7. Extensive exercising is common. inappropriate compensatory measures to avoid
8. Feelings of depression and anxiety often gaining weight (e.g., self induced vomiting;
accompany this disorder. excessive use of laxatives, diuretics, or enemas;
9. May engage in the binge-and-purge syndrome fasting; and extreme exercising).
from time to time (see following section on bulimia ● Eating binges may be viewed as pleasurable but
nervosa). are followed by intense self-criticism and
depressed mood.
Other symptoms may develop over time, including: ● Individuals with bulimia are usually within normal
● Thinning of the bones (osteopenia or weight range-some a few pounds underweight,
osteoporosis) some a few pounds overweight.
● Mildt anemia and muscle wasting and weakness ● Obsession with body image and appearance is a
● Brittle hair and nails predominant feature of this disorder. Individuals
● Dry and yellowish skin with bulimia display undue concern with sexual
● Growth of fine hair all over the body (lanugo) attractiveness and how they will appear to others.
● Severe constipation ● Binges usually alternate with periods of normal
● Low blood pressure eating and fasting.
● Slowed breathing and pulse ● Excessive vomiting may lead to problems with
● Damage to the structure and function of the heart dehydration and electrolyte imbalance.
● Brain damage ● Gastric acid in the vomitus may contribute to the
● Multiorgan failure erosion of tooth enamel.
● Drop in internal body temperature, causing a
person to feel cold all the time Predisposing Factors to Anorexia Nervosa and
● Lethargy, sluggishness, or feeling tired all the time Bulimia Nervosa
● Infertility Physiological
A. Genetics: A hereditary predisposition to eating
Bulimia nervosa disorders has been hypothesized on the basis of
- Bulimia nervosa is a condition where people have family histories and an apparent association with
recurrent and frequent episodes of eating other disorders for which the likelihood of genetic
unusually large amounts of food and feeling a lack influences exist. Some studies identify higher
of control over these episodes. concordance rates in monozygotic than in
- Bulimia nervosa (commonly called the binge dizygotic twins (Sadock, Sadock, & Ruiz, 2015).
and-purge syndrome) is an eating disorder Anorexia nervosa is more common among sisters
characterized by binge-eating followed by of those with the disorder than among the general
behavior that compensates for the overeating population. Several studies have reported a higher
such as forced vomiting, excessive use of than expected frequency of mood and substance
laxatives or diuretics. fasting, excessive exercise, use disorders among first-degree biological
or a combination of these behaviors. relatives of individuals with eating disorders (Puri
- People with bulimia nervosa may be slightly & Treasaden, 2011).
underweight, normal weight, or over overweight. B. Neuroendocrine Abnormalities: Some
- The disorder occurs predominantly in females and speculation has occurred regarding a primary
begins in adolescence or early adult life hypothalamic dysfunction in anorexia nervosa.
Symptomatology (Subjective and Objective Data) Support for this hypothesis is gathered from the
● Binges are usually solitary and secret, and the fact that many people with anorexia nervosa
individual may consume thousands of calories in experience amenorrhea before the onset of
one episode. starvation and significant weight loss.

28 MCAES
 C. Neurochemical Influences: Neurochemical Common Nursing Diagnoses and Interventions (for
influences in bulimia may be associated with the Anorexia Nervosa and Bulimia Nervosa)
neurotransmitters serotonin and norepinephrine.
This hypothesis has been supported by the IMBALANCED NUTRITION: LESS THAN BODY
positive response these individuals have shown to REQUIREMENTS
therapy with the selective serotonin reuptake - Definition: Intake of nutrients insufficient to meet
inhibitors (SSRIs). Some studies have found high metabolic needs (NANDA International [NANDA-I],
levels of endogenous opioids in the spinal fluid of 2018, p. 157)
clients with anorexia, promoting the speculation - Possible Contributing Factors ("related to")
that these chemicals may contribute to denial of a. [Refusal to eat]
hunger (Sadock et al., 2015). Some of these b. [ingestion of large amounts of food,
individuals have been shown to gain weight when followed by self-induced vomiting]
given naloxone, an opioid antagonist. Questions c. [Abuse of laxatives, diuretics, and/or diet
still remain as to whether neurochemical changes pills]
are causal or are an outcome of the body's d. [Physical exertion in excess of energy
reaction to changes in nutrition and mood produced through caloric intake

Psychosocial Interventions With Selected Rationales

A. Psychodynamic Theory: Psychodynamic 1. If a client is unable or unwilling to maintain
theories suggest that the development af an adequate oral intake, physicians may order a
eating disorder is rooted in an unfulfilled sense of liquid diet to be administered via nasogastric tube.
separation-individuation. When events occur that Nursing care of the individual receiving tube
threaten the vulnerable ego, feelings of lack of feedings should be administered according to
control over one's body (self) emerge. Behaviors established hospital procedures. The client's
associated with food and eating provide feelings of physical safety is a nursing priority, and without
control over one's life. adequate nutrition, a life-threatening situation
B. Family Dynamics: Historically, parents of children exists.
with eating disorders have been presumed to be For oral diet:
over controlling and perfectionistic, causing 2. In collaboration with a dietitian, determine the
pathology in their children. This theory has been number of calories required to provide adequate
problematic, at least in part, since not all siblings nutrition and realistic (according to body structure
in the same family develop eating disorders. There and height weight gain, Adequate calories are
is not sufficient evidence to support these claims, required to affect a weight gain of 2 to 3 pounds
and they may have contributed to a resistance per week.
toward seeking health care based on parents' fear 3. Explain to the client details of the behavior
that they will be judged as "the cause of the modification program as outlined by the physician.
problem." The Academy for Eating Disorders has Explain benefits of compliance with prandial
published a position statement (2009) that routine and consequences for noncompliance.
Includes the following: Behavior modification bases privileges granted or
- The AED stands firmly against any model restricted directly on weight gain and loss. Focus
of eating disorders in which family is placed on emotional issues rather than on food
influences are seen as the primary cause and eating specifically.
of eating disorders, condemns statements 4. Sit with clients during mealtimes for support and to
that blame familles for their child's illness, observe the amount ingested. A limit (usually 30
and recommends that families be included minutes) should be imposed on time allotted for
in the treatment of younger patients, meals. Without a time limit, meals can become
unless this is clearly ill advised on clinical lengthy, drawn-out sessions, providing clients with
grounds attention based on food and eating.

29 MCAES
 5. Clients should be observed for at least 1 hour using a matter-of-fact, nonpunitive approach
following meals. This time may be used by client regarding the tube insertion and subsequent
to discard food stashed from tray or to engage in feedings.
self-induced vomiting ● As nutritional status improves and eating habits
are established, begin to explore with the client
Binge-eating disorder the feelings associated with his or her extreme
- Binge-eating disorder is a condition where people fear of gaining weight. Emotional issues must be
lose control over their eating and have recurring resolved if maladaptive responses are to be
episodes of eating unusually large amounts of eliminated.
food.
- Unlike bulimia nervosa, periods of binge-eating Binge-eating disorder
are not followed by purging, excessive exercise, or Symptoms include:
fasting. As a result, people with binge-eating - Eating unusually large amounts of food in a
disorder often are overweight or obese. specific amount of time, such as a 2-hour period
- The etiology of binge-eating disorder is unknown. - Eating even when you're full or not hungry
- Brain imaging studies of people with binge-eating - Eating fast during binge episodes
disorder reveal increased activity in the - Eating until you're uncomfortably full
orbitofrontal cortex, which are the centers - Eating alone or in secret to avoid embarrassment
associated with reward and pleasure responses - Feeling distressed, ashamed, or guilty about your
such as those seen in response to substances of eating
abuse (Balodis, Grilo, & Potenza, 2015). - Frequently dieting, possibly without weight loss
- This finding has supported the hypothesis that
binge-eating disorder may be an illness of Obesity
addiction. - The following formula is used to determine the
degree of obesity in an individual:
Intervention with Rationale: weight (kg) Body mass index (BMI) = height (m)2
● Clients may need to be accompanied to the ● The BMI range for normal weight is 20 to 24.9.
bathroom if self-induced vomiting is suspected. Studies by the National Center for Health
● Strict documentation of intake and output. This Statistics indicate that overweight is defined as a
information is required to promote client safety BMI of 25.0 to 29.9 (based on U.S. Dietary
and plan nursing care. Guidelines for Americans).
● Weigh clients daily immediately on arising and ● Based on criteria of the World Health
following first voiding. Always use the same scale, Organization, obesity is defined as a BMI of 30.0
if possible. Client care, privileges, and restrictions or greater. These guidelines, which were released
will be based on accurate daily weights. If weight by the National Heart, Lung, and Blood Institute in
loss occurs, enforce restrictions. Restrictions and July 1998, markedly increased the number of
limits must be established and carried out Americans considered to be overweight.
consistently to avoid power struggles and to ● The average American woman has a BMI of 26,
encourage client compliance with therapy. and fashion models typically have BMIs of 18.
● Do not discuss food or eating with client once Anorexia nervosa is characterized by a BMI of 17
protocol has been established. However, do offer or lower. In extreme anorexia nervosa, the BMI
support and positive reinforcement for obvious may be less than 15.
improvements in eating behaviors. Discussing
food with client provides positive feedback for Avoidant restrictive food intake disorder
maladaptive behaviors. - Avoidant restrictive food intake disorder (ARFID),
● Client must understand that if, because of poor previously known as selective eating disorder, is a
oral intake, nutritional status deteriorates. tube condition where people limit the amount or type of
feedings will be initiated to ensure client's safety. food eaten.
Staff must be consistent and firm with this action,

30 MCAES
 - Unlike anorexia nervosa, people with ARFID do 1. Establish a trusting relationship with clients by
not have a distorted body image or extreme fear of being honest, accepting, and available and by
gaining weight. keeping all promises. Convey unconditional
- ARFID is most common in middle childhood and positive regard. The therapeutic nurse-client
usually has an earlier onset than other eating relationship is built on trust.
disorders. 2. Acknowledge client's anger at feelings of loss of
- Many children go through phases of picky eating, control brought about by the established eating
but a child with ARFID does not eat enough regimen associated with the program of behavior
calories to grow and develop properly, and an modification. Anger is a normal human response
adult with ARFID does not eat enough calories to and should be expressed in an appropriate
maintain basic body function. manner. Feelings that are not expressed remain
unresolved and add an additional component to
Symptoms include: an already serious situation.
- Dramatic restriction of types or amount of food 3. When nutritional status has improved, begin to
eaten explore with the client the feelings associated with
- Lack of appetite or interest in food his or her extreme fear of gaining weight.
- Dramatic weight loss Emotional issues must be resolved if maladaptive
- Upset stomach, abdominal pain, or other behaviors are to be eliminated.
gastrointestinal issues with no other known cause 4. Avoid arguing or bargaining with the client who is
- Limited range of preferred foods that becomes resistant to treatment. State matter-of-factly which
even more limited ("picky eating" that gets behaviors are unacceptable and how privileges
progressively worse) will be restricted for noncompliance. It is essential
that all staff members are consistent with this
Common Nursing Diagnoses and Interventions intervention if positive change is to occur
INEFFECTIVE ADOLESCENT EATING DYNAMICS 5. Explore family dynamics. Involve the family in
- Definition: Altered eating attitudes and behaviors treatment as much as possible and as
resulting in over or under eating patterns that appropriate. Family-based approaches to
compromise nutritional health (NANDA-1, 2018, p. treatment such as the Maudsley approach have
163) demonstrated efficacy in treating anorexia nervosa
- Possible Contributing Factors ("related to") in children and adolescents. Clients must
a. [Delayed ego development] recognize how maladaptive eating behaviors are
b. [Unfulfilled tasks of trust and autonomy] related to emotional problems and impact family
c. Altered family dynamics dynamics.
d. Depression 6. Explore with client ways in which he or she may
e. Eating Disorder feel in control within the environment without
f. Anxiety resorting to maladaptive eating behaviors. When a
g. Media influence on eating behavior and client feels control over major life issues, the need
perpetuation of unhealthy expectations for to gain control through maladaptive eating
body image] behaviors will diminish.
h. Media influence on knowledge of high 7. Educate families about dangers associated with
calorie unhealthy foods adolescent's unmonitored use of internet sites.
i. [Unmet dependency needs) Several internet sites dedicated to unhealthy
j. [Feelings of helplessness and lack of eating behaviors not only describe ways to
control in life situation accomplish rapid weight loss but also how to
k. [Possible chemical imbalance caused by conceal weight loss from health-care professionals
malfunction of hypothalamus) (e.g., drinking lots of fluids before getting weighed
l. [Unrealistic perceptions] or adding weights to pocketed garments)

Interventions With Selected Rationales

31 MCAES
DISTURBED BODY IMAGE/LOW SELF-ESTEEM 6. Help clients realize that perfection is unrealistic
- Definition: Disturbed body image is defined as and explore this need with him or her. As client
confusion in mental picture of one's physical self begins to feel better about self, identities positive
(NANDA-I, 2018, p. 276). Low self-esteem is self-attributes, and develops the ability to accept
defined as negative evaluation and/or feelings certain personal inadequacies, the need for
about one's own capabilities (pp. 272-275) unrealistic achievements should diminish
- Possible Contributing Factors ("related to") 7. Help clients claim ownership of angry feelings and
a. [Lack of positive feedback) recognize that expressing them is acceptable if
b. [Perceived failures] done so in an appropriate manner. Be an effective
c. [Unrealistic expectations (on the part of role model. Unexpressed anger is often fused
self and others)] inward on the self, resulting in depreciation of
d. [Delayed ego development] self-esteem.
e. [Unmet dependency needs)
f. [Morbid fear of obesity] OBESITY
g. [Perceived loss of control in some aspect - Definition: A condition in which an individual
of life accumulates excessive fat for age and gender that
exceeds overweight (NANDA-1, 2018, p. 169)
Interventions With Selected Rationales - Possible Contributing Factors ("related to")
1. Help clients reexamine negative perceptions of a. [Compulsive eating]
self and recognize positive attributes. Encourage b. Excessive intake in relation to metabolic
reframing of irrational thinking about body image needs
and self-worth. Client's own identification of c. [Sedentary lifestyle]
strengths and positive attributes can increase a d. [Genetics)
sense of self-worth. e. [Unmet dependency needs-fixation in oral
2. Offer positive reinforcement for independently developmental stage)
made decisions influencing client's life. Positive
reinforcement enhances self-esteem and may - Defining Characteristics ("evidenced by")
encourage client to continue functioning more a. Weight 20% over ideal for height and
independently. frame [Body mass index of 30 or more]
3. Offer positive reinforcement when honest feelings
related to autonomy and dependence Issues Goals/Objectives
remain separated from maladaptive eating Short-term Goal
behaviors. 1. Client will verbalize understanding of what must
4. Help client develop a realistic perception of body be done to lose weight.
image and relationship with food. The client needs Long-term Goal
to recognize that his or her perception of body 1. Client will demonstrate change in eating patterns
image is unhealthy and that maintaining control resulting in a steady weight loss.
through maladaptive eating behaviors is
dangerous even life threatening Interventions With Selected Rationales
5. Promote feelings of control within the environment 1. Encourage the client to keep a diary of food
through participation and independent decision intake. A food diary provides the opportunity for
making. Through positive feedback, help the client the client to gain a realistic picture of the amount
learn to accept self as is. Including weaknesses as of food ingested and provides data on which to
well as strengths. Client must come to understand base the dietary program.
that he or she is a capable, autonomous individual 2. Discuss feelings and emotions associated with
who can perform outside the family unit and who eating. This helps to identify when a client is
is not expected to be perfect. Control of his or her eating to satisfy an emotional need rather than a
life must be achieved in other ways besides physiological one.
dieting and weight loss

32 MCAES
 3. With input from the client, formulate an eating plan Cause
that includes food from the required food groups - There's no single cause of pica. In some cases, a
with emphasis on low-fat intake. It is helpful to Ito deficiency in iron, zinc, or another nutrient may be
keep t the plan as similar to the client's usual associated with pica. For example, anemia,
eating pattern as possible. Diet must eliminate usually from Iron deficiency, may be the
calories while maintaining adequate nutrition, underlying cause of pica in pregnant women.
Client is more likely to stay on the eating plan it he - Your unusual cravings may be a sign that your
or she is able o participate in its creation and if if body is trying to replenish low nutrient levels.
deviates as little as possible from usual types of - People with certain mental health conditions, such
foods. as schizophrenia and obsessive-compulsive
4. Identify realistic increment goals for weekly weight disorder (OCD), may develop pica as a coping
loss,sonable weight loss (1 to 2 pounds per week) mechanism.
results in more lasting effects. Excessive, rapid - Some people may even enjoy and crave the
weight loss max result in fatigue and irritability and textures or flavors of certain nonfood items. In
may ultimately lead to failure in meeting goals for some cultures, eating clay is an accepted
weight los, Motivation is more easily sustained by behavior. This form of pica is called geophagia.
meeting "stairstep" goals.
5. Plan a progressive exercise program tailored to How is pica diagnosed?
individual goals and choices. Exercise may - There's no test for pica.
enhance weight loss by burning calories and - The doctor will diagnose this condition based on
reducing appetite, increasing energy toning history and several other factors.
muscles, and enhancing a sense of well-being and - Pica is the diagnosis given to someone who
accomplishment. Walking is an excellent choice regularly and persistently eats non-food
for overweight individuals. substances such as chalk, soap or paper for more
6. Discuss the probability of reaching plateaus when than one month.
weight remains stable for extended periods. - It also extends to any edible items that hold no
Clients should know that this is likely to happen as nutritional value, such as ice.
changes in metabolism occur. Plateaus cause
frustration, and client may need additional support Complications associated with pica
during these times to remain on the weight-loss - poisoning, such as lead poisoning
program. - parasitic infections
7. Provide instruction about medications to assist - intestinal blockages
with weight loss if ordered by the physician. - Choking
Appetite-suppressant drugs (e.g lorcaserin,
phentermine) and others that have weight loss as How is pica treated?
a side effect leg, fluoxetine, topiramate) may be - Treatment begins by treating any complications
helpful to someone who is severely overweight. acquired from eating nonfood items.
Drugs should be used for this purpose for only a - For example, if severe lead poisoning from eating
short period while the individual attempts to adjust paint chips, the doctor may prescribe chelation
to the new pattern of eating therapy. (medication is given that binds with lead.
This will allow for the excrete the lead in the urine.
Pica - If caused by nutrient imbalances, they may
- Pica is a condition that mostly affects pregnant prescribe vitamin or mineral supplements.
people and children. - psychological evaluation maybe made to
- People with it feel compelled to eat non-food determine if the person have OCD or another
items, such as dirt and things that are dangerous. mental health condition. Depending on the
They may be unable to stop. diagnosis, they may prescribe medications,
therapy, or both.

33 MCAES
 - If a person with pica has an intellectual disability more likely to spit out regurgitated food. Children
or mental health condition, medications for are more likely to rechew and reswallow the food
managing behavioral problems may also help
reduce or eliminate their desire to eat non nutritive Complication of Rumination disorder
items - Rumination disorder can lead to malnutrition,
weight loss, damage to teeth and gums, and
Rumination disorder electrolyte disturbances if left untreated
- According to the DSM-5 criteria, a person with
rumination disorder will repeatedly regurgitate Rumination disorder vs. reflux
their food effortlessly and painlessly for more than - Symptoms of rumination disorder are different
a month. The regurgitated food may be from those for acid reflux and GERD:
re-chewed, re-swallowed, or spat out and it is not - In acid reflux, acid used to break down food in the
caused by a medical condition such as a stomach rises into the esophagus. That may
gastrointestinal condition. cause a burning sensation in the chest and a sour
- also known as rumination syndrome, is a rare and taste in the throat or mouth.
chronic condition. It affects infants, children, and - In acid reflux, food is occasionally regurgitated,
adults. but It tastes sour or bitter, which is not the case
- People with this disorder regurgitate food after with regurgitated food in rumination disorder.
most meals. Regurgitation occurs when recently - Acid reflux more often occurs at night, particularly
ingested food rises into the esophagus, throat, in adults. That's because lying down makes it
and mouth, but isn't involuntarily or forcefully easier for the contents of the stomach to rise up
expelled from the mouth as it is in vomiting. the esophagus. Rumination disorder occurs
- The key difference between rumination disorder shortly after the ingestion of food.
and conditions like bulimia nervosa is that typically - Symptoms of rumination disorder don't respond to
a person with rumination disorder won't appear to treatments for acid reflux and GERD
make an effort to bring up their food and it can
happen spontaneously or without intent. Risk factors
- However, people with anorexia nervosa, bulimia - Rumination disorder can affect anyone, but it's
nervosa, binge eating disorder or most commonly seen in infants and children with
avoidant/restrictive food intake disorder may also intellectual disabilities.
have rumination disease - Some sources suggest rumination disorder is
more likely to affect females, but additional studies
Symptoms are needed to confirm this.
- The main symptom of this disorder is the repeated - Other factors that may increase the risk of
regurgitation of undigested food. rumination disorder in both children and adults
- Regurgitation typically occurs between a half hour include:
to two hours after eating. People with this a. having an acute illness
condition regurgitate every day and after almost b. having a mental illness
every meal. c. experiencing a psychiatric disturbance
d. undergoing major surgery
Other symptoms may include: e. undergoing a stressful experience
- bad breath - More research is needed to identify how these
- weight loss factors contribute to rumination disorder
- stomach aches or indigestion
- tooth decay Diagnosis
- dry mouth or lips - There's no test for rumination disorder.
- Signs and symptoms of rumination disorder are - The doctor will perform a physical exam and ask
the same in both children and adults. Adults are to describe the child's symptoms and medical

34 MCAES
 history. The more detailed your answers, the
better.
- A diagnosis is mostly based on the signs and
symptoms described.

Treatment
- Treatment for rumination disorder is the same in
both children and adults.
- Treatment focuses on changing the learned
behavior responsible for regurgitation. Different
approaches may be used. The doctor will tailor the
approach based on age and abilities.
- The simplest and most effective treatment for
rumination disorder in children and adults is
diaphragmatic breathing training.
- It involves learning how to breathe deeply and
relax the diaphragm. Regurgitation cannot occur
when the diaphragm is relaxed.
- Apply diaphragmatic breathing techniques during
and right after meals. Eventually. rumination
disorder should disappear.

Other treatments for rumination disorder can include:

- changes in pasture, both during and right after a
meal
- removing distractions during meal times
- reducing stress and distractions during meal times
- psychotherapy
- There is currently no medication available for
rumination disorder

35 MCAES
ABUSE

36 MCAES
ABUSER - Making threats
- Believes his wife belongs to him (like property) - Refusing to speak to or ignoring the victim
- Has strong feelings of inadequacy and low
self-esteem PHYSICAL ABUSE
- Poor problem-solving and social skills - Shoving and pushing
- Emotionally immature, needy, irrationally jealous, - Severe battering and choking
and possessive. - Broken limbs and ribs
- Often experiences a sense of power and control - Brain damage
- Homicide
ABUSED
- Dependency is the trait most commonly found in
abused wives
- Perceives herself as unable to function without her
husband
- Often suffers from low self-esteem
- Defines her success as a person by her ability to
remain loyal to her marriage and “make it work.”

DOMESTIC VIOLENCE
- Intimate partner violence
- Domestic abuse
- Dating violence
- Spousal abuse
- Intimate partner abuse
RISK FACTORS
DOMESTIC VIOLENCE - include poverty
- Defined as a pattern of behavior in any - lack of education
relationship that is used to gain or maintain power - witnessing family violence as a child
and control over an intimate partner. Statistics - having a low sense of self-worth
show that most abuse is perpetrated by someone - attitudes of male domination
the victims knows.Victims of abuse are found - substance abuse, especially alcohol abuse
across the lifespan, and they can be spouses or
partners, children or older adults or parents. CLINICAL PICTURE OF ABUSE AND VIOLENCE
- Victims of abuse or violence can certainly have
LAW AGAINST VIOLENCE physical injuries needing medical attention , but
REPUBLIC ACT 9262 they also experience psychological injuries with a
- Act defining violence against women and broad range of responses.
theirchildrenrepublic act 7610 (anti-child abuse) A. Agitated and visibly upset
special protection of children against B. Withdrawn and aloof.
abuse,exploitation and discrimination act C. Appearing numb or oblivious
D. Self esteem extremely low they view
INTIMATE PARTNER VIOLENCE themselves as unlovable
- Is the mistreatment of one person by another in E. Trust issue
the context of an emotionally intimate relationship. - Domestic violence remains undisclosed for
- The relationship may be spousal , between months or even years because victims fear their
partners , boyfriend ,girlfriend or an estranged abusers.
relationship. - Victims frequently suppress their anger and
- The abuse can be emotional or psychological , resentment and do not tell anyone
physical ,sexual or combination. - This is particularly true in cases of childhood
sexual abuse.
PSYCHOLOGICAL ABUSE (EMOTIONAL ABUSE) - Survivors of abuse often suffer in silence and
- Name calling continue to feel guilt and shame
- Belittling (to make another person feel as though - Children particularly come to believe that
they aren’t important ) somehow they are at fault and did something to
- Screaming , Yelling deserve or provoke the abuse.
- Destroying property

37 MCAES
 - As adult they usually try to feel guilt or shame for legally prohibits the abuser from approaching or
not trying to stop the abuse contacting her.
- Survivors feel degraded , humiliated and - Battered women’s shelters can provide temporary
dehumanized. housing and food for abused women and their
- Victims or survivor of abuse in relationship their CHILDREN (DSWD , 163 Bantay bata)
emotional reactions are likely erratic, intense and - Individual psychotherapy or counseling, group
perceive as unpredictable therapy, or support and self-help groups can help
- Even when survivors of abuse desire closeness abused women deal with their trauma
with another person , they may perceive actual
closeness as intrusive and threatening. FAMILY VIOLENCE
- Encompasses spouse battering: neglect and
NURSING RESPONSIBILITIES physical or emotional or sexual abuse of children
- Nurses should be particularly sensitive to the - Family members tolerate abusive and violent
needs of the client whois abused to feel safe , behaviors from relatives they would never accept
secure and in control of their body. from strangers
- Nurses should take care to maintain the client’s - In violent families , the home, which is normally a
personal space, assess the client’s level of anxiety safe haven of love and protection, may be the
- Nurses should ask permission before touching most dangerous place for the victim
them for any reason
Characteristics of Violent Families
TYPES OF ABUSE SOCIAL ISOLATION - Members of these families keep to
1. Physical abuse themselves and usually do not invite others into the home
2. Psychological abuse or tell anyone what is happening
3. Sexual abuse ABUSE OF POWER AND CONTROL - The family
member who is abusive almost always holds a position
PHYSICAL ABUSE and control over the victim ( child , spouse, or older adult
- Shoving and pushing parents ) the abuser exerts not only physical power but
- Severe battering also economic and social control.
- Choking ALCOHOL AND OTHER DRUG ABUSE
INTERGENERATIONAL TRANSMISSION PROCESS -
PSYCHOLOGICAL ABUSE Shows that the patterns of violence are perpetuated from
- Name-calling one generation to the next through role modeling and
- Belittling social learning.
- Screaming
- Yelling CHILD ABUSE
- Destroying property - MALTREATMENT- Defined as the intentional
- Making threats injury of a child.
- physical abuse or injuries
SEXUAL ABUSE - neglect or failure to prevent harm
- Biting nipples - failure to provide adequate physical or emotional
- Pulling hair care or supervision
- Slapping and hitting - abandonment
- Rape - sexual assault or intrusion
- overt torture or maiming (mutilate , disfigure or
STALKING - Repeated or persistent attempts to impose wound seriously)
unwanted communication or contact on another person.
Common Perpetrators
CYBERSTALKING - can be monitoring , following , or - Fathers , Stepfathers, Uncles , Older Siblings and
intruding into another’s social media Live-in Partners
- Most reported cases involve father-daughter
TREATMENT AND INTERVENTION incest
- Allows police to make arrests in cases of domestic
violence TYPES OF CHILD ABUSE
- A woman can obtain a restraining order SEXUAL ABUSE
(protection order) from hercounty of residence that - Involves sexual acts performed by an adult on a
child younger than 18 years old.

38 MCAES
 - Sexual abuse may consist of a single incident or situations with puppets or dolls rather than talk
multiple episodes over a protected period of time. about what happened or their feeling.
- Incest , Rape and Sodomy performed directly by
the person with an object , oral-genitalcontact and
acts of molestation such as rubbing , fondling , or
exposing adult’s genitals.
- Second type of sexual abuse involves exploitation,
such as making promoting or sellingpornography
involving minors, and coercion of minors to
participate in obscene act

PHYSICAL ABUSE
- Often result from unreasonably severe corporal
punishment or unjustifiable punishment.
- Such as hitting an infant for crying or soiling their
diapers, burning, biting, cutting, piking, twisting
limbs or scalding with hot water.
- The victims often has evidence of old injuries (ex:
scars, untreated fractures, or multiple bruises of ELDER ABUSE
various age - Elder abuse is the maltreatment of older adults by
family members or others in a caregiver role
NEGLECT - Physical abuse
- Malicious or ignorant withholding of physical, - sexual abuse
emotional or educational necessities for the child’s - psychological abuse
well being. - neglect
- Abandonment , inadequate supervision, reckless - financial exploitation
disregard for the child safety , punitive , exploitive - denial of adequate medical treatment
or abusive emotional treatment ,spousal abuse in
the child’s presence , Giving the child the Clinical Picture
permission to be truant or failing to enroll the child - The victim may have bruises and fractures
in school. - May lack needed eyeglasses or hearing aids
- May be denied food, fluids or medications or may
PSYCHOLOGICAL ABUSE (EMOTIONAL ABUSE) be restrained in a bed or chair
- Includes verbal assaults, such blaming, screaming
name calling and using sarcasm, constant family PHYSICAL ABUSE INDICATORS
discord characterized by fighting, yelling and - Frequent , unexplained injuries accompanied by a
chaos. habit of seeking medical assistance from various
locations.
Clinical Picture - Reluctance to seek medical treatment for injuries
The abuser does not consider the children as people or denial of their existence.Disorientation or
with rights and feelings grogginess , indicating misuse of medications
- Burns or scalds maybe an identifiable shape ,such
as cigarette marks PSYCHOSOCIAL ABUSE INDICATORS
- Bruises may have familiar, recognizable shapes - Change in older adult’s general mood or usual
such as belt buckles or teeth marks. behavior.
- Children who are sexually abused may have - Isolated from previous friends or family
urinary tract infection ,bruised , red and swollen - Sudden lack of contact from other people outside
genitals , tears in the rectum or vagina the older adult’s home.
- Hesitance to talk openly
Treatment and Intervention: - Anger or Agitation
- Ensure the child’s safety and well being - Withdrawal or depression
- Given the high risk of psychological problems ,a
thorough psychiatric evaluation is also indicated MATERIAL ABUSE INDICATORS
- Very young child may communicate best through - Unpaid bills
play therapy where they draw or act outwith - Standard living below the older adult’s means

39 MCAES
 - Sudden sale or disposal of the older adult’s DATE RAPE (ACQUAINTANCE RAPE)
property/possessions - May occur on a first date or on a ride home from a
- Unusual or inappropriate activity in ban accounts party OR when two people have known each other
- Recent changes in will or power of attorney when from some time.
the older adult is not capable of making those - The rate of serious injuries associated with dating
decisions violence increases with the increased
- Missing valuable belongings that are not just consumption of alcohol by either the victim or the
misplaced perpetrator.

NEGLECT INDICATORS Common Myths About Rape

- Poor personal hygiene - Rape is about having sex
- Lack of needed medications or therapies - When woman submit to rape, she really wants it to
- Dirt, fecal or urine smell or other health hazards in happen.
the older adult’s living environment. - Women who dress provocatively are asking for
- Rashes , sore or lice on the older adult rape
- The older adult has an untreated medical - Walking alone at night is an invitation of rape
condition or malnourished or dehydrated not - Rape occurs only between heterosexual couples.
related to a known illness - Rape usually happens between strangers
- Inadequate material items , such as clothing, - Rape is a crime of passion
blanket, furniture and television
Treatment and Interventions
WARNING INDICATORS FROM CAREGIVER - Giving as much control as possible back to the
- The older adult is not given an opportunity to victim is important.
speak forself, have visitors, or see anyone without - Prophylactic treatment for sexually transmitted
the presence of the caregiver. diseases
- Attitudes of indifference or anger toward the older - HIV testing is strongly encourage at specified
adult intervals
- Blaming the older adult for their illness or - Victims are also encourage in safe sex practices
limitations. until results of HIV testing are available
- Defensiveness - Counseling
- Previous history of abuse or problems with alcohol - Therapy is usually supportive approach and
or drugs focuses on restoring victim’s sense of control

TREATMENT AND INTERVENTIONS COMMUNITY VIOLENCE

- Removal of older adult or caregiver is necessary - It is interpersonal violence perpetrated by
individuals who are NOT intimately related to
RAPE AND SEXUAL ASSAULT / RAPE thevictim
- Is the penetration of an act of sexual intercourse - Bullying (verbal aggression,
with a person against their will and without their - Physical acts )
consent. - Public shooting
- Whether that will is overcome by force , fear of - Ostracism (ignoring and excluding a target
force ,drugs or intoxication. individual from the society)
- Rape is a crime of violence and humiliation of the - Hazing or initiation rites
victimexpressed through sexual means.
- It is also considered rape is the victim is incapable TREATMENT AND INTERVENTION
if exercising rational judgement because of - Counseling , referrals
mentaldeficiency or because they are younger - Convey acceptance and support for the client
than the age of consent
POINTS TO CONSIDER WHEN WORKING WITH
- Rape requires only slight penetration of theouter CLIENTS WHO ARE ABUSED OR TRAUMATIZED
vulva or rectum. - These clients have many strengths they may not
- Full erection and ejaculation are not necessary realize as a nurse we can help them move from
- Forced act of oral sex and anal penetration. being victims survivors
- The person who is raped may also be - The nurse should help the client focus on the
physicallybeaten and injured present rather than dwell on horrific things in past.

40 MCAES
SEXUAL
DYSFUNCTION
ETC

41 MCAES
Three general groups of sexual and gender problems: Dyspareunia- Genital pain associated with
1. Sexual Dysfunction sexualintercourse causing marked distress or
2. Paraphilia interpersonal difficulties.
3. Gender dysphoria Vaginismus- Persistent or recurrent involuntary
contractions of the perineal muscles surrounding the
Sexual Dysfunction- Is characterized by a disturbance in outer-third of the vagina when vaginalpenetration with
the processes of the sexualresponse cycle or by pain is penis, finger, tampon, or speculum is attempted, causing
associated with sexual intercourse marked distress or interpersonal difficulties

Sexual desire disorders involves a disruption in the What are paraphilias

desire of the sexual response cycles: ● Are sometimes referred to as sexual deviations or
Hypoactive sexual desire disorder - characterized by a perversions.
deficiency or absence of sexual fantasies and a lack of ● Paraphilias include fantasies, behaviors, or sexual
desire of sexual activity that cause marked distress or
urges focusing on unusual objects, activities, or
interpersonal difficulty
situations.
Sexual aversion disorder- involves aversion to and ● Sexual urges or sexual fantasies with non-human
active avoidance of genital sexual contact with asexual objects
partner that causes marked distress or interpersonal ● Sexual behaviors involving humiliation or suffering
difficulty. of oneself or another person
● Adult sexual behavior that involves children or
Sexual arousal disorders are a disruption of the non- consenting adults
excitement phase of the sexual response cycle.
Female sexual response disorder – persistent or
Common Paraphilias
recurrent inability to attain or to maintain, until completion
of sexual activity, an adequate lubrication-swelling ● Exhibitionism
response of sexual excitement, which causes marked ● Fetishism
distress or interpersonal difficulty ● Frotteurism
● Pedophilia
Male erectile disorder- Persistent or recurrent inability to ● Masochism
attain or maintain until completion of the sexual activity,an ● Sadism
adequate erection, which causes marked distress or ● Transvestitism
interpersonal difficulty
● Voyeurism
Orgasmic disorders are disruptions of the orgasm
phase of the sexual response cycle EXHIBITIONISM
Female orgasmic disorders- Persistent or recurrent ● A tendency to sexually expose oneself to others.
delay in, or absence of, orgasm following a normalsexual ● For example, a man's behavior is exhibitionistic
excitement phase, which causes marked distress or when he expose part his naked body, usually his
interpersonal difficulty genitals, to a total stranger.
Male orgasmic disorder- Persistent or recurrent delay in,
● The sexual behavior is almost always limited to
or absence of, orgasm following a normalsexual
excitement phase, which causes marked distress or the genital exposure, and the person may make
interpersonal difficulty. no further harmful and advance forward the
stranger.
Premature Ejaculation – persistent or recurrent onset of ● Most often exhibitionism begins during
orgasm and ejaculation with minimal sexual stimulation adolescence and continues into adulthood
before, on,or shortly after penetration and before the
person wishes it, causing marked distress or interpersonal FETISHISM
difficulty
● People with urges and behavior which are
associated with non-living objects.
Sexual pain disorders involve pain associated with
sexual activity. ● For example, the object of the fetish could be an
article of female clothing, like female underwear.

42 MCAES
 ● Usually the fetish begins in adolescence and ● A person permits another to use arm or leg
tends to be quite chronic into adult life. restraints accompanied by acts of heating,
whipping, or cutting
FROTTEURISM
● When the focus of sexual urges are related to the TRANSVESTISM
touching or rubbing of their body against a ● Cross-dressing by heterosexual males is called
non-consenting, unfamiliar woman. transvestic fetishism or transvestitism.
● Most commonly, the man chooses to attack in a ● The fetish male usually has a variety of female
crowded public location. clothes that he uses to cross- dress.
● Then he disappears into the throng of people ● While some males will wear only one special piece
● o Usually begins in adolescence of female apparel, others fully dress as a female
● o The abnormal behavior tends to decrease when ● And use full facial make-up to achieve a total
the man reaches his late twenties. female appearance.

PEDOPHILIA VOYEURISM
● Focuses on his sexual fantasies and behavior ● seeking sexual pleasure by secretly observing
towards children. another - "peeping Tom".
● People who enjoy child pornography or "kiddie ● o The activity brings on sexual excitement and
porn" are pedophiles. may conclude with masturbation by the voyeur.
● Pedophiles are sexually attracted only towards ● o Voyeurism usually start in adolescence and
children and are not at all attracted towards adults. tends to persist into adulthood
● Pedophilia is usually a chronic condition.
● When a pedophile becomes sexually active with a Do Paraphilias affects males, females and both?
child he/she may: - Paraphilias are primarily male disorders.
● Undress the child Encourage the child to watch
them masturbate How are paraphilias related?
● Touch or fondle the child's genitals Forcefully ● Cognitive, behavior, and psychoanalytic therapies.
perform sexual acts on the child ● Some prescription medicines used to help
decrease the compulsive thinking associated with
SADISM the paraphilias.
● Deriving pleasure, often sexual from mistreating ● Hormones are prescribed occasionally for those
others. experiencing intrusive sexual thoughts, urges, or
● Some of the severe activities involved in sexual abnormally frequent sexual behaviors.
sadism include burning, beating stabbing, raping
and killing. What happens to someone with paraphilias?
● Usually the thoughts and/or behaviors of sexual ● The course of paraphilias is usually chronic in
sadism begin in adolescence or early adulthood. nature.
● The behaviors are not increase in severity with ● The prognosis for complete recovery is generally
time. considered to be guarded.

MASOCHISM EXHIBITIONISM
● Getting of pleasure, often sexual, from being hurt ETIOLOGY
or humiliated. ● There are different theories related to
● Sometimes the masochistic acts are limited to exhibitionistic behaviors
verbal humiliation or blindfolding. ● Many stemming from the psychoanalysis (bringing
● However, masochistic behavior might include repressed fears and conflicts to the conscious
being bound or beaten. mind)
● Masochism may become even more harmful. ● They suggest that childhood trauma (e.g. sexual
abuse) or significant childhood experience

43 MCAES
 ● Over a period of at least 6 months, patients have
SYMPTOMS recurrent, intense, sexually arousing fantasies,
● This disorder is characterized by either intense sexual urges, or behaviors involving nonliving
sexually arousing fantasies, urges, or behaviors in objects.
which the individual exposes his or her genitals to ● The fantasies, sexual urges, or behaviors cause
an unsuspecting stranger. clinically significant distress or impairment in
● To be considered diagnosable, the fantasies, social, occupational, or other important areas of
urges, or behaviors must cause significant distress functioning.
in the individual of be disruptive or her everyday ● Patients do not limit the fetish objects to articles of
functioning. female clothing used in cross- dressing or to
devices designated for the purpose of tactile
HISTORY genital stimulation.
● Over a period of at least 6 months, patients have
recurrent, intense, sexually arousing, sexual SYMPTOMS
urges, or behaviors that involve exposing their ● To be considered diagnosable, the fantasies,
genitals to unsuspecting strangers. urges, or behaviors must cause significant distress
● The fantasies, sexual urgers, or behaviors cause in the individual.
clinically significant distress or impairment in ● Or be disruptive to his or her everyday functioning.
social, occupational, or other important areas of
functioning. TREATMENT
● Psychotherapy aimed at uncovering and working
TREATMENT through the underlying cause of the behavior.
● Typically psychotherapy aimed at uncovering and ● Prognosis is good
working through the underlying cause of the
behavior. FROTTEURISM
● Medications to assist the client in resisting urges, ETIOLOGY
but are typically not utilized in treatment. ● Like most disorders in this category, many
● Prognosis is good although often there are other theories exist in attempt to explain how this
issues which may surface once the behaviors are disorder develops.
extinguished. ● Most experts agree that there are underlying
● If this is the case, these issues must be worked issues related to childhood which play a major in
through as well. the etiology

FETISHISM SYMPTOMS
ETIOLOGY ● This disorder is characterized by either intense
● Most experts agree that there are underlying sexually arousing fantasies, urges, or behaviors in
issues related to childhood which play a major role which the individual touches or rubs against an
in the etiology. non- consenting person in a sexual manner.
● This often occurs in somewhat conspicuous
SYMPTOMS situations such as on a crowded bus or subway.
● Intense sexually arousing fantasies urges, or
behaviors in which the individual uses a nonliving HISTORY
object (e.g., woman's high heeled shoe, stockings) ● Over a period of at least 6 months, patients have
in a sexual manner. recurrent, intense, sexually arousing fantasies,
● The individual requires this object to become sexual urges, or behaviors involving rubbing
sexually aroused and is therefore unable to be against and touching a nonconsenting person.
aroused without it. ● The fantasies, sexual urges, or behaviors cause
clinically significant distress or impairment in
HISTORY

44 MCAES
 social, occupational, or other important areas of ● Medical treatment such as "chemical castration"
functioning. (which is actually a hormone medication which
reduce testosterone and therefore sexual urges)
TREATMENT have been investigated with very mixed results
● Typically involves psychotherapy aimed at ● Prognosis varies although it is typically good if the
uncovering and working through the underlying individual has insight into his behaviors and his
cause of the behavior. Prognosis is good although own childhood issues.
often there are other issues which may surface ● Combined with an antisocial personality (which is
once the behaviors are extinguished. usually what is seen on the news or in movies).
● If this is the case, these issues must be worked ● However, treatment prognosis declines,
through as well. sometimes significantly.

PEDOPHILE SEXUAL MASOCHISM

ETIOLOGY ETIOLOGY
● A large percentage if individuals with this disorder ● There are different theories related to sexual
were sexually abused as children, although the masochism, many stemming from the
vast majority of adults who were abused do not psychoanalytic camp.
develop pedophilia or pedophilic behaviors. ● They suggest that childhood trauma (e.g. sexual
● There is also those who argue pedophilia results abuse) or significant childhood experiences can
from feelings of inadequacy with same age peers, manifest itself in exhibitionistic behavior
and therefore a transfer of sexual urges to
children. SYMPTOMS
● Over a period of at least 6 months, patients have
SYMPTOMS recurrent, intense, sexually arousing fantasies,
● This disorder is characterized by either intense sexual urges, or behaviors involving the act of
sexually arousing fantasies, urges, or behavior being humiliated, beaten, bound, or otherwise
involving sexual activity with a prepubescent child made to suffer.
(typically age 13 or younger). ● The fantasies, sexual urges, or behaviors cause
● To be considered for this diagnosis, the individual clinically significant distress or impairment in
must be at least 16 years old and at 5 year older social, occupational, or other important areas of
than the child. functioning.

HISTORY HISTORY
● Over a period of at least 6 months, patients have ● Over a period of at least 6 months, patients have
recurrent, intense, sexually arousing fantasies, recurrent, intense, sexually arousing fantasies,
sexual urges, or behaviors involving sexual activity sexual urges, or behaviors involving the acts in
with a prepubescent child or children. which psychological or physical suffering of the
● The fantasies, sexual urges, or behaviors cause victim is sexually exciting to the patient.
clinically significant distress or impairment in ● The fantasies, sexual urges, or behaviors cause
social, occupational, or other important areas of clinically significant distress or impairment in
functioning. social, occupational, or other important areas of
● The patient must be aged 16 years or older and at functioning.
least 5 years older than the child or children
TREATMENT
TREATMENT ● Typically involves psychotherapy aimed at
● Typically involves psychotherapy to work on deep uncovering and working through the underlying
rooted issues concerning sexuality, feelings of cause of the behavior.
self, and often childhood abuse.

45 MCAES
 ● prognosis is good although often there are other ● They suggest that childhood trauma (e.g. sexual
issues which may surface once the behaviors are abuse) or significant childhood experiences can
extinguished. manifest itself in exhibitionistic behavior
● If this is the case, these issues must be worked
through as well. SYMPTOMS
● This diagnosis is used for heterosexual males who
SEXUAL SADISM have sexually arousing fantasies, urges, or
ETIOLOGY behaviors involving cross- dressing (wearing
● There are different theories related to sexual female clothing).
sadism, many stunning from the psychoanalytic ● To be considered diagnosable, the fantasies,
camp. urges, or behaviors must cause significant distress
● They suggest that childhood trauma (e.g. sexual in the individual or be disruptive to his or her
abuse) or significant childhood experiences can everyday functioning
manifest itself in exhibitionistic behavior
HISTORY
SYMPTOMS ● Over a period of 6 months, heterosexual male
● Sexually sadistic behaviors are typically evident by patients have recurrent, intense, sexually arousing
early adulthood, and often start with masochistic fantasies, sexual urges, or behaviors involving
or sadistic play in childhood. cross-dressing.
● The disorder is characterized by either intense ● The fantasies, sexual urges, or behaviors cause
sexually arousing fantasies, urges, or behaviors in clinically significant distress or impairment areas
which the individual is sexually aroused caused by of functioning.
causing humiliation or physical suffering of
another person. TREATMENT
Typically involves psychotherapy aimed at
HISTORY uncovering and working through the underlying
● Over a period of at least 6 months, patients have cause of the behavior.
recurrent, intense, sexually arousing fantasies, ● Prognosis is fair.
sexual urges, or behaviors involving the acts in ● With some individuals, there may also be an
which psychological or physical suffering of the underlying discomfort with gender identity which
victim is sexually exciting to the patient. will complicate treatment prognosis
● The fantasies, sexual urges, or behaviors cause ● As with most disorders in this disorder, other
clinically significant distress or impairment in issues may arise as treatment progresses and
social, should be addressed.

TREATMENT VOYEURISM
● Typically involves psychotherapy aimed at ETIOLOGY
uncovering and working through the underlying ● There are different theories related to sexual
cause of the behavior sadism, many stunning from the psychoanalytic
● Prognosis is good although often there are other camp.
issues which may surface once the behaviors are ● They suggest that childhood trauma (e.g. sexual
extinguished. abuse) or significant childhood experiences can
manifest itself in exhibitionistic behavior
TRANSVESTIC FETISHISM
ETIOLOGY SYMPTOMS
● There are different theories related to sexual ● This disorder is characterized by either intense
sadism, many stunning from the psychoanalytic sexually arousing fantasies, urges, or behaviors
camp. which the individual observes an unsuspecting

46 MCAES
 stranger who is naked, disrobing, or engaging in Coprophilia is sexual activity involving feces.
sexual activity. Klismaphilia is sexual activity involving enemas.
● To be considered diagnosable, the fantasies, Urophilia is sexual activity involving urine.
urges, or behaviors must cause significant distress Masturbation is sexual self-gratification.
in the individual or be disruptive to his or her
everyday functioning Psychotherapy
● Cognitive-behavioral therapy: This type of therapy
HISTORY involves applying behavioral therapy techniques to
● Over a period of at least 6 months, patients have modify the patient's sexual deviations by altering
recurrent, intense, sexually arousing fantasies, distorted thinking patterns and making patients
sexual urges, or behaviors involving the act of cognizant of the irrational justifications that lead to
observing an unsuspecting person who is naked, their sexual variations.
in the process of disrobing, or engaging in sexual ● This therapy also incorporates relapse prevention
activity. techniques, helping the patient to control the
● The fantasies, sexual urges, or behaviors cause undesirable behaviors by avoiding situations that
clinically significant distress or impairment in may generate initial desires.
social, occupational, or other important areas of ● Many times, therapists apply the technique of
functioning "covert sensitization, in which patients harmful
● Patients derive sexual gratification from seeing sexual variation is paired with an unpleasant
sex organs and sexual acts; scopophilia is a stimulus, such as that of a person with alcoholism
synonym for VOYEURISM (not a DSM-IV who is administered Antabuse, in order to deter
criterion) them from repeating the act.
● This approach has been proven effective in cases
TREATMENT of
● Typically involves psychotherapy. ● Another technique employed by therapists is that
● Aimed at uncovering and working through the of orgasmic reconditioning.
underlying cause of the behavior. ● In this approach, a patient is reconditioned to a
● Prognosis is good although often there are other more appropriate stimulus by masturbating to his
issues which may surface once the behaviors are or her typical, less socially acceptable stimulus.
extinguished. ● Then, just before orgasm, the patient is told to
● If this is the case, issues must be worked through concentrate on a more acceptable fantasy.
as well. ● This is repeated at earlier times before orgasm
until, soon, the patient begins his masturbation
Paraphilias not otherwise specified: fantasies with an appropriate stimulus.
Necrophilia ● Social skills training: Because many believe that
- involves an erotic attraction or sexual interest in paraphilias develop in patients who lack the ability
corpses. to develop relationships, many therapists and
This paraphilia is rare and seldom reported to the police. physicians use social skills training to treat
Patients typically work in mortuaries and funeral parlors. patients with these types of disorders. They may
This also involves dangerous situations where the work on such issues as developing intimacy,
individual could actually acquire infections from the carrying on conversations with others, and
corpse. assertive skills training.
● Many social skills training groups also teach basic
Scatologia involves making obscene phone calls. sexual education, which is very helpful to this
Partialism is sexual interest exclusively focused on a patient population.
particular body part. ● Twelve-step programs: Many physicians and
Zoophilia involves sexual activity with animals (ie, both therapists refer patients with paraphilias to 12-step
actual sexual contact and sexual fantasies, higher in programs designed for sexual addicts.
psychiatric patients).

47 MCAES
 ● Similar to alcoholics anonymous, these programs
are designed to give control to group members,
who lead most of the sessions.
● The program incorporates cognitive restructuring
with social support to increase awareness of the
problem.
● The group also focuses on the sense of a "higher
power" and each individual's reliance upon his or
her spirituality.
● Group therapy: This mode of therapy involves
breaking through the denial so commonly found in
people with paraphilias by surrounding them with
other patients who share their illness.
● Once they begin to admit that they have a sexual
divergence, the therapist begins to address
individual issues such as past sexual abuse or
other problems that may have led to the sexual
disorder.
● When these issues have been identified,
beginning Gestalt-type therapy (with the victim, if
any) may be desirable to help patients get past the
guilt and shame associated with their particular
paraphilia.
● The goal of this type of therapy is to lead the
patient to a "healthy remorse."
● These patients require lifetime therapy in order to
reduce the likelihood of relapse

GENDER DYSPHORIA
● Gender Dysphoria- is diagnosed when an
individual has a strong and persistent sense of
incongruence between experienced or expressed
gender and the gender assigned at birth, usually
anatomical and called natal.
● The person experiences clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
● In boys, there is preoccupation with traditionally
feminine activities, a preference for dressing in
girls' or women's clothing, and an expressed
desire to be a girl or grow up to be a woman.
● Girls may resist parental attempts to have them
wear dresses or other feminine attire, wear boys'
names, and express the desire to grow a penis
and grow up to be a man.

48 MCAES