NSG 526/ NSG526 Exam 3 V1 – Advanced Psychiatric Mental Health Nursing Practice 2026/2027 | Wilkes | Latest Questions & Verified Answers

NSG 526/ NSG526 Exam 3 V1 – Advanced Psychiatric Mental Health Nursing Practice 2026/2027 | Wilkes | Latest Questions & Verified Answers Norms are considered the "right" patterns of behavior for a society Event interpretation should be included for problem-solving therapy for a child with conduct disorder. Family therapy can promote the greatest change in an adolescent's behavior. The Developmental Theoretical approach describes a family's progression through the lifecycle. Establishing a therapeutic alliance is important because acceptance and trust convey a feeling of security in an adolescent. Most children will adopt the same world view as their parents (ex. If a child was brought up by parents who thought the world was hostile they would most likely adopt this view as they grow older. Bibliotherapy uses books and a librarian as resources. When conducting a counseling session for a group of at risk adolescents on drug use it is important to have their peers involved in teaching some problem-solving skills. Play therapy is important because it allows the child to play out their fears and frustrations. Therapeutic drawing is a helpful technique is a child feels self-blame regarding their parent's divorce. Objective observations help the most in evaluating outcomes of child therapy. Schizoid personality disorder Individual psychotherapy is the appropriate modality to use with this disorder. The best response by the PMHNP when speaking with a client with BPD who has been in counseling for management of self-harm behaviors who now wants to cut themselves is to assist the client to identify an appropriate coping strategy. Understand that if a client with BPD who was making progress but recently had an anxiety producing situation arise and now cut herself is that even though this behavior is dysfunctional, it is mostly the patient's best effort to cope. Self-mutilation is mainly due to fear of abandonment or the increase of independence BPD is often characterized by an inability to tolerate perceived rejection. Patients will respond better to limit setting if the PMHNP can reflect back to the client an understanding and validation of their emotional distress. Clients with BPD have not successfully achieved the developmental stage of separation-individuation. Paranoid Personality Disorder do not trust others easily, and it's best to use a respectful neutral approach. Paranoid Personality Disorder are critical of others because they project blame for their own shortcomings onto others. Self-mutilation occurs because a client may feel that pain is better than not feeling anything, it also results from feelings of abandonment, it can be a manipulative gesture, and it is also happens when a safety plan has been put in place. DBT helps to replace irrational thoughts. Respecting a client's boundaries important in establishing a therapeutic relationship with a patient with BPD providing a safe environment is the priority for any client who is a victim of a serious crime/assault MCI Expectant category Injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible Black MCI CATEGORY Unresponsive patients with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomical sites and organs, 2nd/3rd degree burns in excess of 60% of body surface area, seizures or vomiting within 24 hr after radiation exposure, profound shock with multiple injuries, agonal respirations; no pulse, no BP, pupils fixed and dilated. Mindfulness The essential part of all skills taught in skills group are the core mindfulness skills. Mindfulness is the capacity to pay attention, non-judgmentally to the present moment. It is derived from teachings of the Buddha, the Zen tradition being perhaps one of its most well-known proponents. Mindfulness is all about living in the moment, experiencing your emotions and all your senses and being aware of them. The psych NP needs to foster a child's healthy characteristics and existing environmental supports no matter how negative (ex a child lives in a homeless shelter). children from different cultures develop at different rates Most psychiatric disorders in children are multifactorial. Paranoid Personality Disorder characteristics Characteristics: suspicious of others; fear others will exploit, harm, or deceive them; fear of confiding in others (fear personal information will be used against them); misread compliments as manipulation; hypervigilant; prone to counterattack; hostile; and aloof. Psychotic episodes may occur in times of stress. Nurses should give straightforward explanations of tests, history taking, and procedures, side effects of drugs, changes in treatment plan, and possible further procedures, to counteract client fear Narcissistic Personality Disorder Characteristics: grandiosity, fantasies of power or brilliance, need to be admired, sense of entitlement, arrogant, patronizing, rude, overestimates self and underestimates others. This behavior covers a fragile ego. In health care setting demand the best of everything. When client is corrected, when boundaries are defined, or when limits are set on client's behavior, client feels humiliated, degraded, and empty. To lower anxiety the client may launch a counterattack. The nurse should gently help the client identify attempts to seek and become perfect, exhibit grandiose behavior, and sense of entitlement splitting BPD A major defense is splitting (alternating between idealizing and devaluing). client schemas cognitive therapy is the modality that prioritizes a client's schema. Schemas stored bodies of knowledge that interact with incoming information to influence selective attention and memory search Bibliotherapy def is an expressive therapy which involves using child and adolescent literature to help the child express feelings in a supportive environment, gain insight into feelings and behavior, and learn new ways to cope with difficult situations. as the process of using books to teach those receiving medical care about their conditions is believed to be one cost-effective and versatile option for the treatment of several mental health issues. When children listen to or read a story they unconsciously identify with the characters and experience a catharsis of feelings. The books selected by the PMH-APRN should reflect the situations or feelings the child is experiencing. theoretical model based on the premise that people are greatly influenced by the characters they identify with in stories. Most professionals agree reading is productive activity that can promote good mental health, as reading has been shown to increase empathy, sharpen the mind, and impact behavior. play therapy is child-centered and typically builds on the foundation of the psychodynamic, object-relations, and attachment theories. Start age 3 plus give us the same type of information that we gather through verbal communication with adults play therapy helpful for posttraumatic stress disorder, disruptive behavior disorders, mood disorders, and reactive attachment disorder. Nondirective play is normally viewed as the best way to begin play therapy. Structured play is rarely used until nondirective play has enabled a full assessment of relevant themes and issues, and the child's trust around anxiety-laden issues has been developed. Symbols in play therapy such as aggressive behavior toward a father doll) can have several meanings and should never be interpreted in a standardized fashion toys with ambiguous meaning diverse uses foster symbolic play more effectively because they allow the child to project his or her own identity and function onto the toys Purpose of play therapy 1. catharsis, the release of strong emotions in order to provide relief from the inner tension they may be causing the child. 2. abreaction, the reliving through play of past events and their related feelings. A child can assimilate 3. to help the child try out other ways of relating to the world or responding to situations. Age 3 child has capacity for role play Cognitive Behavioral Therapy in kids 1. focus on the child's conscious rather than unconscious issues. 2. emphasis is placed on more effective coping in the present rather than on mastery over unresolved feelings associated with the child's past experiences CBT in kids over 7 years old treat depression, conduct disorder, ADHD, and anxiety Behavioral techniques, without the cognitive component, are also widely used to address therapeutic goals for 3- to 6-year-old children and those with mental retardation, learning and communication disorders, pervasive developmental disorders, tic disorders, and elimination disorders. Cognitive behavioral treatment for kid is a reeducation and relearning process involving the development of new ways of thinking about life and new behaviors that are more adaptive and more functional for the child. process of cognitive restructuring involves strategies finding out what the child means by statements he makes, teaching him to question the "evidence" he's using to maintain any irrational beliefs, helping him identify other options for what a situation might mean, listing advantages and disadvantages of a particular belief, and teaching him to use self-talk or directives to himself to help change or reframe a situation. For example, "Stop and wait; don't get angry until you find out more Family Therapy This method is selected when interactions among family members need attention in order to address specific problems exhibited by the child. The goal is to increase the likelihood that improvements in the child's mental health will occur and will be supported in the home with consistent and sustained family patterns If children under age 7 are involved in family therapy, the nurse may choose to alternate between having the child present and seeing the parents or other family members only becasue child's presence provides information for clinical assessment, allows for direct comment on and discussion of the dynamics that occur among parents and children, and provides opportunities for the PMH-APRN to model effective interaction with the child, as well as teach the family about normal development and positive parenting. However, there may be issues for discussion that are beyond the child's capacity to understand and/or inappropriate for discussion in front of the child. Meeting with the parents alone enables these issues to be more openly addressed in a setting with fewer distractions. Family play therapy Usually, the first half of the family session involves either directive or nondirective play. In the second half, the parents talk with the therapist about family issues that arose during the play, while the child continues to play or engages in discussion as desired or when invited. If children are protected from experiencing negative events and developing coping skills they may be unable to cope and adapt to crisis situations in later life. Crisis occurs when there is a perceived challenge or threat that overwhelms the capacity of the individual to cope effectively with the event. disrupts the life of the individual experiencing the event. In a crisis the person's habits and coping patterns are suspended. Often, unexpected emotional (e.g., depression) and biologic (e.g., nausea, vomiting, diarrhea, headaches) responses occur. Although a person may become extremely anxious, depressed, or elated, feeling states do not determine whether a person is in a crisis. If functioning is severely impaired, a crisis is occurring A crisis is generally regarded as time limited, lasting no more than 4 to 6 weeks. There is no such thing as a chronic crisis. People who live in constant turmoil are not in crisis but in chaos. A crisis can also represent a turning point in a person's life, with either positive or negative outcomes. It can be an opportunity for growth and change because new ways of coping are learned. can initiate a crisis Either internal or external demands that are perceived as threats to a person's physical or emotional functioning. Many life events can evoke a crisis, such as pandemics, natural disasters (e.g., floods, tornadoes, earthquakes) and manmade disasters (e.g., wars, bombings, airplane crashes) as well as traumatic experiences (e.g., rape, sexual abuse, assault). In addition, interpersonal events (divorce, marriage, birth of a child) may create a crisis event in the life of any person. A crisis is not the same as a psychiatric emergency that requires immediate intervention. A person in crisis may not need an immediate intervention and should not be viewed as having a mental disorder. However, if the person is significantly distressed or social functioning impaired, an Axis I diagnosis of acute stress disorder should be considered. The person with an acute stress disorder has dissociative symptoms and persistently re-experiences the event (APA). The basis of our understanding of the biopsychosocial implications of a crisis began in the 1940s when Eric Lindemann (l944) studied bereavement reactions among the friends and relatives of the victims of the Coconut Grove nightclub fire in Boston in 1942. That fire, in which 493 people died, From those results, he hypothesized that during the course of one's life, some situations, such as the birth of a child, marriage, and death, evoke adaptive mechanisms that lead either to mastery of a new situation (psychological growth) or impaired functioning. In 1961, psychiatrist Gerald Caplan defined a crisis as occurring when a person faces a problem that cannot be solved by customary problem-solving methods. During period of disequilibrium, there is a rise in inner tension and anxiety, followed by emotional upset and an inability to function. This conceptualization of phases of a crisis is used today. Four phases According to Caplan, during a crisis, a person is open to learning new ways of coping to survive Phase 1 A problem arises that contributes to increase in anxiety levels. The anxiety stimulates the implementation of usual problem-solving techniques of the person. Phase 2 The usual problem-solving techniques are ineffective. Anxiety levels continue to rise. Trial-and error attempts are made to restore balance. Phase 3 The trial-and-error attempts fail. The anxiety escalates to severe or panic levels. The person adopts automatic relief behaviors. Phase 4 When these measures do not reduce anxiety, anxiety can overwhelm the person and lead to serious personality disorganization, which signals the person is in crisis. Maturational Crisis According to Erikson; are a normal part of growth and development, and that successfully resolving a crisis at one stage allows the child to move to the next. The child develops positive characteristics after experiencing a crisis. If he or she develops less desirable traits, the crisis is not resolved. This concept of maturational crisis assumes that psychosocial development progresses by an easily identifiable, orderly process. The concept of developmental crisis continues to be used today to describe unfavorable person-environment relationships that relate to maturational events, such as leaving home for the first time, completing school, or accepting the responsibility of adulthood. The accomplishment of developmental tasks throughout the life cycle will impact the interpretation of crisis events during the transition of an individual from one stage of life to another. A situational crisis occurs whenever a specific stressful event threatens a person's biopsychosocial integrity and results in some degree of psychological disequilibrium. The event can be an internal one, such as a disease process or any number of external threats. A move to another city, a job promotion, or graduation from high school can initiate a crisis even though they are positive events. If a person enters a new situation without adequate coping skills a crisis may develop, resulting in dissonance (inconsistency between attitude and behavior). Situational crisis examples: top 12 Items on The Holmes - Rahe Life Stress Inventory The Social Readjustment Rating Scale Death of spouse Divorce Marital Separation from mate Detention in jail or other institution Death of a close family member Major personal injury or illness COVID-19 Marriage Being fired at work Marital reconciliation with mate Retirement from work Major change health/behavior of a family member Pregnancy/Abortion Adventitious Crisis is initiated by unexpected unusual events that can affect an individual or a multitude of people. In such situations, people face overwhelmingly hazardous events that may entail injury, trauma, destruction, or sacrifice. Such an event involves a physically aggressive and forced act by a person, a group, or an environment. National disasters (e.g., racial persecutions, kidnappings, riots, war); violent crimes (e.g., rape, murder, and assault and battery); and natural disasters (e.g., earthquakes, floods, forest fires, hurricanes) are examples of events that precipitate this type of crisis (Hazelwood & Burgess, 2001). 9/11 is an example of an adventitious crisis. The goal for people experiencing a crisis is to return to the pre-crisis level of functioning The role of the PMH-APRN in crisis provide a framework of support systems that guide the client through the crisis and facilitate the development and use of positive coping skills. Also must be aware that the individual may be at high risk for suicide or homicide. In a crisis the NP should PMH-APRN should assess for unusual behaviors and determine the level of involvement of the person with the crisis. In addition, assess for evidence of self-mutilation activities that may indicate the use of self-preservation measures to avoid suicide During an adventitious crisis (e.g., flood, hurricane, forest fire) that affects the well-being of many people the NP the interventions of the PMH-APRNwill be a part of the community's efforts to respond to the event. when a personal crisis occurs the person in crisis may have only the PMH-APRN to respond to his or her needs. After the assessment, the PMH-APRN must decide whether to provide the care needed or to refer the person to a psychiatrist. Biologic Domain/Assessment usually undergo initial changes. a crisis can be physically exhausting. Disturbances in sleep and eating patterns and the reappearance of physical or psychiatric symptoms are common. Changes in body function may include tachycardia, tachypnea, profuse perspiration, nausea, vomiting, dilated pupils, and extreme shakiness. Some victims may exhibit loss of control and have total disregard for their personal safety. The victims are at high risk for injury, which may include infection, trauma, and head injuries (France, 2002). If the victim's sleep patterns are disturbed or nutrition is inadequate, the victim will not have the physical resources to deal with the crisis. While medication cannot resolve a crisis, the judicious use of psychopharmacologic agents can help reduce its emotional intensity. Psychological Domain/Assessment focuses on the victim's emotions and coping strengths. In the beginning of the crisis, the victim may report the feeling of numbness and shock. Responses to psychological distress should be differentiated from symptoms of psychiatric illnesses of the victim Psychological Domain At the beginning of a crisis assess the victim for behaviors that indicate a depressed state, the presence of confusion, uncontrolled weeping or screaming, disorientation, or aggression. The victim may be suffering from loss of feelings of well-being and safety. In addition, panic responses, anxiety, and fear may be present. The ability to cope by problem-solving may be disrupted. Safety interventions to protect the person in crisis from harm preventing the person from committing suicide or homicide, arranging for food and shelter (if needed), and mobilizing social support. Once the person's safety needs are met, the PMH-APRN can address the psychosocial aspects of the crisis Counseling reinforces healthy coping behaviors and interaction patterns; identifying the victim's emotions and positive coping strategies; If counseling strategies do not work, other stress reduction and coping enhancement interventions can be used. if pt cannot cope then refer to in patient psych Social Domain/Assessment Assessment of the impact of the crisis on the victim's social functioning is essential because a crisis usually severely disrupts social proficiencies. Assist the victims to maintain a calm demeanor, obtain and distribute information about the crisis and the victims of the crisis. Initiate attempts to reunite victims and their families. nursing interventions for the social domain include the individual, the family, and the community. A crisis often disrupts a victim's social network leading to changes in available social support. Development of a new social support network may help the victim cope more effectively with the crisis. Federal Emergency Management Agency (FEMA sends a team of specialists who review the devastation of disaster. They provide counseling and mental health services, and arrange for many of the victims to access other services needed for survival, including training programs. Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services (DHHS) are available to assist both victims of and responders to the disaster. Phases of Disaster 1. Pre-warning of the disaster. This phase entails preparing victims for possible evacuation of the environment, mobilization of resources, and review of community disaster plans. 2. Disaster event occurs. Here the rescuers provide resources, assistance, and support as needed to preserve the biopsychosocial functioning and survival of the victims. 3. Recuperative effort. The focus here is to implement strategies for healing the sick and injured, preventing complications of health problems, repairing damages, and reconstructing the community. The first category of disaster victims victims who may or may not survive. If they survive, the victims often suffer severe physical injuries. The more serious the physical injury, the more likely the victim will experience a mental health problem such as PTSD, depress ion, anxiety, or other mental health problems (North et al., 2002; Pfefferbaum et al., 2001). Victims and families will need ongoing health care to prevent complications related to both physical and mental health. The 2nd category of disaster victims includes the professional rescuers. These are persons who are less likely to suffer physical injury but who often suffer psychological stress. The professional rescuers, such as policemen, firefighters, nurses, and so on, have more effective coping skills than do volunteer rescuers who are not prepared for the emotional impact of a disaster. However, many professional responders have reported experiencing PTSD for many months following the traumatic event in which they were involved The 3rd category of disaster victims The third category includes everyone else involved in the disaster. Psychological effects may be experienced worldwide by millions of people as they experience terrorism or disaster vicariously or as direct victims of the terrorism/disaster event (Hall et al., 2003). After an act of terrorism, most people will experience some psychological stress, including an altered sense of safety, hypervigilance, sadness, anger, fear, decreased concentration, and difficulty sleeping. Others may alter their behavior by traveling less, staying at home, avoiding public events, keeping children out of school, or increasing smoking and alcohol use. interventions developed by the PMH-APRN in collaboration with the victim should address individual outcomes specific to that victim Victims experiencing head injuries or psychic trauma after a disaster may have to be hospitalized. During a disaster, a victim with a mental illness may experience regression to his or her pretreatment condition and may require short-term inpatient hospitalization. disaster Biologic Domain/Assessment The PMH-APRN should assess physical reactions that may involve many changes in body functions, such as tachycardia, tachypnea, profuse perspiration, nausea, vomiting, dilated pupils, and extreme shakiness. Virtually any organ may be involved. Some victims may exhibit panic reactions and loss of control and have a total disregard for their personal safety. The victims may be suicidal or homicidal and are at high risk for injuries that may include infection, trauma, and head injuries Triage Red Category 1 Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. Conditions of Category 1 Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and 2nd/3rd degree burns of 15%-40% total body surface area. Triage yellow Delayed: Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. Category 2 Conditions of category 2 Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and CNS injuries. category 3 green Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. category 3 conditions Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances. Psychological Domain/Assessment disaster assess the victim for behaviors that indicate a depressed state, presence of confusion, uncontrolled weeping or screaming, disorientation, or aggressive behavior. Ideally, the PMH- APRN should assess the coping strategies the victim uses to normally manage stressful situations ABCs of psychological first aid A (arousal), B (behavior), and C (cognition) Debriefing (the reconstruction of the traumatic events by the victim) may be helpful for some. current research does not support debriefing as a useful treatment for the prevention of PTSD after traumatic incidents; compulsory debriefing is not recommended Social Domain/Assessment disaster the PMH-APRN should maintain a calm demeanor, obtain and distribute information about the disaster and the victims, and reunite victims and their families. To receive a diagnosis of a personality disorder an individual must demonstrate the criteria behaviors persistently and to such an extent that they impair the ability to function socially and occupationally. In some people, the underlying feelings and behaviors may be intermittent and interfere interpersonally without impairment. Instead of having a personality disorder, the individual is said to have traits of the disorder. Personality traits are defined as "prominent aspects of the personality that are exhibited in a wide range of important social and personal contexts" Ten personality disorders are recognized as psychiatric diagnoses and are organized into three clusters based on the dimensions odd-eccentric, dramatic-emotional, and anxious-fearful behaviors or symptoms. Cluster A consists of the disorders that most broadly characterize odd and eccentric misfit disorders, including paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster B personality disorders disorders show great emotionality and impulsivity, meaning they act without considering the consequences of the act or alternate actions; these disorders consist of antisocial personality disorder (APD), borderline personality disorder (BPD), histrionic personality disorder, and narcissistic personality disorder. Dramatic and erratic behavior best characterizes people with cluster B disorders. Dependent Personality Disorder Characteristics: inability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit care taking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have co-existing depression. Schizoid Personality Disorder Characteristics: avoids close relationships, is socially isolated, has poor occupational functioning, and appears cold, aloof, and detached. Social awareness is lacking and relationships generate fear and confusion in the client. Nurses should strive for simplification and clarity to help decrease client anxiety. In the DSM-IV-TR, BPD is defined as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of begins by early adulthood and is present in a variety of diagnostic characteristics of BPD. Evidence supports a biopsychosocial etiology women with BPD had a 16% smaller amygdale than did the healthy control Biologic abnormalities are associated with three BPD episodes impulsive, aggressive, and suicidal behavior episodes may be related to the irritability and impulsiveness in BPD A decrease in serotonin activity and an increase in α2-noradrenergic receptor sites People with BPD manifest psychotic-like symptoms paranoid thinking, dissociation, depersonalization, and derealization. These symptoms seem to be associated with intense anxiety. Also hypothesized that increase in dopamine may be responsible for transient psychotic states The psychoanalytic views of BPD focus on two important psychoanalytic concepts separation-individuation and projective identification separation-individuation in BPD A person with BPD has not achieved the normal and healthy developmental stage of separation individuation, during which a child develops a sense of self, a permanent sense of significant others (object constancy), and integration of seeing both bad and good components of self. BPD lack the ability to separate from the primary caregiver and develop a separate and distinct personality or self-identity. Psychoanalytic theory suggests that these separation difficulties occur because the primary caregivers' behaviors have been inconsistent or insensitive to the needs of the child. Projective identification- BPD is a defense mechanism by which people with BPD protect their fragile self-image. For example, when overwhelmed by anxiety or anger at being disregarded by another, they defend against the intensity of these feelings by unconsciously blaming others for what happens to them. cognitive schemas in BPD Individuals with BPD develop dysfunctional beliefs and maladaptive schemas leading them to misinterpret environmental stimuli continuously, which in turn leads to rigid and inflexible behavior patterns in response to new situations and people biosocial viewpoint proposed by Marsha Linehan and colleagues sees BPD as a multifaceted problem a combination of a person's innate emotional vulnerability and his or her inability to control that emotion in social interactions (emotional dysregulation) and the environment BPD is believed to develop when emotionally vulnerable individuals react with an invalidating environment, a social situation that negates private emotional responses and communication. When core emotional responses and communications are continually dismissed, trivialized, devalued, punished, and discredited (invalidated) by respected or valued persons, the vulnerable individual becomes unsure about their feelings. The most severe form of invalidation occurs in situations of child sexual abuse. the abusing adult has told the child that this is a "special secret" between them. The child experiences feelings of fear, pain, and sadness, yet this trusted adult continuously dismisses the child's true feelings and tells the child what he or she should feel. People with BPD have problems in regulating their moods, developing a sense of self, maintaining interpersonal relationships, maintaining reality-based cognitive processes, and avoiding impulsive or destructive behavior. a core characteristic of BPD Affective instability (rapid and extreme shift in mood) is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. Persons with BPD also have difficulty recognizing negative facial affects of others and experiencing negative emotions, particularly sadness, anger, and disgust Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed, seen in BPD Four factors of identity are most commonly disturbed role absorption (narrowly defining self within a single role), painful incoherence (distressed sense of internal disharmony), inconsistency (lack of coherence in thoughts, feelings, and actions), and lack of commitment People with BPD have an extreme fear of abandonment as well as a history of unstable, insecure attachments. Continually disappointed in relationships, these individuals, who already are intensely emotional and have a poor sense of self, feel estranged from others and inadequate in the face of perceived social standards. Intense shame and self-hate follow. These feelings often result in self-injurious behaviors, such as cutting the wrist, self-burnings, or head banging. In social situations, people with BPD use elaborate strategies to structure interactions. they restrict their relationships to ones in which they feel in control. They distance themselves from groups when feeling anxious (which is most of the time) and rarely use their social support system. They do not want to burden anyone; they fear rejection and also assume that people a tired of hearing them repeat the same issues The thinking of people with BPD is dichotomous they evaluate experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure, trustworthy or deceitful), which informs extreme interpretations of events that would normally be viewed as including both positive and negative aspects. Another cognitive dysfunction common in BPD is dissociation times when thinking, feeling, or behaviors occur outside a person's awareness. conceptualized on a continuum from minor dissociations of daily life, such as daydreaming, to a breakdown in the integrated functions of consciousness, memory, perception of self or the environment, and sensory-motor behavior. Dissociation serves a useful purpose in the case of driving a familiar road, dissociation alleviates the boredom of driving. It is also a coping strategy for avoiding disturbing events. In dissociating, the person does not have to be aware of or remember traumatic events. There is a strong correlation between dissociation and self-injurious behavior In BPD there is often failure to engage in active problem solving. Instead, problem solving is attempted by soliciting help from others in a helpless, hopeless manner. Suggestions are rarely taken. Impulsivity is also characteristic of people with BPD Because impulse-driven people have difficulty delaying gratification or thinking through the consequences before acting on their feelings, their actions are often unpredictable. Essentially, they act in the moment and clean up the mess afterward. Gambling, spending money irresponsibly, binge eating, engaging in unsafe sex, and abusing substances are typical of these individuals. They can also be physically or verbally aggressive. Job losses, interrupted education, and unsuccessful relationships are common. parasuicidal behavior is deliberate self-injury with intent to harm oneself The prevalence of self-injurious behavior is estimated to be present in half of the clients with BPD Dialectal Behavioral Therapy (DBT) developed by Marsha M. Linehan specifically to treat individuals with borderline personality disorder. reducing parasuicidal (self-injuring) and life-threatening behaviors. Next came reducing behaviors that interfered with the therapy/treatment process, and finally reducing behaviors that reduced the client's quality of life. borderlines are known for crisis-strewn lives and extreme emotional lability (emotions that shift rapidly). DBT maintains that some people react abnormally to emotional stimulation Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to return to baseline. Because of their past invalidation, the do not have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task. DBT adherent behaviorist theory with some cognitive therapy An individual component in which the therapist and client discuss issues that come up during the week, recorded on diary cards and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and client work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed. DBT targets behaviors in a descending hierarchy Decreasing high-risk suicidal behaviors Decreasing responses or behaviors (by either therapist or client) that interfere with therapy Decreasing behaviors that interfere with/reduce quality of life Decreasing and dealing with post-traumatic stress responses Enhancing respect for self Acquisition of the behavioral skills taught in group Additional goals set by client The group, which ordinarily meets once weekly for about 2 - 2.5 hours, in which clients learn to use specific skills that are broken down into 4 modules: core mindfulness skills, emotion regulation skills, interpersonal effectiveness skills, and distress tolerance skills. The Four Modules of DBT Mindfulness, Interpersonal Effectiveness, Emotional Regulation, Distress Tolerance Interpersonal Effectiveness Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.Individuals with BPD frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation.The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect. Emotion Regulation Individuals with BPD and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. DBT skills for emotion regulation include: Identifying and labeling emotions Identifying obstacles to changing emotions Reducing vulnerability to emotion mind Increasing positive emotional events Increasing mindfulness to current emotions Taking opposite action Applying distress tolerance techniques Distress Tolerance Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully. Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality. Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness. Safety Interventions Clients with BPD are usually admitted to the inpatient setting because of threats of self-injury. Clients with BPD should be continuously assessed for self-injurious behavior or suicide attempts. It is important to ask the client about specific self-abusive behaviors, such as cutting, scratching, or swallowing. The client may wear long sleeves to hide injury on the arms. Specifically asking about thoughts of hurting oneself when experiencing a major upset provides an opportunity for prevention and for coaching the client toward alternative self-soothing measures. Remembering that self-injury is an effort to self-sooth by activating endogenous endorphins, the advance practice psychiatric/mental health nurse can assist the client to find more productive and enduring ways to find comfort. Five Senses Exercise Pharmacologic Interventions for bpd Less medication is better for people with BPD. Clients with BPD may be taking several medications, particularly if they have a comorbid disorder, such as a mood disorder or substance abuse. Pharmacotherapy is used to control emotional dysregulation, impulsive aggression, cognitive disturbances, and anxiety as an adjunct to psychotherapy Sleep Enhancement Facilitation of regular sleep-wake cycles may be needed because of disturbed sleep patterns. Conservative approaches should be exhausted before recommending medication. Establishing a regular bedtime routine, monitoring bedtime snacks and drinks, and avoiding foods and drinks that interfere with sleep should be tried. If relaxation exercises are used, they should be adapted to the tolerance of the individual. Moderate exercises (e.g., brisk walking) 3 to 4 hours before bedtime activates both serotonin and endorphins, thereby enhancing calmness and a sense of well-being before bedtime. For clients who have difficulty falling asleep and experience interrupted sleep, it helps to establish some basic sleeping routines. The bedroom should be reserved for only two activities: sleep and sex. Therefore, the client should remove the television, computer, and exercise equipment from the bedroom. If the client is not asleep within 15 minutes, he or she should get out of bed and go to another room to read, watch television, or listen to soft music. If the client is not asleep in 15 minutes, the same process should be repeated. Special consideration must be made for clients who have been physically and sexually abused and who may be unable to put themselves in a vulnerable position, such as lying down in a room with other people or closing their eyes. These clients may need additional safeguards to help them sleep, such as a night light or repositioning the furniture to afford easy exit. Establishing Personal Boundaries and Limitations Personal boundaries are highly context specific; for example, stroking the hair of a stranger on the bus would be inappropriate, but stroking the hair and face of one's intimate partner while sitting together would be appropriate. Our personal physical space needs or boundaries are distinct from behavioral and emotional limits we have. Testing limits s a natural way of identifying where the boundaries are and how strong they are. Therefore, it is necessary to state clearly the enduring limits (e.g., the written rules or contract) and the consequences of violating them. The limits must then be consistently maintained. Clarifying limits requires making explicit what is usually implicit. Despite the clinical setting (e.g., hospital, day-treatment setting, outpatient clinic), the PMH-APRN must clearly state the day, time, and duration of each contact with the client and remain consistent in those expectations. additional strategies for establishing the boundaries of the relationship include Documenting in the client chart the agreed-on appointment expectations Sharing the treatment plan with the client Confronting violations of the agreement in a non-punitive way Discussing the purpose of limits in the therapeutic relationship and applicability to other relationships. Behavioral Interventions goal of behavioral interventions is to replace the dysfunctional behaviors with positive ones helping clients control emotions and behavior by acknowledging and validating desired behaviors and ignoring or confronting undesired behaviors. if the behavior is irritating but not harmful or demeaning, it is best to ignore rather than focus on it. However, grossly inappropriate and disrespectful behaviors require confrontation. this incident can be used to help the client understand why such behavior is inappropriate and how it can be changed. The PMH-APRN should explore with the client what happened, what events led up to the behavior, what were the consequences, and what feelings were aroused. Cognitive Therapeutic Interventions the major goal of cognitive therapeutic interventions is emotional regulation - recognizing and controlling the expression of feelings. Clients often fail even to recognize their feelings; instead, they respond quickly without thinking about the consequences. Remember, the time needed for taking action is shorter than the time needed for thinking before acting. Pausing makes up for the momentary lag between the limbic and autonomic response and the prefrontal response. the communication triad The triad provides a specific syntax and order for clients to identify and express their feelings and seek relief. The sentence" consists of three parts: An "I" statement to identify the prevailing feeling A nonjudgmental statement of the emotional trigger What the client would like differently or what would restore comfort to the situation. "Joe, I feel angry ("I" statement with ownership of feeling) when you interrupt me (the trigger or conditions of the emotion), and I would like you to apologize and try not to do that with me (what the client wants and the remedy)." delay gratification When the client wants something that is not immediately available, the PMH-APRN can teach clients to distract themselves, find alternate ways of meeting the need, and think about what would happen if they have to wait to meet the need. practice of thought stopping help the client to control the inappropriate expression of feelings. the person identifies what feelings and thoughts exist together. For example, when the person is ruminating about a perceived hurt, the individual might say "STOP THAT" (referring to the ruminative thought) and engage in a distracting activity. (e.g., instead of ruminating about an angry situation, think about a neutral or positive self-affirmation) The concept of acting out is complex. The term has been used to describe a variety of behaviors, ranging from antisocial, destructive acts to unconscious impulses expressed in action rather than in symbolic words or symptoms. Acting out may, and often does, include destructive actions and seemingly undefinable behaviors. The term describes a re-creation of the client's life experiences, relationships with significant others, and resulting unresolved conflicts. Temperament is the constitutional makeup of the child at birth, specifically the child's behavioral and psychophysiological attributes. For instance, infants who have been exposed to drugs in utero may be very sensitive to stimulation from lights, sounds, or touch child-parent psychotherapy attempts to enhance the goodness-of-fit between parent and child in order to increase their enjoyment in one another and provide the child with a more supportive foundation for optimal mental health. Parent-child interaction Separation and reunion. Examine how child reacts to separation and reunion with parent Thought process: Looseness of associations, magical thinking, preservation, echolalia, ability to distinguish fantasy from reality (by age 4 children have some understanding of what is real or made up), flight of ideas Memory Test recall after 5 minutes (school-age children should be able to remember three objects after 5 minutes) Abstraction Children ages 12 or younger not expected to have abstractive thought abilities (young children have concrete thinking) Oppositional defiant disorder (ODD) is an enduring pattern of angry or irritable mood and argumentative, defiant, or vindictive behavior lasting at least 6 months with at least four of the associated symptoms: Loses temper, Touchy or easily annoyed, Angry or resentful, Argues with authority, Actively defies or refuses to comply with request or rules from authority figures, Blames others, Deliberately annoys others, Spiteful or vindictive Oppositional defiant disorder (ODD) tx Therapy is mainstay: Z Individual therapy Z Family therapy, with emphasis on child management skills Z Evidence-based treatment: child and parent problem-solving skills training (American Academy of Child and Adolescent Psychiatry [AACAP], 2007b). X IncredibleYears (group intervention) X Parent-child interactional therapy (individual or family intervention) X Adolescent Transitions Program (ATP; individual or family and group intervention) Cluster C- anxious, nervous behavior Dependent personality disorder Reporting requirements for Child Protective Services it is mandatory to report suspicions of all five recognized types of abuse and neglect (i.e. physical abuse, sexual abuse, emotional abuse, neglect, and exposure to family violence) If you know or suspect that a child under the age of 18 is being abused or neglected, or is at risk of being abused or neglected, you are required to report Flooding s a term first introduced by early behavior therapists in relation to the treatment of anxiety by immediate and prolonged exposure to feared stimuli A more extreme behavioural therapy is flooding. Rather than exposing a person to their phobic stimulus gradually, a person is exposed to the most frightening situation immediately. For example, a person with a phobia of dogs would be placed in a room with a dog and asked to stroke the dog straight away. kinds of behaviors are possible indicators of a mental illness in a 3-year-old child has repeated tantrums or consistently behaves in a defiant or aggressive way seems sad or unhappy, or cries a lot is afraid or worried a lot gets very upset about being separated from you, or avoids social situations starts behaving in ways that they've outgrown, like sucking their thumb or wetting the bed has trouble paying attention, can't sit still or is restless. trouble sleeping or eating physical pain that doesn't have a clear medical cause - for example, headaches, stomach aches, nausea or other physical pains. not doing as well as usual at school having problems fitting in at school or getting along with other children not wanting to go to social events like birthday parties. Primary prevention: stopping mental health problems before they start. is aimed at lowering the occurrences of mental disorders. An example of primary prevention is when a PMHNP conducts a stress management class for graduate students; conducts a smoking prevention classes; or drug abuse resistance education. Secondary prevention supporting those at higher risk of experiencing mental health problems. is aimed at decreasing the number of existing cases of mental disorders. Secondary prevention is geared towards screening, early case findings, health promotion and providing effective treatment. Some examples of secondary prevention practices include establishing telephone hotlines, disaster responses and crisis interventions. Tertiary prevention helping people living with mental health problems to stay well. aims at lowering the disability and intensity of a mental disorder. Tertiary prevention is geared towards rehabilitative services, and preventing, or delaying complications. Examples of tertiary prevention include developing and overseeing day treatment programs; involving in case management for physical, housing, and vocational needs; educating patients on social skills; and interventions that promote advanced recovery and reduction of relapse risk