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BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder: DSM Diagnosing and Empirically-Based Treatment SULTAN ALGHAMDI ALBAHA UNIVERSITY

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INTRODUCTION Borderline personality disorder (BPD) (called emotionally unstable personality disorder, borderline type in the ICD-10) is a personality disorder characterized by unusual variability and depth of moods.[1] These moods may secondarily affect cognition and interpersonal relationships.[n 1] Other symptoms of BPD include impulsive behavior, intense and unstable interpersonal relationships, unstable self-image, feelings of abandonment and an unstable sense of self.[2] People with BPD often engage in idealization and devaluation of themselves and of others, alternating between high positive regard and heavy disappointment or dislike.[3] Selfharm and suicidal behavior are common and may require inpatient psychiatric care.[4] This disorder is recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) only in individuals over age 18. However, symptoms of BPD can also be found in children and adolescents. Without treatment, symptoms may worsen, potentially leading to suicide attempts.[n 2] There is an ongoing debate about the terminology of this disorder, especially the word "borderline."[5][6] The ICD-10 manual refers to this disorder as Emotionally unstable personality disorder and has similar diagnostic criteria. There is related concern that the diagnosis of BPD stigmatizes people with BPD and supports discriminatory practices.[7]

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Abstract The DSM-IV is widely used in the mental health field. Some of its many uses include providing a common language among professionals about psychopathology and delineating criteria for diagnosing individuals with mental disorders. This paper explores the purpose, history, and limitations of the DSM diagnostic approach. A case study is provided and the DSM-IV-TR is used to diagnosis borderline personality disorder. The disorder is described and an empirically-based treatment plan is offered.

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Borderline Personality Disorder: DSM Diagnosing and Empirically-Based Treatment The APA (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM) is widely used by mental health professionals. It provides a common language about psychopathology among clinicians, researchers, students, and other mental health professionals. Since its inception into the field of mental health, it has made a huge impact on clinical practice, research, and education. Although it has advanced the field of mental health, there is still criticism of the DSM classification system. Despite its limitations, it continues to be considered an important reference for mental health professionals. This paper will explore the DSMs use within the field of psychopathology. Then it will be applied to a case study of a 14 year-old girl with mental health concerns including a diagnosis of borderline personality disorder. Her symptoms will be described, criteria for diagnosis will be applied, and a proposed treatment plan will be provided. DSM The DSM-IV organizes mental disorders into multi-axial categories and provides research-based information on each mental disorder, including diagnostic features, subtypes, specific demographic features, prevalence, course, familial pattern, and differential diagnosis. It has made an impact in many realms of the mental health profession. In clinical work, the DSM diagnostic criterion is used for charting clients cases and communicating with other professionals. The DSM is used to facilitate research on etiology and treatment of mental disorders. In education, the DSM is seen as the authoritative source of information about mental disorders (First, 2002, p. 69) The DSMs history goes back over a half century. The first and second editions of the DSM were based on the psychodynamic approach and attributed the causation of mental disorders to environmental events. In 1980, the DSM-III was published and took on a more medical approach to psychopathology. This edition introduced a multi-axial classification system that took into account the

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clients environment and functioning and also provided widely accepted a theoretical definitions and diagnostic criteria for each mental disorder (Regier, Narrow, First, & Marshall, 2002). The current edition, DSM-IV-TR, is the result of two empirically-based revisions of the DSM-III. Although the current edition of DSM has far surpasses previous editions (Regier et al, 2002, p. 169) and is internationally used, there is still some controversies, limitations, and ethical concerns of this classification system. Jablensky (2002) points a number of flaws, including how criteria is not weighed for diagnostic importance, axis II has an absurdly high level of comorbidity, and reliability, at best, is modest (p. 114). Much of the literature on the limitations of the DSM-IV-TR focuses on the lack of cultural context considerations in diagnosing. Lee (2002) explains the role culture plays in assessing and treating psychopathology. Paykel (2002) points out that the DSM is all very Western centered and ignores syndromes which may appear in other cultures (p. 98). Regier et al (2002) agrees that the DSM-IV is limited in its applicability to diverse populations, but also states that it is limited in cross-cultural applicability as it does not fully address the different meanings of illness, treatment, and idioms of distress across the diverse array of ethnic, racial, and cultural groups in the United States (p. 169). Kastrup (2002) asserts the DSM-IV-TR classification system should be effectively applied in all settings and cultures. The DSM-IV is not due to be updated with a newer edition for a few years yet. In the meantime, literature discusses how clinicians can take action to ensure culture is considered when diagnosing and treating individuals with mental disorders. Mezzich (2002) stresses the importance of providing a comprehensive diagnosis that takes into account biological, psychological, and social information. Constantine, Hage, Kindaichi, & Bryant (2007) recommend learning about the historical and present implications of oppression in the lives of marginalized populations, gaining self-awareness of own cultural background and biases, acquiring knowledge about other worldviews and culture-

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specific values of culturally-diverse individuals, and becoming competent in devising and carrying out multicultural interventions (p. 24).

CASE STUDY The following case study is to be used to demonstrate how the DSM-IV-TR and other literature in the filled of psychopathology are used to diagnosis mental disorders. Client Demographic and Descriptive data. Zahra an 14 years old, She is Saudi female , she appears untidy (her hair is too long colored blonde, oily and not brushed coming to her face and with body odor). She is petite always like to wear same clothes, and she has above average IQ. FAMILY AND SOCIAL HISTORY Zahra was neglected and emotionally, physically, and sexually abused by her father and her stepmother throughout much of her childhood. She was sent to her auntie for care at age 7. Parents, school administrators, and human service professionals that have worked with Zahra report that she is difficult to handle. Her behavioral and emotional disturbances have caused her to move around many times, from relatives to relatives. At age 10 Zahra moved in to his another auntie who seems to dont have a child that has been her foster parents. At first, Zahra seemed to be happy to be part of a stable family and almost immediately displayed intense love for her new mother and father. Her parents report, though, that Zahra was a challenge from the start of their relationship with her. She displayed inappropriate behaviors for her age (masturbating openly, lying, tantrums, swearing and destroying property when

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upset). For awhile this behavior was met with patience and understanding on the parents part. Other relatives children have moved into the home and two were adopted into the family. As time went on, Zahra presented more signs and symptoms of emotional disturbance. The emotional outbreaks gradually got worse and often involved yelling profanity and threats and destroying property. She often manipulates and lies to others to get her way. Zahra has been admitted to the BALJURASHI PSYCHIATRIC ward of the hospital two times in the last year for emotional breakdowns and suicide ideation and attempts (took pills). Her parents report that they cannot handle her and just dont know what to do with her. Zahra has a difficult time making and keeping friends. Her relationships with friends are often intense, but short-lived and full of conflict. Presenting problem Zahras behavior has gotten to a point that warrants serious attention and demands an actionoriented treatment plan that addresses many aspects of Zahras life. She has been expelled from school because of her emotional outbursts and complete disregard for authority. She has been waking up in the middle of the night to get on the internet to communicate with older guys. When confronted by her parents about the inappropriateness of her actions, a physical altercation occurred in which her mother slapped her face and caused her nose to bleed. Police were called and her mother was arrested. The interactions between Zahras and her mother after the arrest have not been positive. A triangle was created between Zahra, her mother, and her father. The conflict between Zahra and her mother pushed the mother into an emotional breakdown. The mother was admitted into a psychiatric ward after an attempt of suicide. Her parents feel helpless and as if Zahra is breaking up the family. The mother reports that Zahra is out of control. The mother is fearful that Zahra will cause her to have another break-down or that Zahra will do something harmful to the other children in the home. Signs and Symptoms

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Zahra reportedly is skilled at manipulating others according to her wants at the time. She is deceitful and lies often. She can appear upbeat and in a pleasant mood (especially when first meeting someone). She can be loving, caring, helpful, and seeking hugs at times but then her mood can change in moments when she is met with resistance or authority. When told she cannot do something she wants to, Zahra yells out whatever she can to hurt the individual standing in her way of doing as she desires. She has little regard for rules at school or home. She has been expelled from public school and is now being tutored at home. She threatens harm against other when upset. She is promiscuous. She is impulsive and fails to think about the consequences of her actions beforehand. She cannot be left alone in the home as she is irresponsible (disregard for home rules, past suicide attempts/threats, lack of consistency with self-care). She has run away from home on numerous occasions when her parents try to enforce rules and limitations. DSM-IV Diagnosis Zahra displays signs and symptoms characteristic of borderline personality disorder (BPD). According to the DSM-IV-TR, individuals with BPD display a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts (2000, p. 710). The following DSM-IV-TR criteria for BPD are present in Zahras case: frantic efforts to avoid real or imagined abandonment; a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of ideation and devaluation; impulsivity in potentially self-damaging areas (e.g., promiscuity, communicating with strangers and possible predators online, and binge eating); recurrent suicidal threats and attempts; affective instability due to marked reactivity of mood (e.g. episodic dysphoria, irritability, or anxiety); chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling her anger (DSM, 2000, p. 710).

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The etiology of BPD is not exactly known but research has found a number of risk factors including childhood neglect and/or abuse (Gunderson, Daversa, Grilo, McGlashan, et al, 2006; Linning & Kearney, 2004), trauma (Donnelly & Amaya-Jackson, 2002), and disrupted attachment (Bradley, Conkin, & Western, 2005). These developmental experiences are common among individuals diagnosed with BPD and can provoke a fear of abandonment, interpersonal instability, and other dysfunctional behaviors associated with BPD (i.e. detachment, emotional instability, uncontrolled anger, emptiness, depression, inability to self-soothe, impulsivity, identity disturbances, self-mutilative behavior, and suicidal ideation) (Becker, Grillo, Edell, & McGlashan, 2002; Bradley et al, 2005; Donnelly & AmayaJackson, 2002; Gunderson et al, 2006; and Linning & Kearney, 2004, and Sanislow et al, 2002) . The disturbances in Zahras behavior and affect causes clinically significant impairment in social and academic functioning, including school expulsion, family turmoil, and lack of friends (APA DSM-IV, 2000, p. 99). Zahras psychological, social, and academic functioning is 20 on the Global Assessment of Functioning (GAF) Scale (DSM-IV, 2000, p. 34) as indicated by the presence of some danger of hurting herself or others (e.g. suicide attempts, frequently violent, threats of harm to others) and lacks desire to maintain personal hygiene (e.g. bathes infrequently and frequently refuses to change clothes, brush hair and care for teeth). Treatment Plan BPD is a complex disorder made up of collection of symptoms, dysfunctional cognitions and behaviors, and maladaptive personality traits, thus treatment should address each of these concerns in a systematic way using a variety of interventions (Sanislow et al, 2002; Livesley, 2004). The following treatment plan incorporates a combination of empirically-based interventions that target the complex problems of Zahra s case:

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Diagnosis

Axis I

V71.09 No diagnosis

Axis II 301.83 Borderline personality disorder Axis III No diagnosis Axis IV Victim of childhood abuse and neglect. Problems with education, primary support group, and social environment. Axis V GAF = 20; some danger of hurting self or others Objective of Treatment Livesley (2004) recommend the ranking of symptoms according to urgency and stability and taking a sequential approach to interventions in which the more urgent and readily changed symptomatic components are addressed first. Ben-Porath (2004) also stresses the importance of establishing an early therapeutic alliance to prevent the common problem of drop-outs or premature termination in treatment of individuals with borderline personality disorder. Thus the initial objective of Zahra s treatment is developing a strong therapeutic alliance, fostering client commitment (Ben-Porath, 2004), and managing and containing self-harm behaviors and related problems with emotion and impulse regulation (Livesley, 2004, p. 187). The focus of treatment then can move to improving social and interpersonal functioning and changing maladaptive cognitions and behaviors. Towards the end of treatment, the objective is to create a healthy sense of self and stable identity (Livesley, 2004). Assessments Assessment for Zahra s case should include a referral for a physical examination and assessment instruments that measure borderline personality symptoms, like the Harkavy-Asnis Suicide

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Survey, Beck Depression Inventory, Life Problems Inventory, Scale for Suicidal Ideation, Symptom Checklist 90-Revised, and the Structured Clinical Interview for DSM-IIIR Personality Disorders, Borderline Personality Module (Rathus & Miller, 2002). Clinician Characteristics The ideal characteristics of the clinician treating Zahra include being able to be understanding, nonjudgmental, and encouraging when faced with resistance or hostility from Zahra . The clinician should be patient and comfortable with slow progress. The clinician should also be knowledgeable about the complexities of the diagnosis and be skilled in a variety of theoretical approaches and interventions (Seligman, 2005, p. 398). Location of Treatment Zahra s case should be treated at an inpatient hospital setting at first with daily sessions to reduce symptoms of suicidal ideation and potentially harmful impulsivity. Once risk of harm to self and others is decreased, twice weekly outpatient sessions in the clinicians office should be scheduled. Interventions to be Used Dialectical behavioral therapy (DBT) is the most empirically supported treatment for borderline personality disorder (Sharma, Dunlop, Ninan, & Bradley, 2007). It has been shown to reduce suicidal ideation, emotional distress, impulsive behaviors, interpersonal difficulties, emotional dysregulation, identity confusion, hospital admittance, and early termination of treatment (Rathus & Miller, 2002). DBT uses a combination of interventions to address specific problems in order of importance, including client-centered interventions to strengthen the therapeutic alliance and commitment fostering interventions (refer to Ben-Porath, 2004 for specific strategies); behavioral interventions to teach selfregulating and interpersonal skills; cognitive interventions to change maladaptive cognitions and

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defense processes; and psychodynamic interventions to address attachment patterns, fear of abandonment, and feelings of rejection and emptiness (Bradley et al, 2005, p. 1016). Emphasis of Treatment Rathus and Miller (2002) explain how DBT is characterized by its balance of acceptance and change, and by its well-specified communication strategies, dialectical strategies, validation strategies, problem-solving strategies, case management strategies, and hierarchy of treatment targets (p. 149). An emphasis on establishing a strong therapeutic relationship should also be stressed throughout the entire treatment process (Ben-Porath, 2004). Numbers For Zahra s case, individual therapy is the primary mode of treatment, with family therapy (Sharma et al, 2007), group therapy (Seligman, 2005), and multifamily skills training groups (Rathus & Miller, 2002) being combined. Timing Literature suggests that Zahra will likely need long-term therapy with short-term goals being established and worked on through the process (Ben-Porath, 2004; Seligman, 2005). Weekly sessions are often not enough, especially in times of crisis or regression (Seligman, 2005, p. 398). Medications Needed The treating physician will likely prescribe some medication to lessen Zahra s symptoms. Pharmacological interventions (e.g. Zoloft, clonazepam, sertraline, quetiapine) are often used to lessen the severity of the symptoms of borderline personality disorder (Sharma et al, 2007). Donnelly and

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Amaya-Jackson (2002) discuss research studies on the effectiveness of a variety of psychotropic drugs medication. Adjunct Services Seligman (2005) suggests a support group may be beneficial for Zahra and family involvement in therapy and skills-building exercises. Prognosis Gunderson et al (2006) examine the predictors of treatment outcomes and provide prognosis information for patients with BPD. Due to Zahra s early history of abuse and neglect prognosis may be poor (p. 824). Seligman (2005) suggests only a fair prognosis for changing underlying personality characteristics (p. 399), but other literature (Livesley, 2004; Sharma et al, 2007) suggests a good prognosis for a reduction in Zahra s BPD symptoms and for positive behavioral changes, especially if a variety of interventions are used in treatment (i.e. DBT). Conclusion The DSM-IV is used often in the mental health field. It provides a common language about mental disorders for professionals and assists in the diagnosing of disorders. It has made an impact in clinical, research, and educational settings. The DSM was first introduced over a half century ago and has undergone many research-based revisions. Although it has advanced the field of psychopathology, there are notable limitations and weaknesses of the DSM classification and diagnosing approach. Limited cultural consideration in diagnosis is one of the most significant limitations of the DSM-IV-TR. There is much literature on multicultural practices that professionals in the mental health field can resource. Zahra is not of a racially marginalized population, but has had a unique upbringing and life experiences (i.e. childhood abuse and neglect and growing up in the foster care system) that must be

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taken into consideration when diagnosing and treating her. The criteria and information within the DSM-IV-TR was used to diagnosis Zahra with borderline personality disorder (BPD). She displays a number of symptoms, negative behaviors, maladaptive cognitions, and other psychosocial problems characteristic of BPD, including instability of interpersonal relationships, fear of abandonment, impulsivity, emotional instability, and suicidal ideation. The complex nature of BPD warrants a comprehensive treatment plan that combines interventions from various approaches to address the symptoms and problems in Zahra s case. Dialectical behavioral therapy has been shown to be effective in reducing problematic symptoms in individuals with BPD. Other research-based interventions that should be part of Zahra s treatment plan include those that foster a strong therapeutic alliance and foster commitment (client-centered interventions), reduce self-harm behaviors and impulsivity (cognitive-behavioral interventions), and address the interpersonal difficulties and fear of abandonment (psychodynamic interventions

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PSYCHIATRIC NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE NURSING EDUCATION STUDENT INSTRUCTOR

DATE

SEMESTER ROTATION

Clients Initials ZAHRA ABDULLAH ALI ALGHAMDI

Gender FEMALE

Age 14

Legal Status SINGLE

Admission Date

Presenting Signs/Symptoms (chief complaint and reasons for admission ) PTA according to her foster parents which is her auntie, Zahra attitude is difficult to handle, she exhibit unnecessary attitudes and inappropriate behavior like masturbating openly, lying, tantrums and destroying and throwing things when angry. An as days her attitude becomes worst according to her auntie, chatting and calling with different guys every night, after came another adopted child to their family seems shes jealous and lack of attention.

Admitting/Primary Diagnosis Axis I: P

S NO DIAGNOSIS

Axis II:
(personality disorder or mental retardation)

BORDERLINE PERSONALITY DISORDER

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Axis III:
(medical diagnoses) NO DIAGNOSIS

Axis IV:
(Stressors client is experiencing)

Victim of childhood abuse and neglect. Problems with education, primary support group, and social environment.

Axis V
(Global Assessment of functioning)

GAF = 20; some danger of hurting self or others


Substance Use (Include use of tobacco, alcohol, street drugs, over-the-counter drugs, length of use and time of last use.) She smoke 3 packs a day and drink liquor with friends.

Allergies/Reactions- not specified Religious Preference Islam Ethnicity Saudi Marital Status Single Occupation Not specified

Define Axes Diagnoses here as well as research about clients diagnosis (es) in narrative form.

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Prescribed Treatments (as per physicians orders)

Oxygen:

NIL

Respiratory Treatment:

I.V. Infusion:

Diet:

Feeding:

Bowel/Bladder:

Hygiene:

Activity:

Other:

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Borderline Personality Disorder DSM IV Criteria Borderline personality disorder DSM IV criteria A. A pervasive pattern of instability of interpersonal relationships, selfimage, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self image or sense of self. 4. Impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5. 5. Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive selfcriticism; chronic feelings of emptiness; dissociative states under stress. b. Self-direction: Instability in goals, aspirations, values, or career plans. AND 2. Impairments in interpersonal functioning (a or b): a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal. B. Pathological personality traits in the following domains: 1. Negative Affectivity, characterized by: a. Emotional liability: Unstable emotional experiences and

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frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. c. Separation insecurity: Fears of rejection

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Therapeutic Communication Process Recording


Directions: Engage in a therapeutic communication session(s) with your client and record what each of you said. This can most easily be done by setting up a 2 column table. After each comment in your column you should analyze whether your communication was therapeutic or nontherapeutic. Use the handout on therapeutic communication to guide you. If your responses are therapeutic, list the technique that you used; if non-therapeutic, state, I should have said Pay special attention to your clients nonverbal communication. State your observations after the clients responses. Your process recording should be about 3 pages long. Not all patients will be able to tolerate a conversation that long all at once, so you may come back several times and try to pick up the thread each time. At the end of the session, try to summarize the theme of what the client was trying to say (anger, sadness, blame-shifting, etc). Therapeutic communication is a new language that is not easy to learn. I wont expect each of your responses to be therapeutic, nor will I mark you off if they arent, so long as you recognize what you could have done better. STUDENT NURSE Hi! My name is Sultan, Im a nursing student. Is it ok if I sit down and talk with you for a few minutes? (broad opening ,offers self) How are you feeling today? (broad opening) I feel terrible!i hate here. Id rather be dead! CLIENT Yes, I guess so

(looks at scar on wrist) Surely things cant be that bad there are many What do you know about how bad I have it? people in the world who have it much Youre just a student nurseyou dont know worse than you. my life!

(NT,

false reassurance, rejected clients message) Could have said, It sounds like youre really upset. Tell me about it. (T, reflected patients conversation, general lead.)

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MENTAL STATUS/ASSESSMENT OF PSYCHIATRIC SYMPTOMS


INSTRUCTIONS: Check box where applicable. If NORMAL is checked, go to next section. X
ENERAL APPEARANCE NORMAL for Age/Culture Facial Expressions: Sad Expressionless Hostile Worried Avoids Gaze Dress: Meticulous Clothing, Hygiene Poor Eccentric Seductive MOTOR ACTIVITY NORMAL for Age/Culture Increased Amount Decreased Amount Agitation Tics Tremor Peculiar Posturing Unusual Gait Repetitive Acts SPEECH NORMAL for Age/Culture Excessive Amount Poverty of Pressure of Slowed Loud Soft Mute Slurred Stuttering INTERVIEW BEHAVIOR NORMAL for Age/Culture Expansive Suspicious Withdrawn Angry Outbursts Irritable Impulsive Hostile Silly Sensitive Apathetic Evasive Passive Aggressive Naive Overly Dramatic Manipulative Dependent Uncooperative Demanding Negative Callous FLOW OF THOUGHT NORMAL for Age/Culture Blocking Circumstantial Tangential Perseveration Flight of Ideas Loose Associations Indecisive Incoherence Neologisms AFFECT NORMAL for Age/Culture Inappropriate Labile Range: Restricted Blunted Flat MOOD NORMAL for Age/Culture Elevated Euphoric Expansive Dysphoric: Depressed Anxious Irritable SENSORIUM NORMAL for Age/Culture Orientation Impaired: Time Place Person Memory: Clouding of Consciousness Inability to Concentrate Amnesia Poor Recent Memory Poor Remote Memory Confabulation INTELLECT NORMAL for Age/Culture Above Normal Below Normal Paucity of Knowledge Vocabulary Poor Serial Sevens Done Poorly Poor Abstraction CONTENT OF THOUGHT NORMAL for Age/Culture Suicidal Thoughts Suicidal Plans Assaultive Ideas Homicidal Thoughts Homicidal Plans Antisocial Attitudes Suspiciousness Poverty of Content Phobias Obsessions/Compulsions Feelings of Unreality Feels Persecuted Thoughts of Running Away Somatic Complaints Ideas of Guilt Ideas of Hopelessness Ideas of Worthlessness Excessive Religiosity Sexual Preoccupation Blames Others Ideas of Reference Magical Thinking Illogical Thinking Illusions: Present Mood-Incongruent Auditory Visual Gustatory Olfactory Somatic Tactile Delusions: Mood-Congruent Mood-Incongruent of Persecution of Grandeur of Reference Somatic Systematized of Being Controlled Bizarre Nihilistic of Poverty Jealousy INSIGHT AND JUDGMENT NORMAL for Age/Culture Poor Insight Poor Judgment Unrealistic Regarding Degree of Illness Doesnt Know Why He is Here Unmotivated for Treatment

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ADDITIONAL COMMENTS:

BRIEF PSYCHIATRIC RATING SCALE DIRECTIONS: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom.

Patient Initials ___________ Physician ______________________________ Date

Not Present

Moderately

Extremely

Very Mild

Moderate

Severe

Severe

SOMATIC CONCERNS preoccupation with physical health, fear of physical illness, hypochondriasis. ANXIETY worry, fear, over-concern for present or future, uneasiness. EMOTIONAL WITHDRAWAL lack of spontaneous interaction, isolation, deficiency in relating to others. CONCEPTUAL DISORGANIZATION thought processes confused, disconnected, disorganized. GUILT FEELINGS self-blame, shame, remorse for past behavior. TENSION physical and motor manifestations of nervousness, over-activation, agitation. MANNERISMS AND POSTURING peculiar, bizarre, unnatural motor behavior (not including tic). GRANDIOSITY exaggerated self-opinion, arrogance, conviction of unusual power or abilities. DEPRESSIVE MOOD sorrow, sadness, despondency, pessimism. HOSTILITY animosity, contempt, belligerence, disdain for others. SUSPICIOUSNESS mistrust, belief others harbor malicious or discriminatory intent. HALLUCINATORY BEHAVIOR perceptions without normal stimulus correspondence. MOTOR RETARDATION slowed, weakened movements or speech, reduced body tone. UNCOOPERATIVENESS resistance, guardedness, rejection of authority, non-compliant. UNUSUAL THOUGHT CONTENT unusual, odd, strange, bizarre thought content. BLUNTED AFFECT reduced emotional tone, reduction in formal intensity of feelings, flatness.

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Severe

Mild

EXCITEMENT emotional tone, agitation, increased reactivity. DISORIENTATION confusion or lack of proper association for person, place, or time.

Global Assessment Scale (Range 0-100) _________________________________________________________________

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Section 2: Psychosocial Assessment


Note:

It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by observing verbal and nonverbal behaviors and making inferences as you and the patient work toward accomplishing a goals and objectives.

a r k l

III. LOVE AND BELONGING l 1. Emotional State t a. What seems to be the clients mood? -Normal for Age/Culture h -Flat Affect -Withdrawn -Depressed -Anxious -Fearful -Uncooperative a -Elevated -Euphoric -Expressive -Other t 2. Clients Life Experience a. How have previous life experiences affected the clients perception of the current health problems? Because of the traumatic abused p caused by a family member to Zahra she experience intense feelings of p revenge and

Related Nursing Diagnoses


Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for

l and physically hatred among the people around her, she is lack of attention
and emotionally abused which brought her under the situation : she has in.she is thinking all the person around her is against her,

b.

How has life changed as a result of the current health problem? Zahra is enable to go out with her friends and family because of her attitude that is difficult to handle, she is enable to express her feelings that normal person is doing, shes to get attention and love from the people around her,(role performance ineffective.

c.

Describe any signs or symptoms that may indicate actual/potential physical/emotional abuse. Lying so that no one will be mad at her, throwing things when angry (risk for violence), uncontrolled anger, depression and emptiness.

3.

Family a. What is the client and familys perception of the illness/admission? hopelessness due to inappropriate attitude present by Zahra and lack of control,

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b.

What evidence indicates that family life has changed? As by family they are thinking that Zarah is the one who will break their family relationship, and that cause also her mother to have breakdown.

c.

How do family members seem to be coping? They are trying to confront negative activity of Zahra but as they dont have knowledge about the disease or disorder their daughter has her mother has breakdown and they feel hopelessness and think that Zahra is the one whos breaking their family

d. 4.

What supportive behaviors from family/significant others are evident? none mentioned

Erikson/Newman/Newman Developmental Stage: a. b. What task is appropriate for this stage of development identity vs. role
confusion

How has this health problem interfered with accomplishing the development tasks for this client?
When they reach the teenage years, children start to care about how they look to others. They start forming their own identity by experimenting with who they are. If a teenager is unable to properly develop an identity at this age, his or her role confusion will probably continue on into adulthood. That happen to Zahra she has difficulty in developing her identity because of the experiences she has unto.

c.

What evidence indicates negative or positive developmental resolution? negative because of outburst emotion when angry, feeling of lonesome and lack of attention but caring and lovable if not angry.

IV. SELF-ESTEEM: 1. Self-Esteem and Body Image a. How is the clients self-esteem threatened by this illness/admission? low self esteem causes her to commit suicide she feel that something is

Related Nursing Diagnoses


Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive

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2.

Coping, Ineffective Coping, Readiness for Enhanced far from her family again. Death Anxiety Decisional Conflict (Specify) Denial, Ineffective b. What is the clients perception of body image and how has it changed? Fear Grieving, Anticipatory she is bulimic and engaged in purge binge diet. body image disturbed and lack of proper hygiene Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness c. What fears/concerns were expressed by the client that relate to clients Personal Identity, Disturbed present illness? Post-Trauma Syndrome Post-Trauma Syndrome, Risk for she fell terrible and rather be dead, suciadal thoughts. Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Culture Rape-Trauma Syndrome, Compound a. What is the clients ethnic background? SAUDI Reaction b. How does culture/language influence communication between client/family Rape-Trauma Syndrome, Silent Reaction and healthcare workers? Lack of parental and support system that unable Relocation Stress Syndrome Relocation Stress Syndrome, Risk for her to recover and for her manipulative behavioral aspects even Self-Esteem, Chronic Low disregarding the authority , she will not accept ideas from others because of Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for her anger and hatred related to abused. Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress c. Which communication factors are relevant and why do you think so? Spiritual Distress, Risk for (Touch, personal space, eye contact, facial expressions, body language) Spiritual Well-Being, Readiness for Enhanced Touch which enables her to feel that somebody is being there for Self-Actualization her. And eye contact which she will feel that you are sincere in Health Maintenance, Ineffective Health Seeking Behaviors (Specify) caring for her. Home Maintenance, Impaired Knowledge, Deficient (Specify) d. Who seems to be making the healthcare decisions in the family? Her foster Knowledge, Readiness for Enhanced (Specify) father because of inability of her mother to cope up with the problems they Noncompliance Therapeutic Regimen: Community, have. Ineffective Management of e. Based on your observations, what role does each family member play? Therapeutic Regimen: Families, Ineffective Management of At first they are caring too much for Zahra but because of the inappropriate Therapeutic Regimen: Management, attitude they disregard her thats why they adopt another relatives and far Effective Therapeutic Regimen: Management, from it attitude of Zahra has worsen.. Ineffective Therapeutic Regimen: Management, Readiness for Enhanced f. Who is responsible for care of a sick family member at home?

wrong with her. And nobody likes her. impaired adjustment due to being

Parents that enable to understand the problem.

g.

What cultural practices related to hospitalization need to be considered? because of their religion she should have to be isolated with the female same case with her.

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3.

Spirituality

V. SELF-ACTUALIZATION 1. What is the clients/familys current level of understanding of their health/illness problem? Parents they have lack of information regarding the disease process because it seems to it how they confront Zahra, they are thinking that it is a simple rebellion towards them, but from the history itself they should understand. That Zahra experiences abused and they should know how to evaluate every aspects of her attitude. And bring her to the institution which she could be treated.

2.

What type of relationship exists with healthcare providers? the care provider should be patient and more on theoretical approaches to manage the problems of the client. Nurse patient interaction.and therapeutic milieu would be effective.

Education/discharge planning: See M.E.T.H.O.D. attached.

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Nursing diagnosis

Desired outcome
Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met, describe outcomes not met) Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care (Explain revisions as needed)

NDX: (Problem) Suicide, risk for And violence risk for

Interventions (I)Independent (C) - Collaborative N1(I)-(C) Maintaining a Safe Environment

Rationale & APA Reference R1 Precautions should be taken to reduce risk of harm to self or others. Remove items that may be used as a weapon. Frequent observation should be performed to ensure patient safety. Awareness of her safety for healthcare professionals should also be priority if there is a risk of harm to others. For example, stay between the door and the patient, with the door open whenever possible. Avoid wearing jewelry such as necklaces, and avoid wearing your hair in a ponytail.

Evaluation of Interventions E-At the end of nursing management, INTERVENTIONS NURSE PATIENT INTERACTIONS PATIENT DEMONTSTRATE LESS SUICIDAL THOUTHGS, S/S AND improved social and interpersonal functioning and changing maladaptive cognitions and behaviors. Towards the end of treatment, and create healthy sense of self and stable identity.

R/T: (etiology/factor): Physically and emotionally abused by family

AEB: (s/sx; defining characteristics)

1.suicidal thoughts.

2.uncontrolled angers

3.maladaptive cognition

*If risk for would exhibit:

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N2(I)-(C) Establish a Therapeutic Relationship with the Patient

R2 Trust and rapport are important with the patient relationship. Be straightforward in communications, and avoid use of medical jargon. Empathy and nonjudgmental attitude is vital.

N3(I)- R3 Maintain Objectivity & Consistency Amongst the Health care Team While empathy is vital, it is equally important to remain objective with the patient. Some patients with personality disorders will attempt to play on the emotions of healthcare professionals to manipulate. Consistent information and interactions with the patient can be assured by developing an interdisciplinary plan of care, and ensuring that communications between healthcare teammembersis consistently

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updated.

Establish a Written Contract with the Patient

This contract should discuss expected behaviors of the patient. It is also important to include that the patient will not harm self or others, and will notify a member of the team if feelings to do so develop.

Set Behavioral Limits

Let the patient know what behaviors are acceptable, and which are not. Also outline potential consequences for inappropriate behavior

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Assist the Patient with Reducing Anxiety

Explore breathing and relaxation techniques to assist the patient in reducing anxiety. Visualization and meditation may also be useful. Medications should be used only after nonpharmacological methods are tried.

Encourage the Patient to Use a Journal

A strategy to assist patients work through their perceptions, responses, and emotions is through the use of a journal. This is both therapeutic and assistive in providing information for the healthcare team.

Recognize Manipulative Behavior

Many persons with PDs attempt to manipulate others, either intentionally or not. Do Not reveal any personal information to the patient. One behavior that is common, particularly with patients diagnosed with borderline or antisocial PD is splitting. The patient attempts to split or divide members of the healthcare team by

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playing one against the other. They may make statement such as, You are the most helpful out of everyone or, You know, the other nurse said you werent as good as she is. Identifying these behaviors and setting limits is essential, as well as communicating the use of these actions to other members of the healthcare team.

Patient and Family Participation

It is important that the patient participate as a member of the healthcare team. They should be allowed to make choices and maintain independency, as long as it is within the limits set. This assists in building rapport and forming therapeutic relationships. Families should also be encouraged to participate as indicated.

Encourage Discussion of Feelings

Patients should be encouraged to discuss feelings that they have, rather than act them out. This assists the

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patient to cope with their emotions and limit behaviors that result in ineffective coping. Discussions should be focused and timelimited as appropriate.

Discuss Expectations

All members of the healthcare team including the patient, should know what the short Term and the longterm goals and expectations are. Hospitalizations for patients with personality disorders are generally short, and are usually related to an acute behavioral episode (such as selfharm). Outlining the expectations can define measurable outcomes.

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NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK (NOTE: MARK ALL THAT APPLY TO YOUR CLIENT)
Oxygen Needs/Circulation Breathing Airway Clearance, Ineffective Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk for Sudden Infant Death Syndrome, Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional Circulation Cardiac Output, Decreased Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Excess Fluid Volume, Risk for Deficit Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) Neurological/Neurovascular Neurological Confusion, Acute Confusion, Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed Neurovascular Dysreflexia, Autonomic Dysreflexia, Risk for Autonomic Peripheral Neurovascular Dysfunction, Risk for Nutrition/Hydration Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Failure to Thrive, Adult Fluid Volume, Deficit Fluid Volume, Deficit, Risk for Infant Feeding Pattern, Ineffective Nausea Nutrition: Imbalanced, Risk for More Than Body Requirements Nutrition: Imbalanced, Less Than Body Requirements Nutrition: Imbalanced, More Than Body Requirements Nutrition: Readiness for Enhanced Oral Mucous Membranes, Impaired Self-Care Deficit, Feeding Swallowing, Impaired Elimination Tissue Perfusion, Ineffective Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention Rest/Activity Activity Intolerance Activity Intolerance, Risk for Disuse Syndrome, Risk for Diversional Activity Deficient Fatigue Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Perioperative Positioning Injury, Risk for Sedentary Lifestyle Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for Enhanced Transfer Ability, Impaired Walking, Impaired Comfort/Sexuality Comfort Pain, Acute Pain, Chronic Sexuality Sexuality Pattern, Ineffective Sexual Dysfunction Safety/Skins/Wounds/Infections/Sensory Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced Body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Skin Integrity, Impaired Skin Integrity, Impaired, Risk for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for Disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for Self-Care Deficit, Bathing/Hygiene Self-Care Deficit, Dressing/Grooming Self-Care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field, Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Poisoning, Risk for Self-Mutilation Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for Anxiety Concerns/Fear/Knowledge Needs Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify)

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Bowel Constipation Constipation, Perceived Constipation, Risk for Diarrhea Incontinence, Bowel Nausea Urinary Fluid Volume, Risk for Imbalanced Infection, Risk for Incontinence, Functional Incontinence, Reflex Incontinence, Risk for Urge Incontinence, Stress Incontinence, Total Incontinence, Urge

Self-Mutilation, Risk for Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for Other-Directed Violence, Risk for Self-Directed Love/Belonging/Culture/Coping/Body Image Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced

Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

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M.E.T.H.O.D. Daily Teaching Plan and Evaluation

PATIENT INITIALS:

LEARNERS PRESENT (circle):

Client

Family

Sig. Other

Other __________

MEDICAL DIAGNOSES:

TECHNIQUES: Discussion

Q/A

Demos Handout(s)

Other __________

Date/
Initial M (Medications): Zoloft, clonazepam, quetiapine

Content
Evaluation

E (Environment): Safe environment

T (Treatments):

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H (Health knowledge of disease):

O (Outpatient/inpatient referrals): (including resources such as websites and organizations):

D: (Diet):

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