MENTAL RETARDATION

• Below average intellectual functioning - IQ of 75 or less

• Deficits in adaptive functioning for age and cultural group
• Onset before age 18
PSYCHOPATHOLOGY
• 30% of the cases have no cause
• Genetic factors – 5% of cases
o PKU, Chromosomal disorders (Down’s & Tay Sach’s)
• Prenatal, Perinatal
o Prematurity
o Something that cuts off oxygen to fetus
o Major is Alcohol & drug abuse – Fetal Alcohol Syndrome
o Illness during pregnancy: Toxemia, Uncontrolled diabetes, Rubella
• Postnatal
o Anything that occurs during childhood 5%
o Meningitis
o Lead poisoning – Insecticides
o High fever
o Asphyxia
• Social, Cultural and Environmental Factors
o 20% of cases of MR
o Poor parenting- deprivation of nutrients and Lack of social stimulation
DIAGNOSIC TESTS
• IQ Tests or Lack of skills
• DSM-IV
o Coded on Axis II
o Mild (50-70)
 Capable of independent living but may need some assistance during times of stress.
 Can go up to 6th grade in school
 Can function in a structured setting
 Can achieve vocational skills for minimum self support
 May not need to go to any type of facilities provided by Dept of Health
 Can work- fast food
 Mental age of 8-12 yrs
o Moderate (35-50)
 Requires supervision and can achieve a 2nd grade level of education
 Could contribute to their own support in a sheltered workshop
 May have some trouble with very fine motor skills, may have problem in speech
 May have some difficulty in peer relationships
 Mental age of 3-7
o Severe (20-35)
 Might be trained in elementary hygiene skills and requires complete supervision
 NO academic or vocational training
 Work with habits. Self-care and Hygiene activity.
 Minimum verbal skills.
 Only able to perform simple tasks under close supervision & instruction
 Wants & needs communicated by acting out behavior
 Act like a toddler
o Profound (below 20)
 Unable to function independently. Constant aid and supervision.
 Cannot benefit from any vocational or academic training.
 May respond to minimum training in self-care. Must be one on one
 No speech development
  Constant supervision and care
HEALTH PROMOTION
• Genetic Counseling
o Advise couple not to have children
o A nurse would not do that; a physician would
• Prenatal Care
o Critical, Decrease prematurity, and other birth complications
• Avoid Substance Abuse
o Teach mothers to avoid alcohol and drugs
SECONDARY PROMOTION
• Nurse important in identifying impairment
o Because the nurse usually does the assessment in Dr’s offices
• Family and child education
o Family needs to be taught how to work with the child
o What Resources are available
• Early Intervention Programs
o Can begin at birth
o Help reduce some impairment
o Begin as newborn
o Mainstreamed in school
NURSING PLAN OF CARE
As if in a med-surg hospital
• High risk for injury
o Create a safe environment
o You as a nurse may have a MR client on a Med Surg floor with another illness. Be careful if
they are ambulatory they may not know not to put their hands in the Sharps container.
o May have seizures – pad side rails
o Ask family about habits: What upsets them
• Self Care Deficit
o Talk with the family and know what the client is able to do
o Respond to (+) reinforcement
• Impaired Verbal Communication
o Learn from the family, words they may say or have the family assist you understanding what
they are saying so that you may have some type of communication with them.
o May be non verbal signals – Know what they mean
• Impaired social interaction
o Keep safe; Don’t let them get into a setting where other people might make fun of them. Or
where they can be injured.
o Respond to token economy and Praise
DIAGNOSTIC TESTS
• EEG – Done to identify a person that has seizures
o Look at Doctors and see if any medications or sleep needs to be withheld prior to the EEG,
because sometimes sleep is withheld to have the person sleep through the EEG. May hold
anticonvulsants, coffee or tea.***
o Need to eat prior to the test. May give oral sedative to induce sleep.
o May do activities during EEG to induce seizure.
• MRI - May have to be sedated – noisy NO METAL
• CT Scan – May have to be sedated
 DIAGNOSTIC TESTS

BLOOD WORK
• Dexamethasone Suppression Test
o One way of diagnosing depression – not used much
o If not depressed decadron suppresses cortoisol level
o They give the person 1mg of decadron at 1100pm. Then the next day they draw a plasma
cortisol level at 4pm and 11pm.
o If greater than 5mg the person is likely to have depression
 If you are not depressed then the decadron level will be lower than 5
 In depressed people the body does not suppress the cortisol secretion

• TSH
o Thyroid Stimulating Hormone
o May be done to rule out a physical cause for depression
o Hypothyroid – Depressed
o Hyperthyroid – Manic
o Done also before a client is put on Lithium to make sure the Thyroid is working fine.
DIAGNOSTIC TESTS
• Personality Tests
o Objective
 Minnesota Multiphasic Personality Inventory
• 550 statements the person answers T or F or cannot say
• Will ask the same question over and over in different ways to prevent you from
lying
• Psychologists will give 3 tests to see how they correlate
 Beck Depression Inventory
• Answers questions
• 21 items weighed 0-3
o Projective
 When the clients thoughts and feelings are projected on the subject
 Rorschach
• Ink Blot test
o The first thing that comes to mind
o Can help in diagnosis
o Given by a clinical psychologist
o Helps differentiate coping skills
 Draw a person test
• What type of person is drawn
• Draw a person & then one of opposite sex
• Done 2 or 3 times to compare
• Guidelines to go by
• Intelligence Tests
o Wechsler Adult Intelligence Scale
 Most common used for IQ testing
 Completes 11 sub tests which yields verbal and performance scores
 16 years and older
o Stanford-Binet Intelligence Test
 Test given to children (2-15 yrs) and more useful in the mentally retarded person.
 Age appropriate subtests to determine mental age
 ANXIETY

• Needed in our daily lives to achieve goals

• A feeling of apprehension, uneasiness, uncertainty resulting from a real or perceived threat whose
actual source is unknown or unrecognized.
• Moderate level of anxiety we use defense mechanisms
• Normal anxiety provides the energy needed to carry out the tasks involved in living and striving toward
goals.
• Becomes abnormal when severity is inappropriate or when it occurs in inappropriate circumstances.*
o Or inappropriate to situation – mildly anxious = defense mechanisms
• A person gets anxiety then the person develops a behavior to get rid of that anxiety – Then it can
become a disorder when a person uses that behavior all the time it interferes with interpersonal
relationships, affects social functioning, or affects job performance.
• The type of maladaptive behavior that occurs is how these are diagnostic. Most of the time is can be
o Anxiety, avoidance, physical symptoms, memory disturbance.
• Primary gain
o “Reward”
o Relief & reduction of anxiety
 When the anxiety is relived so that is a reward
• Secondary gain
o “Fringe benefits of being ill”
o Seen on Somatoform disorders
o Attention, release from responsibility, getting one’s way, dependent”
 Having people taking care of you, Boss or husband
 DO not seek help unless someone demands it
 Feel life is unpleasant living under these conditions
PEOPLE WITH THESE DISORDERS
• Are aware that they are experiencing distress
• Are aware that their behaviors are not rational or maladaptive
• Are unable to identify the specific cause of why there behaviors are ocuring
• Are unaware of any possible psychological causes of the distress
• Feel helpless to change their situation – Not psychotic
PSYCHOPATHOLOGY
• Biochemical
o Neurotransmitters Seritonin and GABA are involved
• Genetics
o Relatives with it
• Psychosocial
o Learned especially phobias. Distorted thinking must always be perfect
o Person thinks they must be approved by everyone in society- distorted thinking & appear
perfect at all times
• Sociocultural
o Differentiate what is normal for this culture and anxiety for another culture
GENERALIZED ANXIETY DISORDER
• Chronic, unrealistic, excessive anxiety and worry, motor tension, 6 months
o Always thinking something bad will happen before doing
o Can start in childhood or adolescence
o No continuum- happens all of a sudden
o Early 20’s have mild symptoms
o Can have depression symptoms also
o Meds: Buspar****
PANIC DISORDER WITHOUT AGORAPHOBIA
• Terror, feeling of impending doom, intense physical discomfort, Depression is Common
 o Recurrent panic attacks – do not know when they are going to occur
o Can have symptoms of depression
o Onset – Late 20’s average
o Can last minutes or occasionally hours
o Meds: Antidepressants – IF MAOI TEACH ABOUT TYRAMINE FOODS****

PANIC DISORDER WITH AGORAPHOBIA

* fear of open spaces
• Symptoms of Panic Disorder
o Has panic attacks and that has caused the person to be housebound
o Are afraid if they have a panic attack they would not be able to get out of that situation.
o Fear of being places from which escape would be difficult
o Feel safe being at home
o Go to extreme measures to avoid a panic attack
o Restricts travel
o Enabler gets control out of situation
o Common Things Avoided:
 Outside home
 Bridge
 Riding in a bus, train, car
 Crowds
Example: If a woman has this disorder and married the client has a lot of secondary gain
• Woman could not function unless she had a support person to do everything for her
• The husband also has a gain it is Control.
SOCIAL PHOBIA
• Fear of appearing shameful, stupid or inept in the presence of others.
• Avoid any situation that would put them at risk such as:
o Speaking, eating, public restrooms, writing. Avoid these situations.
 Only experience anxiety when they have to do this
 Fine as long as you avoid what you are afraid of
 May affect social or occupation
 If job depends on it, may go to seek help
 Meds:Inderal****
SPECIFIC PHOBIA
• Fear of object or situation
o Snakes, spiders, flying, heights
• Anxiety only in presence or thinking about phobia
o More common in women as long as it does not interfere in functioning they can lead a normal
life
o Same physical symptoms of panic attack can occur
o Occurs more in women – Can be learned from parents
o Desensitization Therapy and Relaxation techniques is an effective tx for Phobias***
• Can learn from parents
OBSESSIVE-COMPULSIVE DISORDER
• Obsessions, compulsions, has to do ritual to avoid anxiety.
• Obsessions
o Unwanted thoughts that occur repeatedly- violence, contamination, doubs
• Compulsions
o The acts you have to do to get rid of the anxiety
 Handwashing, counting, checking, or touching
• A disorder when interferes with client’s life
o Thoughts recurrent in head
o Actions- to relieve anxiety
• If takes over life is OCD
Main ND for OCD – Ineffective Individual Coping****
POST TRAUMATIC STRESS DISORDER
 • Re-experience trauma in dreams, images, flashbacks, survival guilt, anxiety, depression, numbing of
responses.
• Experienced an abnormal trauma that normal people do not experience
• Get depressed and affects their whole life
• Occurs within 3 months or later
• Become emotionally numb
• Coping skills affect whether or not gets better
Whether or not you develop PTSD depends on your coping skills
o If you are a good coper you are less likely to have traumatic stress disorder
• May unconsciously react
• Rape, military combat, earthquake, tornado
• Trouble with jobs
• Difference in relationships
• People can become numb and do not respond normally to emotion
• May have depression
HEALTHY LIFESTYLE
To deal with anxiety in general
• Manage Stress
o Relaxation
 If you are relaxed you won’t feel anxious
 Develop your own system of relaxation
 Have to be practiced
 Abdominal breathing
o Nutrition
 Well balanced vitamin B&C and decrease caffeine intake
o Exercise
 Decreases Stress & anxiety
oSleep
 8 hours per night
SECONDARY PREVENTION
• Early diagnosis / treatment
o Parents should watch children and notice if they are having any problems with anxiety and
intervene early
o Sooner the better disrupts lives less
• Relaxation techniques
o Deep breathe, abd. Visualize, progressive muscle relaxation can be used with all these
disorders
o Can’t be tense & relaxed at one time
• Cognitive restructuring
o Replacing negative. Self talk with positive self talk changes distorted thinking- changing what
thinking
o Can be used with all disorders
• Behavior Modification – Used in Phobias
o Systematic Desensitization
 First taught relaxation techniques
 Helping person face phobia using gradual exposure
 Done several days a week
o Flooding
 Exposed to large amounts to endure until anxiety decreases
 Get as anxious as possible & will then have to relax
o Response Prevention
 Used with OCD
 Refuse the person of perform their rituals
 Done with a treatment team – the staff sets limits
 They have to be allowed to perform rituals so they can become comfortable with the
environment.
  They become comfortable then they gradually decrease the time they can spend on
their ritual.
 Would not be done by a nurse it would be done as a team approach
o Thought Stopping
 Used for OCD
 Shout stop – or snap rubber band on wrist to change thinking
 Bead bucket- give away bands
• Group Therapy
o PTSD and Some phobias have self help groups
o Self help – leader is a person who has gotten over the disorder
HOSPITALIZATION
o Only in the hospital if they have prolonged or severe anxiety, health is in danger or they are
suicidal.
• Milieu Therapy
o Must have a Structured routine – creates less anxiety because they know what to expect
o Activities
 Gets mind off self
 Are self centered & always thinking about self
o Therapeutic Interactions

The nurse is very involved in the care of the clients b/c whenever they are anxious you
need to STAY WITH THE CLIENT.
 Support the other therapies they are going to
o Self care activities
 May affect ability to care for themselves
 Hygiene may be affected
 All adl’s affected
 May not eat – Nutrition affects – OCD may not take time to eat because are doing
rituals, Phobic may be afraid of germs so will not eat certain foods
 May not take time to go the BR – Set a time to go to BR
 OCD – takes hours to dress or perform hygiene
 Most all have trouble sleeping PTSD have nightmares, stay with client until calm
 May wash their hands too much. Watch for physical health also.
MEDICAL PLAN OF CARE
• MEDICATIONS
o Antianxiety
 Usually given for short periods of time in order to engage in other therapies in order to
reduce anxiety.
 Benzodiazepines
• Panic Disorders & General Anxiety
• Are addictive & overused
• Use only until coping mechanisms achieved
• Ativan, Xanax, Tranzene, Valium, Librium, Klonopin
o Supress CNS – Absorbed in the GI tract – DO NOT give antacids
when giving these medications because will delay working
o No alcohol
• Common Side Effects:
o Drowsiness- if put to sleep is too high
o Ataxia
o Weakenss
o Decrease pulse and BP
o In elderly or debilitated persons there may be an adverse affect that
will make the person more excited & agitated
 Miscellaneous
• Vistaril- antihistamine
• Buspar
 o is only used for Generalized Anxiety Disorder****
o is less sedating
o won’t cause dependence
o does not work rapidly- takes 2-3 weeks to work
• Beta Blockers – Inderal for Social Phobia
o Works on the physical symptoms of anxiety helps relax the person
o Take only when giving a speech or anything that causes anxiety
• Antidepressants
o All can be used for Panic Attacks
o Tricyclics(TCA)
 Panic
 OCD (Aanfranil)
 PTSD
o SSRI
 Panic
 Phobias
 OCD – Luvox or Prozac
o MOAI
 Panic
 Social Phobias
 PTSD
o Kava
 Is an herb
 Don’t take with cns meds
 Causes
• Gi upset
• Headaches
• Dizziness
• Allergic skin problems
NURSING PLAN OF CARE
• Anxiety – p460
o If having a panic attack -- Stay with client
o Take to environment with decreased stimuli
o Nurse should appear calm – Slow down your breathing they will follow “Breath with me”
o May have to give an antianxiety agent (PRN Ativan)
o Once calm teach relaxation techniques
o Teach positive self talk
o Increase exercise
o Decrease caffeine
o Discuss what happened so you can ID a pattern- once they are better
o Keep simple, clear words,
 Take over-tell them what to do
• Ineffective individual coping – Seen in clients with OCD
o Focus on client not symptoms
o Will be uncomfortable in hospital – DO NOT take away their ritual – they must become
accustomed to the environment.
o With a team approach you would begin to limit rituals
o Watch for their physical health – Handwashing – can have hands raw and sore
o Reluctant to get help because rituals are done in secret
o Only time they are in the hospital is because husband or wife is threatening to leave them or
their job depends on it.
o Never hurry them to make a decision – They have to make a “perfect” decision so give them
time.
o Thought stopping, Rubber band
o Medications: Tricyclic (Anafranil), SSRI (Luvox or Prozac)
• Fear – Clients with Phobias
o Rarely in hospital
o Mainly support their therapy that they are engaging in
o Practice relaxation techniques
o Role model – Do not be afraid
o A nurse does not make a client face a phobic object – it is not in the nurses job description.
o Listen to their feelings
• Posttraumatic Stress response p 464.
o Assessing patterns of sleep due to nightmares
o If they wake up with nightmares – Stay with Them until they feel better. They may need to talk,
Be there for them
o Often these people will abuse drugs and alcohol to self medicate so assess for substance
abuse
o If a rape client – respect wishes and do not give a male staff member
 SOMATOFORM DISORDERS

• Anxiety transformed into physical symptoms

• Physical symptoms suggesting medical disease
• Precipitated by psychological factors
• More acceptable than mental illness
• Medical costs – expensive
• Side Effect: Addiction to medications
• Not follow through with psych consult
• Having Physical symptoms (instead of mental) gets sympathy from others
• Malingering is deliberately having symptoms
PSYCHOPATHOLOGY
• Biological
• Genetic
o Runs in families - Some type of conflict that is causing anxiety
• Cultural
o Mainly women
o Sometimes greek & peurto Rican men
• Psychosocial
o Psychoanalytical - Repressed Conflict
• Behavioral
o May have learned that if they are helpless they may manipulate others in to doing what they
want them to.
SOMATIZATION DISORDER
• Multiple physical complaints but they don’t focus on one specific disease
• General – Usually Neuro or GI
• Multiple providers (doctors)
• Impairs social and occupational functioning
THERE IS NO PHYSICAL
• They have altered their life pattern because they think they are sick REASON FOR THE
• Chronic, begins before age 30 SYMPTOMS THEY ARE
HYPOCHONDRIASIS HAVING
• Feel they have a specific serious disease and physical complaints follow that disease pattern.
• Misinterprets body symptoms
• Over 6 months
• Impairs social and occupational functioning
• May “Doctor shop” they feel they are not getting the proper care
• ND: Ineffective Individual Coping /2nd Gain; Attention and relief from having to go to work***
PAIN DISODERS
• Severe and prolonged pain that is out of the ordinary for their condition
• Must believe them & treat their pain
• Impairs social and occupational functioning.
• If there is a physical condition present then the pain is accepted
• Often the pain will allow the person to avoid unpleasant activities or get support they may not get
otherwise.
• Person might get addicted to pain medication
• May request surgery – Back pain
CONVERSION DISORDER
• Loss of or change in bodily function resulting from a psychological conflict
• Occurs after extreme psychological stress
• Most Conversion reactions resemble a neurological disease
o Ex. Paralysis, seizures, blindness, numbness in different areas of the body
• Sudden onset, after severe stress
• La belle indifference- seem unconcerned
o If a normal person were to suddenly become blind the would panic
 o This disorder is diagnosed by “La belle indifference” apathetic about having this problem (don’t
really care)
o Because being blind has gotten them out of a difficult situation
o A lot of Primary (getting out of that situation) and Secondary gain (all the attention they would
receive)
• Recover
• ND: Ineffective Individual Coping – With these clients you may have physical diagnosis
• Primary Gain: Getting out of the situation
• Secondary Gain: Attention****
SECONDARY PREVENTION
• Healthy lifestyle may help prevent some of this
• Med surg setting rather than psych settings because of their physical symptoms
o Will go through many diagnostic tests trying to rule out things
o Many will have surgery
o Very difficult clients to care for
o They are always on the call light with complaints
o Nurse client relationship is very important
 Have the client trust you, do what you say you are going to do. If you said you would be
there in 10 minutes—Be there in 10 minutes
• Diagnostic tests
o To rule out other disorders
• Difficult clients
o Always have on light always want pain meds every 2-3 hours
o Have Client trust you
• Individual and group therapy
o Will help because in group will talk about how client expresses anxiety through physical
symptoms
o Work on having them directly verbalize their feelings
• Family therapy
o Important family may reinforce “sick” behavior
o Need to be aware of the secondary gain
o Need to give attention to client when they are not sick
• Cognitive Restructuring
o Negative self thoughts to positive
MILIEU THERAPY
• Self Care Activities are impaired with these disorders
o Treat them as if they really have that condition
o Expect them to be as independent as they can
o Matter of Fact approach
o Support client self-care
• Relaxation techniques
• Assertiveness Training
o Helps client being able to verbalize to have their needs met rather than getting their needs met
through physical symptoms.
• Biofeedback
o Teach relaxation
• Case Manager
o Help save medical cost
o Govern what providers the patient sees
• Exercise
o Can help the persons self of well-being
MEDICAL PLAN OF CARE
• SSRI for Depression
• Recognize addiction of antianxiety, pain and sedatives
NURSING PLAN OF CARE
• Ineffective individual coping p.490
• Remember with Somatoform Disorders there is no physical reason for their problems; once you have
discovered there is no physical reason you don’t keep repeating tests (checking pulse)
• Spend time with the client other than when they are asking for you to come down for a physical
complaint.
• Do chart about physical complaints but do not spend a lot of time standing there listening to all their
physical complaints
• Make agreement
o “I will stay in your room and talk to you as long as you don’t talk about your physical
complaints”
• Helps them learn to talk about other things
• Encourage to attend Assertiveness training so they know how to ask to get their needs met
• Teach stress reduction techniques
o Distract client
o Involve in other activity
o Talk about something else
o Avoid rejection
o Do what you say you are going to do
 DISSOCIATIVE DISORDERS
• Disruption in consciousness, memory, identity, or perception of environment
• Person has such an overwhelming anxiety that personality disorganization happens
• Unaware of their overwhelming anxiety
• Anxiety is repressed because what has happened to them is so awful that if they were to face it, it
would be overwhelming
• Causes a person to “tune out” what has happened to them- saving their mind
• Associated with Childhood abuse
DISSOCIATIVE AMNESIA
• Inability to recall important personal information
• Generalized
o Can’t remember anything about their entire life
• Localized
o Memory loss occurs for all incidence associated with a traumatic event for a specific time
period following event
• Selective
o Inability to recall incidence associated with a traumatic event.
o Ex. May remember a car accident but cant remember that someone was killed in the accident”
• Generally this terminates abruptly and the person is completely normal, so they get over it very quickly
and may not have any other episodes.
DISSOCIATIVE FUGUE
• Triggered by a traumatic event
• Sudden unexpected travel away from home or the customary work place
• Inability to recall identity and information about their past
• Assume new identity; then all of a sudden they will go back to their original identity and have Amnesia
for the Fugue state.
o EX. You come to school one day
o The next thing you know you are in Dallas
o When you are in Dallas, you assume a new identity and get a job
o All of a sudden the police find you walking down this road and the only thing you can remember
is that you are from Jackson MS and don’t know how you got there.
• No recurrences, Recovery is rapid and complete
DISSOCIATIVE IDENTITY DISORDER
• Multiple Personality- 2 or more subpersonalities
• Generally there is a “main” personality that is most often in charge; occasionally the subpersonality will
take over the “main” personality
• Each has own memories, behavior patterns, social relationships
• Most of the time the “Main” personality is not aware of the other personalities but the subpersonalities
are aware of the primary.
• Primary or “Main” personality will have “lost time” due to the take over of the Subpersonality
SECONDARY PREVENTION
• Diagnostic tests
o Will be done to rule out any medical causes for amnesia
• Hospitalized when suicidal
o Try to keep them from Dissociating
 Have them wrap themselves in a blanket
• Reinforces external boundaries
 Hold a handful of ice or counting
• Helps them focus on something real
 Assign a certain chair that is a safe place
• Suicide is a high risk because it is the other personalities that are trying to kill them
• Behavioral therapy
• Family therapy
o Family life is very chaotic
MILIEU THERAPY
• Safe environment
o Very important
o Can be manipulative – They can find the one thing in the room to commit suicide with
o Watch closely
• OT / Art therapy
o Express themselves
• Unit meetings
o Help them feel part of the unit and not so isolated
MEDICAL PLAN OF CARE
• Medication
o Antianxiety – Ativan, Klonopin
 SSRI and Tricylic
o Antidepressants – Depression is a part of this illness
• Hypnotherapy
o Used as an adjunct to counseling – used to meet the other personality
o Have the longest type of talk therapy – May take years for all of the personalities to become
united as one
• Narcotherapy
o Interviewing the client under the influence of Pentathol (like general anesthesia)
o For fugue, amnesia, and did
NURSING PLAN OF CARE
• Personal identity disturbance p 502
o Provide safe environment\
o Don’t tell pt who they are
o Talk to each personality as they present
o Don’t push client to regain memory or any lost memory
o Keep environment simple
o Supportive of client
o Work on stress reduction (holding ice in hand, blanket)
o If client does not remember relationships you need to do family intervention
• High risk for violence to self
o Side affect of Depression