Neurotic Disorder:

Neurotic disorder (neurosis)is a less severe form of psychiatric disorder where patients show either excessive or
prolonged emotional reaction to any given stress. These disorders are not caused by organic disease of the brain and,
however severe; do not involve hallucinations and delusions.

F40-F48 - Neurotic, stress-related and somatoform disorders

CLASSIFICATION [ICD 1O]

F40 Phobic anxiety disorder

F41 Other anxiety disorders
F42 Obsessive - compulsive disorder
F43 Reaction to severe stress, and adjustment disorders
F44 Dissociative [conversion] disorders
F45 Somatoform disorders
F48 Other neurotic disorders

PHOBIC ANXIETY DISORDERS

Anxiety disorders are abnormal states in which the most striking features are mental and physical symptoms of
anxiety, which are not caused by organic brain disease or any other psychiatric disorder.

A phobia is an unreasonable fear of a specific object, activity or situation.

This irrational fear is characterized by the following features:

• It is disproportionate to the circumstances that precipitate it.
• It cannot be dealt with by reasoning or controlled through will power.
• The individual avoids the feared object or situation.
In phobic anxiety disorders, the individual experiences intermittent anxiety which arises in particular circumstances,
i.e. in response to the phobic object or situation.

ICD-10 Classification of phobic anxiety disorders

F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified

F40.0 Agoraphobia
Agoraphobia without History of Panic Disorder
Introduction:
Agoraphobia without accompanying panic disorder is less common than the type that precipitates panic attacks.
Impairment can be severe. In extreme cases the individual is unable to leave his or her home without being
accompanied by a friend or relative. If this is not possible the person may become totally confi ned to his or her home.

Definition:
In this disorder, there is a fear of being in places or situations from which escape might be difficult, or in which help
might not be available if a limited symptom attack or panic-like symptoms (rather than full panic attacks) should
occur.
It is possible that the individual may have experienced the symptom(s) in the past and is preoccupied with fears of
their recurrence.

Epidemiology:
Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.
It is diagnosed more commonly in women than in men.

DSM-IV-TR diagnostic criteria for agoraphobia without history of panic disorder

A. The presence of agoraphobia related to fear of developing panic-like symptoms.
Agoraphobia is the fear of being in places or situations from which escape might be difficult (or embarrassing) or
in which help might not be available in the event of suddenly developing a symptom(s) that could be
incapacitating or extremely embarrassing.
Examples include:
Dizziness or falling,
Depersonalization or derealisation,
Loss of bladder or bowel control,
Vomiting, or
Cardiac distress.
As a result of this fear, the person either restricts travel or needs a companion when away from home, or else
endures agoraphobic situations despite intense anxiety.

Common agoraphobic situations include being outside the home alone, being in a crowd or standing in a line,
being on a bridge, and travelling in a bus, train, or car.

B. Criteria for panic disorder have never been met.

C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition.

D. If an associated general medical condition is present, the fear is clearly in excess of that usually associated with
the condition.

F40.1 Social phobias

Definition:
Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated
negatively by others. The individual has extreme concerns about being exposed to possible scrutiny by others and
fears social or performance situations in which embarrassment may occur.
-(APA, 2000)
Exposure to the phobic situation usually results in feelings of panic anxiety, with sweating, tachycardia, and dyspnea.

Examples-
Fear of speaking or eating in a public place,
Fear of using a public restroom, or
Fear of writing in the presence of others.
In general social situations, such as saying things or answering questions in a manner that would provoke
laughter on the part of others.

Epidemiology:
Onset of symptoms of this disorder often begins in late childhood or early adolescence and runs a chronic, sometimes
lifelong, course.
It appears to be equally common among men and women.
The DSM-IV-TR diagnostic criteria for social phobia:
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed
to unfamiliar people or to possible scrutiny by others.
The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or
embarrassing.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a
situationally bound or situationally predisposed panic attack.

C. The person recognizes that the fear is excessive or unreasonable

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes
significantly with the person’s normal routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition and is not better accounted for by another mental disorder (e.g.,
panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a
pervasive developmental disorder, or schizoid personality disorder).

H. If a general medical condition or another mental disorder is present, the fear in criterion A is unrelated to it
(e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in
anorexia nervosa or bulimia nervosa)

F40.2 Specific (isolated) phobias

Definition:
Specific phobia was formerly called simple phobia. The essential feature of this disorder is a marked, persistent, and
excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or
situation.
-(APA, 2000)
Exposure to the phobic stimulus produces overwhelming symptoms of panic, including palpitations, sweating,
dizziness, and difficulty breathing

Epidemiology:
Phobias may begin at almost any age.
The disorder is diagnosed more often in women than in men
Diagnostic Criteria for Specific Phobia

A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific
object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take
the form of a situationally bound or situationally predisposed panic attack.

C. The person recognizes that the fear is excessive or unreasonable. NOTE: In children, this feature may be
absent.

D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the
person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is
marked distress about having the phobia.

F. In individuals under 18 years, the duration is at least 6 months.

G. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better
accounted for by another mental disorder. The diagnosis may be further specified as: Animal type Natural
environment type (e.g., heights, storms, water) Blood-injection-injury type Situational type (e.g., airplanes,
elevators, enclosed places)

Etiological Factors:
1. Psychoanalytical Theory
Freud believed that phobias develop when a child experiences normal incestuous feelings toward the opposite-sex
parent (Oedipal/Electra complex) and fears aggression from the same-sex parent (castration anxiety).
To protect themselves, these children repress this fear of hostility from the same-sex parent and displace it onto
something safer and more neutral, which becomes the phobic stimulus. The phobic stimulus becomes the symbol for
the parent, but the child does not realize this.

Modern-day psychoanalysts believe that other unconscious fears may also be expressed in a symbolic manner as
phobias.
For example,
a female child who was sexually abused by an adult male family friend when he was taking her for a ride in his boat
grew up with an intense, irrational fear of all water vessels. Psychoanalytical theory postulates that fear of the man
was repressed and displaced onto boats. Boats became an unconscious symbol for the feared person, but one that the
young girl viewed as safer since her fear of boats prevented her from having to confront the real fear.

2. Learning Theory
Classic conditioning in the case of phobias may be explained as follows: A stressful stimulus produces an
“unconditioned” response of fear. When the stressful stimulus is repeatedly paired with a harmless object, eventually
the harmless object alone produces a “conditioned” response: fear.
This becomes a phobia when the individual consciously avoids the harmless object to escape fear.

Phobias also may be acquired by direct learning or imitation (modeling) (e.g., a mother who exhibits fear toward an
object will provide a model for the child, who may also develop a phobia of the same object)

3. Cognitive Theory
Cognitive theorists espouse that anxiety is the product of faulty cognitions or anxiety-inducing selfinstructions.
Two types of faulty thinking have been investigated: negative self-statements and irrational beliefs.
Cognitive theorists believe that some individuals engage in negative and irrational thinking that produces anxiety
reactions. The individual begins to seek out avoidance behaviors to prevent the anxiety reactions, and phobias result.

4. Biological Aspects
a. Temperament:
Children experience fears as a part of normal development. Most infants are afraid of loud noises.

Examples-
Common fears of toddlers and preschoolers include strangers, animals, darkness, and being separated from parents or
attachment figures. During the school-age years, there is fear of death and anxiety about school achievement. Fears of
social rejection and sexual anxieties are common among adolescents.

Innate fears
For example, a 4-year-old girl is afraid of dogs. By age 5, however, she has overcome her fear and plays with her own
dog and the neighbors’ dogs without fear. Then, when she is 19, she is bitten by a stray dog and develops a dog
phobia.

b. Life Experiences:
Certain early experiences may set the stage for phobic reactions later in life. Some researchers believe that phobias,
particularly specific phobias, are symbolic of original anxiety-producing objects or situations that have been repressed.

Examples include:
● A child who is punished by being locked in a closet develops a phobia for elevators or other closed places.
● A child who falls down a flight of stairs develops a phobia for high places.
● A young woman who, as a child, survived a plane crash in which both her parents were killed has a phobia for
airplanes.

I) NURSING DIAGNOSIS: FEAR

RELATED TO: Causing embarrassment to self in front of others, being in a place from which one is unable to
escape, or a specific stimulus
EVIDENCED BY: Behaviour directed toward avoidance of the feared object or situation

Outcome Criteria:
Short-Term Goal
Client will discuss the phobic object or situation with the health-care provider within (time specified).

Long-Term Goal
By time of discharge from treatment, client will be able to function in presence of phobic object or situation without
experiencing panic anxiety

Nursing Intervention:
1. Reassure client that he or she is safe.
R-At the panic level of anxiety, client may fear for his or her own life.

2. Explore client’s perception of the threat to physical integrity or threat to self-concept.

R-It is important to understand client’s perception of the phobic object or situation to assist with the desensitization
process.

3. Discuss reality of the situation with client to recognize aspects that can be changed and those that cannot.
R-Client must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can
progress.

4. Include client in making decisions related to selection of alternative coping strategies. (e.g., client may choose
either to avoid the phobic stimulus or to attempt to eliminate the fear associated with it.)
R-Allowing the client choices provides a measure of control and serves to increase feelings of self-worth.

5. If client elects to work on elimination of the fear, techniques of desensitization or implosion therapy may be
employed.
R-Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the
phobic stimulus under nonthreatening conditions.

6. Encourage client to explore underlying feelings that may be contributing to irrational fears, and to face them rather
than suppress them.
R-Exploring underlying feelings may help the client to confront unresolved conflicts and develop more adaptive
coping abilities.

II) NURSING DIAGNOSIS: SOCIAL ISOLATION

RELATED TO: Fears of being in a place from which one is unable to escape
EVIDENCED BY: Staying alone; refusing to leave room or home

Outcome Criteria:
Short-Term Goal
Client will willingly attend therapy activities accompanied by trusted support person within 1 week.

Long-Term Goal
Client will voluntarily spend time with other clients and staff members in group activities by time of discharge from
treatment.

Nursing Intervention:
[Link] an accepting attitude and unconditional positive regard. Make brief, frequent contacts. Be honest and keep
all promises.
R- These interventions increase feelings of self-worth and facilitate a trusting relationship.

[Link] group activities with client if it may be frightening for him or her
R- The presence of a trusted individual provides emotional security

[Link] cautious with touch. Allow client extra space and an avenue for exit if anxiety becomes overwhelming.
R- A person in panic anxiety may perceive touch as threatening.

4. Administer tranquilizing medications as ordered by physician. Monitor for effectiveness and adverse side effects.
R- Antianxiety medications, such as diazepam, chlordiazepoxide, or alprazolam, help to reduce level of anxiety in
most individuals, thereby facilitating interactions with others

[Link] with client signs and symptoms of increasing anxiety and techniques to interrupt the response (e.g.,
relaxation exercises, “thought stopping”)
R- Maladaptive behaviors, such as withdrawal and suspiciousness, are manifested during times of increased anxiety.

6. Give recognition and positive reinforcement for voluntary interactions with others
R- This enhances self-esteem and encourages repetition of acceptable behaviours.

F41 Other anxiety disorders

F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified

F41.0 Panic disorder [episodic paroxysmal anxiety]

This disorder is characterized by recurrent panic attacks, the onset of which is unpredictable and manifested by intense
apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical
discomfort.

The symptoms come on unexpectedly; that is, they do not occur immediately before or on exposure to a situation that
usually causes anxiety (as in specific phobia). They are not triggered by situations in which the person is the focus of
others’ attention (as in social phobia). Organic factors in the role of etiology have been ruled out.

At least four of the following symptoms must be present to identify the presence of a panic attack.
 Palpitations, pounding heart, or accelerated heart rate
 Sweating
 Trembling or shaking
 Sensations of shortness of breath or smothering
 Feeling of choking
 Chest pain or discomfort
 Nausea or abdominal distress
 Feeling dizzy, unsteady, lightheaded, or faint
 Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself)
 Fear of losing control or going crazy
 Fear of dying
 Paresthesias (numbness or tingling sensations)
 Chills or hot flashes

The attacks usually last minutes, or more rarely, hours. The individual often experiences varying degrees of
nervousness and apprehension between attacks. Symptoms of depression.

Epidemiology:
The average age of onset of panic disorder is the late 20s.
The disorder may last for a few weeks or months or for a number of years.

Panic Disorder With Agoraphobia

Panic disorder with agoraphobia is characterized by the symptoms described for panic disorder.

In addition, the individual experiences a fear of being in places or situations from which escape might be difficult (or
embarrassing) or in which help might not be available in the event that a panic attack should occur (APA, 2000).
This fear severely restricts travel, and the individual may become nearly or completely housebound or unable to leave
the house unaccompanied.

Common agoraphobic situations include being outside the home alone; being in a crowd or standing in a line; being
on a bridge; and travelling in a bus, train, or car.

F41.1 Generalized anxiety disorder

Generalized anxiety disorder is characterized by chronic, unrealistic, and excessive anxiety and worry.
The symptoms have existed for 6 months or longer and cannot be attributed to specific organic factors, such as
caffeine intoxication or hyperthyroidism.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
identifies the following symptoms associated with generalized anxiety disorder.
The symptoms must have occurred more days than not for at least 6 months and must cause clinically signifi cant
distress or impairment in social, occupational, or other important areas of functioning.
● Excessive anxiety and worry about a number of events that the individual finds difficult to control
● Restlessness or feeling keyed up or on edge
● Being easily fatigued
● Difficulty concentrating or mind “going blank”
● Irritability
● Muscle tension
● Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Etiological Factors:
1. Psychodynamic Theory
The psychodynamic view focuses on the inability of the ego to intervene when conflict occurs between the id and the
superego, producing anxiety. For various reasons (unsatisfactory parent-child relationship, conditional love or
provisional gratification), ego development is delayed.

When developmental defects in ego functions compromise the capacity to modulate anxiety, the individual resorts to
unconscious mechanisms to resolve the conflict.

Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety

Biological Aspects
a. Genetics
Panic disorder has a strong genetic element (Harvard Medical School, 2006). The concordance rate for identical twins
is 30 percent, and the risk for the disorder in a close relative is 10 to 20 percent.

Hollander and Simeon (2008) report on research findings of an association between panic disorder and a variant of the
gene that controls the manufacture of the protein cholecystokinin, which has been known to induce panic attacks when
it is injected.

b. Neuroanatomical
Structural brain-imaging studies in patients with panic disorder have implicated pathological involvement in the
temporal lobes, particularly the hippocampus.

c. Biochemical.
Abnormal elevations of blood lactate have been noted in clients with panic disorder.
Likewise, infusion of sodium lactate into clients with anxiety neuroses produced symptoms of panic disorder.

d. Neurochemical.
Stronger evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder.
Norepinephrine is known to mediate arousal, and it causes hyperarousal and anxiety.
The neurotransmitters serotonin and gamma aminobutyric acid (GABA) are thought to be decreased in anxiety
disorders.

e. Medical Conditions.
The following medical conditions have been associated to a greater degree with individuals who suffer panic and
generalized anxiety disorders than in the general population.
● Abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes
● Acute myocardial infarction
● Pheochromocytomas
● Substance intoxication and withdrawal (cocaine, alcohol, marijuana, opioids)
● Hypoglycemia
● Caffeine intoxication
● Mitral valve prolapse
● Complex partial seizures

Clinical Features
Generalized anxiety disorder (GAD) ismanifested by the following signs of motor tension, autonomic hyperactivity,
apprehension and vigilence, which should last for at least 6months in order to make a diagnosis:

Psychological:
Fearful anticipation, irritability, sensitivity to noise, restlessness, poor concentration, worrying thoughts and
apprehension.

Physical:
• Gastrointestinal-dry mouth, difficulty in swallowing, epigastric discomfort, frequent or loose motions
• Respiratory=-constriction in the chest, difficulty inhaling, overbreathing
• Cardiovascular-palpitations, discomfort in chest
• Genitourinary-frequency or urgent micturition, failure of erection, menstrual discomfort, amenorrhea
• Neuromuscular system-tremor, prickling sensations, tinnitus, dizziness, headache, aching muscles
• Sleep disturbances-insomnia, night terror
• Other symptoms: depression, obsessions, depersonalization, derealization

F42 Obsessive - compulsive disorder

F42.0 Predominantly obsessional thoughts or ruminations
F42.1 Predominantly compulsive acts [obsessional rituals]
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive - compulsive disorders
F42.9 Obsessive - compulsive disorder, unspecified

Definition:
According to ICD9, obsessive-compulsive disorder is a state in which "the outstanding symptom is a feeling
ofsubjective compulsion - which must be resisted - to carry out some action, to dwell on an idea, to recall an
experience, or ruminate on an abstract topic.

Unwanted thoughts, which include the insistency of words or ideas are perceived by the patient to be inappropriate or
nonsensical.
The obsessional urge or idea is recognized as alien to the personality, but as coming from within the self.
Obsessional rituals are designed to relieve anxiety, e.g. washing the hands to deal with contamination. Attempts to
dispel the unwelcome thoughts or urges may lead to a severe inner struggle, with intense anxiety."

Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Either obsessions or compulsions:
Obsessions as defined by 1, 2, 3, and 4:
1. Recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance as
intrusive and inappropriate and that cause marked anxiety or distress.
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other
thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not
imposed from without as in thought insertion).

Compulsions as defined by 1 and 2:

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating
words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be
applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts either are not connected in a realistic way withwhat they are
designed to neutralize or prevent or are clearly excessive.

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are
excessive or unreasonable. NOTE: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or
significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social
activities or relationships.

D. If another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g.,
preoccupation with food in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern
with appearance in the presence of body dysmorphic disorder, preoccupation with having a serious illness in the
presence of hypochondriasis, preoccupation with sexual urges or fantasies in the presence of a paraphilia, or guilty
ruminations in the presence of major depressive disorder).

E. This disturbance is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a
general medical condition.

Etiological Factors:
Psychoanalytical Theory
Psychoanalytical theorists propose that individuals with OCD have weak, underdeveloped egos (for any of a
variety of reasons: unsatisfactory parent-child relationship, conditional love, or provisional gratification).
The psychoanalytical concept views clients with OCD as having regressed to earlier developmental stages of
the infantile superego—the harsh, exacting, punitive characteristics that now reappear as part of the psychopathology.
Regression to the pre-Oedipal anal-sadistic phase, combined with use of specific ego defense mechanisms
(isolation, undoing, displacement, reaction formation), produces the clinical symptoms of obsessions and compulsions
(Sadock & Sadock, 2007).
Aggressive impulses (common during the anal-sadistic developmental phase) are channeled into thoughts and
behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt
(generated by the punitive superego).

Learning Theory
Learning theorists explain obsessive-compulsive behavior as a conditioned response to a traumatic event. The
traumatic event produces anxiety and discomfort, and the individual learns to prevent the anxiety and discomfort by
avoiding the situation with which they are associated. This type of learning is called passive avoidance (staying away
from the source).
When passive avoidance is not possible, the individual learns to engage in behaviors that provide relief from the
anxiety and discomfort associated with the traumatic situation. This type of learning is called active avoidance and
describes the behavior pattern of the individual with OCD (Sadock & Sadock, 2007).

Biological Aspects
Recent findings suggest that neurobiological disturbances may play a role in the pathogenesis and maintenance of
OCD.
Neuroanatomy.
Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD. Functional
neuroimaging techniques have shown abnormal metabolic rates in the basal ganglia and orbitofrontal cortex of
individuals with the disorder (Hollander & Simeon, 2008).

Physiology.
Electrophysiological studies, sleep electroencephalogram studies, and neuroendocrine studies have suggested that
there are commonalities between depressive disorders and OCD.

Biochemical Factors.
A number of studies have implicated the neurotransmitter serotonin as influential in the etiology of obsessive-
compulsive behaviors. Drugs that have been used successfully in alleviating the symptoms of OCD are clomipramine
and the selective serotonin reuptake inhibitors (SSRIs), all of which are believed to block the neuronal reuptake of
serotonin, thereby potentiating serotoninergic activity in the central nervous system

Clinical Picture
Obsessional thoughts
These are words, ideas and, beliefs that intrude forcibly into the patient's mind. They are usually unpleasant and
shocking to the patient and may be obscene or blasphemous.

Obsessional images
These are vividly imagined scenes, often of a violent or disgusting kind involving abnormal sexual practices.

Obsessional ruminations
These involve internal debates in which arguments for and against even the simplest everyday actions are reviewed
endlessly.

Obsessional doubts
These may concern actions that may not have been completed adequately. The obsession often implies some danger
such as forgetting to turn off the stove or not locking a door. Itmay be followed by a compulsive act such as the person
making multiple trips back into the house to check if the stove has been turned off. Sometimesthesemay take the
formofdoubting the very fundamentals ofbeliefs,such as, doubting the existence of God and so on.

Obsessional impulses
These are urges to perform acts usually of a violent or embarrassing kind, such as injuring a child, shouting in church
etc.

Obsessional rituals
Thesemay include both mental activities such as counting repeatedly in a special way or repeating a certain form of
words, and repeated but senseless behaviours such as washing hands 20 or more times a day. Sometimes such
compulsive acts may be preceded by obsessional thoughts; for example, repeated handwashing may be preceded by
thoughts of contamination. These patients usually believe that the contamination is spread from object to object or
person to person even by slight contact and may literally rub the skin offtheir hands by excessive hand washing

Obsessive slowness:
Severe obsessive ideas or extensive compulsive rituals characterize obsessional slowness in the relative absence of
manifested anxiety. This leads to marked slowness in daily activities.

NURSING DIAGNOSIS: INEFFECTIVE COPING

RELATED TO: Underdeveloped ego, punitive superego; avoidance learning; possible biochemical changes
EVIDENCED BY: Ritualistic behavior or obsessive thoughts

Outcome Criteria:
Short-Term Goal
Within 1 week, the client will decrease participation in ritualistic behavior by half.

Long-Term Goal
By time of discharge from treatment, client will demonstrate ability to cope effectively without resorting to obsessive-
compulsive behaviors or increased dependency.

Nursing Intervention:
1. Work with client to determine types of situations that increase anxiety and result in ritualistic behaviors.
R- Recognition of precipitating factors is the first step in teaching the client to interrupt the escalating anxiety

2. Initially meet the client’s dependency needs as required. Encourage independence and give positive reinforcement
for independent behaviors.
R- Sudden and complete elimination of all avenues for dependency would create intense anxiety on the part of the
client. Positive reinforcement enhances selfesteem and encourages repetition of desired behaviors.

3. In the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the
behavior.
R- To deny client this activity may precipitate panic anxiety

4. Support client’s efforts to explore the meaning and purpose of the behavior.
R- Client may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition is
important before change can occur.

5. Provide structured schedule of activities for client, including adequate time for completion of rituals.
R- Structure provides a feeling of security for the anxious client

6. Gradually begin to limit amount of time allotted for ritualistic behavior as client becomes more involved in other
activities.
R-Anxiety is minimized when client is able to replace ritualistic behaviors with more adaptive ones.

7. Give positive reinforcement for nonritualisticbehaviors.

R- Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors

8. Help client learn ways of interrupting obsessive thoughts and ritualistic behavior with techniques such as thought
stopping, relaxation, and physical exercise
R- Knowledge and practice of coping techniques that are more adaptive will help client change and let go of
maladaptive responses to anxiety

NURSING DIAGNOSIS: INEFFECTIVE ROLE PERFORMANCE

RELATED TO: Need to perform rituals
EVIDENCED BY: Inability to fulfill usual patterns of responsibility
Outcome Criteria:
Short-Term Goal
Client will verbalize understanding that ritualistic behaviors interfere with role performance in order to decrease
anxiety

Long-Term Goal
Client will be able to resume rolerelated responsibilities by time of discharge from treatment.

Nursing Intervention:
1. Determine client’s previous role within the family and extent to which this role is altered by the illness. Identify
roles of other family members.
R- This is important assessment data for formulating an appropriate plan of care.

2. Discuss client’s perception of role expectations.

R- Determine if client’s perception of his or her role expectations are realistic.

3. Encourage client to discuss conflicts evident within the family system. Identify how client and other family
members have responded to this conflict.
R- Identifying specific stressors, as well as adaptive and maladaptive responses within the system, is necessary before
assistance can be provided in an effort to create change.

4. Explore available options for changes or adjustments in role. Practice through role-play.
R- Planning and rehearsal of potential role transitions can reduce anxiety.

5. Encourage family participation in the development of plans to effect positive change, and work to resolve the cause
of the anxiety from which the client seeks relief through use of ritualistic behaviors.
R- Input from the individuals who will be directly involved in the change will increase the likelihood of a positive
outcome.

6. Give client lots of positive reinforcement for ability to resume role responsibilities by decreasing need for ritualistic
behaviors.
R-Positive reinforcement enhances self-esteem and promotes repetition of desired behaviour

Care Plan for the Client With Panic Disorder or Generalized Anxiety Disorder
NURSING DIAGNOSIS: PANIC ANXIETY RELATED TO: Real or perceived threat to biological integrity or self-
concept EVIDENCED BY: Any or all of the physical symptoms identified by the DSM-IV-TR.

Short-Term Goal
The client will verbalize ways to intervene in escalating anxiety within 1 week.

Long-Term Goal
By time of discharge from treatment, the client will be able to recognize symptoms of onset of anxiety and intervene
before reaching panic level.

Nursing Intervention:
Stay with the client and offer reassurance of safety and security. Do not leave the client in panic anxiety alone.
R- The client may fear for his or her life. Presence of a trusted individual provides a feeling of security and assurance
of personal safety.

2. Maintain a calm, nonthreatening, matter-of-fact approach.

R- Anxiety is contagious and may be transferred from staff to client or vice versa. Client develops a feeling of security
in the presence of a calm staff person

3. Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences.
R- In an intensely anxious situation, the client is unable to comprehend anything but the most elemental
communication.

4. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor).
R- A stimulating environment may increase level of anxiety

5. Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects.
R- Antianxiety medication provides relief from the immobilizing effects of anxiety.

6. When level of anxiety has been reduced, explore possible reasons for occurrence.
R-Recognition of precipitating factor(s) is the first step in teaching client to interrupt escalation of anxiety.

7. Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression (relaxation techniques, such
as deep-breathing exercises and meditation, or physical exercise, such as brisk walks and jogging)
R- Relaxation techniques result in a physiological response opposite that of the anxiety response. Physical activities
discharge excess energy in a healthful manner.

NURSING DIAGNOSIS: POWERLESSNESS

RELATED TO: Impaired cognition
EVIDENCED BY: Verbal expressions of no control over life situation and nonparticipation in decision making
related to own care or life situation

Outcome Criteria:
Short-Term Goal
Client will participate in decision making regarding own care.

Long-Term Goal
Client will be able to effectively problem solve ways to take control of life situation, thereby decreasing feelings of
powerlessness and anxiety.

Nursing Intervention:
1. Allow client to take as much responsibility as possible for self-care practices.
Examples include:
a. Allow client to establish own schedule for self-care activities.
b. Include client in setting goals of care.
c. Provide client with privacy as need is determined.
d. Provide positive feedback for decisions made. Respect client’s right to make those decisions independently, and
refrain from attempting to influence him or her toward those that may seem more logical.
R- Providing choices will increase client’s feelings of control

2. Assist client to set realistic goals.

R- Unrealistic goals set the client up for failure and reinforce feelings of powerlessness.

3. Help identify areas of life situation that client can control.

R-Client’s emotional condition interferes with the ability to solve problems. Assistance is required to perceive the
benefits and consequences of available alternatives accurately

4. Help client identify areas of life situation that are not within his or her ability to control. Encourage verbalization of
feelings related to this inability.
R- This will assist the client to deal with unresolved issues and learn to accept what cannot be changed.

F43 REACTION TO STRESS AND ADJUSTMENT DISORDER

F43.0 Acute stress reaction
F43.1 post-traumatic stress disorder
F43.2 adjustment disorders
.20 Brief depressive reaction
.21 Prolonged depressive reaction
.22 Mixed anxiety and depressive reaction
.23 With predominant disturbance of other emotions
.24 With predominant disturbance of conduct
.25 With mixed disturbance of emotions and conduct
.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified

F43.0 Acute stress reaction

It is characterized by symptoms like anxiety, despair and anger or over activity. These symptoms are clearly related to
the stressor. If removal from the stressful environment is possible, the symptoms resolve rapidly.

F43.1 post-traumatic stress disorder

Definition:
Post-traumatic stress disorder (PTSD) is described as the development of characteristic symptoms following
exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity
of others.
-DSM-IV-TR
The symptoms may occur after learning about unexpected or violent death, serious harm, or threat of death or
injury of a family member or other close associate (APA, 2000).
The individual may experience the trauma alone or in the presence of others.
Examples of some experiences that may produce this type of response include
- participation in military combat,
- experiencing violent personal assault,
- being kidnapped or taken hostage,
- being tortured,
- being incarcerated as a prisoner of war,
- experiencing natural or man-made disasters,
- surviving severe automobile accidents, or
- being diagnosed with a life-threatening illness.
Characteristic symptoms include –
- Re-experiencing the traumatic event,
- A sustained high level of anxiety or arousal,
- A general numbing of responsiveness.
- Intrusive recollections or nightmares of the event are common.
- Depression
Some individuals may be unable to remember certain aspects of the trauma.
The full symptom picture must be present for more than 1 month and cause significant interference with social,
occupational, and other areas of functioning. If the symptoms have not been present for more than 1 month, the
diagnosis assigned is acute stress disorder.
The disorder can occur at any age. Symptoms may begin within the first 3 months after the trauma or there
may be a delay of several months or even years.

Etiological Factors-
a) Psychosocial Theory
1. The Traumatic Experience.
Specific characteristics relating to the trauma have been identified as crucial elements in the determination of an
individual’s long-term response to stress.
They include:
● Severity and duration of the stressor
● Degree of anticipatory preparation for the event
● Exposure to death
● Numbers affected by life threat
● Amount of control over recurrence
● Location where the trauma was experienced (e.g., familiar surroundings, at home, in a foreign country)

2. The Individual.
Variables that are considered important in determining an individual’s response to trauma include:
● Degree of ego-strength
● Effectiveness of coping resources
● Presence of pre-existing psychopathology
● Outcomes of previous experiences with stress/trauma
● Behavioural tendencies (temperament)
● Current psychosocial developmental stage
● Demographic factors (e.g., age, socioeconomic status, education)

3. The Recovery Environment.

It has been suggested that the quality of the environment in which the individual attempts to work through the
traumatic experience is correlated with the outcome.
Environmental variables include:
● Availability of social supports
● The cohesiveness and protectiveness of family and friends
● The attitudes of society regarding the experience
● Cultural and subcultural influences

b) Learning Theory
Learning theorists view negative reinforcement as behaviour that leads to a reduction in an aversive experience,
thereby reinforcing and resulting in repetition of the behaviour.
The avoidance behaviours and psychic numbing in response to a trauma are mediated by negative reinforcement
(behaviours that decrease the emotional pain of the trauma).
Behavioural disturbances, such as anger and aggression and drug and alcohol abuse, are the behavioural patterns that
are reinforced by their capacity to reduce objectionable feelings.

c) Cognitive Theory
These models take into consideration the cognitive appraisal of an event and focus on assumptions that an individual
makes about the world. Epstein (1991) outlines three fundamental beliefs that most people construct within a personal
theory of reality.
They include the following:
● The world is benevolent and a source of joy.
● The world is meaningful and controllable.
● The self is worthy (e.g., lovable, good, and competent).
As life situations occur, some disequilibrium is expected to occur until accommodation for the change has been made
and it has become assimilated into one’s personal theory of reality. An individual is vulnerable to PTSD when the
fundamental beliefs are invalidated by a trauma that cannot be comprehended and a sense of helplessness and
hopelessness prevail.
One’s appraisal of the environment can be drastically altered.
d) Biological Aspects
It has been suggested that an individual who has experienced previous trauma is more likely to develop symptoms
after a stressful life event.
These individuals with previous traumatic experiences may be more likely to become exposed to future
traumas because they can be inclined to reactivate the behaviours associated with the original trauma.

NURSING DIAGNOSIS: POST-TRAUMA SYNDROME

RELATED TO: Distressing event considered to be outside the range of usual human experience
EVIDENCED BY: Flashbacks, intrusive recollections, nightmares, psychological numbness related to the
event, dissociation, or amnesia

Outcome Criteria
Short-Term Goals
• Client will begin a healthy grief resolution, initiating the process of psychological healing (within time frame
specific to individual).
• Client will demonstrate ability to deal with emotional reactions in an individually appropriate manner.

Long-Term Goal
The client will integrate the traumatic experience into his or her persona, renew significant relationships, and establish
meaningful goals for the future.

Nursing Interventions
1. a. Assign the same staff as often as possible.
b. Use a nonthreatening, matterof-fact, but friendly approach.
c. Respect client’s wishes regarding interaction with individuals of opposite sex at this time (especially important if
the trauma was rape).
d. Be consistent; keep all promises; convey acceptance; spend time with client.
R- A post-trauma client may be suspicious of others in his or her environment. All of these interventions serve to
facilitate a trusting relationship.

2. Stay with client during periods of flashbacks and nightmares. Offer reassurance of safety and security and that these
symptoms are not uncommon following a trauma of the magnitude he or she has experienced.
R-Presence of a trusted individual may calm fears for personal safety and reassure client that he or she is not “going
crazy.”

3. Obtain accurate history from significant others about the trauma and the client’s specific response.
R-Various types of traumas elicit different responses in clients (e.g., human-engendered traumas often generate a
greater degree of humiliation and guilt in victims than trauma associated with natural disasters).

4. Encourage the client to talk about the trauma at his or her own pace. Provide a nonthreatening, private environment,
and include a significant other if the client wishes. Acknowledge and validate client’s feelings as they are expressed.
R- This debriefing process is the first step in the progression toward resolution.

5. Discuss coping strategies used in response to the trauma, as well as those used during stressful situations in the
[Link] those that have been most helpful, and discuss alternative strategies for the future. Include
availablesupport systems, including religious and cultural influences. Identify maladaptive coping strategies (e.g.,
substance use, psychosomatic responses) and practice more adaptive coping strategies for possible future post-trauma
responses.
R-Resolution of the post-trauma response is largely dependent on the effectiveness of the coping strategies employed.

[Link] the individual to try to comprehend the trauma if possible. Discuss feelings of vulnerability and the
individual’s “place” in the world following the trauma.
R- Post-trauma response is largely a function of the shattering of basic beliefs the victim holds about self and world.
Assimilation of the event into one’s persona requires that some degree of meaning associated with the event be
incorporated into the basic beliefs, which will affect how the individual eventually comes to reappraise self and world.

NURSING DIAGNOSIS: COMPLICATED GRIEVING

RELATED TO: Loss of self as perceived prior to the trauma or other actual/perceived losses incurred
during/following the event
EVIDENCED BY: Irritability and explosiveness, self-destructiveness, substance abuse, verbalization of survival guilt
or guilt about behaviour required for survival.

Outcome Criteria:
Short-Term Goal
Client will verbalize feelings (guilt, anger, self-blame, hopelessness) associated with the trauma.

Long-Term Goal
Client will demonstrate progress in dealing with stages of grief and will verbalize a sense of optimism and hope for
the future.

Nursing Intervention:
1. Acknowledge feelings of guilt or self-blame that client may express.
R-Guilt at having survived a trauma in which others died is common. The client needs to discuss these feelings and
recognize that he or she is not responsible for what happened but must take responsibility for own recovery.

2. Assess stage of grief in which the client is fixed. Discuss normalcy of feelings and behaviours related to stages of
grief.

3. Assess impact of the trauma on client’s ability to resume regular activities of daily living. Consider employment,
marital relationship, and sleep patterns.

4. Assess for self-destructive ideas and behaviour.

5. Assess for maladaptive coping strategies, such as substance abuse.

6. Identify available community resources from which the individual may seek assistance if problems with
complicated grieving persist.

F43.2 adjustment disorders

It is characterized by predominant disturbance of emotions and conduct. This disorder usually occurs within one
month of a significant life change.

Treatment for Stress and Adjustment Disorders

Drug treatment
• Antidepressants
• Benzodiazepines

Psychological therapies
• Supportive psychotherapy
• Crisis intervention
• Stress management training

Treatment Modalities:
Individual Psychotherapy
Insight-oriented psychotherapy focuses on helping patients understand the hypothesized unconscious meaning of the
anxiety, the symbolism of the avoided situation, the need to repress impulses, and the secondary gains of the
symptom. The psychotherapist also can use logical and rational explanations to increase the client’s understanding
about various situations that create anxiety in his or her life.

Cognitive Therapy
The cognitive model relates how individuals respond in stressful situations to their subjective cognitive
appraisal of the event. Cognitive therapy strives to assist the individual to reduce anxiety responses by altering
cognitive distortions.
Cognitive therapy for anxiety is brief and time limited, usually lasting from 5 to 20 sessions. Brief therapy
discourages the client’s dependency on the therapist, which is prevalent in anxiety disorders, and encourages the
client’s self-sufficiency.
Rather than offering suggestions and explanations, the therapist uses questions to encourage the client to
correct his or her anxiety-producing thoughts. The client is encouraged to become aware of the thoughts, examine
them for cognitive distortions, substitute more balanced thoughts, and eventually develop new patterns of thinking.
Cognitive therapy is very structured and orderly, which is important for the anxious client who is often
confused and lacks self-assurance. The focus is on solving current problems. Together, the client and therapist work to
identify and correct maladaptive thoughts and behaviors that maintain a problem and block its solution.

Behavior Therapy
Two common forms of behaviour therapy include systematic desensitization and implosion therapy (flooding).

A) Systematic desensitization
It was developed by Joseph Wolpe, based on the behavioral principle of counter conditioning.
In this patients attain a state of complete relaxation and are then exposed to the stimulus that elicits the anxiety
response. The negative reaction of anxiety is inhibited by the relaxed state, a process called reciprocal inhibition.
It consists of three main steps:
1. Relaxation training
2. Hierarchy construction
3. Desensitization of the stimulus

1. Relaxation training:
There are many methods which can be used to induce relaxation, some of them are:
• Jacobson's progressive muscle relaxation
• Hypnosis
• Meditation or yoga
• Mental imagery
• Biofeedback

2. Hierarchy construction:
Here the patient is asked to list all the conditions which provoke anxiety. Then he is asked to list them in a descending
order of anxiety provocation.

3. Desensitization of the stimulus:

This can either be done in reality or through imagination.
At first, the lowest item in hierarchy is confronted. The patient is advised to signal whenever anxiety is produced.
With each signal he is asked to relax. After a few trials, patient is able to control his anxiety gradually.

B) Implosion Therapy (Flooding)

Implosion therapy, or flooding, is a therapeutic process in which the client must imagine situations or
participate in real-life situations that he or she finds extremely frightening for a prolonged period of time.
Plenty of time must be allowed for these sessions because brief periods may be ineffective or even harmful. A session
is terminated when the client responds with considerably less anxiety than at the beginning of the session.
In flooding, the therapist “floods” the client with information concerning situations that trigger anxiety in him
or her. The therapist describes anxiety-provoking situations in vivid detail and is guided by the client’s response; the
more anxiety provoked, the more expedient is the therapeutic endeavour.

C) Thought stoppage
Thought stopping is a technique to help an individual to learn to stop thinking unwanted thoughts.
Following are the steps in thought stopping:
• Sit in a comfortable chair, bring to mind the unwanted thought concentrating on only one thought per procedure.
• As soon as the thought forms, give the command 'Stop!' Follow this with calm and deliberate relaxation of muscles
and diversion of thought to something pleasant.
• Repeat the procedure to bring the unwanted thought under control.

Other psychological therapies

• Jacobson's progressive muscle relaxation technique, yoga, pranayama, meditation and self-hypnosis.

Psychopharmacology
Anxiolytics:
Antianxiety drugs are also called anxiolytics and minor tranquilizers

Action
Antianxiety drugs depress subcortical levels of the central nervous system (CNS), particularly the limbic system and
reticular formation. They may potentiate the effects of the powerful inhibitory neurotransmitter GABA in the brain,
thereby producing a calmative effect.

Panic Disorder-
Antidepressants –
tricyclics clomipramine and imipramine

SSRIs-
Paroxetine, fluoxetine, and sertraline

Antihypertensive Agents-
beta blockers (e.g., propranolol) and alpha2 -receptor agonists (e.g., clonidine)
Propranolol has potent effects on the somatic manifestations of anxiety (e.g., palpitations, tremors)

Generalized Anxiety Disorders

Benzodiazepines-
E.g. Alprazolam, lorazepam, and clonazepam
Major risk - physical dependence and tolerance

first-line choice of treatment - SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs), and buspirone

The antianxiety agent, buspirone (Buspar)-Drug of choice

Disadvantage - 10- to 14-day delay in alleviating symptoms
Benefit - lack of physical dependence and tolerance

Phobic Disorders
Anxiolytics.
Benzodiazepines
e.g. alprazolam and clonazepam

Antidepressants.
The tricyclic imipramine and the monoamine oxidase inhibitor (MAOI) e.g. phenelzine have been effective in
diminishing symptoms of agoraphobia and social phobia.

SSRIs E.g. paroxetine and sertraline

Antihypertensive Agents.
The beta-blockers, propranolol and atenolol
The beta blockers appear to be quite effective in reducing the symptom such as sweaty palms, racing pulse, trembling
hands, dry mouth, labored breathing, nausea, and memory loss.

Obsessive-Compulsive Disorder
Antidepressants.
The SSRIs fluoxetine, paroxetine, sertraline, and fluvoxamine

tricyclic antidepressant-clomipramine
Post-Traumatic Stress Disorder
Antidepressants.
The SSRIs E.g. Paroxetine and sertraline
The tricyclic antidepressants (e.g., amitriptyline and imipramine),
MAO inhibitors (e.g., phenelzine), and trazodone

Anxiolytics E.g. Alprazolam

Antihypertensives.
The beta blocker propranolol and alpha2 -receptor agonist clonidine have been successful in alleviating some of the
symptoms such as reductions in nightmares, intrusive recollections, hypervigilance, insomnia, startle responses, and
angry outbursts.

Other Medications.
Carbamazepine, valproic acid, and lithium carbonate have been reported to alleviate symptoms of intrusive
recollections, flashbacks, nightmares, impulsivity, irritability, and violent behavior in PTSD clients.

F44 DISSOCIATIVE (CONVERSION) DISORDERS

Conversion disorder is characterized by the presence of one or more symptoms suggesting the presence of a
neurological disorder that cannot be explained by any known neurological or medical disorder. Instead, psychological
factors like stress and conflicts are associated with onset or exacerbation of the symptoms. Patients are unaware of the
psychological basis and are thus not able to control their symptoms.

ICD 10 Classification:
F44 Dissociative [conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative [conversion] disorders
F44.8 Other dissociative [conversion] disorders
.80 Ganser's syndrome .81 Multiple personality disorder
.82 Transient dissociative [conversion] disorders occurring in childhood and adolescence
.88 Other specified dissociative [conversion] disorders
F44.9 Dissociative [conversion] disorder, unspecified

Features of the disorder include:

• The symptoms are produced because they reduce the anxiety of the patient by keeping the psychological conflict out
of conscious awareness, a process called as primary gain.
• These symptoms of conversion are often advantageous to the patient.
For example, a woman who develops psychogenic paralysis of the arm may escape from taking care of an elderly
relative. Such an advantage is called as secondary gain.
• The patient does not produce the symptoms intentionally.
• The patient shows less distress or shows lack of concern about the symptoms, called as belle indifference.
• Physical examination and investigations do not reveal any medical or neurological abnormalities.

Types of Dissociative Disorders

F44.0 Dissociative Amnesia
Dissociative amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature,
that is too extensive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or a
neurological or other general medical condition (APA, 2000).

Five types of disturbances in recall have been described.

In the following examples, the individual is involved in a traumatic automobile accident in which a loved one is killed.

1. Localized amnesia:
The inability to recall all incidents associated with the traumatic event for a specific time period following the event
(usually a few hours to a few days).
Example:
The individual cannot recall events of the automobile accident and events occurring during a period after the accident
(a few hours to a few days).

2. Selective amnesia:
The inability to recall only certain incidents associated with a traumatic event for a specific period after the event.
Example:
The individual may not remember events leading to the impact of the accident but may remember being taken away in
the ambulance.
3. Continuous amnesia:
The inability to recall events occurring after a specific time up to and including the present

Example:
The individual cannot remember events associated with the automobile accident and anything that has occurred since.
That is, the individual cannot form new memories although he or she is apparently alert and aware.

4. Generalized amnesia:
The rare phenomenon of not being able to recall anything that has happened during the individual’s entire lifetime,
including personal identity.

5. Systematized amnesia:
With this type of amnesia, the individual cannot remember events that relate to a specific category of information
(e.g., one’s family) or to one particular person or event.

The individual with amnesia usually appears alert and may give no indication to observers that anything is wrong,
although some clients may present with alterations in consciousness, conversion symptoms, or in trance states.

Clients suffering from amnesia are often brought to general hospital emergency departments by police who have
found them wandering confusedly around the streets. Onset of an amnestic episode usually follows severe
psychosocial stress. Termination is typically abrupt and followed by complete recovery.

The DSM-IV-TR Diagnostic Criteria for Dissociative Amnesia

A. The predominant disturbance is one or more episodes of inability to recall important personal information, usually
of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.

B. The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue,
post-traumatic stress disorder, acute stress disorder, or somatization disorder and is not due to the direct physiological
effect of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g.,
amnestic disorder due to head trauma).

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning

Treatment:
Many cases of dissociative amnesia resolve spontaneously when the individual is removed from the stressful situation.

Intravenous administration of amobarbital is useful in the retrieval of lost memories

F44.1 Dissociative fugue

The characteristic feature of dissociative fugue is a sudden, unexpected travel away from home or customary place of
daily activities, with inability to recall some or all of one’s past (APA, 2000). An individual in a fugue state cannot
recall personal identity and often assumes a new identity.

Clients with dissociative fugue often are picked up by the police when they are found wandering in a somewhat
confused and frightened condition after emerging from the fugue in unfamiliar surroundings. They are usually
presented to emergency departments of general hospitals.

On assessment, they are able to provide details of their earlier life situation but have no recall from the beginning of
the fugue state.
Duration is usually brief—that is, hours to days or more rarely, months—and recovery is rapid and complete.

Diagnostic Criteria for Dissociative Fugue

A. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with
inability to recall one’s past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the
direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning.

F44.2 Dissociative Stupor

In this, patients are motionless and mute and do not respond to stimulation, but they are aware of their surroundings. It
is a rare condition.

F44.3 Trance and possession disorders

This disorder is very common in India. It is characterized by a temporary loss of both the sense of personal identity
and full awareness of the person's surroundings. When the condition is induced by religious rituals, the person may
feel taken over by a deity or spirit. The focus of attention is narrowed to a few aspects of the immediate environment,
and there is often a limited but repeated set of movements, postures and utterances.

F44.4 Dissociative motor disorders

It is characterized by motor disturbances like paralysis or abnormal movements.
Paralysis may be a monoplegia, paraplegia or quadriplegia. The abnormal movement may be tremors, choreiform
movements or gait disturbances which increase when attention is directed towards them. Examination reveals normal
tone and reflexes.

F44.5 Dissociative Convulsions (hysterical fits or pseudo-seizures)

It is characterized by convulsive movements and partial loss of consciousness. Differential diagnosis with true
seizures is important.

F44.6 Dissociative Sensory Loss and Anesthesia

It is characterized by sensory disturbances like hemianesthesia, blindness, deafness and glove and stocking anesthesia
(absence of sensations at wrists and ankles).

F44.8 Other dissociative [conversion] disorders

.80 Ganser's syndrome
Ganser's syndrome is a rare condition with four features: giving 'approximate answers' to questions designed
to test intellectual functions, psychogenic physical symptoms, hallucinations and apparent clouding of consciousness.
The term 'approximate answers' denotes answers (to simple questions) that are plainly wrong, but are clearly
related to the correct answers in a way that suggest that the latter is known.
For example, when asked to add three and three a patient might answer seven and when asked four and five, might
answer ten; each answer is one greater than the correct answer. Hallucinations are usually visual and may be elaborate.

.81 Dissociative Identity Disorder

Dissociative identity disorder (DID) was formerly called multiple personality disorder. This disorder is characterized
by the existence of two or more personalities in a single individual.

Only one of the personalities is evident at any given moment, and one of them is dominant most of the time over the
course of the disorder.
Each personality is unique and composed of a complex set of memories, behavior patterns, and social relationships
that surface during the dominant interval.
The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress.

The DSM-IV-TR (APA, 2000) states:

The time required to switch from one identity to another is usually a matter of seconds but, less frequently, may be
gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes,
changes in voice or demeanor, or disruption in the individual’s train of thought.

- Before therapy, the original personality usually has no knowledge of the other personalities, but when there are two
or more subpersonalities, they are usually aware of each other’s existence.
- Most often, the various subpersonalities have different names, but they may be unnamed and may be of a different
gender, race, and age.
- The various personalities are almost always quite disparate and may even appear to be the exact opposite of the
original personality.
For example, a normally shy, socially withdrawn, faithful husband may become a gregarious womanizer and heavy
drinker with the emergence of another personality.
- Generally, there is amnesia for the events that took place when another personality was in the dominant position, and
clients report “gaps” in autobiographical histories.
- Sometimes, however, one personality does not experience such amnesia and retains complete awareness of the
existence, qualities, and activities of the other personalities.
- Subpersonalities that are amnestic for the other subpersonalities experience the periods when others are dominant as
“lost time” or blackouts.
- They may “wake up” in unfamiliar situations with no idea where they are, how they got there, or who the people
around them are. They may frequently be accused of lying when they deny remembering or being responsible for
events or actions that occurred while another personality controlled the body.

Diagnostic Criteria for Dissociative Identity Disorder

A. The presence of two or more distinct personality states (each with its own relatively enduring pattern of perceiving,
relating to, and thinking about the environment and self).

B. At least two of these identities or personality states recurrently take control of the person’s behavior.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior
during alcohol intoxication) or a general medical condition (e.g., complex partial seizures).

Etiological Implications for Dissociative Disorders

Genetics
The DSM-IV-TR suggests that DID is more common in first-degree relatives of people with the disorder than in the
general population. The disorder is often seen in more than one generation of a family

Neurobiological
It is possible that dissociative amnesia and dissociative fugue may be related to neurophysiological dysfunction. Areas
of the brain that have been associated with memory include the hippocampus, amygdala, fornix, mammillary bodies,
thalamus, and frontal cortex.
Psychodynamic Theory
- Freud (1962) believed that dissociative behaviors occurred when individuals repressed distressing mental contents
from conscious awareness. He believed that the unconscious was a dynamic entity in which repressed mental contents
were stored and unavailable to conscious recall.
- The repression of mental contents is perceived as a coping mechanism for protecting the client from emotional pain
that has arisen from either disturbing external circumstances or anxiety-provoking internal urges and feelings.
- In the case of depersonalization, the pain and anxiety are expressed as feelings of unreality or detachment from the
environment of the painful situation.

Psychological Trauma
A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the
individual’s capacity to cope by any means other than dissociation.
These experiences usually take the form of severe physical, sexual, or psychological abuse by a parent or significant
other in the child’s life. The most widely accepted explanation for DID is that it begins as a survival strategy that
serves to help children cope with the horrifying sexual, physical, or psychological abuse. In this traumatic
environment, the child uses dissociation to become a passive victim of the cruel and unwanted experience. He or she
creates a new being who is able to endure the overwhelming pain of the cruel reality, while the primary self can then
escape awareness of the pain. Each new personality has as its nucleus a means of responding without anxiety and
distress to various painful or dangerous stimuli.

Care Plan for the Client with Dissociative Disorder

NURSING DIAGNOSIS: DISTURBED THOUGHT PROCESSES
RELATED TO: Severe psychological stress and repression of anxiety
EVIDENCED BY: Loss of memory

Outcome Criteria:
Short-Term Goal
Client will verbalize understanding that loss of memory is related to stressful situation and begin discussing stressful
situation with nurse or therapist.

Long-Term Goal
Client will recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations.

Nursing Interventions
1. Obtain as much information as possible about the client from family and significant others if possible. Consider
likes, dislikes, important people, activities, music, and pets.
R- A comprehensive baseline assessment is important for the development of an effective plan of

2. Do not flood client with data regarding his or her past life.
R- Individuals who are exposed to painful information from which the amnesia is providing protection may
decompensate even further into a psychotic state.

3. Instead, expose client to stimuli that represent pleasant experiences from the past such as smells associated with
enjoyable activities, beloved pets, and music known to have been pleasurable to the client.
As memory begins to return, engage client in activities that may provide additional stimulation.
R- Recall may occur during activities that simulate life experiences.

4. Encourage client to discuss situations that have been especially stressful and to explore the feelings associated with
those times.
R- Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues
that may be contributing to the dissociative process.
5. Identify specific conflicts that remain unresolved, and assist client to identify possible solutions. Provide instruction
regarding more adaptive ways to respond to anxiety
R- Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only
temporary.

NURSING DIAGNOSIS: INEFFECTIVE COPING

RELATED TO: Severe psychosocial stressor or substance abuse and repressed severe anxiety
EVIDENCED BY: Sudden travel away from home with inability to recall previous identity

Outcome Criteria
Short-Term Goals
• Client will verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial stress.
• Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation.

Long-Term Goal
Client will demonstrate ability to cope with stress (employing means other than dissociation).

Nursing Interventions:
1. Reassure client of safety and security through your presence. Dissociative behaviors may be frightening to the
client.
R- Presence of a trusted individual provides feeling of security and assurance of freedom from harm.

2. Identify stressor that precipitated severe anxiety.

R- This information is necessary for the development of an effective plan of client care and problem resolution.

3. Explore feelings that client experienced in response to the stressor. Help client understand that the disequilibrium
felt is acceptable in times of severe stress.
R- Client’s self-esteem is preserved by the knowledge that others may experience these behaviors under similar
circumstances.

4. As anxiety level decreases and memory returns, use exploration and an accepting, nonthreatening environment to
encourage client to identify repressed traumatic experiences that contribute to chronic anxiety.
R- Client must confront and deal with painful issues to achieve resolution.

5. Have client identify methods of coping with stress in the past and determine whether the response was adaptive or
maladaptive.
R- In times of extreme anxiety, client is unable to evaluate appropriateness of response. This information is necessary
for client to develop a plan of action for the future.

6. Help client define more adaptive coping strategies. Make suggestions of alternatives that might be tried. Examine
benefits and consequences of each alternative. Assist client in the selection of those that are most appropriate for him
or her.
R- Depending on current level of anxiety, client may require assistance with problem-solving and decision-making.

7. Provide positive reinforcement for client’s attempts to change.

R- Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

8. Identify community resources to which the individual may go for support if past maladaptive coping patterns return.
R- Knowledge alone that this type of support exists may provide the client with a feeling of security. Use of the
resources may help to keep the client from decompensating.

NURSING DIAGNOSIS: DISTURBED PERSONAL IDENTITY

RELATED TO: Childhood trauma/abuse
EVIDENCED BY: The presence of more than one personality within the individual

Outcome Criteria
Short-Term Goals
• Client will verbalize understanding about the existence of multiple personalities within the self.
• Client will be able to recognize stressful situations that precipitate transition from one personality to another.

Long-Term Goals
• Client will verbalize understanding of the reason for existence of each personality and the role each plays for the
individual.
• Client will enter into and cooperate with long-term therapy, with the ultimate goal being integration into one
personality.

Nursing Interventions
1. The nurse must develop a trusting relationship with the original personality and with each of the subpersonalities.
R- Trust is the basis of a therapeutic relationship. Each of the personalities views itself as a separate entity and must
initially be treated as such.

2. Help client understand the existence of the subpersonalities and the need each serves in the personal identity of the
individual.
R- Client may initially be unaware of the dissociative response. Knowledge of the needs each personality fulfils is the
first step in the integration process.

3. Help client identify stressful situations that precipitate transition from one personality to another. Carefully observe
and record these transitions.
R- Identification of stressors is required to assist client in responding more adaptively and to eliminate the need for
transition to another personality

4. Use nursing interventions necessary to deal with maladaptive behaviors associated with individual subpersonalities.
For example, if one personality is suicidal, precautions must be taken to guard against client’s self-harm. If another
personality has a tendency toward physical hostility, precautions must be taken to protect others.
R- The safety of the client and others is a nursing priority.

5. Help subpersonalities understand that their “being” will not be destroyed but rather integrated into a unified identity
within the individual.
R- Because subpersonalities function as separate entities, the idea of total elimination generates fear and
defensiveness.
6. Provide support during disclosure of painful experiences and reassurance when client becomes discouraged with
lengthy treatment.
R- Positive reinforcement may encourage repetition of desirable behaviors.

NURSING DIAGNOSIS: DISTURBED SENSORY PERCEPTION (VISUAL/KINESTHETIC)

RELATED TO: Severe psychological stress and repression of anxiety
EVIDENCED BY: Alteration in the perception or experience of the self or the environment
Outcome Criteria
Short-Term Goals
Client will verbalize adaptive ways of coping with stress.
Long-Term Goals
Client will demonstrate the ability to perceive stimuli correctly and maintain a sense of reality during stressful
situations.
Nursing Interventions
1. Provide support and encouragement during times of depersonalization. Clients manifesting these symptoms may
express fear and anxiety at experiencing such behaviors. They do not understand the response and may express a fear
of going insane.
R- Support and encouragement from a trusted individual provide a feeling of security when fears and anxieties are
manifested.

2. Explain the depersonalization behaviors and the purpose they usually serve for the client.
R- This knowledge may help to minimize fears and anxieties associated with their occurrence.

3. Explain the relationship between severe anxiety and depersonalization behaviors. Help relate these behaviors to
times of severe psychological stress that client has experienced.
R- The client may be unaware that the occurrence of depersonalization behaviors is related to severe anxiety.
Knowledge of this relationship is the first step in the process of behavioral change.

4. Explore past experiences and possibly repressed painful situations, such as trauma or abuse.
R- Traumatic experiences may predispose individuals to dissociative disorders.

5. Discuss these painful experiences with client, and encourage him or her to deal with the feelings associated with
these situations. Work to resolve the conflicts these repressed feelings have nurtured.
R- Conflict resolution will serve to decrease the need for the dissociative response to anxiety.

6. Discuss ways the client may more adaptively respond to stress, and use role-play to practice using these new
methods.
R- Having practiced through roleplay helps to prepare client to face stressful situations by using these new behaviors
when they occur in real life.

Treatment:
• Free Association & Hypnosis
Techniques of persuasion and free or directed association are used to help the client remember. In other cases,
hypnosis may be required to mobilize the memories. Hypnosis is sometimes facilitated by the use of pharmacological
agents, such as sodium amobarbital or thiopental (Sadock & Sadock, 2007). Once the memories have been obtained
through hypnosis, supportive psychotherapy or group psychotherapy may be employed to help the client integrate the
memories into his or her conscious state

• Abreaction therapy-Clients are assisted to recall past traumas in detail. They must mentally re-experience the abuse
that caused their illness. This process, called abreaction, or “remembering with feeling,” is so painful that clients may
actually cry, scream, and feel the pain that they felt at the time of the abuse. During therapy, each personality is
actively explored and encouraged to become aware of the others across previously amnestic barriers. Traumatic
memories associated with the different personality manifestations, especially those related to childhood abuse, are
examined.
• Supportive psychotherapy - manipulation of the environment or psychotherapeutic support may help to diminish
stress or help the client adapt to stress in the future.
Intensive, long-term psychotherapy with the DID client is directed toward uncovering the underlying
psychological conflicts, helping him or her gain insight into these conflicts, and striving to synthesize the various
identities into one integrated personality. When integration is achieved, the individual becomes a totality of all the
feelings, experiences, memories, skills, and talents that were previously in the command of the various personalities.
He or she learns how to function effectively without the necessity for creating new personalities to cope with life.
• Behaviour therapy (aversion therapy, operant conditioning, etc.)
• Drug therapy: Drugs have a very limited role. A few patients have anxiety and may need short-term treatment with
benzodiazepines
• Cognitive therapy - may be useful in helping the client attempt a change in inappropriate or irrational thinking
patterns.

• Creative therapies, such as art and music, allow clients to express and explore thoughts and emotions in “safe”
ways.

• Group therapy can be helpful in providing the client with ongoing encouragement from supportive peers.

• Family therapy sessions may be used to explore the trauma that precipitated the fugue episode and to educate
family members about the dissociative disorder.

F45 SOMATOFORM DISORDERS

These disorders are characterized by repeated presentation with physical symptoms which do not have any physical
basis, and a persistent request for investigations and treatment despite repeated assurance by the treating doctors.
These disorders are divided into following categories:

ICD 10 Classification –
F45 Somatoform disorders
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
.30 Heart and cardiovascular system
.31 Upper gastrointestinal tract
.32 Lower gastrointestinal tract
.33 Respiratory system
.34 Genitourinary system
.38 Other organ or system
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified

F45.0 Somatization Disorder

Somatization disorder is characterized by chronic multiple somatic symptoms in the absence of physical disorder.
The symptoms are vague, presented in a dramatic manner and involve multiple organ systems.

F45.2 Hypochondriasis
Hypochondriasis is defined as a persistent preoccupation with a fear or belief of having a serious disease despite
repeated medical reassurance.

F45.3 Somatoform Autonomic Dysfunction

In this disorder, the symptoms are predominantly under autonomic control, as if they were due to a physical disorder.
Some of them include palpitation, hiccoughs, hyperventilation, irritable bowel, dysuria, etc.

F45.4 Persistent Somatoform Pain Disorder

The main feature in this disorder is severe, persistent pain without any physical basis. It may be of sufficient severity
so as to cause social or occupational impairment. Preoccupation with the pain is common.

TREATMENT MODALITIES
Individual Psychotherapy
The goal of psychotherapy is to help clients develop healthy and adaptive behaviors, encourage them to move beyond
their somatization, and manage their lives more effectively. The focus is on personal and social difficulties that the
client is experiencing in daily life as well as the achievement of practical solutions for these difficulties. Treatment is
initiated with a complete physical examination to rule out organic pathology. Once this has been ensured, the
physician turns his or her attention to the client’s social and personal problems and away from the somatic complaints

Group Psychotherapy
Group therapy may be helpful for somatoform disorders because it provides a setting where clients can share their
experiences of illness, can learn to verbalize thoughts and feelings, and can be confronted by group members and
leaders when they reject responsibility for maladaptive behaviors. It has been reported to be the treatment of choice
for both somatization disorder and hypochondriasis, in part because it provides the social support and social
interaction that these clients need.

Behavior Therapy
Behavior therapy is more likely to be successful in instances when secondary gain is prominent. This may involve
working with the client’s family or significant others who may be perpetuating the physical symptoms by rewarding
passivity and dependency and by being overly solicitous and helpful. Behavioral therapy focuses on teaching these
individuals to reward the client’s autonomy, self-sufficiency, and independence.

Psychopharmacology
Antidepressants
Clomipramine (Anafranil)
These are often used with somatoform pain disorder. They have been shown to be effective in relieving pain,
independent of influences on mood.

serotonin and norepinephrine reuptake inhibitors (SNRIs)

venlafaxine and duloxetine have demonstrated utility as analgesic agents and bypass several of the untoward effects
commonly associated with the TCAs.

Anticonvulsants
such as phenytoin (Dilantin), carbamazepine (Tegretol), and clonazepam (Klonopin) have been reported to be
effective in treating neuropathic and neuralgic pain, at least for short period.