I.

ADJUSTMENT DISORDER
ADJUSTMENT
Adjustment is the process of modifying ones behaviour in changed circumstances
or an altered environment in order to fulfil psychological, physiological and social needs
[Mary.C.Townsend]

ADJUSTMENT DISORDER
An adjustment disorder is a type of mental disorder resulting from maladaptive, or
unhealthy, responses to stressful or psychologically distressing life events. This low level of
adaptation then leads to the development of emotional or behavioural symptoms [Gale
encyclopedia of mental disorders]
Maladaptive reaction to an identifiable psychosocial stressor, that occurs within three
months after the onset of the stressor [Dr.M.S.Bhatia].
An adjustment disorder is characterized by a maladaptive reaction to an identifiable
psychosocial stressor or stressors that results in the development of clinically significant
emotional and behavioural symptoms [APA, 2000]
HISTORY
The concept of adjustment and impulse control disorders dates back to the 19 th century.
They were classified as having personality disorders. The other terms used for adjustment
disorders are Transient Situational Personality disorders, Transient Situational Disturbances,
Post Traumatic Stress Disorder, and Maladaptive Reaction.
EPIDEMIOLOGY
Various studies have shown its prevalence as 0.1 to 10 percent depending on the
sample studied. They may begin at an age and seen in both sexes. Adjustment disorder is
more common in women than in men by about 2 to 1[APA, 2000].
DIAGNOSTIC CRITERIA FOR ADUSTMENT DISORDERS
A] The development of emotional or behavioural symptoms in response to an identifiable
stressors occurring within3 months of the onset.
B] These symptoms or behaviours are clinically significant as evidenced by either of the
following1. Marked distress that is in excess of what would be expected from exposure to the stressor.
2. Significant impairment in social or occupational or academic functioning.
C] The stress related disturbances does not meet the criteria for another specific axis I
disorder and is not merely an exacerbation f a pre existing axis I or axis II disorder.
D] The symptoms do not represent bereavement.
E] Once the stressor or its consequences has terminated, the symptoms do not persist for
more than additional 6 months .
ACUTE: If the disturbance lasts less than 6 months.
CHRONIC: If the disturbance lasts for 6 months or longer.
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CLASSIFICATION OF ADJUSTMENT DISORDERS [DSM-IV-TR]

1.
2.
3.
4.
5.

Adjustment Disorder with Anxiety.

Adjustment Disorder with Depressive Mood.
Adjustment Disorder with Disturbance of Conduct.
Adjustment Disorder with Mixed Disturbance of Emotions and Conduct.
Adjustment Disorder Unspecified
Adjustment Disorder with Work (or academic) inhibition.
Adjustment Disorder with Withdrawal
Adjustment Disorder with Physical complaints
Adjustment Disorder with Atypical features
1. Adjustment Disorder with Anxiety.
This type of adjustment disorder diagnosed when the predominant
manifestation involves such symptoms as nervousness, worry and jitteriness. It
needs differentiation from Anxiety disorders.
2. Adjustment Disorder with Depressive Mood.
This is the most commonly diagnosed adjustment disorder. The
predominant symptoms are of minor depression .i.e., sad mood, tearfulness,
hopelessness and exceed what is an expected or normative response to an identified
psychosocial stressor. The major differential diagnosis is Major depression and
Uncomplicated Bereavement.
3. Adjustment Disorder with Disturbance of Conduct.
The predominant manifestation of this disorder involves conduct in
which there is violation of the rights of others or of major age appropriate societal
norms and values. E.g. Truancy, Vandalism, Reckless driving, Fighting, Defaulting
on legal responsibilities. Differential diagnosis must be made from conduct disorder
or antisocial personality disorder.
4. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct.
The predominant features of this disorder include emotional
disturbances like anxiety or depression as well as disturbances of conduct.
5. Adjustment Disorder Unspecified
This subtype is used when the maladaptive reaction is not consistent
with any of the other categories.
Adjustment Disorder with Work (or academic) inhibition.
The predominant manifestation of this category is an inhibition in
work or academic functioning occurring in an individual whose previous work
or academic performance has been adequate. Differential diagnosis is
depressive disorder and anxious disorder.
Adjustment Disorder with Withdrawal
The symptomatic manifestations are social withdrawal without
significant depressive or anxious moods.
Adjustment Disorder with Physical complaints
The clinical symptoms include physical complaints such as
backache, headache, and fatigue or other aches and pains of duration less than
6 months. Somatoform disorders are major differential but they have duration
of at least 6 months.

Adjustment Disorder with Atypical features

This category is used when adjustment disorder cannot be
classified in any of the specific categories.
ETIOLOGY AND PREDISPOSING FACTORS TO ADJUSTMENT DISORDERS
1. Family and genetic factors/Biological Theory
Sadock and Sadock suggest that monozygotic twins show greater concordance
than dizygotic twins. Family and genetic factors accounts for approximately 20 percent and
the likelihood of developing symptoms in response to traumatic life events is partially under
genetic control.
Chronic disorders such as cognitive disorders or mental retardation will impair
the ability of an individual to adapt to stress, causing increased vulnerability to adjustment
disorder.
2. Psychosocial Theories
There are several factors play an important role in determining who will
experience an adjustment disorder following a stressful life event. Those factors include the
intensity or severity of the stress, the quality of the support and vulnerability of the
individual. This is also related to a dysfunctional grieving process. The individual may
remain in the denial or anger stage, with inadequate defense mechanisms to complete the
grieving process.
Freud theorized that traumatic childhood experiences created fixation points
during development that might prompt the individuals when stressed, or particularly
following certain stresses to regress.
3. Transactional Model of Stress or Adaptation
It depicts the interaction between the individual and his environment. The type
of stressor that one experiences may influence ones adaptation .Continuous stressors were
commonly cited than the sudden-shock stressors as precipitants to maladaptive functioning.
Both situational and intrapersonal factors contribute to an individuals stress
response. Situational factors include personal and general economic conditions, occupational
and recreational opportunities, and availability of support systems such as family, friends,
neighbours and cultural or religious support groups. Intrapersonal factors such as
constitutional vulnerability also predisposes to adjustment disorders. Some studies suggest
that a child with difficult temperament is at greater risk for developing adjustment disorder.
Other intrapersonal factors such as social skills, presence of psychiatric illness, coping
strategies, degree of flexibility and level of intelligence influences ones ability to adjust to a
painful life change.

TREATMENT MODALITIES
According to Strain and Newcorn (2003), the major goals of therapy for these
individuals are :
To relieve symptoms associated with a stressor
To enhance coping with stressors that cannot be reduced or removed
To establish support systems that maximize adaptation
THERAPIES ARE:
1. Individual Psychotherapy
Individual Psychotherapy allows the client to examine the stressor that is causing
the problem. Treatment works to remove these blocks to adaptation so that normal
development progression can resume. Techniques are used to clarify links between the
current stressor and past experiences, and to assist with the development of more adaptive
coping strategies.
2. Family Therapy
The focus of treatment is shifted from the individual to the system of
relationships in which the individual is involved. The maladaptive response can be viewed as
a symptomatic of dysfunctional family system. All family members are included in the
therapy and the emphasis is placed on communication, family roles and interaction patterns
among the family members.
3. Behavioural Therapy
The goal of therapy is to replace ineffective response patterns with more
adaptive ones. The situations that promote ineffective responses are identified and designed
reinforcement schedules, along with role modelling and coaching are used to alter the
maladaptive response patterns. This type of treatment is very effective when implemented in
an inpatient setting where the client behaviour and its consequences may be more readily
controlled.
4. Self Help Groups
Group experiences with or without a professional facilitator provide an arena
for comparing their experiences and responses with individuals with similar life experiences
Hope is derived from knowing that others have survived and even grown from similar
experiences . Members of the group exchange advice, share coping strategies and provide
support and encouragement for each other.
5. Crisis Intervention
The therapist or other intervener becomes a part of the individuals life
situation for providing guidance and support and to help in mobilizing the resources needed
to resolve the crisis. Crisis intervention is short term and it relies on orderly problem solving
techniques. The ultimate goal is to resolve the immediate crisis, restore adaptive functioning
and promote personal growth.
6. Psychopharmacology
Adjustment disorder is not commonly treated with medications as their effect
may be temporary and only mask the real problem. It will interfere with the possibility of
finding more permanent solution. Also it can cause psychological and physiological
dependence.
When the client with adjustment disorder has symptoms of anxiety or
depression, anti anxiety drugs or anti depressant drugs can be prescribed.

IMPULSE CONTROL DISORDERS

IMPULSIVE
The urge or inclination to act without consideration to the possible
consequences of ones behaviour.

IMPULSE CONTRO DISORDERS

The DSM-IV-TR (APA, 2000) describes the essential features as:
1. Failure to resist an impulse, drive or temptation to perform an act that is harmful to
the person or others.
2. An increasing sense of tension or arousal before committing the act.
3. An experience of pleasure, gratification or relief at the time of committing the act.
Following the act there may or may not be regret, self-reproach or guilt.
HISTORY
The concept of impulse disorders dates to the 19 th century. Pinel and Esquirol
introduced the concept of instinctive impulse and the term instinctive monomania. In
1836, Marc first described Kleptomania.
CLASSIFICATION
Pathologic gambling
Kleptomania
Pyromania
Intermittent Explosive disorder
Trichotillomania
Rhinotillexomania
Compulsive buying
Isolated explosive disorder
1. PATHOLOGICAL GAMBLING
It is defined as persistent and recurrent maladaptive gambling behaviour
(APA,2000)
Life time prevalence rate of pathological gambling range from 0.4 to 3.4
percent in adults and 2.8 to8 percent among adolescents and college students (APA, 2000).It
is more common in men than women. It usually begins in adolescence and waxes and wanes,
tending to be chronic.
DIAGNOSTIC CRITERIA
A. Persistent and recurrent maladaptive gambling behaviour as indicated by five (or more) of
the following:
(1) Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences,
handicapping or planning the next venture, or thinking of ways to get money which to
gamble)
(2) Needs to gamble with increasing amounts of money in order to achieve the desired
excitement
(3) Has repeated unsuccessful efforts to control, cut back, or stop gambling
(4) Is restless or irritable when attempting to cut down or stop gambling
(5) Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g.
Feelings of helplessness, guilt, anxiety, depression)
5

(6) After losing money gambling, often returns another day to get even (chasing ones
losses)
(7) Lies to family members, therapist, or others to conceal the extent of involvement with
gambling
(8) Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance
gambling
(9) Has jeopardized or lost a significant relationship, job, or educational or career opportunity
because of gambling
(10) Relies on others to provide money to relieve a desperate financial situation caused by
gambling
B. The gambling behaviour is not better accounted for by a manic episode.
ETIOLOGY AND PREDISPOSING FACTORS
BIOLOGICAL INFLUENCES

GENETIC

The fathers of men with the disorder and mothers of women with the disorders
are more likely to have the disorder than the general population(Sadock and
Sadock,2003).Both pathological gambling and alcohol dependence are more common
among the parents of individuals of pathological gambling than in the general
population.(APA,2000)

PHYSIOLOGICAL

Abnormalities in the serotonergic and non adrenergic receptor systems

(Moreyra, 2000) and also dysfunction in the dopaminergic system. Many
studies indicated that alterations in the EEG patterns of pathologic gamblers.
PSYCHOSOCIAL INFLUENCES
Sadock and Sadock (2003) reports that several predisposing factors such as
loss of parent by death, separation, divorce or desertion before the child is 15 years of
age , inappropriate parental discipline [absence , inconsistency or harshness] ,
exposure to and availability of gambling activities for the adolescent , a family
emphasis on material and financial symbols and a lack of family emphasis on saving ,
planning and budgeting.
Psychoanalysts views pathological gambling in terms of psychosexual
maturation. Theory says that gambling is compared to masturbation; both of these
activities derive motive force from a build up of tension that is released through
repetitive actions or the anticipation of them. Another theory suggests a masochistic
component to pathological gambling and the gamblers inherent need for punishment,
which is achieved through losing (Moreyra et al, 2000)
TREATMENT MODALITIES
Therapies like Behavioural therapy, Cognitive therapy and Psychoanalysis
proved to be successful in treating pathologic gamblers (Moreyra
et al, 2000).
Medications like SSRIS, Clomipramine, Lithium, Carbamazepine and
Naltrexone shown to be effective.
Most effective treatment of pathological gambling is participation by the
individual in Gamblers Anonymous [GA].This organization is for inspirational
group therapy .GA membership requires only an expressed desire to stop
gambling. Treatment is based on peer pressure, public confession, and the
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availability of other reformed gamblers to help individuals resist the urge to

gamble. Gam-Anon is for the family and spouses of compulsive gamblers and
the Gam-a-Teen is for adolescent children of compulsive gamblers.

2. KLEPTOMANIA
The DSM-IV-TR describes Kleptomania as the recurrent failure to resist
impulses to steal items even though the items are not needed for personal use or
for their monetary value. The stolen items are either given away, discarded,
returned surreptitiously or kept and hidden (Sadock and Sadock, 2003)
The individual with kleptomania steals purely for the sake of stealing
and for the sense of relief and gratification that follows an episode. The
impulsive stealing in response to increasing tension even though the individual
knows that the act is wrong, he or she cannot resist the force of mounting
tension and the pursuit of pleasure and relief that follows. The individual may
feel shame or remorse following the incident. Symptoms of depression and
anxiety have been associated with this disorder.
Onset of the disorder is usually in adolescence. It is more common
among women than men.
DIAGNOSTIC CRITERIA
A. Recurrent failure to resist impulses to steal objects that are not needed
for personal use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in
response to a delusion or a hallucination.
E. The stealing is not better accounted for by conduct disorder, a manic
episode, or antisocial personality disorder
ETIOLOGY AND PREDISPOSING FACTORS
BIOLOGICAL INFLUENCES
Brain disease and Mental retardation have been associated with
Kleptomania. (Sadock and Sadock, 2003) Disinhibition and poor impulse control have
been linked with cortical atrophy in the frontal region and enlargement of the lateral
ventricles of the brain.
PSYCHOSOCIAL INFLUENCES
Cupchick [2000] states that most individuals who steal compulsively
do so in response to some personal crisis such as life threatening diagnosis or the
death of a loved one.
TREATMENT MODALITIES
Insight oriented psychodynamic psychotherapy is the most helpful with
those individuals who experience guilt and shame and are thus motivated to change
their behaviour.
Behavioural therapy methods like systematic desensitization, aversive
conditioning and a combination of aversive conditioning and altered social
contingencies are proved to be effective. (Sadock and Sadock, 2003)
Medications like SSRIS, tricyclic antidepressants, trazodone, lithium,
valporate and Naltrexone are very helpful .
ECT is shown to be effective in some cases.
7

3. PYROMANIA
Pyromania is described as Motivation less arson.
Pyromania is the inability to resist the impulse to set fires. The act of starting
the fire is preceded by tension or affective arousal. The individual experiences
intense pleasure, gratification, or relief when setting the fires, witnessing their
effects or participating their after math. The sole motive for setting the fire is
self gratification, not revenge, insurance collection or sabotage. They make
precautions to avoid apprehension.
The onset of symptoms is usually in childhood. It is more common
n males than in females. Features associated with pyromania include low
intelligence, learning disabilities, alcoholism, psychosexual dysfunction,
chronic personal frustrations, resentment of authority figures and the
occurrence of sexual arousal secondary to fires.

DIAGNOSTIC CRITERIA
A. Deliberate and purposeful fire-setting on more than one occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to fire and its situational
contexts (e.g., paraphernalia, uses, consequences).
D. Pleasure, gratification, or relief when setting fires, or when witnessing or participating in
their aftermath.
E. The fire-setting is not done for monetary gain, as an expression of sociopathical ideology,
to conceal criminal activity, to express anger or vengeance, to improve ones living
circumstances, in response to a delusion or hallucination, or as a result of impaired judgment
(e.g., in dementia, mental retardation, substance intoxication).
F. The fi re-setting is not better accounted for by conduct disorder, a manic episode, or
antisocial personality disorder
DS
ETIOLOGY AND PREDISPOSING FACTORS
BIOLOGICAL INFLUENCES
Mild mental retardation and learning disabilities have associated with fire
setting. Low cerebrospinal fluid levels of 5-hydroxyindole acetic acid[5HIAA] and 3methoxy-4-hydroxyphenyl glycol[MHPG] also found in individuals with pyromania.
Also a hypoglycaemic tendency is seen in these individuals.
PSYCHOSOCIAL INFLUENCES
Three major psychoanalytical issues associated with the impulsive fire setting
includes:
1. An association between fire setting and sexual gratification
2. A feeling of impotence and powerlessness
3. Poor social skills.
Freud viewed fire as a symbol of sexuality. He suggested that the warmth
radiated by fire can be compared to the sensation that accompanies a state of sexual
excitation. Clients masturbate after setting fires and describe the gratification they
experience as orgasmic. Other psychoanalysts suggested that the fire may symbolize
activities deriving from various levels of libidinal and aggressive development . The y
view the act of fire setting as a means of relieving accumulated rage over the
frustration caused by a sense of social, physical and sexual inferiority(Sadock and
Sadock, 2003)
TREATMENT MODALITIES
8

Treatment of clients with Pyromania is difficult because o the lack of

motivation for change. Denial of problems, refusal to take responsibility for their
behaviour, and alcoholism interfere with the improvement. Sadock and Sadock in
2003, states that Incarceration may be the only method of preventing a recurrence.
Behaviour therapy can be administered in the institution.
M-IV-TR Criteria 312.33

4. INTERMITTENT EXPLOSIVE DISORDER

This disorder is characterized by discrete episodes of failure to resist
aggressive impulses that result in serious assaultive acts or destruction of property
[APA,2000].
The individual is not normally an aggressive person between episodes
and the degree of aggressiveness expressed during the episodes is grossly out of proportion to
any precipitating psychosocial stressors. The symptoms appear suddenly, without any
apparent provocation and the violence is usually the result of an irresistible impulse. Some
clients report sensorium changes such as confusion during episodes or amnesia for events that
occurred during episodes. Symptoms terminate abruptly, commonly lasting only minutes or at
most a few hours and are followed by feelings of genuine remorse and self reproach about the
inability to control and the consequences of the aggressive behaviour.
Symptoms of the disorder most often begin in adolescence or young
adulthood and gradually disappear as the individual approaches middle age. Clients have
history of learning disabilities, hyper kinesis and proneness to accidents in childhood. It
occurs most often in males than in females.
DIAGNOSTIC CRITERIA
A. Several discrete episodes of failure to resist aggressive impulses that result in serious
assaultive acts or destruction of property.
B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to
any precipitating psychosocial stressors.
C. The aggressive episodes are not better accounted for by another mental disorder (e.g.,
antisocial personality disorder, borderline personality disorder, a psychotic disorder, a
manic episode, conduct disorder, or attention deficit/hyperactivity disorder) and are 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., head trauma, Alzheimers disease).
ETIOLOGY AND PREDISPOSING FACTORS
BIOLOGICAL INFLUENCES
Disorder is most common in first degree biological relatives of people with the
disorder than in general population. Predisposing factors include perinatal trauma,
infantile seizures, head trauma, encephalitis, minimal brain dysfunction and
hyperactivity.
PSYCHOSOCIAL INFLUENCES
Clients have strong identifications with assaultive parental figures. The typical
history includes a chaotic and violent early family milieu with heavy drinking by one
or both parents, parental hostility, child abuse , threats to life and the emotional or
physical unavailability of a father figure.
TREATMENT MODALITIES
9

Group therapy with its elements of group loyalty, peer pressure,

expectation and confrontation may be useful. Family therapy may be helpful when the
client is an adolescent or young adult.
Medications include mood stabilizers like Lithium, anticonvulsants like
Carbamazepine, Gabapentin, Phenytoin, and Valporate, Serotonin modulating drugs
like SSRIS, Buspirone, Clomipramine, Trazodone and beta blockers like
propraonolol are proved to be effective. The newer atypical antipsychotics are also a
better choice.

5. TRICHOTILLOMANIA
The DSM-IV-TR defines the disorder as recurrent pulling out of ones hair
resulting in noticeable hair loss. An increasing sense of tension immediately before pulling
out the hair or when attempting to resist the behaviour and results in a sense of gratification
from pulling out the hair. The most common sites are scalp, eyebrows and eye lashes. These
areas of hair loss are more likely found on the opposite side of the bodyfrom the dominant
hand. Pain is seldom reported. Tingling and pruritus in the area are common.
The disorder usually begins in childhood and may be accompanied by nail
biting, head banging, scratching, biting, or other acts of self mutilation. It occurs more often
in women than in men.
DIAGNOSTIC CRITERIA
A. Recurrent pulling out of ones hair resulting in noticeable hair loss.
B. An increasing sense of tension immediately before pulling out the hair or when attempting
to resist the behaviour.
C. Pleasure, gratification, or relief when pulling out the hair.
D. The disturbance is not better accounted for by another mental disorder and is not due to a
general medical condition (e.g., a dermatological condition).
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
.

ETIOLOGY AND PREDISPOSING FACTORS

BIOLOGICAL INFLUENCES
It presents as a major symptom in mental retardation , obsessive compulsive
disorder and depression.
PSYCHOSOCIAL INFLUENCES
Onset can be related to stressful situations. Other factors include disturbances in
mother-child relationships, fear of abandonment and recent object loss. Studies done
by Lochner et al, 2002, proved that there is relation between Trichotillomania and
history of childhood abuse or emotional neglect.
TREATMENT MODALITIES
Behaviour modification is the best treatment choice. Techniques like Covert
desensitization and habit reversal practices can be implemented. A system of rewards and
punishment are applied to modify the hair pulling behaviours.
Psychodynamic interventions have been used in children. Exploration is
conducted into areas of parent-child relationships or other areas of potential conflict.

10

Medications like Chlorpromazine, Amitryptiline and Lithium carbonate and

SSRIs augmented pimozide are reported to be effective.

6. RHINOTILLEXOMANIA
Rhinotillexomania or Nose picking causes moderate to marked interferences
with daily functioning. Time spent is usually 15 minutes to 2 hours a day. Epistaxis and
perforation of nasal septum are complications. Associated habits include picking cuticles,
picking at skin, biting finger nails and pulling out hair.
Treatment includes behaviour modification, anxiolytics including SSRIS.

7. COMPULSIVE BUYING
It is defined as frequent preoccupation with buying or impulses to buy that is
experienced as irresistible, intrusive or senseless or frequent buying of items that are not
needed, or shopping for longer periods of time than intended. It interferes with social or
occupational functioning or results in financial problems.

8. ISOLATED EXPLOSIVE DISORDER

In the past, it was referred to as Catathymic Crisis. It is a single, discrete
episode in which failure to resist an impulse led to a single, violent externally directed act
that had a catastrophic impact on others. The degree of aggressivity expressed during the
episode was grossly out of proportion to any precipitating psychosocial stressor. Before the
episode, there were no signs o generalized impulsivity or aggressiveness. It is not due to
schizophrenia, antisocial personality disorder, or conduct disorder. For example, an individual
without any apparent reason suddenly began shooting at total strangers in a fit of rage and
then shot himself.
CONCLUSION
Adjustment disorders are relatively common. Impulse control disorders are
quite rare but involve compulsive acts that may be harmful to the individual or to others.
Clinical symptoms include inability to function socially or occupationally in response to a
psychosocial stressor.

NURSING MANAGEMENT
A] Ineffective Coping
Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses,
and/or inability to use available resources.
Assessment Data

Impulsive behavior

Acting-out behavior

Suicidal behavior

Discomfort with sexual feelings

11

Poor social skills

Anxiety

Difficulty expressing feelings

Unmet needs for affection, closeness, and peer group acceptance

Ineffective relationships

Lack of leisure skills

Expected Outcomes
Immediate
The client will:

Not harm self or others

Abstain from using alcohol and drugs

Identify consequences of maladaptive behavior patterns

Comply with structured daily routine, including educational, social, and recreational
activities

Stabilization
The client will:

Eliminate maladaptive coping patterns (alcohol and drug use, acting out, suicidal
behaviour)

Complete daily expectations independently

Verbalize accurate information regarding substance use, sexual activity, and prevention of
HIV transmission

Community
The client will:

Express satisfaction with peer and family relationships

Demonstrate use of the problem-solving process in decision-making

Implementation
NURSING INTERVENTIONS

RATIONALE

* denotes collaborative interventions

State rules, expectations, and responsibilities Clear expectations give the client limits to
clearly to the client, including consequences which his or her behavior must conform and
12

for exceeding limits.

what to expect if he or she exceeds those

limits.

Use time out (removal to a neutral area) when Time out periods are not punishment but an
the client begins to lose behavioral control.
opportunity for the client to regain control.
Instituting time out as soon as the clients
behavior begins to escalate may prevent acting
out and give the client a successful experience
in self-control.

Encourage the client to verbalize feelings.

Identifying and verbalizing feelings is difficult

for an adolescent but is a necessary initial step
toward resolving difficulties.

Allow the client to express all feelings in an The client may have many negative feelings
appropriate, non-destructive manner.
that he or she has not been allowed or
encouraged to verbalize.

Ask the client to clarify feelings if he or she is Clarification avoids any misunderstanding of
vague or is using jargon (Can you explain that what the client means and helps the client
to me?).
develop skill in verbally expressing himself or
herself.

Encourage a physical activity if the client is

better able to discuss difficult issues while
doing something physical (eg, take a walk with
the client while talking).

Physical activity such as walking provides an

outlet for anxious energy, which is common in
stressful situations. Also, eye contact, which
may be difficult for the client who feels
uncomfortable, can be diminished while
walking with someone.

Provide a safe environment for the client.

The clients safety is a priority.

Provide factual information about sexual

issues, substance use, and consequences of
high-risk behavior. Teach the client about
transmission of HIV infection and how to
prevent it.

Adolescents frequently have inadequate or

incorrect information. Any client who may be
sexually active or who may use intravenous
drugs is at increased risk for HIV infection.

Written information, such as pamphlets, often Written information allows the client to be
13

is helpful.

exposed initially to the material privately,

which may be less embarrassing for him or
her.

Assess the clients understanding of

information through discussion and feedback
(eg, return explanation by the client in his or
her own words). Do not rely on asking Did
you understand? or Do you have any
questions?

Adolescents frequently will deny questions or

say they understand when they do not to
decrease discomfort, avoid admitting they do
not understand, or avoid further discussion.

Use a matter-of-fact approach when discussing A matter-of-fact approach will decrease the
these emotionally charged issues with the clients anxiety and demonstrate that these
client.
issues are a part of daily life, not topics about
which one needs to be ashamed.

Avoid looking shocked or disapproving if the Testing behaviour, to see your reaction, is
client makes crude or outrageous statements.
common in adolescents.

Teach the client a simple problem-solving The adolescent client has probably not thought
process: describe the problem, list alternatives, about using a systematic approach to solving
evaluate choices, and select and implement an problems and may not know where to begin.
alternative.

Have the client list actual concerns or problems Listing concerns helps clarify the clients
he or she has been having.
thinking and provides data about the problems
that he or she would like to resolve.

Assist the client in applying the problem- Personal experience in using the problemsolving process to situations in his or her life.
solving process is more useful to the client
than using hypothetical examples.

Discuss the pros and cons of possible choices Guiding the client through the process while
the client has made.
discussing actual concerns shows him or her
how to use the process.

Avoid offering personal opinions. Ask the The clients ability to make more effective
client, Knowing what you know now, what decisions is a priority. Your opinions diminish
14

might you do next time that happens?.

the clients opportunity to develop skills in this

area.

B] Interrupted Family Processes

Change in family relationships and/or functioning.
Assessment Data

Inadequate parent-child interactions

Ineffective communication about family roles, rules, and expectations

Rigid family roles

Inability to express feelings openly and honestly

Situational, developmental, or maturational transition or crisis

Expected Outcomes
Immediate
The client will:

Express feelings within the family group

Listen to feelings of family members

Stabilization
The client will:

Participate in family problem-solving

Negotiate behavioral rules and expectations with parents

Community
The client will:

Demonstrate compliance with negotiated rules independently

Report satisfaction with family communication and relationships

Implementation

NURSING INTERVENTIONS

RATIONALE

* denotes collaborative interventions

Help the client clarify issues he or she would Anticipatory discussion may decrease the
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like to discuss with his or her parents. A written clients discomfort and help the client be
list may be helpful.
specific and avoid generalizations. Writing the
ideas ensures that important issues will not be
forgotten due to anxiety and provides a focus
to keep the client on task.

Encourage the client to use I statements to

describe what he or she thinks or feels, rather
than general statements, such as I think . . .,
I feel . . ., I need . . . and so forth.

Statements using I assume responsibility for

the statement of feelings, are less likely to be
blaming in nature, and can help the client learn
how to share his or her own thoughts and
feelings.

* Encourage the clients parents to Parents also can benefit from assistance to
communicate with the client in the same way make I statements and focus on feelings
(see above).
rather than blaming.

* Facilitate family sessions for sharing

feelings, concerns, and ideas. Establish limits
in these meetings that encourage mutual
support, self-responsibility, and emotional
safety.

Such meetings can be a semi-formalized

method for initiating family interaction.
Adolescents and their parents may find this
difficult to do without assistance.

* Help the client and parents take turns talking Your role is to facilitate communication, not to
and listening. Do not get drawn into giving get involved in family dynamics. You must not
opinions or advice.
give the perception of taking sides.

* Help clarify statements made by others. Your communication skills can be helpful in
Provide a summary for the family group saying clarifying ideas. A summary statement can
Sounds like . . .
reiterate important discussion points and
provide closure.

* Guide the client and parents toward

negotiating expectations and responsibilities to
be followed at home. A written contract may be
helpful.

Negotiating may be unfamiliar to the

adolescent and his or her parents, but is a skill
that can help adolescents separate from
parents, which is an important developmental
task. Writing the agreement increases clarity
for all parties and decreases the chances for
future manipulation or misunderstanding.

C] Situational Low Self-Esteem

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Development of a negative perception of self-worth in response to a current situation

(specify).
Assessment Data

Negative self-image

Low self-esteem

Feelings of doubt

Minimizing strengths

Underachievement

Emotional distancing of significant others

Absence of satisfactory peer relationships

Ineffective communication skills

Expected Outcomes
Immediate
The client will:

Identify feelings of doubt and uncertainty

Give and receive honest feedback with peer group

Stabilization
The client will:

Make realistic, positive self-statements

Identify own strengths and weaknesses realistically

Express feelings in an acceptable manner

Community
The client will:

Verbalize increased feelings of self-worth

Report increased satisfaction with peer relationships

Implementation

NURSING INTERVENTIONS

RATIONALE

* denotes collaborative interventions

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Provide direct, honest feedback on the clients The client may not have had feedback about
communication skills.
his or her communication skills.

Be specific with feedback (eg, You look at the General statements are less helpful to the client
floor when someone is talking to you.). Do than specific feedback.
not assume the client will know what you mean
by general or abstract comments.

Role-model specific communication skills (ie, Modelling desired behaviours and skills gives
listening, validating meaning, clarifying, and the client a clear picture of what is expected.
so forth).
Practicing skills enhances comfort with their
use.

Encourage clients to practice skills and discuss The stage can be set for honest sharing if the
feelings with each other. Suggest to the client client feels he or she is not too different from
that he or she may have concerns similar to peers.
others and that perhaps they could share them
with each other.

Give positive feedback for honest sharing of Positive feedback increases the frequency of
feelings and concerns (eg, You were able to desired behaviour.
share your feelings even though it was
difficult.).

Do not allow the client to dwell on past The client may believe that past unacceptable
problems, reliving mistakes, or making self- behaviour makes him or her a bad person.
blame. Help the client separate behaviour from
the sense of personal worth.

Help the client make the transition from a

focus on the past to a focus on the present. For
example, asking, What might you do
differently now? or What can be learned
from . . .? can be used to help the client with
that transition.

Once you have heard the client express

feelings about past behaviour, it is not useful to
allow the client to ruminate -the past cannot be
changed.

REFERENCES
1. Dr.M.S.Bhatia,Essentials of Psychiatry, sixth edition, CBS Publishers (2010), PageNo:
385-392
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2. Mary.C.Townsend, Psychiatric Mental Health Nursing-Concepts of care in Mental health

practice, 5th edition, Jaypee publishers, PageNo: 674-689
3. Jerald Kay, Allan Tasman, Essentials of Psychiatry, John Wiley and sons Ltd publishers
(2006), PageNo: 756-784
4.Benjamin James Sadock, Virginia Alcott Sadock,Kaplan and Sadocks Synopsis of
Psychiatry,10th edition ,Wolters Kluwer India Pvt Ltd, Newdelhi(2007), PageNo: 773-789

THANK YOU

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