Psychiatric Nursing: Complete Study notes

Beliefs  Feelings  Behavior Therapeutic Communication Techniques • What you see, you say • What you hear, you say  restating Sigmund Freud • Father of Psychoanalysis • Structure of Personality (Id, Ego, Supe ...

Beliefs  Feelings  Behavior Therapeutic Communication Techniques • What you see, you say • What you hear, you say  restating Sigmund Freud • Father of Psychoanalysis • Structure of Personality (Id, Ego, Superego) Dominant ID Mania D eat Antisocial mpulsive drink Narcissistic want to urinate want PLEASURE defecate PLEASURABLE PRINCIPLE Pain Avoidance It’s all “I” DOMINANT SUPER EGO Obsessive - compulsive UPER EGO Anorexia Nervosa hould not mall voice of God CONSCIENCE PRINCIPLE GO Xecutive Secretary Impaired Reality Schizophrenia REALITY PRINCIPLE LIBIDO  sexual energy responsible for survival PSYCHOSEXUAL THEORY 1. ORAL STAGE • 0 – 18 Months old • Survival • I want to eat, sleep, urinate, defecate • ID formation • Cry & Suck  mouth Child Cries Feed the Infant Ignore the Infant   Successful Unsuccessful  Narcissistic Defense Mechanism: o FIXATION  when a person is stuck in a certain developmental stage o REGRESSION  return to an earlier developmental stage • EGO is develop in the 6th month 2. ANAL STAGE • Ateen – 3 years old (18 mos – 3 y.o.) • Toilet training • Super Ego develop Toilet Training Good Mother Bad Mother   Successful Unsuccessful Too Rigid Training Dirty  Disorganized Clean Disobedient Organized  Obedient ANTISOCIAL  (Anal Expulsive) OBSESSIVE – COMPULSSIVE (Anal Retentive) 3. PHALLIC • 3 – 6 y.o. • Penis/ Vagina • Parents is the significant person • Called as Preschooler • Oedipus Complex  little boy loves mommy • Electra Complex  little girl loves daddy • Identification  boy associates with daddy, girl assoc. with mommy • Castration  fear of the little boy to daddy • Penis Envy  envy of little girl towards daddy Dr. Karen Horney  opposition to penis envy • Level of Awareness o Conscious  highest level of awareness o Preconscious  Tip of the tongue o Unconscious  deepest level of awareness • Birth Trauma  First traumatic experience of child • REPRESSION  unconscious forgetting of an anxiety provoking concept • SUPRESSION  conscious forgetting of an anxiety provoking concept 4. LATENCY STAGE • 6 – 12 years old • SCHOOlatency • Sexual energy is dormant • Reading, Riting, Rithmetic • SUBLIMATION  placing sexual energies toward a more productive endeavors 5. GENITAL STAGE • 12 y. o. – above • Gising • Genital PHARMA MOMENTS ANTIANXIETY VLAST ME VAIB Valium – ate V Miltown - Meal Vistaril - largavista Libreum - L Equanil – Aqua Kneel Attarax – Mga bato (rocks) Ativan - Ate Guy Inderal – hindi ralph Seraks – Sera Ulo Busfar – sasakay ng bus Tranxene - Transit ERIK ERIKSON • PSYCHOSOCIAL THEORY OF DEVELOPMENT Age + - Affecting Major Factor 0-18 mos. Trust Mistrust Feeding 18 mos. – 3 y.o. Autonomy AU nal TO ilet training NO favorite word MY Shame/ doubt Toilet Training 3 – 6 y.o. Initiative Guilt Independence 6 – 12 y.o. Industry Inferiority In da-school 12 – 20 y.o. Identity Role confusion Peer 20 – 25 y.o. Intimacy Isolation Love 25 – 45 y.o. Generativity Stagnation Parenting 45 y.o. and above Ego Integrity Despair Reflection MASLOW’S HEIRARCHY OF NEEDS 1. Physiologic Needs o Air, food, water, shelter, rest, sleep, activity and temperature maintenance that are crucial for survival 2. Safety and Security Needs o Safe in physical and psychological aspects 3. Love and Belonging Needs o Giving and receiving affection, attaining a place in a group, maintaining the feeling of belonging 4. Self – esteem Needs o Self esteem – feelings of independence, competence and self respect o Esteem from others – recognition, respect, appreciation 5. Self Actualization o One’s maximum potential and realize one’s abilities and qualities BEHAVIORAL MODELS 1. Ivan Pavlov • Classical Conditioning Model • All behavior are learned  Food  dog  Salivation  Bell  Food  Dog  Salivation  Bell  Salivation 2. B.F. Skinner • Operant Conditioning • All behaviors are unlearned • Reward (+ reinforcement) and Punishment (- Reinforcement) BRAIN LOBES ACTION Frontal  Language, Learning, Personality, Judgment Temporal  hearing, smelling Parietal  Taste, touch Occipital  Vision Sensory Integration Voluntary Motor Involuntary VOLUNTARY NERVOUS SYSTEM • Somatic Nervous System AcetylCholine  Brain  Spinal Cord  Motor Nerve  Muscle Fiber INVOLUNTARY NERVOUS SYSTEM • Autonomic Nervous System Sympathetic Parasympathetic HR   RR   GI  Constipation  Diarrhea GU  Urinary retention  Urinary Frequency Neuro Epi/ Nor Acetyl Choline PHARMA MOMENTS MONOAMINE OXIDASE INHIBITORS AR M PLAN N DIL P NATE ANTIPARKINSON CAPABLES Cogentin Artane Parlodel Akineton Benadryl Larodopa Eldepryl Symmetryl THERAPEUTIC COMMUNICATION Therapeutic Non-Therapeutic • Offer your self  I’ll stay with you • Silence • Making observations o You seem sad • Active listening o Nodding o Eye contact o Lean forward • Who, what, when, where • General leads o Go on, I’m listening, what else? • Broad opening - best Opening line o How are you today? o How are you? • Restating • Clarrification • Refocusing  we are talking about the exam • Focusing  tell me about • Don’t worry be happy • Everything’s gonna be alright • Ignoring the client • Changing the subject • Nice weather we’re having o Adjectives – value based perception, should not be use • You are the most beautiful client • Why • Arguing • Flattery • You should do this now • In my opinion DEFENSE MECHANISMS  Fight for stress DISPLACEMENT • Transfer of feelings to a less threatening object rather than the one who provoke it • Boss shouts at you, you shout at your subordinate DENIAL • Failure to acknowledge an unacceptable trait or situation • “I’m not an alcoholic” DISSOCIATION • Psychological flight from self • A type of amnesia • “Sino ka, Sino ako?” REGRESSION • Return to an earlier developmental stage • Return to thumbsucking REPRESSION • Unconscious forgetting of an anxiety provoking concept • Hindi ko maalala RATIONALIZATION • Illogical reasoning for a socially unacceptable trait • “sayang ang beer sa ref, kaya ko ininum” • I drink because I don’t want to waste the beer in the ref REACTION FORMATION • doing the opposite of your intention • plastic • sasabunutan kita. . . ay kuklulutin lang kita UNDOING • Doing the opposite of what you have done due to guilt • orocan, plastic, Tupperware • “ay pinatid kita, halika punta kita sa clinic” IDENTIFICATION • Assume trait for personal, social, occupational role • Tulad niya PROJECTION • Attributing to others one’s acceptable trait • Pasa load • “hindi ako alcoholic, sila yon” INTROJECTION • Assume another person’s trait as your own • • “ako din” • Not just you, me too SUPPRESSION • Conscious forgetting of an anxiety provoking concept • Hindi ko alam yan SUBLIMATION • Placing sexual energies toward a more productive endeavors • Angry at life, put anger in singing CONVERSION • Repressed angers put towards physical symptoms affecting nervous system leading to sensory numbness and motor paralysis • Biglang mangingig COMPENSATION • Overachievement in one area to cover a defective part • Pilay pero magaling kumanta SUBSTITUTION • Replacing a difficult goal with a more accessible one • Gusto ko Disneyland. Enchanted nalang. STOP  GABA  Inhibitory Gamma Amino Butyric Acid GO  Epinephrine/ Norepinephrine SNS Exitatory ANXIETY Anticholinergic side effect Constipation Urinary Retention Within 1 week Dry Mouth Rebound Blurred Vision phenomenon Seizure Abrupt Anti-Anxiety Dependence Withdrawal Drowsy No Alcohol No Coffee Develop Orthostatic Hypotension Prevetion of O.H. 1. Sit Down 2. Dangle feet Gradually 3. Stand Up Gradually Tapered Dose RELAXED ANXIETY • Vague sense of impending doom Mild Moderate Severe Panic +1 +2 +3 +4 Widened acing ont know what uicide Perceptual to say/do afety Don’t touch client Field RN Meds IRECTIVE Respi Alkalosis Restless Bown Bag Enhanced Learning Capacity “You Seem Restless “ Assess : Level of Anxiety Nx Dx : Ineffective Individual Coping Powerlessness Impaired Skin Integrity Planning/ Implementation:   level of anxiety   environmental Stimuli  Relaxation Technique • Showing pictures of flower, waterfalls • Hearing sounds of chirping birds Evaluation : Effective individual coping ENERALIZED ANXIETY DISORDER months excessive worrying • Might be mild, moderate and severe anxiety S/Sx • Restless • Difficulty of concentration • Sleep Disorders • Palpitations • Edge of the seat • Easy fatigability PANIC DISORDER • 15 – 30 Minutes escalation of SNS • AGORAPHOBIA  fear of open space/ public places • SOCIAL PHOBIA  fear of public POST TRAUMATIC STRESS DISORDER Trauma Disaster Accident Flashbacks War VICTIMS  Survivors Rape Nightmares Earthquake Soldier 6 years old  Anxiety SOMATOFORM   > no pretension Assignments/ “I am sick” > no organic Homeworks  basis  MALINGERING > unconscious No Assignments/ pretending to be sick Homeworks (Conscious) PSYCHOSOMATIC   > Real pains/ illness You Think Absent > Real symptoms “Teacher may > 4 major types get angry” * Hypertension * Migraine Escape from Mama Care * Stress Ulcer Teacher  * Asthma PRIMARY GAIN  Attention (Behavior  anxiety) SECONDARY GAIN SOMATOFORM DISORDERS SOMATOFORM Nervous System Illusion of structural defect CONVERSION DISORDER BODY DYSMHORPIC DISORDER La Belle Indifference  emotional disattachment from disability Minor Discomfort Interpreted as major illness HYPOCHONDRIASIS “Maliit na butas, pinalalaki” Favorite Past Time: Doctor Hopping Nursing Focus: Feelings PSYCHOSOMATIC DISORDERS  Anxiety SNS PNS  BP Vasoconstriction Bronchoconstriction   Hypertension Cerebral Artery Left Gastric Artery Asthma   Migraine Stress Ulcer OBSESSIVE – COMPULSIVE Belief/ thought  Feelings Door Open   Anxiety Burglar may go inside Obsession   anxiety (thought)  Returns to house (Action)  Anxiety  Compulsion PHOBIA • Irrational fears • Etiology o Knowledge o Experience • Immediate Nursing Intervention  remove the stimuli • SYSTEMATIC DESENSITIZATION o Gradual exposure to feared object PHARMA MOMENTS ANTIPSYCHOTIC AGENT SSTTCMHP Stelazine - sexy star Clozaril – closed reel Serentil – serena Mellaril – maraming reel Thorazine – babaeng Tora Haldol – hahaha Trilafon - tri-band phone Prolixin – pero lick scene ALCOHOLISM Etiology: Intergenerational Transmission • From one generation to another generation Alcohol  Blackout  awake but unaware  Confabulation  inventing stories to  self-esteem  Denial  “I am not an alcoholic” Dependence  “I can’t live without it”  Enabling  significant other tolerates abusers Another term CO – DEPENDENCY TOLERANCE   Substance to achieve a previous effect DETOXIFICATION • Withdrawal with MD supervision • Check Alcohol, Mouthwash, Elixer void alcohol version therapy lcoholics Anonymous  self help group ntabuse  DISULFIRAM  Never drink alcohol  12 hour interval/ 12 h last alcohol intake B1 Vitamin Deficiency or else: nausea, vomiting and hypotension  Wernicke’s Encephalopathy  motor Complications  Korsakoff’s Psychosis  memory Delirium Tremens  24 – 72 h after last dose of alcohol  untreated withdrawal syndrome ormocation  bugs crawling under the skin amily Therapy  mother, father, brother AUTISM Autistic Savant  autistic with a special talent Assess • Appearance  flat affect, consistent movement • Behavior  repetitive, ritualistic • Communication  echolalia, incomprehensible Nx Dx • Impaired verbal communication • Impaired social interaction • Self mutilation • Risk for injury Planning/ Implementation • Maslow’s hierarchy of needs • Constancy, promote safety Evaluation • Expressive therapy  drawing, muscic etc • Enhanced communication • Improved social interaction • Safety ATTENTION DEFICIT HYPERACTIVE DISORDER • Onset : 7 y.o. and below • Duration : 6 months and above • Settings : 2  House and school • Id Dominant : Mom or RN will act as superego ADHD   Glucose  Frontal Lobe  impaired judgement   ADHD S/Sx  Ritalin  Frontal Lobe   Judgement   ADHD S/Sx (stimulant) Assess • Appearance  dirty • Behavior  clumsy, impatient, easily distracted, hyperactive • Communication  talkative, blurts out in class Nx Dx • Risk for injury • Impaired social interaction Planning/ Implementation tructure  separate room for eating, playing, sleeping and etc chedule  time for everything et limits  afety Evaluation • Minimize Risk for Injury • Improved social interaction • Safety Residual ADHD grows up not antisocial Meds: Ritalin, dexedrin, pemoline, adderal Best time to give: once a day: AFTER MEALS: prevent lost of appetite Don’t give at bedtime  STIMULANT  causes insomnia Give 6 hours prior bedtime if bid EATING DISORDERS 18 mos. – 3 y.o. 6 y.o.  class valedictorian/ model student   Toilet Training social inactive/ no BF   Clean weighing Obedient Organized Thought Feeling Behavior I Am Fat   Self Esteem  Diet, Diet, Diet Anorexia Nervosa Eating Disorders Bulimia Diet, diet, diet Eating Pattern Eat, eat, vomit <85% of expected body Weight Normal weight 3 mos. ammenorhea Menstruation Irregular menstruation Karen Carpenter Dao Ming Xi Da Ming Sugat/ suka Vomiting Dental caries Wounded knuckles Metabolic alkalosis Metabolic acidosis Vomiting Fluid Volume Deficit  ARRHYTHMIA (fatal complication) Diarrhea Interventions • Restore fluid and electrolyte balance • Collaborative regarding menu contract • Target weight gain • After meals: stay 30 mins – 1 hour PHARMA MOMENT LITHIUM L evel 0.6 – 1.2 mEq/L ausea, vomiting, diarrhea Increase urination Lithium Toxicity Tremors, fine hand a+ Hydration 3 L/day Increase Kidney Uu  diarhea Mouth, dry ANTIPARKINSON ANTICHOLINERGIC ABC DOPAMINERGIC PLSE Artane Parlodel Akineton Larodopa Benadryl Symmetyl Cogentin Eldepryl SCHIZOPHRENIA • Ego disintegration • Impaired reality perception • Genetic vulnerability • Stress – Diathesis Model o Too much stress in the reality will lead client to escape it and go to the fantasy world • Biological Theory o Dopamine level is High • The exact cause is unknown ffect  appropriate, inappropriate, flat, blunt (incomplete emotion) mbivalence  torn between 2 opposing forces utism ssociative Looseness Symptoms Negative Positive Hypoactive Hyperactive Withdrawn Sociable Apathy Flight of Ideas Talkative Assess : Content of Thought Nx Dx : Disturbed thought process Planning/ Implementation: • Present reality • Provide safety Evaluation : Improve thought process Assess : Hallucination/ Illusions Nx Dx : Disturbed sensory perception Planning/ Implementation: • Present reality • Provide safety Evaluation : Improve sensory perception Assess : Suspicious Nx Dx : Risk for other directive behavior Planning/ Implementation: • Present reality • Provide safety Evaluation : Eliminate/ minimize risk for other-directed violence Assess : Suicidal Nx Dx : Risk for self directive behavior Planning/ Implementation: • Present reality • Provide safety Evaluation : Eliminate/ minimize risk for self-directed violence Flight or Looseness I am going to the mall. I am going to the mall. Where is the light? The mall is big. Go here. Big is the tree. Mineral Water. The tree is tall. Magical Thinking • Believes to have a magical power • I can turn you into a frog Echolalia  I repeat what you say  Parrots Echopraxia  I repeat what you do Word Salad  words, no rhyme Clang Association  words with rhyme : Dunk, plank, sunk Neologism  creation of new words Plinking, hustash • Clarification  done in case of neologism Delusion: Persecutory  NBI is out to get me/ someone will harm the client Religious  I am Jesus Christ Grandeur  I am the queen of the world. Ideas of reference  Nurses are talking about me. Concrete Association  pilosopo “what will you wear?” “clothes” Thought Blocking  Halucinations Illusion Stimulus Absent Present Visual X  Auditory X  Tactile X  In case of hallucinations do: Hallucinations Acknowledgment • I know you the voices are real to you Reality orientation • But I don’t hear them Diversion • Lets go to the garden But if nothing in the preceeding intervention are seen Assess what the voices are saying SCHIZOPRENIA Normally Acetylcholine = ON Dopamine = OFF Your always ON High Dopamine= Schizophrenia With parkinsON Antipsychotics = makes Dopamine goes down ON Extrapyramidal Side Effects • AKATHISIA o Restless, inability to sit o Makati siya, ahh kati siya • AKINESIA o Muscle rigidity o Ahh kiniss siya • DYSTONIA o 3 features  TORTICOLLIS • Wry neck  OCULOGYRIC CRISIS • Fixed stare  OPISTHOTUNOS • Arched back • TARDIVE DYSKINESIA o Irreversible side effects of antipsychotics o Lip smacking o Tongue protruding o Cheeks puffing • NEUROLEPTIC MALIGNANT SYNDROME o Hyperthermia among client taking antipsychotic o Hyperthermia with muscle rigidity Other Side Effects • Photosensitivity o Sunscreen o Wide brimmed hat • Agranulocytosis o Report immediately Sore throat  1st sign to appear PHARMAMOMENTS ANTIDEPRESSANTS ANTSAAVE PPZ Asendin – ascending Norpramin – sabaw ng knorr Tofranil – Tofu Sinequan – nood ng Sine Quan ang title Anafranil – kina Ana Praning Aventyl – kina Aven Til Midnight tayo Vivactil – Bye Back till next week Elavil – Eh love mo ba ako Prozac – Pero saka na Paxil - Taksil Zoloft – mag Solo ka BIPOLAR DISORDER – Mania more common • Female • 20 years old and above • Stressful life • Obese TASK Caregiver Role Strain Safety Safety Lithium – 2 – 4 weeks before effect SE  Compensation  interfere ADLs,  harm others SE  Compensation  interfere ADLs,  harm others TASK  increases client’s self esteem • Gross motor skills via sublimation • Escorted walk outdoors • Punching bag No group games  compition will increase anxiety 3 or more signs confirms disorder G F S P E E D randiose light of ideas leeplessness ressured speech xagerated SE xtraneous stimuli (easily distracted) istractibility PERSONALITY DISORDERS SCHIZOID • I don’t want people • Believes he can stand on his own • Never had a best friend • Avoid groups and social activities  no enjoyment • Cares more about computers and pets AVOIDANT • I avoid people, I fear criticism • Have talent but no confidence ANTISOCIAL • I break the law as motto • As a child,: steal, lie, always get reprimanded • Adult – grand robbery, illegal activitist against the law, drug addiction, drives fast, unsafe sex, thrill seeker • Good talker, charmer, witty manipulator BORDERLINE – my life is an emptyglass Dependent • I can’t live without you •  self esteem • poor decision making skills Histrionic • excited, dramatic but manipulative • center of attention Narcissistic • I love myself • Insensitive, arrogant • I am the best Obsessive – Compulsive • I am organized • Perfectionist • Provide time to do rituals Paranoid • Suspicious Passive Aggressive • Always say yes but resistance is hidden Serotonin   MAO kills Serotonin MAO   Serotonin   MAO   Serotonin   TYRAMINE RICH FOODS vocado ged Cheese eer hocolate ermented Foods ickles reserved Foods oy Sauce Antidepressant  no effect  ECT ELECROCONVULSIVE THERAPY • Pre o Informed consent o NPO 6 – 8 hours prior • Meds o Atropine  dry mouth o Barbituate  Sedative o Succinylcholine  muscle relaxant, prevent seizure • Post o Side-lying – lateral o S/E  headache, dizziness,  TEMPORARY MEMORY LOSS  distinct sign • 70 – 110 volts • 20 – 30 seconds • ½ hour asleep post PHARMAMOMENTS SUBSTANCE ABUSE Downers (ABONM INE) Alcohol Morph Barbituates Code NARCAN  antidote Opiates Hero Narcotics Marijuana Uppers (CHA) Cocaine Hallucinogen Amphetamines OVERDOSE Alcohol Cocaine HR RR BP Coma LOC Seizure  Psych well being NARCAN  Narcotic Antagonist  narcotic overdose DETOXIFICATION  withdrawal with MD Supervision METHADONE Withdrawal  reverse of effect or opposite of overdose DEPRESSION   Serotonin, if unresponsive to drugs, ECT The Grief Process • Denial  no! this can’t be true • Anger  why me, why me, why now • Bargaining  if something happens, then I’ll give something back • Depression  I’m down 2 weeks or more s/sx  major depression • Acceptance  client acts according to situation C TASK Stay Sensitivity to client needs SUICIDE Verbal Non Verbal • I wont be a problem anymore • This is my last day on earth • I’ll soon be gone • Take this ring, its yours (giving of valuable) • Sudden change in mood Who will commit Suicide? Sex – Male (more successful)/ female (hesitant) Age – 15 –24 y/o or above 45 Depression Patient with previous attempt ETOH – ethanol - alcoholics Rirrational Social support lacking Organized plan  greater risk No family Sickness, terminal SUICIDE TRIAD • Loss of spouse • Loss of job • Aloneness Is Patient is SUICIDAL; nurse should: DIE • Direct question – “Are you going to commit suicide?” • Irregular interval of visit to pt. room • Early AM and period of endorsement – the time pt’s commit suicide Best approach for suicidal pt. : Direct approach Nursing Management: Close surveillance Hospital area majority sucide will happens at: • weekends 1- 3 am Sunday • Weekend  less staff personnel • Early AM  every one is asleep Give simple task. Don’t give complex  may cause depression ex. Jigsaw • Water plants • Wash the dishes except sharps CHILD ABUSE (think B) • Burns, bruise, bone fractures, BUNGI! • Don’t bathe the child, don’t brush teet. Body of evidence will be lost • Bantay Bata 163 LEVELS OF MENTAL RETARDATION • Profound o < 20 o thinks like an infants o can’t be trained o stay with the patient • Severe o 20 – 35 • Moderate o 35 – 50 o can be train o mental age is 2 – 7 y/o o pre-operational stage • Mild o 50 – 70 o meantal age is 7 – 12 o educable o can go to school • Borderline o 70 - 90 • Normal o 90 – 100 JOHN PIAGET’S COGNITIVE THEORY 0 – 2 Sensorimotor Baby can sense, see, perceive and hear. Object permanence 2 – 4 Preconceptual Language 4 – 7 Intuitive Unidimentional classification characteristic. Child can fix toys according to size, color, height = one at a time 7 – 12 Conservation Concrete Association Multidimensional 12  Formal Operation Good abstract thinking. Can interpret words ALZHEIMER NOMIA  don’t know name of objects GNOSIA  problem with senses PHASIA  can’t say it PRAXIA  can’t do it Cocaine  Nasal Septum perforation Marijuana  impaired Lung Structure eroine withdrawal ikab atsing u hu hu CRITICAL REVIEW TEST TAKING TECHNIQUES 1. Assess the answer, use circle 2. Initial priority TRUST ABC ASSESS 3. Good Word/ Bad Word 4. S Technique eek support it tay upervised ee = observed eem = notice assi t feeling 5. 2 same answer/ 2 same mistake 6. Words to watch out for Inappropriate Most Not included Except All but one 7. Umbrella RELATIONSHIP Preorientation Orientation Working Termination Self awareness Trust Discussion Evaluation Setting Contract Resistance PRACTICE OF NURSING Level of Prevention 1 2 3 Healthy Ill Relapse Community Demog. Crisis Intervention AA SELF HELP GROUPS nique niversality r not alone RESTATE  exact words REFLECT  use other words DEPRESSION Endogenous Reactive Internal external Chemical Barbituate withdrawal  LIBRIUM (Chloridiazepoxide) TOFRANIL  Antidepressant/ Anticholinergic  pupil dilation  midriasis Catharsis  Feelings Free Association  Ideas ATTITUDE THERAPIES Active friendliness  ask permission assive Friendliness aranoid anipulative nic atter of Fact No Demand  Depressed Kind Firmness  Anorexic Crisis  4 – 6 weeks Goal  Return the client to the pre-crisis level of functioning PSC Perception  what do you think about it? Coping  what will you do about it? Support  who will be there for you? Kulit kulit kulit kulit  Perseveration  stick to 1 topic Ulit Ulit Ulit  Verbigeration DISSOCIATION Dissociative Amnesia  don’t know themselves Fugue  Far Dissociative Identity Disorder Multiple Personality D.O.