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Nursing Care of Clients with Disorders Related to Anxiety and Alterations in Mood


A. Primary initial deficit occurs in mood or ability to manage anxiety, although there may be changes in
cognition and behavior
B. Anxiety disorders are the most common of all psychiatric disorders, resulting in distress and functional
impairment; rarely treated in inpatient settings unless anxiety is extreme and functioning is impaired or if
treated concurrently with another mental health disorder
C. Anxiety and depressed mood may find expression in physical symptoms associated with somatoform and
dissociative disorders
D. Acting out occurs because of fear, not antisocial tendencies
E. Anxiety is contagious and can be communicated to others


A. Provide an environment that limits demands and permits attention to resolution of conflicts; establish a
trusting relationship
B. Identify precipitating stressors and limit them if possible
C. Intervene to protect from acting out on impulses that may be harmful to self or others
D. Accept symptoms as real to client; do not emphasize or call attention to them
E. Attempt to limit client’s use of negative defenses, but do not try to stop them until ready to give them up
F. Help to develop appropriate ways of managing anxiety-producing situations through problem solving and
cognitive/behavioral therapies; assist to expand supportive network; assist significant others to
understand the client’s situation
G. Plan a routine schedule of activities
H. Manage aggressive behavior progressively (e.g., diversion, limit setting, medication administration,
seclusion, restraints)
I. Collect and document information to assist with determining presence of both an anxiety disorder and
depression (comorbidity)
J. Encourage to develop a balance between work and relaxation


Data Base
A. Etiologic factors
1. Psychologic, behavioral, and neurobiologic theories are postulated; the latter is most promising
2. Functions to permit some measure of social adjustment
3. Commonly begins in early adulthood as a result of environmental factors and pressures of decision
making; early life is rigid and orderly
4. Excessive anxiety and worry involves at least two life situations
5. Unrelated to physiologic effects of substances or a medical condition
B. Behavioral/clinical findings
1. Persistent anxiety (longer than 6 months) and excessive worry associated with three or more of the
following symptoms: restlessness (akathisia) or feeling on-edge, becomes easily fatigued, difficulty
concentrating, irritability, muscle tension, and sleep disturbance
2. Inability to control the anxiety
3. Impairment in social or occupational relationships
4. Symptoms of autonomic hyperarousal (e.g., tachycardia, tachypnea, dizziness, and dilated pupils);
however, they are less prominent than in other anxiety disorders
C. Therapeutic interventions: same as those listed under Panic Disorders

Nursing Care of Clients with Generalized Anxiety Disorder

See General Nursing Care of Clients with Anxiety Disorders under Major Disorders Associated with
Anxiety and Nursing Care of Client with Panic Disorder under Panic Disorder

Data Base
A. Etiologic factors
1. Biochemical and genetic theories are most often cited as the underlying cause; no one gene or
biochemical dysfunction has been identified
2. Onset varies, most often noted between late adolescence and mid-30s; infrequently may begin in
childhood or after age 45; early life rigid and orderly
3. Discrete periods of intense discomfort for more than 1 month in duration

4. Recurrent attacks of severe anxiety may be associated with a stimulus or can occur spontaneously
5. Pressures of decision making regarding lifestyle that occur in early adult years act as precipitating
6. Functions to permit some measure of social adjustment
B. Behavioral/clinical findings
1. Brief attacks of overwhelming, intense discomfort
2. Attack must be accompanied by four or more of the following symptoms: palpitations or accelerated
heart rate; sweating; trembling or shaking; shortness of breath; feelings of choking, chest pain, or
discomfort; nausea or abdominal distress; depersonalization; fear of losing control; fear of dying;
paresthesias; and chills or hot flashes
C. Therapeutic interventions
1. Complete diagnostic workup to rule out physical illness
2. Psychotherapy, family therapy, group therapy, cognitive/ behavioral therapies
3. Psychotropic medications: sedative/hypnotic and antianxiety agents are used short term when client is
unable to cope or accomplish daily activities and until healthier coping emerges; antidepressants are
used prophylactically in long-term therapy (see Chapter 16, Related Pharmacology, Psychotropic
Medications, Sedative and Hypnotic Agents and Antianxiety/ Anxiolytic Medications)

Nursing Care of Clients with Panic Disorder

1. Progression of somatic symptoms
2. Interference in activities of daily living (ADLs) and social and occupational functioning
3. Situational triggers that may precipitate the onset of an attack
4. Determination whether panic symptoms are relate to a phobia (e.g., agoraphobia)
1. See General Nursing Care of Clients with Anxiety Disorders
2. Remain with client during an attack; maintain safety
3. Remain calm and in control of the situation
4. Assign to a private room if hospitalized because it decreases environmental stimuli
5. Administer prescribed medications
1. Identifies situations that increase anxiety
2. Demonstrates increased use of anxiety-reducing behaviors
3. Follows prescribed treatment regimen
4. Reports a decreased number of panic attacks

Data Base
A. Etiologic factors
1. Anxiety unconsciously transferred to an inanimate object or situation, which then symbolically
represents the conflict and can be avoided
2. Anxiety is severe if the object, situation, or activity cannot be avoided
OBSESSIVE-COMPULSIVE DISORDER 1. Type and use of ritual or obsession
(OCD) 2. Level of anxiety (e.g., mild, moderate, severe,
Data Base 3. Level of interference in lifestyle
A. Etiologic factors 4. Extent of danger inherent in ritual or obsession
1. Chronic anxiety disorder with decreased levels 5. Behaviors associated with other anxiety disorders
of serotonin Planning/Implementation
2. Control of anxiety with obsessions (intrusive 1. See General Nursing Care of Clients with
recurring thoughts) or compulsions (repetitive Anxiety Disorders
ritualistic behaviors) 2. Allow performance of the ritual initially unless
3. Compulsive behavior precedes obsessive ritual causes harm and must be stopped (e.g.,
thinking excessive hand washing causing skin damage);
4. Symptoms worsen with stress eventually attempt to limit length and frequency
5. OCD symptoms are similar in adults and of the ritual
children; adults recognize behavior is 3. Support attempts to reduce dependency on the
excessive and interferes with daily activities ritual
but cannot be controlled; children do not have 4. Role model appropriate behavior and discuss
this insight adaptive responses
6. Pressures of decision making regarding Evaluation/Outcomes
lifestyle that occur in the early adult years act 1. Decreases obsessive thoughts and length and
as precipitating factors; some evidence that frequency of ritual
early life patterns were rigid and orderly 2. Follows prescribed treatment regimen
B. Behavioral/clinical findings 3. Learns new adaptive coping responses
1. Major defensive mechanisms are isolation,
undoing, and reaction formation; intellectual
and verbal defenses are used POSTTRAUMATIC STRESS DISORDER
2. Thoughts persist and become repetitive and (PTSD)
obsessive Data Base
3. Demonstrates indecisiveness and a striving for A. Etiologic factors
perfection and superiority 1. Follows a devastating event that is outside
4. Anxiety and depression present in various the range of usual human experience (e.g.,
degrees, particularly if rituals are prevented rape, assault, military combat, hostage
5. Obsessions or compulsions consume most of situations, natural or precipitated disasters)
client’s waking hours (at minimum more than 2. Neurobiology of PTSD does not follow the
1 hour per day) and interfere with ADLs, usual fight-or-flight stress response; studies
occupation, social activities, or relationships indicate a complex interaction of
6. Limiting or interrupting a ritual increases neuroendocrinology, neuroanatomy, genetics,
anxiety and traumatic stress
C. Therapeutic interventions 3. Adult’s response involves intense fear,
1. Same as those listed under Panic Disorder helplessness, or horror; child’s response
2. Behavior modification to attempt to limit involves disorganized or agitated behaviors
length and/or frequency of ritual 4. Traumatic event is persistently
3. Cognitive therapy reexperienced as flashbacks, distressing
4. Psychotropic medications: clomiPRAMINE dreams, sense of reliving the experience, or
(Anafranil) and fluvoxamine (Luvox) to exposure to situations (including
control symptoms anniversaries) that foster recall of the event
B. Behavioral/clinical findings
1. Exposure to a traumatic event resulting in
Nursing Care of Clients with Obsessive- death, threatened death, or serious injury to
Compulsive Disorders others or self
2. Responds to traumatic event with intense 5. Cognitive restructuring and reframing
fear, confusion, helplessness, horror, or denial
3. Feelings of isolation and detachment;
depression Nursing Care of Clients with Posttraumatic
4. Interrupted concentration; difficulty sleeping Stress Disorder
5. Violent outbursts of anger Assessment/Analysis
6. Hypervigilance; hyperarousal; exaggerated 1. History of traumatic experience
startle reflex; avoidance of associated stimuli 2. Sleep-pattern disturbances, outbursts of anger,
7. Risk taking behaviors; substance abuse in and decreased concentration
attempt to control symptoms 3. Screening for symptoms of major depression,
C. Therapeutic interventions phobias, and substance abuse
1. Same as those listed under Panic Disorder 4. Behaviors associated with other anxiety
2. Behavior modification to provide controlled disorders
exposure to recall of event Major Disorders Associated with Anxiety 439
3. Use of eye movement, desensitization, CHAPTER 19 Nursing Care of Clients with
reprocessing techniques (EMDR) Disorders Related to Anxiety and Alterations in
4. Imagery, relaxation, and meditation Mood 440
Planning/Implementation symptoms permit avoidance of an
1. See General Nursing Care of Clients with Anxiety unacceptable activity
Disorders 2. Symptom or deficit is not related to an
2. Stay with client when memory of event returns to underlying medical condition, to substances, or
conscious level to a cultural norm; distinguishes conversion
3. Protect from acting out violently with disregard from psychophysiologic disorders associated
for safety of self or others with tissue changes
Evaluation/Outcomes 3. Symptoms permit some measure of social
1. Uses positive coping mechanisms to manage adjustment
anxiety and reactions to the traumatic event and 4. Onset before 30 years of age; may recur
its flashbacks 5. Physical illness frequently used by family as
2. Verbalizes a decrease in dreams or flashbacks excuse for problems; early life often rigid and
regarding the traumatic event orderly
3. Follows prescribed treatment regimen 6. Pressures of decision making regarding
lifestyle in early adult years act as precipitating
MAJOR SOMATOFORM DISORDERS B. Behavioral/clinical findings
GENERAL NURSING CARE OF CLIENTS 1. Symptoms or deficits that affect voluntary
WITH SOMATOFORM DISORDERS motor or sensory function (e.g., paralysis,
blindness, deafness)
A. Identify when anxiety is translated into physical
2. Conflicts or stressors (usually dependence
illness or bodily complaints (somatization)
versus independence) precede initiation or
B. Establish a trusting relationship
exacerbation of symptoms or deficits
C. Provide an environment that limits demands on
3. Noticeable lack of concern about problem
and permits attention to resolution of conflicts
(“la belle indifference”)
D. Identify pattern of recurring clinically significant
4. Impairment may vary over different
somatic symptoms; accept that symptoms are real
episodes; may not follow anatomic structure
to client
(e.g., paralysis or numbness may circle foot or
E. Attempt to limit client’s use of negative defenses,
arm [stocking-and-glove anesthesia])
but do not try to stop them until ready to give
C. Therapeutic interventions
them up
1. Complete diagnostic workup to rule out
F. Help to develop appropriate ways of managing
physical problems
anxiety-producing situations through problem
2. Psychotherapy, family therapy, group
solving and cognitive therapies
therapy as necessary to resolve severe
G. Accept physical symptoms but do not talk about,
emotional problems
emphasize, or call attention to them
3. Psychotropic medications: antidepressants
H. Minimize sick-role behavior; encourage
(selective serotonin reuptake inhibitors
independence within abilities; avoid providing
[SSRIs]); antianxiety agents rarely helpful (see
secondary gains
Chapter 16, The Practice of Mental
I. Encourage to develop a balance between work and
Health/Psychiatric Nursing, Related
Pharmacology: Psychotropic Medications,
J. Help to identify and label needs met by symptoms
Nursing Care of Clients with Conversion
Data Base
A. Etiologic factors
1. Anxiety unconsciously converted to physical Assessment/Analysis
symptoms that are not under voluntary control; 1. Presence of physical symptoms with no
usually localized to one area of the body; pathophysiologic basis
2. Level of concern regarding physical symptoms
3. Degree of impairment
4. Level of anxiety 2. Onset usually during adolescence but can
Planning/Implementation begin in childhood; may continue for years
See General Nursing Care of Clients with 3. No predisposing factor in early life or family
Somatoform Disorders patterns is identified
Evaluation/Outcomes B. Behavioral/clinical findings
1. Uses problem solving rather than physical 1. History of multiple plastic surgeries to
symptoms to manage anxiety-producing situations correct imagined defects
2. Decreases episodes that use physical symptoms 2. Preoccupation with imagined deficit causes
to manage anxiety avoidance or impairment in social and
occupational relationships
BODY DYSMORPHIC DISORDERS 3. Often exhibits symptoms of depression or
obsessive-compulsive personality traits Major
Data Base Somatoform Disorders 441
A. Etiologic factors
1. Preoccupation (not of a delusional intensity)
with a defect in appearance, either imagined or
exaggerated, even if there is a slight defect
C. Therapeutic interventions Nursing Care of Clients with Hypochondriasis
1. Same as those listed under Conversion Assessment/Analysis
Disorder 1. Level of preoccupation with symptoms
2. Duration and degree of impaired functioning
associated with symptoms
Nursing Care of Clients with Body Dysmorphic
3. History of psychosocial precipitant stressors
Assessment/Analysis See General Nursing Care of Clients with
1. Preoccupation with imagined physical defects Somatoform Disorders
2. History of medical and surgical therapies to Evaluation/Outcomes
correct imagined defects 1. Accepts that there is no physical basis for the
3. Ability to manage stressful situations symptoms
4. Level of anxiety 2. Uses more effective coping mechanisms to
Planning/Implementation manage anxiety
See General Nursing Care of Clients with 3. Continues therapy even after condition has
Somatoform Disorders improved
1. Uses problem solving rather than physical defect
to manage anxiety-producing situations DISSOCIATIVE DISORDERS
2. Verbalizes that emphasis on physical defect is Data Base
exaggerated A. Characterized by either a sudden or a gradual
3. Accepts and is comfortable with self disruption in integrated functions of
consciousness, memory, identity, or perception of
HYPOCHONDRIASIS the environment
B. May be transient or become a well-established
Data Base pattern
A. Etiologic factors C. Etiologic factors: related to increased stress or
1. Preoccupation with belief that there is a serious traumatic event(s) such as sexual abuse during
illness because of misinterpretation of physical childhood
symptoms D. Types
2. Diagnostic evaluation does not support beliefs 1. Dissociative amnesia: inability to recall
and does not allay client fears important personal information, usually of a
3. Client’s knowledge of symptoms associated traumatic or stressful nature as distinguished
with a disease aids in development of a similar from ordinary forgetfulness
set of symptoms, leading to a conclusion that 2. Dissociative fugue: sudden, unexpected
the disease is present travel accompanied by an inability to recall
4. Psychosocial stresses influence development of one’s past, identity confusion, or assumption
this disorder of a new identity
5. Usually begins between 20 and 30 years of 3. Dissociative identity (also known as
age; can occur across the life span multiple personality disorder): coexistence of
B. Behavioral/clinical findings two or more distinct personalities within an
1. Misinterpretation and exaggeration of physical individual
symptoms 4. Depersonalization: persistent or recurrent
2. Inability to accept reassurance even after feeling of being detached from one’s mental
exhaustive testing and therapy; leads to “doctor processes or body that is accompanied by
shopping” intact reality testing
3. History of repeated absences from work E. Behavioral/clinical findings
4. Adoption of sick role and invalid lifestyle 1. Inability to recall important personal
C. Therapeutic interventions information usually of a traumatic or stressful
1. Same as those listed under Conversion nature
2. Gaps in recalling aspects of one’s life 1. See General Nursing Care of Clients with
history; usually related to traumatic episodes Anxiety Disorders
F. Therapeutic interventions 2. Assist with treatment plan to alleviate
1. Complete diagnostic workup to rule out symptoms
possibility of organic causes (e.g., brain tumor) 3. Reinforce effective coping skills
2. Psychotherapy (e.g., individual, family) 4. Assist with problem solving
3. Development of more effective and 5. Encourage involvement in individual long-term
satisfying ways to manage anxiety therapy and family therapy
1. Recalls and identifies past experiences
Nursing Care of Clients with Dissociative accurately
Disorders 2. Verbalizes increased satisfaction with family
Assessment/Analysis and work relationships
1. Identity; memory; consciousness 3. Ceases incidents of being absent without
2. Physical condition explanation
3. Psychosocial component to discover 4. Develops more effective coping mechanisms to
fundamental anxiety source manage anxiety CHAPTER 19 Nursing Care of
4. History of emotional trauma in childhood Clients with Disorders Related to Anxiety and
5. Suicidal risk Alterations in Mood 442
6. Recent use of alcohol or drugs
expansive as full mania; a distinct period of
elevated or irritable mood that is different from
MAJOR DISORDERS RELATED TO mania; duration of at least 4 days
ALTERATIONS IN MOOD 2. Mania: elevated, expansive, or irritable mood
GENERAL NURSING CARE OF CLIENTS accompanied by hyperactivity, grandiosity,
WITH MOOD DISORDERS and loss of reality
C. Neurobiologic perspective
A. Monitor nutritional intake and elimination
1. Neurotransmitters, or certain chemicals in the
B. Keep environment nonchallenging with
brain that regulate mood, have been identified
decreased stimuli; avoid boredom; focus on
(e.g., serotonin, dopamine, norepinephrine, and
gamma-aminobutyric acid [GABA])
C. Observe for mood swings, irritability, and
a. Increased levels of norepinephrine,
depressive episodes
dopamine, and serotonin in acute mania
D. Protect from suicide or violent acting out; keep
b. Decreased levels of norepinephrine,
under constant observation if necessary; keep
dopamine, and serotonin in depression
communication open and direct; ask if client has
2. Research suggests this disorder results from
a specific plan to commit suicide
complex interactions among chemicals,
E. Keep activities simple, uncomplicated, and
including neurotransmitters and hormones
repetitive and of short duration requiring little
3. Family and twin studies suggest a genetic
component, but no gene has been identified
F. Base activities on client’s status: psychomotor
except in rare, familial forms of the disorder
retardation in depression and hyperactivity in
4. Biologic rhythms and physiology related to
mania; initiate one-to-one interactions with client
depression show abnormal sleep
and eventually expand to one or two other people
electroencephalogram (EEG), sensitivity to
G. Observe for adverse effects of drugs; monitor
absence of sunlight, and circadian rhythm
therapeutic blood levels if appropriate
H. Encourage to continue medications even after
D. Physiologic theory postulates that mood also
symptoms abate
may respond to drugs or a variety of physical
I. Provide information regarding special dietary
precautions when taking certain medications
1. Drugs associated with depressive status:
(e.g., monoamine oxidase inhibitors [MAOIs])
alcohol, sedative-hypnotics, amphetamine
J. Assist with developing coping strategies; plan for
withdrawal, glucocorticoids, propranolol,
follow-up support and supervision
risperidone, and steroid contraceptives
2. Drugs associated with manic status: cocaine,
BIPOLAR DISORDER MAOIs, tricyclic antidepressants, steroids, and
Data Base levodopa
A. Characterized by a cyclical disturbance of mood, 3. Physical illness, such as brain attack
encompassing emotional extremes: episodes of (cerebrovascular accident) and some endocrine
vehement energy of mania, despair and lethargy disorders (e.g., Cushing disease and
of depression, or a mixture of both hypothyroidism) can lead to depressive
B. Presence of one or more manic or hypomanic episodes
episodes with a history of depressive episodes; 4. Obesity is a related factor to depression
predominant mood is elevated or irritable, E. May be response to loss (dysfunctional
accompanied by one or more of these symptoms: grieving), increased stress, or change in life
hyperactivity, lack of judgment with no regard events, role, and sleeping and/or eating patterns;
for consequences, pressured speech, flight of overreaction to stress may lead to suicide
ideas, distractibility, inflated self-esteem, risky F. Generally occurs between 20 and 40 years of
behavior, and hypersexuality age; however, reported in clients older than 50
1. Hypomanic: mood elation with higher than years, and increasingly in children and
usual activity and social interaction, but not as adolescents
G. Resumption of customary activities between


Data Base
A. Etiologic factors: see Data Base under Bipolar
B. Behavioral/clinical findings
1. Either a depressed mood or loss of interest
or pleasure, occurring during a 2-week period,
with a change in level of functioning, plus five
or more of the following:
a. Change in weight
b. Insomnia (especially early morning
c. Psychomotor agitation or retardation
d. Fatigue
e. Worthless feelings or inappropriate guilt
f. Somatic complaints
g. Diminished hygiene
h. Concentration difficulties
i. Inability to make decisions
j. Social withdrawal
k. Pessimism
l. Suicidal behavior progresses from suicidal
ideation, suicide threats, suicide gestures,
suicide attempts, to successful suicides;
presuicidal behaviors include no interest in
the future, giving away personal possessions
Major Disorders Related to Alterations in
Mood 443
2. Orientation and logic unaffected
3. Sex drive (libido) decreased
4. Constipation and urinary retention
5. Anniversary reaction: depression and suicidal gestures may increase as anniversary of
loss of loved object nears
C. Therapeutic interventions
1. Antidepressant medications that increase the level of norepinephrine and serotonin (see
Chapter 16, The Practice of Mental Health/Psychiatric Nursing, Related Pharmacology:
Psychotropic Medications, Antidepressants)
2. Cognitive and behavioral psychotherapy
3. High-protein, high-carbohydrate diet; dietary supplements if necessary
4. Electroconvulsive therapy (ECT)
a. Brief electrical stimulus applied to brain, resulting in a seizure that alters brain
chemistry and eventually alters mood
b. Used most often for recurrent depressions, delusions, suicidal ideation, and clients
who are resistant to drug therapy
c. A depolarizing muscle relaxant causes paralysis (e.g., succinylcholine [Anectine]),
which reduces intensity of muscle contractions during tonic/clonic stage of seizure;
given after a short-acting barbiturate or other sedative/anesthetic such as propofol
d. Side effects: fatigue, muscle soreness, mild temporary confusion, and short-term
memory loss; effects should resolve a few weeks after treatment ends

Nursing Care of Clients during a Depressive Episode of Bipolar Disorder

(Table 19-1: Bipolar Disorder: Symptoms of Depression)
1. Feelings of worthlessness, guilt; often fearful of feelings
2. Suicidal ideation or acting out; presence of a plan increases the danger of suicide; may be
ambivalent about suicide
3. Depressed mood, loss of interest or pleasure, and slowing of psychomotor activity
4. Weight for recent changes and to establish a baseline
5. Changes in sleep patterns
6. Changes in ability to concentrate
1. See General Nursing Care of Clients with Mood Disorders
2. Accept inability to carry out daily routines; assist with ADLs
3. Set expectations that can be achieved
4. Provide realistic praise whenever possible
5. Involve in simple repetitious tasks and activities
6. Accept feelings of worthlessness as real; do not deny, condone, or approve feelings
7. Spend time with client to demonstrate recognition of client’s worth
8. Protect from acting on suicidal thoughts, especially when depression begins to lift;
suicide is a real and ever-present danger throughout entire illness
9. Teach about ECT procedure
a. Informed consent required
b. Never left alone during and after the procedure; remain in recovery for 1 to 3 hours
after procedure; criteria for return to unit includes stable vital signs, alert, oriented, and
able to ambulate without assistance
c. Eliminate food and fluids for 6 to 8 hours before procedure
d. Asleep at beginning of procedure; short-acting sedative administered
e. Oxygen administered before and after the procedure
f. Full-body muscle response is minimized by medication; muscle-paralyzing agent
g. Brief electrical stimulus (no more than 2 seconds) precipitates seizure that eventually
causes an elevation in mood
h. May experience disorientation, headache, and muscle aches for about 1 hour after
procedure; analgesic given to treat headache
i. May experience temporary memory loss during and for several weeks after
completion of therapy
10. Refer for grief counseling, assertiveness training, and anger management
1. Remains free from injury
2. Verbalizes feelings
3. Verbalizes increased feelings of self-worth
4. Continues prescribed treatment regimen
5. Returns to preillness level of functioning


Data Base
A. Etiologic factors: see Data Base under Bipolar Disorder
B. Behavioral/clinical findings
1. Persistently elevated, expansive, or irritable mood for a duration of 1 week, plus three
or more of the following:
a. Grandiosity
b. Insomnia
c. Verbosity (pressured speech)
d. Flight of ideas
e. Hypersexuality
Table 19-1 Bipolar Disorder: Symptoms of Depression
Affect Cognition Physiolog Behavior
Apathy Pessimism Anorexia Decreased
Anhedonia Worry Insomnia ADLs
Anxiety Poor Early- Irritability
Anger concentrat morning Agitation
Guilt ion awakening Psychomot
Helplessne Slowed Fatigue or
ss thinking Constipatio retardation
Loneliness Indecisiven n Social
Low self- ess Impotence withdrawa
esteem Hypochond Decreased l
Sadness riasis libido Crying
Emptiness Suicidal Hypersomn Self-
Flat ideation ia and abusive
expression Negative compulsiv acts
self- e eating Substance
appraisal initially in abuse
Psychosis some
changes to