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MH review

Mental Health Final Review

Schizophrenia Positive symptoms related to behavior, thought, and speech (agitation, delusions, hallucinations, tangential speech patterns)
Schizophrenia Negative symptoms social withdrawal, lack of emotion, lack of energy, flattened affect, decreased motivation, decreased pleasure in activities
Conventional antipsychotic medications mainly control Schizophrenia Conventional antipsychotic medications mainly control positive symptoms of psychosis. Use these medications for clients who are: Able to take them successfully and are able to tolerate the side effects. Violent or particularly aggressive
Atypical antipsychotic agents for schizophrenia Atypical antipsychotic agents are medications of choice for clients receiving initial treatment, as well as for treating breakthrough episodes in clients on conventional medication therapy, as the atypical agents are more effective with fewer SE.
Advantages of atypical antipsychotic agents include Relief of both positive and negative symptoms. Decrease in affective(depression, anxiety) and suicidal behaviors. Decrease in neurocognitive symptoms.Fewer or no extrapyramidal symptoms (EPS), including tardive dyskinesia, due to less dopamine blockade.
Examples of ANTIPSYCHOTICS – CONVENTIONAL Prototype=chlorpromazine (Thorazine), others=Haloperidol (Haldol), Fluphenazine (Prolixin), high potency Molindone (Moban), medium potency Loxapine (Loxitane), medium potency Thioridazine (Mellaril), low potency Thiothixene (Navane), high potency Pu
ANTIPSYCHOTICS – CONVENTIONAL Therapeutic Uses Treatment of acute and chronic psychosis Schizophrenia Bipolar disorder – primarily the manic phase Tourette’s syndrome Delusional and schizoaffective disorder Dementia Prevention of nausea/vomiting
ANTIPSYCHOTICS – CONVENTIONAL Side Effects Acute dystonia,Parkinsonism (Bradykinesia Rigidity Shuffling gait Drooling Tremors) Akathisia (Inability to sit or stand still) Tardive dyskinesia Orthostatic hypotension Sedation Seizures Photosensitivity Contact dermatitis Agranulocytosis (lower WBC)
ANTIPSYCHOTICS – CONVENTIONAL MEDICATION/FOOD INTERACTIONS avoid OTC medications that contain anticholinergic(sleep aids)avoid alcohol and med Advise clients to avoid hazardous activities(driving)Avoid concurrent use of levodopa Avoid concurrent use with other medications that prolong QT interval
Examples of ANTIPSYCHOTICS – ATYPICAL Prototype Medication: risperidone (Risperdal)others Olanzapine (Zyprexa) Quetiapine (Seroquel) Aripiprazole (Abilify) Ziprasidone (Geodon) Clozapine (Clozaril)
ANTIPSYCHOTICS – ATYPICAL Therapeutic Uses Negative and positive symptoms of schizophrenia Psychosis induced by levodopa therapy Relief of psychotic symptoms in other disorders (bipolar disorder)
ANTIPSYCHOTICS – ATYPICAL SIDE/ADVERSE EFFECTS DM,weight gain, hypercholesterolemia, Orthostatic hypotension, Anticholinergic effectsSymptoms of agitation, dizziness, sedation, and sleep disruption mild EPS
Olanzapine (Zyprexa) Low risk of EPS • High risk of diabetes, weight gain, and dyslipidemia • Other adverse effects include: ◯◯ Sedation ◯◯ Orthostatic hypotension ◯◯ Anticholinergic effects
Quetiapine (Seroquel) Low risk of EPS • Moderate risk of diabetes, weight gain, and dyslipidemia • Other adverse effects include: ◯◯ Cataracts ◯◯ Sedation ◯◯ Orthostatic hypotension ◯◯ Anticholinergic effects
Aripiprazole (Abilify) Low or no risk of EPS • Low or no risk of diabetes, weight gain, dyslipidemia, orthostatic hypotension, and anticholinergic effects • Adverse effects include: ◯◯ Sedation ◯◯ Headache ◯◯ Anxiety ◯◯ Insomnia ◯◯ Gastrointestinal upset
Ziprasidone (Geodon) Low risk of EPS • Low risk of diabetes, weight gain, and dyslipidemia • Other adverse effects include: ◯◯ Sedation ◯◯ Orthostatic hypotension ◯◯ Anticholinergic effects ◯◯ ECG changes and QT prolongation that may lead to torsades de pointes
Clozapine (Clozaril) Low risk of EPS • High risk of weight gain, diabetes, and dyslipidemia • Risk for fatal agranulocytosis ◯◯ Baseline and weekly monitoring of WBC recommended ◯◯ Notification of the provider of signs of infection (fever, sore throat, mouth lesions) is
Alert Clients are responsive and able to fully respond by opening their eyes and attending to a normal tone of voice and speech. They answer questions spontaneously and appropriately.
Lethargy Clients are able to open their eyes and respond but are drowsy and fall asleep readily.
Obtundation Clients need to be lightly shaken to elicit a response, but they may be confused and slow to respond.
Stupor Clients require painful stimuli (pinching a tendon, rubbing the sternum) to elicit a brief response. They may not be able to respond verbally.
Coma No response can be achieved from repeated painful stimuli. XX Abnormal posturing in the client who is comatose
Decorticate rigidity Flexion and internal rotation of upper-extremity joints and legs
Decerebrate rigidity Neck and elbow extension and wrist and finger flexion
Mental State Examination This examination is used to objectively evaluate a client’s cognitive status by determining the following: ☐☐ Orientation to time and place ☐☐ Attention span and ability to calculate by counting backwards in multiples of seven ☐☐ Registration and rec
Glasgow Coma Scale This examination is used to obtain baseline data about a client’s level of consciousness and for ongoing evaluation of the client. ■■ Eye, verbal, and motor response is evaluated, and a number based on that response is assigned. The highest 15 coma 3
Axis I All mental health diagnosis except for those found in Axis II
Axis II Any personality disorder diagnosis and mental retardation
Axis III Any general medical diagnosis, such as asthma
Axis IV Pertinent psychosocial problems and problems that may affect diagnosis, treatment, and prognosis of mental disorders, such as poor family support
Axis V Global assessment of functioning (GAF) – An assessment of present and past-year functioning that rates the client’s level of functioning in the areas of work performance, social abilities, and psychological ability on a scale of 1 to 100.
GAF 80-100 generally indicate normal or near-normal function
GAF 60-80 indicate moderate problems
GAF 40 or below serious mental disability and/or functioning impairments.
DELIRIUM ONSET Rapid over a short period of time
DEMENTIA ONSET Gradual deterioration of function over months or years
DELIRIUM Clinical Manifestations Occurrence of impairments in memory, judgment, ability to focus, and ability to calculate. These impairments may fluctuate throughout the day. • LOC is usually altered. • Restlessness and agitation Sundowning,Personality change is rapid.
DEMENTIA Clinical Manifestations Impairments in memory, judgment, speech, agnosia, executive functioning and movement (apraxia). Impairments do not change throughout the day. • LOC unchanged Restlessness and agitation Sundowning. Behaviors stable.Personality change is gradual
DELIRIUM Cause Caused secondary to another medical condition, such as infection (in older adults), or to substance abuse
DEMENTIA Cause Generally caused by a chronic disease (Alzheimer’s disease) or is the result of chronic alcohol abuse • May be caused by permanent trauma
Denial Both clients and family members may refuse to believe that changes, such as loss of memory, are taking place, even when those changes are obvious to others.
Confabulation Clients may make up stories when questioned about events or activities that they do not remember. This may seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that they do not remember the occasion.
Perseveration Clients avoid answering questions by repeating phrases or behavior. This is another unconscious attempt to maintain self-esteem when memory has failed.
Those at highest risk for suicide include Those at highest risk for suicide include adolescent, young adult, and older adult males; Native Americans as a group; and persons with comorbid mental illness (depressive disorders, anxiety disorders, substance abuse, schizophrenia, personality disord
SAD PERSONS The SAD PERSONS scale is a valuable tool that evaluates 10 major risk factors for suicide and assigns scores for each.
Substance abuse Involves a repeated use of chemical substances, leading to clinically significant impairment over a 12-month period,
Substance dependence Involves repeated use of chemical substances, leading to clinically significant impairment over a 12-month period
The presence of tolerance A need for higher and higher doses of a substance to achieve the desired effect (requiring larger amounts of alcohol to feel euphoric)
The phenomenon of withdrawal The stopping or reduction of intake that results in specific physical and psychological clinical manifestations (tremors and headaches when the substance is not available)
A laboratory blood alcohol concentration (BAC) of ___% is considered legally intoxicated for adults operating automobiles in every U.S. state. A laboratory blood alcohol concentration (BAC) of 0.08% is considered legally intoxicated for adults operating automobiles in every U.S. state.
Alcohol Effects of excess Altered judgment, decreased motor skills, decreased level of consciousness (which can include stupor or coma), respiratory arrest, peripheral collapse, and death (can occur with large doses)
Alcohol Chronic use Direct cardiovascular damage, liver damage (ranging from fatty liver to cirrhosis), erosive gastritis and GI bleeding, acute pancreatitis, and sexual dysfunction
Alcohol WITHDRAWAL Effects usually start within Effects usually start within 4 to 12 hr of the last intake of alcohol, peak after 24 to 48 hr, and then subside.
Alcohol WITHDRAWAL Clinical findings include Clinical findings include abdominal cramping, vomiting, tremors, restlessness and inability to sleep, increased heart rate, blood pressure, respiratory rate, temperature, and tonic-clonic seizures.
Alcohol withdrawal delirium may occur Alcohol withdrawal delirium may occur 2 to 3 days after cessation of alcohol and may last 2 to 3 days. This is considered a medical emergency.
Benzodiazepines (diazepam [Valium])TOXIC EFFECTS Increased drowsiness and sedation, agitation, disorientation, nausea, and vomiting • Respiratory depression • An antidote, flumazenil (Romazicon), available for IV use for benzodiazepine toxicity
Benzodiazepines (diazepam [Valium])WITHDRAWAL SIGNS/SYMPTOMS Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, and sometimes seizure activity
Barbiturates (pentobarbital [Nembutal], secobarbital [Seconal])TOXIC EFFECTS Respiratory depression and decreased level of consciousness, which may be fatal • No antidote to reverse barbiturate toxicity
Cannabis (marijuana, hashish [more potent])TOXIC EFFECTS Chronic use – Lung cancer, chronic bronchitis, and other respiratory effects • In high doses, occurrence of paranoia (delusions, hallucinations)
Barbiturates (pentobarbital [Nembutal], secobarbital [Seconal])WITHDRAWAL SIGNS/SYMPTOMS Milder symptoms – The same as those seen in alcohol withdrawal • Severe symptoms – Lifethreatening convulsions, delirium, and cardiovascular collapse similar to that of alcohol withdrawal
Cannabis (marijuana, hashish [more potent])WITHDRAWAL SIGNS/SYMPTOMS Some depression
Cocaine TOXIC EFFECTS • Mild toxicity – Dizziness, irritability, tremor, and blurred vision • Severe effects – Hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse, and death
Cocaine WITHDRAWAL SIGNS/SYMPTOMS Craving, depression, fatigue, and sleeping (similar to those of cocaine) • Not life threatening
Nicotine Long-term effects Cardiovascular disease (hypertension, stroke) and respiratory disease (emphysema, lung cancer); with smokeless tobacco, irritation to oral mucous membranes and cancer
Nicotine WITHDRAWAL SIGNS/SYMPTOMS Abstinence syndrome is evidenced by irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, and difficulty concentrating.
Opioids (heroin, morphine, hydromorphone [Dilaudid]) TOXIC EFFECTS Decreased respirations and level of consciousness, which may cause death • An antidote, naloxone (Narcan), available for IV use to relieve symptoms of overdose
Opioids (heroin, morphine, hydromorphone [Dilaudid]) WITHDRAWAL SIGNS/SYMPTOMS Abstinence begins with sweating and rhinorrhea progressing to(gooseflesh), tremors, and irritability followed by weakness, n/v, muscles and bones pain,and spasms. • Withdrawal is unpleasant but not life-threatening, and it is self-limiting 7-10 d
Alcohol withdrawal Diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Librium), carbamazepine (Tegretol), and clonidine (Catapres)
Alcohol abstinence Disulfiram (Antabuse), naltrexone (ReVia), and acamprosate (Campral)
Opioid withdrawal Methadone (Dolophine) substitution, clonidine (Catapres), buprenorphine (Subutex), and buprenorphine combined with naloxone (Suboxone)
Nicotine withdrawal Bupropion (Wellbutrin) and nicotine replacement therapy (nicotine gum [Nicorette], nicotine patch [Nicotrol])
Anxiety mild restlessness, increased motivation, irritability
Anxiety moderate agitation, muscle tightness
Anxiety severe (inability to function, ritualistic behavior, unresponsive
panic distorted perception or hallucinations, loss of rational thought, immobility).
Panic disorder Clients experience recurrent panic attacks
Phobias Clients fear a specific object or situation to an unreasonable level.
Obsessive compulsive disorder (OCD) Clients have intrusive thoughts of unrealistic obsessions and try to control these thoughts with compulsive behaviors (repetitive cleaning of a particular object, constantly performing hand hygiene).
Generalized anxiety disorder (GAD) – Clients exhibit uncontrollable, excessive worry for more than 6 months.
Acute stress disorder Exposure to a traumatic event causes numbing, detachment, and amnesia about the event for not more than four weeks following the event.
Posttraumatic stress disorder (PTSD) Exposure to a traumatic event causes intense fear, horror, flashbacks, feelings of detachment and foreboding, restricted affect, and impairment for longer than one month after the event. Symptoms may last for years.
Panic disorder Episodes typically last Episodes typically last 15 to 30 min.
Social phobia Clients have a fear of embarrassment, are unable to perform in front of others, have a dread of social situations, believe that others are judging them negatively, and have impaired relationships.
Agoraphobia Clients avoid being outside and have an impaired ability to work or perform duties.
Cognitive reframing The anxiety response can be decreased by changing cognitive distortions. This therapy assists clients to identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk.
antidepressants (sertraline [Zoloft], amitriptyline [Elavil]), sedative hypnotic anxiolytics (diazepam [Valium]), serotonin norepinephrine reuptake inhibitors (venlafaxine [Effexor]), and nonbarbiturate anxiolytics (buspirone [BuSpar]) to manage anxiety.
Transference Transference occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client’s personal life.
Countertransference Countertransference occurs when a health care team member displaces characteristics of people in her past onto a client.
Altruism Dealing with anxiety by reaching out to others
Sublimation Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
Suppression Voluntarily denying unpleasant thoughts and feelings
Repression Putting unacceptable ideas, thoughts, and emotions out of conscious awareness
Displacement Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
Reaction formation Overcompensating or demonstrating the opposite behavior of what is felt
Somatization Developing a physical symptom in place of anxiety
Undoing Performing an act to make up for prior behavior
Rationalization Creating reasonable and acceptable explanations for unacceptable behavior
Passive aggression Indirectly behaving aggressively, but appearing to be compliant
Acting-out behaviors Managing emotional conflicts through actions, rather than selfreflection
Dissociation Temporarily blocking memories and perceptions from consciousness
Devaluation Expressing negative thoughts of self or others
Idealization Expressing extremely positive thoughts of self or others
Splitting Demonstrating an inability to reconcile negative and positive attributes of self or others
Projection Blaming others for unacceptable thoughts and feelings
Denial Pretending the truth is not reality to manage the anxiety of acknowledging what is real
Mild Mild anxiety occurs in the normal experience of everyday living. • It increases one’s ability to perceive reality. • There is an identifiable cause of the anxiety. • Other characteristics include a vague feeling of mild discomfort, impatience, and app
Democratic This style supports group interaction and decision making to solve problems.
Laissez-faire The group process progresses without any attempt by the leader to control the direction of the group.
Autocratic The leader completely controls the direction and structure of the group without allowing group interaction or decision-making to solve problems.
Mania An abnormally elevated mood, which may also be described as expansive or irritable; usually requires inpatient treatment.
Hypomania less severe episode of mania that lasts at least 4 days accompanied by three to four clinical findings of mania. Hospitalization, however, is not required, and the client with hypomania is less impaired.
Mixed episode manic episode and an episode of major depression experienced by the client simultaneously. The client has marked impairment in functioning and may require admission to an acute care mental health facility to prevent self-harm or otherdirected violence.
Rapid cycling Four or more episodes of acute mania within 1 year.
Bipolar I disorder The client has at least one episode of mania alternating with major depression.
Bipolar II disorder The client has one or more hypomanic episodes alternating with major depressive episodes. Bipolar II differs from bipolar I in that clients do not have manic phases in bipolar II.
Cyclothymia The client has at least 2 years of repeated hypomanic episodes alternating with minor depressive episodes.
Medication for Bipolar disorder Lithium carbonate (Eskalith) ■■ Antiepileptic agents that act as mood stabilizers, including valproic acid (Depakote), clonazepam (Klonopin), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax)
Waxy Flexibility When put in a certain position the pt. maintains this position for long periods of time
Autonomy Emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected.
Beneficence Refers to one’s duty to benefit or promote the good of others
Nonmaleficence: Abstaining from negative acts toward another; includes acting carefully to avoid harm.
Justice Based on the notion of a hypothetical social contract between free, equal, and rational persons; concept of justice reflects a duty to treat all individuals equally and fairly.
Veracity Refers to one’s duty to be truthful always
Negligence A general term that denotes conduct lacking in due care Carelessness A deviation from the standard of care that a reasonable person would use in a particular set of circumstances
Frontal lobe- controls voluntary movement, emotions
Parietal lobe- control perception and interpretation of most sensory info
Temporal lobe- auditory, short term memory
Occipital lobe- visual perception
Serotonin Increase- Anxiety Decrease- Depression
Dopamine Increase- Schizophrenia, Mania Decrease- Parkinson’s Disease, Depression
Norepinephrine Increase- Mania, Anxiety, Schizophrenia Decrease- Depression
GABA Increase- Reduction of Anxiety Decrease- Mania, Anxiety, Schizophrenia
Acetylcholine Increase- Depression Decrease- Alzheimer’s disease, Huntington’s chorea, Parkinson’s disease
Mild slight increase in VS, increased perceptual field & ability to learn
Moderate decreased ability to think, increased physical discomfort, selective inattention; narrowed perceptual field
Severe thinking is much impaired, increase P/BP, dry mouth, upset stomach, trembling, tense, increase startle response; extremely narrowed perceptual field
Panic unable to process, may lose touch with reality, dizzy, could have chest pain, palpitations, agitation, trembling, completely disrupted perceptual field
Panic Attack – Sudden overwhelming anxiety of such intensity that it results in apprehension, fearfulness, or terror, often associated with impending doom
Panic Attack Signs & Symptoms Palpitations Increased HR Diaphoresis Chills Hot flashes Fear of dying Dizziness Shakiness Pounding heart Paresthesias GI issues
For Panic Disorders (panic attacks) Specific Interventions Stay calm Stay with patient Remove patient from stimulating environment Talk down Try least restrictive first before giving meds Meds (benzos)
Body Dysmorphic Disorder Patient has normal appearance or minor defect but is preoccupied with imagined defective body part
Conversion Disorder Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness
Dissociative Amnesia Inability to recall personal information often occurring after traumatic event
Generalized amnesia inability to recall entire lifetime
Localized amnesia inability to remember all events in certain periods
Selective amnesia some but not all events recalled
Dissociative Fugue Sudden, unexpected travel away from home and inability to recall one’s identify and information about one’s past Individual may assume new identity
Dissociative Identity Disorder Presence of two or more distinct personality states that take control of behavior
Paranoid Personality Disorder Believe others are lying, cheating, or exploiting them Perceive hidden malicious meaning in benign comments Inability to work collaboratively with others
Schizoid Personality Disorder Neither desires nor enjoys human relationships Fixated on personal thought/fantasies Demonstrates emotional coldness, detachment, and flat affect
Schizotypal Personality Disorder Behavior or appearance is odd, eccentric, or peculiar Odd, elaborate style of dressing, speaking, interacting Magical thinking manifested Unusual perceptual experiences
Antisocial Personality Disorder Chronic irresponsibility and unreliability Lack of regard for law and rights of others Persistent lying and stealing for personal gain Conning others for personal gain Lack of remorse for hurting others Reckless disregard for others’ safety
Borderline Personality Disorder Difficulty controlling emotions Stormy relationships with anger and fighting Persistent unstable self-image Use of splitting (idealizing and devaluing same person)
Histrionic Personality Disorder Attention grabbing, self-dramatizing expression of emotions Sexually provocative clothing/behaviors Excessive concern with appearance Extreme sensitivity to others approval False sense of intimacy with others Constant sudden emotional shifts
Narcissistic Personality Disorder Inflated sense of self-importance Constant attention-grabbing behavior Manipulation of others No regard for feelings of others Arrogant manner toward others
Avoidant Personality Disorder Hypersensitive to criticism/rejection Self-imposed social isolation Preoccupied with being criticized/rejected Strongly wants relationship but shies away Avoids occupation involving interpersonal contact Views self as socially inept, inferior
Obsessive-Compulsive Personality Disorder Preoccupied with details, rules, lists Perfectionist Unable to share responsibility with others Devoted to work, exclusion of pleasurable activities Financial stinginess
Dependent Personality Disorder Difficulty with decision making Others assume responsibility for person’s life Fear of disagreeing with others Preoccupied with fear of being left alone
Schizophrenia: Paranoid Person is intensely suspicious toward others Paranoid ideas cannot be corrected by experiences or modified by facts or reality
Schizophrenia: Catatonic Posturing: holding arms/legs rigid for long periods Waxy flexibility: when placed in awkward position, holds position for long time Stereotyped behavior: obsessively following routine Negativism and resistance or automatic obedience Echolalia: Echopr
Schizophrenia: Disorganized Characterized by: Looseness of associations Grossly inappropriate affect Bizarre mannerisms Incoherent speech Fragmented and poorly organized hallucinations/delusions Frequent giggling or grimacing in response to internal stimuli
Undifferentiated Active signs of disorder present, but individual does not meet criteria for other types
Residual Active-phase symptoms no longer present, evidence of residual symptoms: lack of initiative, social withdrawal, inability to work/study, vague speech, magical thinking
stress-diathesis model Early life trauma sensitizes stress pathways in brain, increasing vulnerability to depression
Cognitive theory: Aaron Beck Automatic negative thoughts (of self, future and the world) related to depression
Learned helplessness: Martin Seligman Individual’s perception of lack of control over stressful life events leads to depression
Major Depressive Disorder cognitive symptoms: depressed mood, feelings of worthlessness and guilt, anhedonia, hopelessness, decreased concentration, recurrent thoughts of death/suicide Physical: weight gain or loss, insomnia or hypersomnia, increased or decreased motor activity
Dysthymic Disorder: DD Characterized by chronic depressive syndrome usually present for most of day, more days than not, for at least a 2-year period
Pica Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age for which this behavior is developmentally inappropriate.
Anorexia Nervosa Refusal to maintain normal weight for age and height Intense fear of gaining weight Disturbed body image Belief that one is fat despite emaciation Loss of menses for at least 3 months
Anorexia Nervosa: Physical Complications Decreased vital signs (temp, pulse, BP) Electrolyte imbalances Leukopenia Osteoporosis Amenorrhea
Bulimia Nervosa Recurrent episodes of binge eating Behavior to prevent weight gain Self-induced vomiting Laxative and diuretic abuse
Binge-Eating Disorder May be variant of compulsive overeating Binge eating reported as being soothing and helpful with mood regulation May be related to depression (overeating is frequently a sign of this disorder)
Autistic disorder Impairment in communication and imaginative play, lack of responsiveness and interest in others, markedly restricted and stereotyped behaviors
Asperger’s syndrome Similar to autistic disorder, with later onset and less severe symptoms
Separation anxiety disorder : excessive anxiety when separated from or anticipating separation from home/parent; can lead to refusal to attend school
Created by: rltromble