NCM 117 Lecture - Prelim PDF

PSYCHIATRIC NURSING (PRELIM) NCM 117 LECTURE
CONCEPTS OF MENTAL HEALTH AND MENTAL Mental Health-Illness Continuum

ILLNESS
INTRODUCTION
PSYCHIATRIC NURSING
“What you see is just the tip, what lies beneath is the truth
about it.”
Psychiatric nursing is a specialized area of nursing

practice, employing theories of human behavior as its
science and purposeful use of self as its art, in the
diagnosis and treatment of human response to actual or
Mental Illness / Mental Disorder
potential mental health problems (ANA).
Mental illness is the inability to see oneself as others do
and not having the ability to conform to the norms of the
Focus of Mental Health
culture and society.
● Well client
● At risk individual
Mental illness / disorder is a clinically significant
● Those with early symptoms of maladjustments.
behavioral or psychological syndrome or pattern that occurs
in an individual and that is associated with present distress
Mental Health
or disability or with significantly increased risk of suffering
Mental health is a state of emotional, psychological, and
death, pain, disability, or an important loss of freedom.
social wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive
Causes:
self-concept, and emotional stability (Videbeck, 2015).
● Genetics and hereditary
● The ability to see oneself as others do and fit into the
● Stress and immunes system
culture and society where one lives.
● Infection
Characteristics of a Mentally Healthy Person

General Criteria to Diagnose Mental Disorder
● Positive attitude toward self
● Dissatisfaction with one’s characteristics, abilities,
● Growth
accomplishments.
● Development
● Ineffective or unsatisfying relationship.
● Self-actualization
● Dissatisfaction with one’s place in the world.
● Integration
● Ineffective coping with life’s events.
● Autonomy
● Lack of personal growth.
● Reality perception
● Environmental mastery
Etiological Factors of Mental Illness
● Individual factors
Factors Influencing Mental Health
○ Caused by heredity and biochemical factors.
● Individual - Person’s biological makeup, autonomy
● Interpersonal factors
and independence, self-esteem, capacity for growth,
● Social factors
vitality, ability to find meaning in life, emotional
○ Loss of an effective support system.
resilience, sense of belonging, reality orientation and
coping or stress management abilities.
Links Between Stress and Illness
● Interpersonal - Or relationship, may include effective
communication, ability to help others, intimacy, and a
balance of separateness and connectedness.
● Social/Cultural or Environmental - Include a sense
of community, access to adequate resources,
intolerance of violence, support of diversity among
people, mastery of environment, and a positive, yet
realistic, view of one’s world.
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Diagnostic and Statistical Manual of Mental Disorders ● According to the National Statistics Office (NSO),
The DSM-IV-TR describes all mental disorders, outlining mental health illnesses are the third most common
specific diagnostic criteria for each based on clinical forms of morbidity for Filipinos.
experience and research. ● In the Philippines, the major causes of major obstacles
are: poverty, leaks into other parts of life in many ways.
THE STATE OF MENTAL HEALTH IN THE PHILIPPINES Impoverished people with mental illnesses are less
The Mental Health Act and Universal Health Care Law likely to seek help because it is unaffordable.
● It was established to enhance the services and to
promote and protect the rights of the Filipinos utilizing Current Information on Mental Health Concern During
psychiatric, neurologic, and psychosocial health the Pandemic
services. However... ● The data from National Center for Mental Health
○ Only 5% of the healthcare expenditure is directed showed that from an average of 13-15 daily calls
toward mental health services. before the pandemic, mental health providers are now
○ 3.6 million Filipinos suffer from at least 1 kind of receiving around 32-37 calls per day.
mental, neurological, or substance use disorder. ● From around 300-400 calls in May 2019 to February
● The Philippines has the third highest rate of mental 2020, it spiked to at least 1,000 calls from April to July.
disorders in the Western Pacific Region. ● DOH - Mental health conditions exacerbated by the
● Stigma and Discrimination: pandemic:
○ Toward mental health issues became part of the ○ Anxiety-related concerns.
Filipino culture, and this has greatly affected the ○ Suicide-related calls peaked in July 2020 with 115
people and the economy. calls.
● The increasing prevalence of mental illnesses also ● An article published in 2019 reports that 14% of
made a huge impact in the country and to the human, Filipinos with disabilities have identified mental
social, and economic capital. disorders.
○ The Philippines is a developing country that
struggles to obtain economic stability because of Variables That Discourage People From Seeking
outdated ways that result in gaps in mental health Treatment
promotion, which in turn bleed into the economy. ● Cultural beliefs emphasizing family and community.
● Shame associated with mental illness due to persistent
Facts stigma.
● Mental illness is the third most common disability in the ● People who need help often try to hide their symptoms
Philippines. instead of discussing them.
● Six million Filipinos live with depression and anxiety. ● Lack of mental health professionals in the Philippines,
● The Philippines has the third highest rate of mental it can be difficult to find an affordable counselor,
disorders in the Western Pacific (Martinez et al., 2020). psychiatrist or therapist.
● Philippines World Health Organization (WHO) Special ● Poor families unable to afford the privilege of therapy
Initiative for Mental Health conducted in 2020 showed or medication.
that > 3.6 million Filipins suffer from at least one kind ● Underinvestment in mental health resources along with
of mental, neurological, or substance use disorder underdeveloped services.
(Department of Health, 2020).
● Suicide rates are reported to be at 3.2 per 100,000 State of Mental Health and Illness in the Philippines
population with higher rates among males (DOH, 2018)
(4.3/100,000) than females (2.0/100,000). ● In a 2004 WHO study, up to 60% of people attending
● The National Center for Mental Health (NCMH) has primary care clinics daily in the country are estimated
revealed a significant increase in monthly hotline calls to have one or more MNS disorders.
regarding depression, with numbers rising from 80 ● The 2000 Census of Population and Housing showed
calls pre-lockdown to nearly 400. that mental illness and mental retardation rank 3rd and
4th respectively among the types of disabilities in the
Who is Affected? country (88/100,000).
● Between 17-20 percent of Filipino adults experience ● Data from the Philippine General Hospital 2014 show
psychiatric disorders, while 10-15 percent of Filipino that epilepsy accounts for 33.44% of adults and
children, aged 5-15 suffer from mental health 66.20% of pediatric neurologic outpatient visits per
problems. year.
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● Drug use prevalence among Filipinos aged 10 to 69 ● The World Health Organization (WHO) estimates that:
years old is at 2.3%, or an estimated 1.8 million users ○ 154 million people suffer from depression.
according to the DDB 2015 Nationwide Survey on the ○ Million from schizophrenia.
Nature and Extent of Drug Abuse in the Philippines. ○ 877,000 people die by suicide every year.
● 2011 WHO Global School-Based Health Survey has ○ 50 million people suffer from epilepsy.
shown that in the Philippines, 16% of students ○ 24 million from Alzheimer’s disease and other
between 13-15 years old have ever seriously dementias.
considered attempting suicide while 13% have actually ○ 15.3 million persons with drug use disorders.
attempted suicide one or more times during the last ● Mental health statistics worldwide (Our World in Data,
year. 2018):
● The incidence of suicide in males increased from 0.23 ○ Anxiety affects 284 million people in the world.
to 3.59 per 100,000 in females (Redaniel, Dalida, and ○ Depression affects 264 million people.
Gunnell, 2011). ○ Alcohol use disorder affects 107 million people.
● Intentional self-harm is the 9th leading cause of death ○ Drug use disorder affects 71 million people.
among 20-24 years old (DOH, 2003). ○ Bipolar disorder affects 46 million people.
● A study conducted among government employees in ○ Schizophrenia affects 20 million people.
Metro Manila revealed that 32% out of 327 ○ Eating disorders affect 16 million people.
respondents have experienced a mental health
problem in their lifetime (DOH, 2006). Mental Health Care Delivery System in the Philippines
● Based on Global Epidemiology on Kaplan and ● There is a scarcity of mental health professionals in
Sadock’s Synopsis of Psychiatry, 2015 and Kaufman’s the Philippines, with only a little over 500 practicing
ClinicalNeurology for Psychiatrists, 7th Edition,2013. psychiatrists.
● Schizophrenia - 1% (1 million) ● The ratio of 0.52 psychiatrists per 100,000 persons is
a. Bipolar - 1% (1 million) lower than other countries with similar income levels
b. Major Depressive Disorder - 17% (17 million) such as Malaysia (1.27 per 100,00) and Indonesia (0.3
c. Dementia - 5% (of older than 65) per 100,000).
d. Epilepsy - 0.06% (600,000) ● Furthermore, access to mental health services is not
equally distributed across the country, as most
State of Mental Health and Illness in the World (WHO, psychiatrists work in for-profit or private sectors in
2020) larger urban cities such as Metro Manila.
● Globally, the most vulnerable population is those aged ● At present, resources are scarce: only 3 to 5 percent of
15-29. Mental health related deaths are also the the total health budget is allocated to mental health,
second leading cause of fatalities in this age group. and there are only around 1,400 psychologists and500
● Mental health and substance use disorders affect 13% psychiatrists in the country.
of the world’s population. ● Feb 4, 2021 - There are 46 outpatient mental health
● The mortality rate of those with mental disorders is facilities available in the country, of which 28% allocate
significantly higher than the general population, with a units that are for children and adolescents only. These
media life expectancy loss of 10.1 years (JAMA facilities treat 124.3 users per 100,000 general
Psychiatry, 2015). population.
● It is estimated mental disorders are attributable to ● In Metro Manila, the cost of therapy per session
14.3% of deaths worldwide, or approximately 8 million ranges from PHP 1,000 to PHP 4,500. Depending on
deaths each year (JAMA Psychiatry, 2015). the case, a patient may visit once or twice a month.
● How Common is MentalIllness? ● Consulting a private doctor can go up to PHP 4,500
○ 970 million people worldwide have a mental per session.
health or substance abuse disorder. ● June 21 2018 - President Rodrigo Duterte signed the
○ Anxiety is the most common mental illness in the landmark Mental Health Act, the first mental health act
world, affecting 284 million people. legislation in the Philippines.
○ Globally, mental illness affects more females ● It outlines a framework for the integration and
(11.9%) than males (9.3%). implementation of optimal mental health conditions,
○ Major depression, anxiety, alcohol use disorders, their family members, and industry professionals.
schizophrenia, bipolar disorder, and dysrhythmia
(persistent mild depression), were identified as
leading causes of disability in the U.S.
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RA 11036 is an act establishing a national mental health THEORETICAL BASES OF PSYCHIATRIC NURSING
policy for the purpose of enhancing the delivery of Psychoanalytic Theory
integrated mental health services, promoting, and protecting ● Sigmund Freud (1856-1939) is the father of
the rights of persons utilizing psychiatric, neurologic, and psychoanalysis and modern psychiatry.
psychosocial health services, appropriating funds therefore,
and for other purposes. Psychodynamic of Human Behavior
● Behavior has meaning and is not determined by
Impact of Philippine Mental Health Care Delivery chance.
System in the Community ● All behavior is goal-directed.
● Mental healthcare in the Philippines faces continued ● The unconscious plays an active role in determining
challenges including underinvestment, lack of mental behavior.
health professionals and underdeveloped community ● The early years of life are extremely important to
mental health services. personal development.
● Although the recent Mental Health Act legislation has
for the first time provided a legal framework for the Personality refers to the aggregate of the physical and
delivery of comprehensive mental healthcare, mental qualities as these interact in characteristic fashion
economic restrictions preventing people from with his environment.
accessing mental healthcare should be considered to ● Personality is expressed through behavior. It is the
enable the population to equitable access appropriate sum total of one’s behavior (John Watson).
care when required.
● Increased investment is urgently needed to improve Personality development refers to the sum of all traits that
the training and recruitment of psychiatrists, nurses, differentiate one individual from another.
psychologists, social workers, and the multidisciplinary ● Total behavior patterns of an individual through which
team members, particularly as large numbers of skilled the inner interests are expressed.
professionals continue to emigrate. ● The individual’s unique and distinctive ways of
behaving and interacting with others.
Mental Health Staff Ratio
● There is 1 doctor for every 80,000 Filipinos (WHO Critical Periods in the Formation of Personality
and Department of Health, 2012). ● Personality of an individual develops in overlapping
● There are a little over 500 psychiatrists in practice. stages that shade and merge together.
The ratio of mental health workers per population in ● Certain goals must be accomplished during each stage
the Philippines is low, at 2-3 per 100,000 population in the development from infancy to maturity.
(WHO and Department of Health, 2005). ○ If goals are not accomplished at specific periods,
● Together, these figures equate to a severe shortage the basic structure of personality will be
of mental health specialists in the Philippines. This weakened.
is further illuminated when compared with the World ○ Factors in every stage persist as a permanent
Health Organization(WHO) - recommended global part of the personality.
target of 10 psychiatrists per 100,000 population. ○ Resolution of the conflicts with each stage is
● The majority of psychiatrists work in for-profit essential to the development.
services or private practices and are mainly based ○ Unresolved conflicts remain in the unconscious
in the major urban areas, particularly in the capital and may at times result in maladaptive behavior.
region known as Metro Manila. ○ Each stage has frustrations and traumas that
must be outgrown.
Basic Needs in Development of Personality

Humanity has certain basic needs that must be satisfied.
● Need to communicate
● Need for security
● Need to move from dependence to independence
● Need to develop self concept
● Need to find relief from organic discomfort
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Factors Influencing Personality

● Heredity
● Environment
● Training
Factors Involved inPersonality Development

● Behavior is a learned response that develops as a
result of past experiences.
● To protect the individual’s emotional well being, these
experiences are organized in the psyche on three
levels:
- Conscious
Anxiety is a feeling of tension, distress and discomfort
- Subconscious
produced by a perceived or threatened loss of inner control.
- Unconscious
LEVELS OF CONSCIOUSNESS BY SIGMUND FREUD
Conscious
A. Part of the mind which functions when the person is

awake that makes a person a thinking being.
B. Focus on here and now.
C. Concerned of thoughts, feelings and sensation, past
experiences are recalled without exerting efforts
D. Corresponds to the “ego or self.”
Subconscious/Preconscious
JOHARI WINDOW
A. Composed of material that has been deliberately
Joseph Luft and Harry Ingham were researching pushed out of consciousness but can be recalled with
human personality at the University of some effort.
California in the 1950s when they devised their B. Part of the mind in which ideas and reactions are
Johari Window. They observed that there are stored and partially forgotten.
aspects of our personality that are: C. Acts as a watchman, it prevents certain unacceptable
disturbing unconscious memories from reaching the
● Known to all
conscious mind.
● Known only by ourselves D. Thought and experiences can be recalled at will.
● Unknown by ourselves but known by others E. This is manifested during the tip of the tongue
● Unknown by self and others experience.
Rather than measuring personality, the window
offers a way of looking at how personality is Unconscious
expressed.
A. Largest part of the mind which exerts the greatest
influence in one’s personality.
B. The storehouse for all memories, feelings, and
responses experienced by the individual during his
entire life.
C. The memories cannot be recalled at will.
D. Contains the largest body of material, greatly
influencing behavior.
E. This can’t be deliberated brought back into
awareness, since it is:
- Usually unaccepted and painful to the individual.
- If recalled, usually disguised or distorted, as in
dreams but it could create anxiety.
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Example: A nurse working in an emergency room is

able to care for the seriously injured by isolating or
separating her feelings and emotions related to the
client’s pain, injuries, or death.
Projection
➔ Attributing one’s own thoughts or impulses to
another person.
DEFENSE MECHANISMS
Example: A student who has sexual feelings towards
➔ is used to protect the ego against anxiety, feelings of
her teacher, tells her friends that the teacher is coming
inadequacy, and worthlessness. They operate on an
onto her.
unconscious level and distort reality.
Rationalization
Denial
➔ Offering an acceptable, logical explanation to make
➔ Unconscious failure to acknowledge an event,
unacceptable feelings and behavior acceptable.
thought, feeling that is too painful for conscious
awareness.
Example: A student who did not do well in a course
says it was poorly taught and the course content was
Example: A woman diagnosed with cancer tells her
not important anyway
family all the tests were negative.
Repression
Displacement
➔ The involuntary exclusion of a painful thought or
➔ The transference of feelings to another person or
memory from awareness.
object.
Example: A young man whose mother died when he
Example: After being scolded by his supervisor at
was 12 cannot tell you how old he was or the year she
work, a man comes home and kicks the dog for barking.
died.
Identification
Sublimation
➔ Attempt to be like someone or emulate the
➔ Substitution of an unacceptable feeling with a more
personality, traits, or behaviors of another person.
socially acceptable one.
Example: A teenage boy dresses and behaves like his

Example: A student who feels too small to play football
favorite singer.
becomes a champion marathon swimmer.
Intellectualization
Suppression
➔ Using reason to avoid emotional conflict.
➔ The voluntary/intentional exclusion of feelings and
ideas.
Example: A wife of a substance abuser describes, in
detail, the dynamics of enabling behavior, yet continues
Example: When about to lose, Tara Scarlet O’Hara
to call her husband’s work to report his Monday morning
says. “I’ll think about it tomorrow.”
absences as an illness.
Undoing
Introjection
➔ Communication or behavior done to negate a
➔ Incorporation of values or qualities of an admired
previously unacceptable act.
person or group into one’s own ego structure.
Example: A young man who used to hunt wild animals
Example: A young man deals with a business client in
now chairs a committee for the protection of animals.
the same fashion his father deals with business clients.
Isolation
➔ Separation of an unacceptable feeling, idea, or
impulse from one’s thought process.
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THEORY OF PSYCHOSEXUAL DEVELOPMENT BY ERIKSON’S STAGES OF PSYCHOSOCIAL

SIGMUND FREUD DEVELOPMENT
● Greatest need: Security. STAGE VIRTUE TASK

● Greatest fear: Anger, anxiety.
Oral Phase ● Narcissistic: Pleasure seeking is through Trust vs. Viewing the world as
eating and sucking; primary narcissism. Mistrust HOPE safe and reliable;
(Birth -18 (self-love) relationships as
Months Old) ● Mouth: Erogenous zone, area of (Infant or Birth-18 nurturing, stable, and
Months Old) dependable.
satisfaction.
● Insecurity in parting with breast or bottle
Autonomy vs. Achieving a sense of
may cause fixation. Shame and WILL control and free will.
● Tension is relieved by sucking and Doubt
swallowing.
● Sucking needs are independent of (Toddler or 1-3
hunger satisfaction. Years Old)
● Primary source of pleasure is elimination Initiative vs. Beginning development

or retention. Guilt PURPOSE of a conscience; learning
● This is the critical period for toilet to manage conflict and
(Preschool or 3-6 anxiety.
training.
Years Old)
Anal Phase ● The anus is a site of tension and sexual
gratification.
Industry vs. Emerging confidence in
(18-36 Months ● Greatest need: power Inferiority COMPETENCE own abilities; taking
Old) ● First experience with discipline and pleasure in
authority. (School Age or accomplishments
● Retention and expulsion (forcing out are 6-12 Years Old)
experienced as pleasurable especially
because these functions come under Identity vs. Formulating a sense of
child-control). Child uses his new skill to Role FIDELITY self and belonging.
please or annoy parenting adults. Confusion
(Adolescence or
12-20 Years Old)
Phallic or ● Genitals are the focus of interest,
Oedipal stimulation, and excitement. Intimacy vs. Forming adults, loving
● Masturbation is common. Isolation LOVE relationships, and
(3-5 Years Old) meaningful attachments
(Young Adult or to others.
Latency ● Resolution of oedipal complex. 18-25 Years Old)
● Sexual drive is channeled into socially
(5-11 or 13 appropriate activities such as school Generativity Being creative and
Years Old) work and sports. vs. Stagnation CARE productive; establishing
the next generation.
(Middle Adult or
Genital ● Final stage of psychosexual
24-45 Years Old)
development.
(11-13 Years ● Involves the capacity for true intimacy.
Ego Integrity Accepting responsibility
Old) vs. Despair WISDOM for oneself and life.
(Maturity or 45
Transference occurs when the client displaces onto the Years Old and
therapist attitudes and feelings that the client originally Above)
experienced in other relationships.
COGNITIVE THEORY (PIAGET, AARON BECK, ALBERT
Countertransference occurs when the therapist displaces ELLIS)
onto the client attitudes or feelings from his or her past. ● Cognitive schemas as personal controlling beliefs
(Beck).
● Cognitive restructuring (Ellis).
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● These models use a cognitive approach based on Interpersonal Process (Peplau)

an individual's ability to think,analyze, judge, decide ● Nurse-Patient relationship.
and do. ● Therapeutic use of self.
● According to the cognitive, replacing irrational ● Therapeutic relationship directed toward meeting the
beliefs with rational beliefs can reduce stress and patient’s needs.
anxiety and self defeating behavior.
ANXIETY LEVELS
Mild
COGNITIVE STAGES OF DEVELOPMENT (JEAN PIAGET)
● Sharpened senses
The child develops a sense of self as ● Increased motivation
Sensorimotor separate from the environment and the ● Alert
concept of object permanence,that is ● Enlarged perceptual field
(Birth-2 Years Old) tangible objects do not cease to exist just
because they are out of sight. He or she ● Can solve problems
begins to form mental images. ● Learning is effective
● Restless
The child develops the ability to express ● Gastrointestinal “butterflies”
Preoperational himself with language, and understands
the meaning of symbolic to classify ● Sleepless
(2-6 Years Old) objects. ● Irritable
● Hypersensitive to noise
The child begins to apply logic to thinking,
Concrete understands spatiality and reversibility,
Operations and is increasingly social and able to Moderate
apply rules; however, thinking is still ● Selectively attentive
(6-12 Years Old) concrete. ● Perceptual field limited to the immediate task
● Can be redirected
The child learns to think and reason in
● Cannot connect thoughts or events independently
Formal Operations abstract terms, further develops logical
thinking and reasoning, and achieves ● Muscle tension
(12-15 Years Old or cognitive maturity. Piaget’s theory ● Diaphoresis
Beyond) suggests that individuals reach. ● Pounding pulse
● Headache
INTERPERSONAL MODEL (SULLIVAN, PEPLAU) ● Dry mouth
➔ Human development results from IPR, and that ● Higher voice pitch
behavior is motivated by avoidance of anxiety and ● Increased rate of speech
attainment of satisfaction (Sullivan). ● Gastrointestinal upset
● Frequent urination
3 Modes: ● Increased automatisms (nervous mannerisms)
1. Prototaxic Mode
● Characteristics of infancy and childhood, involves Severe
brief, unconnected experiences that have no ● Perceptual field reduced to one detail or scattered
relationship to one another. details
● Cannot complete tasks
2. Parataxic Mode ● Cannot solve problems or learn effectively
● Begins in early childhood as the child begins to ● Behavior geared toward anxiety relief and is usually
connect experience in sequence. ineffective
● Feels awe, dread, or horror
3. Syntaxic Mode ● Doesn’t respond to redirection
● Which begins to appear in school-aged children ● Severe headache
and becomes more predominant in ● Nausea, vomiting, diarrhea
preadolescence, the person begins to perceive ● Trembling
him or herself and the world within the context of ● Rigid stance
environment and can analyze experience in a ● Vertigo
variety of settings. Maturity may be defined as ● Pale
predominance of syntaxic mode. ● Tachycardia
● Chest pain
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● Crying LAZARUS INTERACTIONAL MODEL

● Ritualistic (purposeless, repetitive behavior Psychological stress is a relationship between the person
and the environment that is appraised by the person as
Panic taxing or exceeding his or her resources and endangering
● Perceptual field reduced to focus on self his or her wellbeing.
● Cannot process environmental stimuli
● Distorted perceptions 3 Types of Appraisal
● Loss of rational thought
● Personality disorganization Primary Appraisal
● Doesn’t recognize danger ● The judgment that individuals make about a particular
● Possibly suicidal event
● Delusions or hallucination possible
● Can’t communicate verbally Secondary Appraisal
● Either cannot sit (may bolt and run) or is totally mute ● The individual’s evaluation of the way to respond to an
and immobile event. Possible strategies, or solutions, as well as
resources and supports are examined.
Anxiety as a Response to Stress
● Stress is the wear and tear that life causes on the body Reappraisal
(Selye, 1956). ● Further appraisal that is made after new or additional
● It occurs when a person has difficulty dealing with life information has been received.
situations, problems, and goals.
● (+) or (-) occurrence EXISTENTIAL MODEL (FRANKL,PERLS, MAY)
● Centers on a person’s present experiences rather than
Hans Selye identified three stages of reaction to stress: past ones.
1. Alarm Reaction Stage ● Holds that alienation from self causes deviant
● Stress stimulates the body to send messages from behavior, and that people can make free choices about
the hypothalamus to the glands (such as adrenal which behavior to display.
gland, to send out adrenaline and norepinephrine
for fuel) ans organs (such as the liver, to reconvert NURSING MODEL (ROGERS, OREM, SISTER ROY,
glycogen stores to glucose for food) to prepare for PEPLAU)
potential defense needs. ● Biopsychosocial being.
● Holistic approach focuses on caring rather than curing.
2. Resistance Stage ● Establishes the nursing process.
● The digestive reduces function to shunt blood to
areas as needed for defense. The lungs take in MEDICAL MODEL
more air, and the heart beats faster and harder so ● Disease is a result of deviant behavior.
that it can circulate this highly oxygenated and ● Identification of neurochemicals as possible causes of
highly nourished blood to the muscles to defend deviant behavior.
the body to fight, flight or freeze behaviors. If the ● Socio-environmental influences.
person adapts to the stress, the body responses
relax, and the gland, organ and systemic response COMMUNICATION MODELS (BERNE, BANDLER,
abate. GRINDLER)
➔ All human behavior is a form of communication and
3. Exhaustion Stage that the meaning of behavior depends on the clarity of
● Occurs when the person has responded negatively communication between sender and receiver.
to anxiety and stress: body is depleted or
emotional components are not resolved, resulting Behavioral Model (Skinner, Wolpe, Eysenck)
in continual arousal of the physiological responses ➔ All behavior, including mental illness, is learned.
and little reserve capacity. Desired behavior can be learned through rewards, and
negative behaviors can be eliminated through
punishment
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HUMANISTIC MODEL (MASLOW) Primary parts:

Maslow (1954) formulated the hierarchy of needs, in which Cerebrum - Controls many things, including:
he used a pyramid to arrange and illustrate the basic drives ● How we think
or needs that motivate people. The most basic needs—the - Left hemisphere: logical reasoning and
physiologic needs of food, water, sleep, shelter, sexual analytical functions; right hemisphere: center for
expression, and freedom from pain— must be met first. The creative thinking, intuition, artistic abilities.
second level involves safety and security needs, which ● What kind of personalities we have.
include protection, security, and freedom from harm or ● Voluntary movement.
threatened deprivation. The third level is love and belonging ● The way we interpret sensations such as sight,
needs, which include enduring intimacy, friendship, and touch, and smell.
acceptance. The fourth level involves esteem needs, which
include the need for self-respect and esteem from others.
The highest level is self actualization, the need for beauty,
truth, and justice.
Cerebellum - Overlies the pons and medulla.

● It is mainly concerned with motor functions that
regulate muscle tone, coordination, and posture.
● Lack of dopamine in this area is associated with
Social Model (Caplan, Szasz)
Parkinson’s and Dementia.
➔ Deviant behavior is defined by the culture in which a
● It controls the way we:
person lives.
○ Walk (movement).
○ Maintain our posture.
Biophysiological Theory and Neurobiological
○ Keep our sense of balance.
Perspective
➔ Genetic factors, neuroanatomy, neurophysiology, and
Brain Stem - Is a major part of Corporate Headquarters.
biological rhythms related to the cause, course, and
● The brainstem is a general term for the area of the
prognosis of mental disorders.
brain between the thalamus and spinal cord. It
controls such vital functions as:
CENTRAL NERVOUS SYSTEM
○ Respiration rate/breathing
BRAIN - In the average adult human, the brain weighs 1.3
○ Blood pressure
to 1.4 kg (about 3 pounds). The brain contains about 100
○ Heartbeat/heart rate
billion nerve cells (neurons) and trillions of support cells
● Structures within the brainstem include the medulla,
called ‘glia.’
pons, tectum, reticular formation, and tegmentum.
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● Necessary in just the right proportions to relay

messages across the synapses.
● Are the chemicals which account for the transmission
of signals from one neuron to the next across
synapses.
DIENCEPHALON
● extends from the cerebrum and sits above the
brainstem.
● 3 Primary Structure: MAJOR NEUROTRANSMITTERS
a. Thalamus - receives & relays sensory information TYPE MECHANISM OF PHYSIOLOGIC EFFECTS
& plays a role in memory & in regulating mood ACTION
b. Hypothalamus - controls the body homeostasis
GLUTAMATE Excitatory Results in neurotoxicity in high
c. Limbic System - regulates emotional responses levels
Limbic System SEROTONIN Inhibitory Food intake, sleep &

wakefulness, temperature
● Thalamus - activity, sensation, emotion regulation, pain control, sexual
● Amygdala - emotional and memory behavior, emotions
● Hypothalamus - temperature regulation, appetite
GABA Inhibitory Modulates other
control, endocrine function, sexual drive, and impulsive neurotransmitters
behavior
ACETYLCHOLINE Excitatory Sleep & wakefulness cycle,
Inhibitory signals muscles to become
SPINAL CORD alert
HISTAMINE Neuro-modulator Alertness, gastric secretions,

cardiac stimulation, peripheral
allergic response
NEUROPEPTIDES Neuro-modulator Enhance, prolong, inhibit, or

limit the effects of principal
neurotransmitters
BRAIN IMAGING TECHNIQUE

Computed Tomography (CT) or Computed Axial
Tomography
● Some people with schizophrenia have been shown to
have enlarged ventricles; this finding is associated with
Neurobiological Theory a poorer prognosis and marked negative symptoms.
➔ Studies reveal that malfunction of certain CNS neurons
which excrete substances known as neurotransmitters, Magnetic Resonance Imaging (MRI)
appear to inhibit or trigger impulses in other neurons ● MRI produces more tissue detail and contrast than CT
and may be responsible for distortions of behavior and can show blood flow patterns and tissue changes
associated with psychiatric disorders. such as edema. It can also be used to measure the
size and thickness of brain structures; Persons with
Neurotransmitters schizophrenia can have as much as 7% reduction in
● Are chemical substances manufactured in the neuron cortical thickness.
that aid in the transmission of information throughout
the body.
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Positron Emission Tomography (PET) & Single Photon PHASES OF CRISIS

Emission Computed Tomography (SPECT)
● Positron emission tomography (PET) and
single-photon emission computed tomography
(SPECT) are used to examine the function of the brain.
PET and SPECT are used primarily for research, not
for the diagnosis and treatment of clients with mental
disorders.
FDDNP with PET

● Recent breakthrough is the use of the chemical
marker.
● FDDNP with PET to identify the amyloid plaques and
tangles of Alzheimer's disease in living clients. TYPES OF CRISIS
● These scans have shown that clients with Alzheimer 1. Maturational Crisis
disease have decreased glucose metabolism in the ● Occurs during one's stages of development.
brain and decreased cerebral blood flow. Some ● Anticipated or predictable events in the normal
persons with schizophrenia also demonstrate course of life.
decreased cerebral blood flow.
2. Situational Crisis
Illness ● Unpredicted or sudden events that threaten the
● Genetic and hereditary individual's integrity.
● Stress and the immune system ● Is a response to a sudden and unavoidable
● Infection as a possible cause traumatic event that largely affects a person’s
identity and roles.
CRISIS
A crisis is any event or period that will lead, or may lead, to 3. Adventitious Crisis
an unstable and dangerous situation affecting an individual, ● Is a social crisis that affects a larger number of
group, or all of society. people.
● In mental health terms, a crisis refers not necessarily ● Natural disasters such as floods, typhoon,
to a traumatic situation or event, but to a person's earthquakes, war or terrorism, riots, violent crimes
reaction to an event. such as rape, murder, and others.
● Occurs when the experience that is causing the
anxiety is overwhelming and the usual coping is no Crisis Intervention
longer effective. ➔ are methods offered to help people who are
incapacitated or have a severely distributed crisis. It
Crisis is a state of disequilibrium resulting from the refers to the methods used to offer immediate, short
interaction of an event with the individual’s or family’s term help to individuals who experience an event that
coping mechanisms, which are inadequate to meet the produces emotional, mental, physical and behavioral
demands of the situation combined with the individual’s or distress or problems.
family’s perception of the meaning of the event (Taylor,
1982). Goals of Crisis Intervention
● To decrease emotional stress and protect the crisis
Crisis is self-limiting.It does not last indefinitely but usually victim from additional stress.
lasts for 4-6 wks. At the end of that time the crisis is ● To assist the victim in organizing and mobilizing
resolved in any of the 3 ways: resources or support systems to meet unique needs
● The person returns to his/her pre-crisis level. and reach a solution for the particular situation that
● The person begins to function at a higher level. precipitated the crisis.
● The person functions at a lower level.
Requisites for the Effective Crisis Intervention
● Ability to create trust via confidentiality and honesty.
● Ability to listen in an attentive manner.
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● Provide the individual with the opportunity to - Raising the person’s self awareness by providing
communicate by talking less. feedback about his/her behavior.
● Being attentive to verbal and nonverbal cues. - Directing the person’s behavior by offering
Pleasant, interested, intonation of voice. Maintaining suggestions or courses of actions.
good eye contact, posture and appropriate social
distance if in a face to face situation. Facilitative Intervention
● Pleasant, interested, intonation of voice. Maintaining ● Designed to meet person’s need for empathic
good eye contact, posture and appropriate social understanding such as:
distance if in a face to face situation. - Encouraging to identify and discuss feelings.
● Remaining undistracted, open, honest, sincere. - Serving as a sounding board for the person.
● Asking open ended questions. - Affirming the person’s self worth.
● Asking permission, never acting on assumptions.
● Checking out sensitive cross-cultural factors Techniques of Crisis Intervention
● Catharsis: The release of feelings that takes place as
Length of Time for Crisis Intervention the patient talks about emotionally charged areas.
● The length of time for crisis intervention may range ● Clarification: Encouraging the patient to express
from one session to several weeks, with the average more clearly the relationship between certain events.
being four weeks. ● Reinforcement of behavior.
● Crisis intervention is not sufficient for individuals with ● Support of defenses.
long standing problems and it may range from 20 ● Rising self esteem.
minutes to 2 or more than 2 hours. ● Exploration of solution
Key Element of Management PHASES OF CRISIS INTERVENTION

Management will depend on the severity and causes of the Immediate Crisis Intervention or Psychological First Aid
crisis as well as the individual circumstances of the patient. ● It involves establishing a rapport with the victim,
● Many relatively minor crises can be managed by gathering information for short term assessment and
providing friendly support in primary care without service delivery and averting a potential state of crisis.
referral. ● Immediate crisis intervention also includes caring for
● Severe crises will require referral to counselors or the the medical, physical, mental health and personal
local mental health team. needs of the victim and providing information to the
● Crisis therapy includes short term behavior/cognitive victim about local resources or services.
therapy and counseling.
● Involvement of family and other key social networks is Second Phase
very important. ● The second phase of crisis intervention involves an
● Therapy should be relatively intense over a short assessment of needs to determine the service and
period and discontinued before dependence on the resources required by the victim in order to provide
therapist develops. emotional support to the victim.
● The risk of suicide and self harm must be assessed at
presentation and each review. Third Phase
● The aims of treatment are to: ● Recovery intervention helps victims re-stabilize their
❖ Reduce distress. lives and become healthy again.
❖ Help to solve problems.
❖ Avoid maladaptive coping strategies such as STEPS IN CRISIS INTERVENTION (AGUILERA, 1982)
self-harm. Assessment
❖ Improve problem solving strategies. ● The assessment process attempts to answer
questions such as:
INTERVENTIONS ○ What has happened? (Identification of problem)
Authoritative Intervention ○ Who is involved?
● Designed to assess the person’s health status and ○ What is the cause?
promote problem-solving such as: ○ How serious is the problem?
- Offering the person new information, knowledge or
meaning.
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Planning Therapeutic Intervention Factors Influencing Assessment

● The person should be involved in the choice of 1. Patient’s participation/feedback.
alternative coping methods. 2. Client’s health status.
● The needs and reactions of significant others must be 3. Patient’s previous experience/misconception regarding
considered. health care.
4. Client’s ability to understand.
Therapeutic Intervention 5. Nurse’s attitude and approach.
● Therapeutic intervention depends on pre-listing skills,
the creativity and flexibility of the crisis worker and General Guidelines
rapidity of the person’s response. 1. Ensure privacy.
● The crisis worker helps the person to establish an 2. Show support and sensitivity.
intellectual understanding of the crisis by noting the 3. Use reliable information sources.
relationship between the precipitating factors and the 4. Consider the patient’s culture.
crisis.
Resolution and Anticipatory Planning

● During the evaluation phase or step of crisis
intervention, reassessment must occur to ascertain
that the intervention is reducing tension and anxiety.
● Assistance is given to formulate realistic plans for the
future, and the person is given the opportunity to
discuss how present experiences may help in coping
Beginning the Interview
with future crises.
1. Biographic Data
2. Socioeconomic Data
3. Cultural Beliefs
4. Chief Complaint
5. Personal History (Ego function and areas of strength).
6. Psychiatric History
7. Psychosocial History
8. Family History
9. Medication History
10. PhysicalIllnesses
Components of a Psychosocial Assessment

● History
● General appearance and motor behavior
● Mood and affect
● Thought process and content
● Sensorium and intellectual process
● Self concept
● Judgment and insight
● Roles and relationship
THE NURSING PROCESS IN PSYCHIATRIC MENTAL ● Physiologic and self care concerns
HEALTH CARE
General Appearance Assessment
ASSESSMENT ● Hygiene
Purpose ● Grooming
● Construct a clear picture of the client's emotional state ● Appropriate dress
● Mental capacity ● Gait
● Behavioral function ● Posture
● Activity
● Eye contact
● Use of cosmetics
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● Facial expressions COMMON SIGNS AND SYMPTOMS OF MENTAL

● Unusual movements or mannerisms DISORDERS
● Disturbances in affect
● Mood - Is an emotional state of an individual. ○ The 6
MENTAL STATUS EXAMINATION
Basic Emotions: Anger, joy, surprise, disgust, sadness,
Judgment and fear
● Correct interpretation of situation. ● Affect - The person’s capacity to vary the outward
● Make appropriate decision making. expression of mood (Joy, acceptance, fear, surprise,
● Soundness of problem solving. sadness, disgust, anger, anticipation).
Orientation
● Recognize person, place and time. DIFFERENT TYPES OF AFFECT
● Level of consciousness. Inappropriate Affect
● Disharmony between thought and emotional response.
● Educational level: cognitive functions.
● Attention: ability to concentrate.
Intellectual ● Retention: ability to retain information.
Flat Affect
Functioning ● Abstract reasoning: ability to interpret or ● No emotion attached to the content of speech.
associate situations, proverbs or
comments.
Blunted Affect
● Ability of the client to recall distant and
● Significantly reduced intensity of emotional expression.
Memory recent events or short and long term
memory.
● Presence of any disturbance in memory. Labile Affect
● Change of emotion from happiness to tearfulness in a
Appearance very short span of time.
● Type, condition and appropriateness of
clothing.
● Personal hygiene, grooming, and Exaggerated Affect
cleanliness. ● Overly dramatic expression of emotion:
- Elated
Appearance Behavior - Depressed
and Behavior ● Behavior during interview: degree of
- Angry
cooperation or resistance.
● Social skills: friendly, shy, withdrawn. - Anxious
● Amount and type of motor activity:
psychomotor agitation or retardation, DISTURBANCES IN THOUGHT
tremors, or restlessness. DELUSIONS
● Presence of disturbances in motor
behavior
False belief that cannot be corrected by reasons.
● Persecutory Delusions (Paranoid): False belief that
Thought Content others are against him or will harm him.
● Delusions, hallucinations. ● Nihilistic Delusions (Cotard’s Syndrome): False
● Helplessness, hopelessness, belief that one denies existence of self or part of self in
Thinking worthlessness.
extreme cases, the person believes that he is already
● Suicidal or homicidal thoughts.
● Suspiciousness, obsessions, denial, dead.
phobia. ● Alien Control: False belief that one's thoughts and
Thought Process actions are controlled by an external force.
● Bizarre, impaired, logical, magical. ● Thought Broadcasting: False belief that one’s
● Ambivalence, circumstantiality,
tangentiality.
thought can be read by others.
● Thought blocking, loose association, flight ● Thought Withdrawal: False belief that one’s thought
of ideas. is taken by others.
● Thought Insertion: False belief that others inserted
Thought Clarity thoughts/ideas into his mind.
● Coherence, confusion or vagueness.
● Ideas of Reference: False belief that situations or
Speech ● Amount, rate, volume, tone, pressure. events in the environment are directly projected into
Pattern ● Mutism, stuttering, slurring. the client.
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● Grandiosity: False belief that one is superior and FLIGHT OF IDEAS

powerful. ● Over productivity of talk and verbal jump in quickly
● Self Depreciation: False belief that one feels from one idea to another. Sometimes, ideas are
unworthy, ugly, or sinful. superficially associated.
● Somatic Delusions: False belief pertaining to body ● Example: “I like the color blue. Do you ever feel blue?
image or function. Feelings can change day to day. The days are getting
● Word Salad: Flow of unconnected words that convey longer.”
no meaning to the listener.
POVERTY OF IDEAS
OBSESSION ● Patient has few ideas and focuses only on negative
● A persistent and irresistible thought that a person is aspects.
driven to think again and again. ● Example:
Q. Do you have children?
HYPOCHONDRIA A. …
● A morbid belief that one is sick. Q. Do you have children?
A. … (mumbles) Yes..
PERSEVERATION
● A tendency to emit the same verbal or motor response
again and again usually as a response to a stimulus. DISTURBANCES IN PERCEPTION
CIRCUMSTANTIALITY ILLUSIONS
● Patient provides a lot of details before finally ● False interpretation of the external stimulus.
answering the question. ● Describes a misinterpretation of a true sensation.
● Also known as circumstantial thinking, or
circumstantial speech, often include excessive HALLUCINATION
irrelevant details in their speaking or writing. ● False sensory perceptions that occur in the absence of
● They maintain their original train of thought but provide an actual external stimuli and it may involve any of the
a lot of unnecessary details before circling back to their senses.
main point. - Gustatory Hallucination (taste)
- Olfactory Hallucination (smell)
TANGENTIALITY - Visual Hallucination (sight)
● Verbal production is not at all related to the question. - Auditory Hallucination (hearing)
- Tactile Hallucination (touch)
THOUGHT BLOCKING
● Sudden stoppage of thought without apparent reason. DEPERSONALIZATION
● A feeling of detachment from the environment and self.
NEOLOGISM ● Going through the motions of life but not experiencing
● Creating new words that only the client understands. it, feeling as though one is in a movie.
● Example: “Chorvahin ang mga echoserang frog!”
DEREALIZATION
LOOSE ASSOCIATION ● A feeling of altered reality.
● Patient’s verbal production is impossible to follow due ● Dream-like state of mind.
to lack of organization and lack of connection between
ideas. DISTURBANCES OF MOTOR BEHAVIOR
WORD SALAD Catatonic Stupor

● Extreme form of loose association, wherein there are ➔ Is a motionless, apathetic state in which one is
no two words that connect together to form any logical oblivious or does not react to external stimuli.
association.
● Example: Colorless green ideas sleep furiously. Stupor
➔ The client is unresponsive to the surroundings but is
CLANG ASSOCIATION conscious.
● Patient speaks in rhymes.
● Example: Rock the boat of a goat wearing a coat.
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Rigidity ● The client finds it difficult to remember things that

➔ The client assumes position and will not move when occurred before a traumatic event.
effort is made to change his position.
Paramnesia
Waxy Flexibility ➔ Incomplete absence of memory.
➔ The client maintains his position which he has been ● Confabulation: Fabricating stories to fill up lapses
originally placed in. of memory caused by anterograde amnesia.
● Blackout: Amnesia experienced by alcoholics
Catatonic Excitement about behavior during drinking bout.
➔ Is a state of constant purposeless agitation and ● False Memory: Recollection of and belief in an
excitation. event that did not actually occur.
● Lethologica: Temporary inability to remember a
Hyperactivity name or proper noun
➔ Presence of motor restlessness and extreme over
activity. Déjà vu
● Impulsiveness: Unpredictable and sudden ➔ Familiarity of events that are unfamiliar.
outburst of activity. ● “Has seen.”
● Compulsion: Unwanted urge to perform
repetitive actions. Jamais Vu
➔ Unfamiliarity of events that are familiar.
Automatism ● “Hasn't seen.”
➔ Unconscious uncontrollable undirected activity Deja Entendu
● Echopraxia: Client imitates actions of others. ➔ Familiarity of sounds that are unfamiliar.
● Echolalia: Client repeats words or statements of ● “Has heard.”
others.
Jamais Entendu
Pressured Speech ➔ Unfamiliarity of sounds that are familiar.
➔ Unrelenting, rapid, often loud talking without pauses. ● “Hasn't heard.”
Stereotype SCHIZOPHRENIA
➔ Repetitive persistent motor activity or speech. ➔ Schizophrenia is a group of disorders characterized by
● Verbigeration: Repetition of words or phrases disturbance in thoughts, feelings, perception and
may not have meaning to the listener. behavior. Severe impairment of mental and social
functioning with grossly impaired reality testing,
Mannerism sensory perception and with deterioration and
➔ Persistent motor behavior. regression of psychosocial functioning.
Tics and Spasm Assessment of Schizophrenia

➔ Unconscious twitching or jerking of muscles usually Diagnostic Criteria
above the shoulder which are involuntary ● Two or more of the following characteristic symptoms
present for significant portion of during a 1-month
DISTURBANCES IN MEMORY period:
Amnesia ○ Delusions
➔ Complete absence of memory. ○ Hallucination
○ Disorganized speech
Anterograde Amnesia (Goldfield’s Syndrome) ○ Grossly disorganized or catatonic behavior
● Forgetting recent events. ○ Negative symptoms
● The client finds it difficult to remember things that ● One or more major areas of social or occupational
occur after a traumatic event. functioning markedly below previously achieved level
such as:
Retrograde Amnesia ○ Work
● Forgetting further events. ○ Interpersonal relations
○ Self-care
17
● Continuous signs for at least 6 months. ❖ Blunted affect - Restricted range of emotional
feeling, tone, or mood.
Symptoms of Schizophrenia ❖ Flat affect - Absence of any facial expression that
● Positive Symptoms - Reflect an excess distortion of would indicate emotions or mood.
normal functions including: ❖ Inattention - Inability to concentrate or focus on a
❖ Delusions - Fixed false beliefs that have no basis topic or activity, regardless of its importance.
in reality.
❖ Hallucinations - False sensory perceptions or ● Disorganized Thinking
perceptual experiences that do not exist in reality. ❖ Echolalia - The client’s imitation or repetition of
❖ Ambivalence - Holding seemingly contradictory what the nurse says.
beliefs or feelings about the same person, event, - Example: Nurse: “Can you tell me how you’re
or situation. feeling?”
❖ Echopraxia - Imitation of the movements and ❖ Circumstantiality
gestures of another person whom the client is ❖ Loose association
observing. ❖ Tangentiality
❖ Flight of ideas - Continuous flow of verbalization in ❖ Flight of ideas
which the person jumps rapidly from one topic to ❖ Word salad - a combination of jumbled words and
another. phrases that are disconnected or incoherent and
❖ Perseveration - Persistent adherence to a single make no sense to the listener.
idea or topic; verbal repetition of a sentence, word, - Example: “Corn, potatoes, jump up, play
or phrase; resisting attempts to change the topic. games,grass, cupboard.”
❖ Associative looseness - Fragmented or poorly ❖ Paranoia
related thoughts and ideas. ❖ Neologism - Words invented by the client.
❖ Ideas of reference - False impressions that - Example: “I’m afraid of grittiz. If there are any
external events have special meaning for the grittiz here, I will have to leave. Are you a
person. grittiz?
❖ Bizarre behavior - Outlandish appearance or ❖ Clang associations - Ideas that are related to one
clothing; repetitive or stereotyped, seemingly another based on sound or rhyming rather than
purposeless movements; unusual social or sexual meaning.
behavior. - Example: “I will take a pill if I go up the hill but
not if my name is Jill, I don’t want to kill.”
● Negative Symptoms - Reflect a lessening or loss of ❖ Referential thinking
normal function such as: ❖ Concrete thinking
❖ Affective flattening and blunting - Restriction of ❖ Verbigeration - The stereotyped repetition of words
flattening in the range and intensity of emotions. or phrases that may or may not have meaning to
❖ Alogia - Tendency to speak little or to convey little the listener.
substance of meaning (poverty of content). - Example: “I want to go home, go home, go
❖ Avolition - Withdrawal and inability to initiate and home, go home.”
persist in goal directed activity. ❖ Stilted language - Use of words or phrases that are
❖ Anhedonia - Inability to experience pleasure. flowery, excessive, and pompous.
Feeling no joy or pleasure from life or any activities - Example: “Would you be so kind, as a
or relationships. representative of Florence Nightingale, as to do
❖ Apathy - Feelings of indifference toward people, me the honor of providing just a wee bit of
activities, and events. refreshment, perhaps in the form of some clear
❖ Catatonia – Psychologically induced immobility. spring water?”
❖ Blunted affect - Restricted range of emotional ❖ Pressured speech
feeling, tone, or mood. ❖ Hallucination
❖ Avolition or lack of volition - Absence of will, ❖ Delusion
ambition, or drive to take action or accomplish ❖ Illusion
tasks. ❖ Autistic thinking
❖ Asociality - Social withdrawal, few or no
relationships, lack of closeness.
18
● Disorganized Behavior brain physiology. Recent researchers have been

❖ Social Withdrawal - Aloof and fails to encourage focusing on infections in pregnant women as a
interpersonal relationships. possible origin for schizophrenia.
❖ Suspiciousness - Sees the world as a hostile
place. Psychodynamic Theory
❖ Psychomotor Retardation - Slow moving and slow ● Poor care giving that leads to psychic alteration (Freud
speaking, and waxy flexibility. and Blueler).
❖ Hyperactivity - Loud rapid speaking, inability to sit ● Loss of ego boundaries.
still. ● Double blind communications pattern within a poor
- Catatonic excitement family relationship.
- Hypervigilance
❖ Regression - Inability to meet basic survival needs. Onset
- Unable to feed oneself. ● Abrupt or insidious.
- Poor personal hygiene. ● Age of onset appears to be an important factor on how
- Inappropriate dress for the weather. well the client fares.
- Aggression ● Those who develop the illness earlier show worse
- Agitation outcomes than those who develop it later.
○ Stereotypy
○ Echopraxia Types of Schizophrenia
● Paranoid Schizophrenia
BLEULER’S FOUR A’S OF SCHIZOPHRENIA ○ Behavioral Pattern: Suspicious
1. Associative Looseness - Also known as derailment, ○ Defense Mechanism: Projection
refers to a thought-process disorder characterized by ○ Characteristics: Extreme suspiciousness, ideas
an absence or lack of connection between thoughts or of reference, delusion of persecution, auditory
ideas. The individual will frequently jump from one idea hallucination, and unpredictable violence.
to an unrelated one. ○ 4 P’s
➢ Projection
2. Autistic Behavior - Person’s thoughts are excessively ➢ Proxemics
involved, and focused outward. ➢ Passive Friendliness
➢ Persecutory Delusion- A person believes
3. Affect - Blunted affect, severe reduction in emotional someone wants to hurt them. They firmly
expressiveness. believe this is true, despite the lack of proof.
○ Considerations
4. Ambivalence - Presence of two equally strong ➢ Consistency to build trust
feelings coexisting and neutralizing each other. ➢ Food: packed or sealed food
➢ Social isolation
5. 5th A: Auditory Hallucinations - New concept. ➢ Develop trust
Etiological Theories ➢ Be reliable and consistent
➢ Safety for other and client
Current etiologic theories focus on biological theories: ➢ Approach non-threatening manner
1. Genetic Factors - Genetic pattern within the family ➢ Never whisper
system (50% chance for the other identical twin, and ➢ Never hold complicated objects
15% for fraternal twins). ➢ Provide solitary
➢ Provide safe and relatively simple activities
2. Neuroanatomic and Neurochemical Factors -
People with schizophrenia have relatively less brain ● Hebephrenic Schizophrenia
tissue and cerebrospinal fluid, enlarged ventricles in ○ Characterized with inappropriate behavior, silly
the brain and cortical atrophy. PET studies suggest crying, laughing, regression, and transient
that glucose metabolism and oxygen are diminished in hallucinations.
the frontal cortical structures of the brain.
● Disorganized Schizophrenia
3. Immunovirologic Factors - Exposure to a virus of the ○ Onset: Early, usually below 18 years old and is
body’s immune response to a virus could alter the insidious
19
○ Behavioral Pattern: Withdrawn Defense ➢ Disorganized catatonic behavior.

○ Mechanism: Regression ➢ Social withdrawal.
○ Characteristics: Inappropriate behavior, silly ➢ Does not meet the criteria for paranoid;
smiles and laughter, somatic delusions, impaired disorganized or catatonic.
ADL.
○ Nursing Diagnosis and Management ● Residual Schizophrenia
➢ Self-care deficit. ○ The patient no longer exhibits overt symptoms, no
➢ Promote self-care. more delusion but still has negative symptoms or
➢ Promote independence. odd benefits or unusual perceptions.
➢ Provide safe and relatively simple activities. ➢ People with residual schizophrenia often
○ Impaired Socialization neglect basic hygiene and need help with
➢ Active friendliness. everyday living activities.
➢ Gain trust. ➢ Absence of prominent delusion, hallucinations,
➢ Provide remotivation and resocialization. disorganized speech and grossly disorganized
➢ Improve socialization skills or catatonic behavior.
➢ Negative symptoms persist or two more
● Catatonic Schizophrenia positive symptoms are present in attenuated
○ With stereotyped position (catatonia), waxy form such as odd belief or unusual perceptual
flexibility, mutism, bizarre mannerisms. experiences.
○ Characteristics
➢ Stupor– Slowed movement. Treatment
➢ Posturing– Weird bizarre positions. ● Psychopharmacology
➢ Rigidity- Cementation/stone-like position. ○ Traditional medication (1950s)
➢ Negativism– resistance towards flexion and ➢ Haloperidol
extension. ➢ Chlorpromazine
➢ Excitability - Hyperactivity. ➢ Thiothixene
○ Onset: Any age group and usually acute and ○ New medications (1990s)
precipitated by an emotionally disturbing ➢ Clozapine
experience. ➢ Risperdal
○ Behavioral Pattern: Withdrawn ➢ Zyprexa
○ Defense Mechanism: Repression ● Maintenance Therapy
○ Catatonic Stupor Characteristics: Sudden onset
of mutism, bizarre mannerisms, waxy flexibility, Nursing Interventions for Clients with Schizophrenia
automatism. ● Promoting the safety of clients and others and the right
○ Catatonic Excitement Characteristics: to privacy and dignity.
Dangerous periods of agitation, impulsive and ○ Approach the client in a nonthreatening manner.
explosive behavior. ○ Give ample personal space to enhance a sense of
○ Nursing Diagnosis and Management: security.
➢ Provide a safe environment. ● Establish therapeutic relationships.
➢ Promote nutrition and hydration. ○ Talk and provide explanations to clients by being
➢ Prevent bowel and bladder problems. simple, direct and easy to understand.
➢ Minimize circulatory problems and loss of ○ Call clients by their name.
muscle tone. ● Using Therapeutic Communication (clarifying feelings
○ Symptoms of more than one type of schizophrenia. and statements when speech and thought are
Has delusions and disorganized behavior but disorganized).
DOES NOT meet the criteria for the above ○ Active listening.
subtypes. ○ Structure appropriate times for rest and sleep;
adjust work/rest activity patterns as needed.
● Undifferentiated Schizophrenia ● Enhance physiological stability/health maintenance.
○ Symptoms of more than one type of schizophrenia. ○ Provide quiet activities, soothing music before
➢ Affect is flat. bedtime, regular hours for going to bed, drinking
➢ Delusion and hallucination. warm milk.
➢ Disorganized speech.
20
● Encourage family/significant other to become involved Related Disorders

in activities to promote independent stratifying lives. 1. Schizophreniform Disorder- The client exhibits the
○ Refer to resources such as occupational symptoms of schizophrenia but for less than 6 months.
therapist/movement therapy/outdoor education Social or occupational functioning may or may not be
program and others. impaired.
● Protect from erratic and inappropriate behavior 2. Schizoaffective Disorder- The client exhibits the
(delusions/hallucinations). symptoms of psychosis and at the same time all the
○ Communicate in a calm, authoritative tone. features of a mood disorder either depression or
○ Address clients by their name. mania.
○ Observe patients for early signs of escalating 3. Delusional Disorder - The client has one or more
behavior. bizarre delusions, the focus of delusion is believable.
● Administer antipsychotic medication as indicated. ○ Central Feature: Presence of 1 or more false
● Accept client’s indifference (e.g., failure to smile or beliefs that persist for at least 1 month.
greet nurse) and avoidance behavior (e.g., hostility or
sarcasm).
SUBTYPES OF DELUSIONAL DISORDER
● Explain staff changes, especially vacations and
absences.
Erotomanic Patient believes that another person is in
○ Encourage the client's affect by verbalizing what love with him.
you observe e.g, “you seem to think that I don’t
want to stay.” Grandiose Patient believes that he has great talent
or has made an important discovery.
Psychosocial Interventions and Psychotherapy
● Counseling and Psychotherapy Jealous Patient believes that his spouse or lover is
unfaithful.
○ Provides clients with understanding of
schizophrenia.
Persecutory Patient believes that he is being plotted
○ Helps clients learn to manage the disease.
against, spied on, maligned or harassed.
● Social Skills Education Somatic Patient believes that he has a physical

○ Client’s ability to interact with others may be deformity, odor or parasite.
altered.
○ Assist with vocational and career education needs.
4. Brief Psychotic Disorder- Client experiences the
sudden onset of at least one psychotic symptom, such
Discharge Goals
as delusion, hallucination, or disorganized speech or
● Physiological well-being maintained with appropriate
behavior which last from 1 day to 1 month.
balance between rest and activity.
○ Identify delusions and increase capacity to cope
5. Shared Psychotic Disorder (Folie à Deux)
effectively with them by elimination of pathological
○ Two people share a similar delusion.
thinking.
○ The person with this diagnosis develops delusion
● Demonstrate increasing/highest level of emotional
in the context of a close relationship with someone
responsiveness possible.
who has psychotic delusions.
○ Establish intrapersonal relationships.
○ Display behavior congruent with verbalization of
Discharge Goals
feelings.
● Demonstrate increasing/highest level of emotional
● Interact socially without decompensation.
responsiveness possible.
○ Maintain reality orientation.
● Establish intrapersonal relationships.
● Family displays effective coping skills and appropriate
● Display behavior congruent with verbalization of
use of resources.
feelings.
○ Demonstrate understanding of and begin to use
● Maintain reality orientations.
appropriate, constructive, effective methods of
● Family displays effective coping skills and appropriate
coping.
use of resources.
● Demonstrate understanding of self and begin to use
appropriately.
21
Current Trends in Schizophrenia Research MOOD DISORDERS

● Brain imaging and mapping. Notable People with Mood Disorder
● Autoimmunity immune systems and dysregulation ● Van Gogh
model. ● Queen Victoria
● Ethical and legal considerations in high risk studies of ● George Frederick Handel
schizophrenia. ● Abraham Lincoln
● Pharmacogenetics and tailored drug treatment.
● The role of nurses and interdisciplinary team.
Categories
Critical Thinking Questions Major 2 or more weeks of sad mood, lack of
● Clients who fail to take medications regularly are often Depression interest in life activities, and other
admitted to the hospital repeatedly, and this can symptoms.
become quite expensive. How do you reconcile the
client’s rights (to refuse treatment or medications) with MDD, also referred to as clinical
the need to curtail avoidable health care costs? depression.
● What is the quality of life for the client with
Bipolar Formerly called ‘manic-depressive
schizophrenia who has a minimal response to Disorder illness.’
antipsychotic medications and therefore poor
treatment outcomes? Mood cycles of mania and/or
● If a client with schizophrenia who experiences frequent depression and normalcy and other
relapses has a young child, should the child remain symptoms.
with the parent? What factors influence this decision?
Who should be able to make such a decision? Related Disorders
● How does the nurse maintain a positive but honest ● Dysthymia- Sadness, low energy, but not severe
relationship with a client’s family if the client does not enough to be diagnosed as a major depression
respond well to antipsychotic medications? disorder.
● Clients who take depot injections of antipsychotic ● Cyclothymia- Mood swings not severe enough to be
medications are sometimes court ordered to comply diagnosed as bipolar disorder.
with this treatment when they are in the community. ● Substance- Induced mood disorder.
● Does this violate the client’s right to ● Mood disorder due to to a general medical condition
self-determination or autonomy? ● Seasonal Affective Disorder (SAD)
● When should clients have the ability to refuse such ● Postpartum or maternity blues
mediations? ● Postpartum depression
● Postpartum psychosis
MOOD DISORDERS AND SUICIDE Biological Theories

Current Issues Related to the Topic ● Genetic Theories
● Euthanasia and assisted suicide are hotly debated ● Neurochemical Theories
topic in our society. ● Neuroendocrine Influences
○ Should either be legal? ○ Hormonal fluctuations
○ Under what circumstances? ● Theories of Cause of Depression: Psychodynamic
○ How should these issues be decided? Theories
● Some people struggle with the idea of wether suicide ○ Aggression turned inward self anger
can ever be the decision of a rational person or ○ Response to separation of object loss.
whether being suicidal is always a sign of ○ Genetic of neuro-biochemical basis-impaired.
mentalillness. neurotransmission system, especially serotonin
● Suicide rates remain high for adolescents and the regulation.
elderly (over the age of 80). ○ Self-approach to anger turned inward.
● Is that a sign of despair and hopelessness? What is ○ Inability to achieve personal ideas.
society’s response to these two populations? ○ Powerless ego.
○ View manic episodes as a “defense” against
underlying depression, with the ID taking over the
22
ego and acting as an undisciplined hedonistic Treatment

being (child). ● Antidepressants
○ Reaction to a distressing life experience. ● SSRIs (Prozac, Zoloft, Paxil, Celexa) prescribed for
○ Rejecting or unloving parents. mild and moderate depression.
○ Depression is a result of specific cognitive ● TCAs (Elavil, Tofranil, Norpramin, Pamelor, Sinequan)
distortions in susceptible people. used for moderate and severe depression.
● Atypical antidepressants (Effexor, Wellbutrin, Serzone)
Cultural Considerations ● MAOIs (Marplan, Parnate, Nardil) are used
● Other behaviors considered age-appropriate can mask infrequently because interaction with tyramine causes
depression. hypertensive crises.
● Somatic complaints are a major manifestation among ● Electroconvulsive Therapy (ECT) is used when
cultures that avoid verbalizing emotions. medications are ineffective or side effects are
○ Asians who are anxious or depressed are more intolerable.
likely to have somatic complaints of headache, ○ 6-15 treatments scheduled three times a week.
backache, or other symptoms. ○ Preparation of clients for ECT is similar to
○ Latin culture complains of “nerves” or headaches. preparation for any outpatient minor surgical
○ Middle Eastern cultures complain of heart procedure.
problems. ○ The client will have some short-term memory
impairment.
Major Depressive Disorder ● Psychotherapy in conjunction with medication is
● Twice common in women and common in single or considered the most effective treatment; useful
divorced people. therapies include behavioral, cognitive, interpersonal
● Involves 2 or more weeks of sad mood, lack of interest therapy.
in life activities, and at least four other symptoms:
○ Changes in appetite or weight, sleep, or APPLICATION OF THE NURSING PROCESS
psychomotor activity. Assessment
○ Decreased energy. ● History: The client’s perception of the problem,
○ Feelings of worthlessness or guilt. behavioral changes, any previous episodes of
○ Difficulty thinking, concentrating, or making depression, treatment, response to the treatment,
decisions. family history of mood disorders, suicide, or attempted
○ Recurrent thoughts of death or suicidal ideation, suicide.
plans, or attempts. ● General Appearance and Motor Behavior: Slouched
● Untreated, can last 6 to 24 months; recurs in 50%-60% posture, latency of response, psychomotor retardation
of people. or agitation.
● Symptoms range from mild to severe. ● Mood and Affect: Hopelessness, helpless, down,
anxious, frustrated, anhedonia, apathetic; affect is sad,
depressed, or flat.
● Thought Processes and Content: Slowed thinking
processes, negative and pessimistic, ruminate,
thoughts of dying or committing suicide.
● Sensorium and Intellectual Processes: Oriented,
memory impairment,difficulty concentrating.
● Judgment and Insight: Impaired judgment, insight
may be intact or limited
● Self-Concept: Low self-esteem, guilty, believe that
others would be better off without them.
1. Bipolar Mixed- Cycles alternate between periods of
● Roles and Relationships: Difficulty fulfilling roles and
mania, normal mood, depression, normal mood,
responsibilities.
mania, and so forth.
● Physiologic Considerations: Weight loss, sleep
2. Bipolar Type 1- Manic episodes with at least one
disturbances, lose interest in sexual activities, neglect
depressive episode.
personal hygiene, constipation, dehydration.
3. Bipolar Type II- Recurrent depressive episodes with at
least one hypomanic episode.
23
● Depression Rating Scales: Zung SelfRating ● The mean age for a first manic episode is the early
Depression Scale, Beck Depression Inventory, the 20s.
Hamilton Rating Scale for Depression. ● Involves mood swing of depression (same symptoms
of major depressive disorder) and mania. Major
Diagnosis symptoms of mania include:
Nursing diagnosis may include the following: ○ Inflated self-esteem or grandiosity
● Risk for suicide ○ Deceased need for sleep
● Imbalanced nutrition: Less than body requirements ○ Pressured speech
● Anxiety ○ Flight of ideas
● Ineffective coping ○ Distractibility
● Hopelessness ○ Increased involvement in goal directed activity or
● Ineffective role performance psychomotor agitation.
● Self-care deficit ○ Excessive involvement in pleasure-seeking
● Chronic low self -esteem activities with a high potential for painful
● Disturbed sleep pattern consequences
● Impaired social interaction
Treatment and Prognosis
Planning/Outcomes ● Medication
The client will: ○ Lithium; regular monitoring of serum lithium levels
● Not injure himself or herself. is needed.
● Independently carry out activities of daily living ○ Anticonvulsant drugs are used for their
(showering, changing clothing, grooming). mood-stabilizing effects; (carbamazepine)
● Establish a balance of rest,sleep, and activity. Tegretol, (Valeric acid) Depakote, Lamictal,
● Establish a balance of adequate nutrition, hydration, Topamax, and Neurontin, as is Klonopin (a
and elimination. benzodiazepine)
● Evaluate self-attributes realistically.
● Socialize with staff, peers, and family/friends. ● Psychotherapy
● Return to occupation or school activities. ○ Psychotherapy combined with medication can
● Comply with antidepressant regimen. reduce the risk of suicide and injury.
● Verbalize symptoms of a recurrence. ○ Useful in mildly depressive or normal portions of
the bipolar cycle. It is not useful during an acute
Intervention manic stage.
● Providing for the client’s safety and safety of others.
Promoting a therapeutic relationship. APPLICATION OF THE NURSING PROCESS
● Promoting activities of daily living and physical care. Assessment
● Using therapeutic communication. ● General Appearance and Motor Behavior:
● Managing medications. Psychomotor agitation; flamboyant clothing or makeup;
● Providing client and family teaching. think, move and talk fast; pressured speech.
● Mood and Affect: Euphoria, exuberant activity,
Evaluation grandiosity, false sense of well being, angry, verbally
● Does the client feel safe? aggressive, sarcastic, irritable.
● Is the client free of uncontrollable urges to commit ● Thought Processes and Content: Flight of ideas,
suicide? circumstantiality, tangentiality, possible grandiose
● Is the client participating in therapy and medication delusions.
compliance? ● Sensorium and Intellectual Process: Oriented to
● Can the client identify signs of relapse? person and place but rarely to time, impaired ability to
● Will the client agree to seek treatment immediately concentrate, may experience hallucinations.
upon relapse? ● Judgment and Insight: Judgment is poor, insight is
limited.
BIPOLAR DISORDER ● Self-Concept: Exaggerated self-esteem.
● Occurs almost equally among men and women. ● Roles and Relationships: Rarely can fulfill role
● It is more common in highly educated people. responsibilities, invade intimate space and personal
business of others, can become hostile space and
24
personal business of others, can become hostile to SUICIDE

others, cannot postpone or delay gratification. ● Poor impulse control
● Physiologic and Self-Care Considerations: ● Poor judgment
Inattention to hygiene and grooming, hunger or fatigue. ● Immature coping skills
● Low self esteem, poor self integration, and identity
Diagnosis ● Depression
Nursing diagnosis may include the following: ● Emotional isolation
● Risk for other-directed violence ● Dysfunctional family interactions
● Risk for injury ● Use of drugs or alcohol
● Imbalanced nutrition: less than body requirements ● Social problems with peers/bullying
● Ineffective coping
● Noncompliance Theories on Suicide
● Ineffective role performance ● Psychoanalytic Theory
● Self-care deficit ○ Suicide is anger turned inwards
● Chronic low self-esteem ○ Life (eros) and death (thanatos) instinct.
● Disturbed sleep pattern ○ Stressful life circumstances can activate the death
wish inherent in each one of us.
Planning/Outcomes ● Sociological Theory
The client will: ○ Suicide and social conditions.
● Not injure himself or others. ○ Suicide rates and poverty level, unemployment,
● Establish a balance of rest, sleep and activity. political and economic instability.
● Establish adequate nutrition, hydration and elimination. ● Interpersonal Theory- Suicide is the outcome of a
● Participate in self-care activities. failure to work or resolve interpersonal conflicts.
● Evaluate personal qualities realistically. ● Biological Theory- Usually attributed to disturbances
● Engage in socially appropriate, reality-based in neurotransmitters.
interaction.
● Verbalize knowledge of his or her illness and APPLICATION OF THE NURSING PROCESS
treatment. Assessment
● Men commit suicide three times the rate of women.
Intervention ● Women are four times more likely than men to attempt
● Provide for the safety of clients and others. suicide.
● Meet physiological needs. ● Popular at Risk:
● Provide therapeutic communication. ○ Men, young women, adults older than 65, and
● Promote appropriate behaviors. separated and divorced people.
● Manage medications. ○ Clients with psychiatric disorders.
● Provide client and family teaching. ● Environmental Factors:
● Set limits on client’s behavior when needed. ○ Isolation
● Remind the client to respect distances between self ○ Recent loss
and others. ○ Lack of social support
● Protect the client’s dignity when inappropriate ○ Unemployment
behaviors occur. ○ Critical life events
● Channel client’s need for movement into socially ○ Family history of depression or suicide
acceptable motor activities. ● Behavioral Factors:
○ Impulsivity
Evaluation ○ Erratic or unexplained changes from usual
● Safety issues. behavior
● Comparison of mood and affect between start of ○ Unstable lifestyle
treatment and present. ● Warnings of suicidal intent
● Adherence to treatment regimen of medication and ● Risky Behaviors
psychotherapy. ● Lethality Assessment:
● Changes in client’s perception of quality of life. ○ Does the client have a specific plan?
● Achievement of specific goals of treatment including ○ Are the means available to carry out this plan?
new coping methods.
25
○ If the client carries out the plan, is it likely to be ● Education to address stressors contributing to
lethal? depressive illness.
○ Has the client made preparations for death? ○ ● Promotions of factors reducing suicide risk in
○ Where and when does the client intend to carry out adolescents (close parent-child relationships,
the plan? academic achievements, family life stability, and
○ Is the intended time a special date or anniversary connectedness with peers and others outside the
that has meaning for the client? family).
● Screening for early detection of risk factors, such as
Planning/Outcomes family strife, parental alcoholism or mental illness,
The client will: history of fighting, and access to weapons in the home.
● Not injure himself or others. ● Nurses and other staff members need to deal with their
● Engage in a therapeutic relationship. own feelings about suicide.
● Establish a no-suicide contract. ● Depressed or manic clients can be frustrating and
● Create a list of positive attributes. require a lot of energy to care for.
● Generate, test, and evaluate realistic plans to address ● Keeping a written journal may help deal with feelings;
underlying issues. talking to colleagues is often helpful.
Intervention ANXIETY AND STRESS RELATED ILLNESS

● Use an authoritative role. Anxiety in Everyday Life
● Provide a safe environment. ● What are the objects of your worries?
● Initiate a no-suicide contract. ● Are there personal worries stemming from your
● Create a support system list. societal role and duties?
Family’s Response ● Do you have personal fear associated with activities or
● Significant others may feel guilty, angry, ashamed, and objects?
sad.
Anxiety is a vague feeling of dread apprehension; it is a
Nurse’s Response response to external or internal stimuli.
● The nurse does not blame or act judgmentally when ● Can have behavioral, emotional, cognitive, and
asking about the details of a planned suicide. Rather, physical symptoms.
the nurse uses a non judgmental tone of voice and ● Effective subjective response to an imagined or real
monitors his or her body language and facial internal or external threat.
expression to make sure not to convey disgust or
blame. Anxiety as a Response to Stress
● Nurses must realize that no matter how competent and ● Stress is the wear and tear that life causes on the body
caring intervention are, a few clients will still commit (Selye, 1956).
suicide. A client’s suicide can be devastating to the ● It occurs when a person has difficulty dealing with life
staff members who treated the client. situations, problems, and goals.
● Oftentimes, nurses must care for terminally ill or ● (+) or (-) occurrence
chronically ill people with a poor quality of life.
● The nurse’s role is to provide supportive care for
Hans Selye identified three stages of reaction to stress:
clients and family.
● Depression is common among the elderly and is Stress stimulates the body to send messages
markedly increased when elders are medically ill. Alarm from the hypothalamus to the glands (such as
● Elders tend to have psychotic features, particularly Reaction adrenal gland, to send out adrenaline and
delusions, more frequently than younger people with Stage norepinephrine for fuel) ans organs (such as
the liver, to reconvert glycogen stores to
depression. glucose for food) to prepare for potential
● Suicide amoung people over the age of 65 is doubled defense needs.
compared to suicide rates of persons younger than 65
years old. The digestive reduces function to shunt blood to
● Elders are treated for depression with ECT more areas as needed for defense. The lungs take in
Resistance more air, and the heart beats faster and harder
frequently than younger ones. Stage so that it can circulate this highly oxygenated
● Elder persons have decreased tolerance of side and highly nourished blood to the muscles to
effects of antidepressant medications defend the body to fight, flight or freeze
26
behaviors. If the person adapts to the stress,

the body responses relax, and the gland, organ Incidence of Anxiety Disorders
and systemic response abate. ● Anxiety disorders are the most common psychiatric
disorders affecting 25% of adults.
Occurs when the person has responded ● More prevalent in women.
Exhaustion negatively to anxiety and stress: body is ● Prevalent in people younger than 45 years.
Stage depleted or emotional components are not
resolved, resulting in continual arousal of the ● More common in divorced and separated persons.
physiological responses and little reserve ● More common in persons of lower socioeconomic
capacity status.
● Onset and clinical courses are variable.
Categories Related Disorders

● Anxiety disorder due to a general medical condition.
Mild Sensation that something is different and warrants
● Substance-Induced Anxiety Disorder
Anxiety special attention; sensory stimulation increases;
focus attention to learn, solve problems, think, act, ● Separation Anxiety Disorder
feel, and protect self; motivated. ● Adjustment Disorder
Moderate Feeling that something is definitely wrong; Etiologies

Anxiety nervous or agitated; can still process information,
Biological Theories
solve problems, and learn new things with
assistance from others; difficulty concentrating but ➔ Anxiety may have an inherited component;
can be directed. neurotransmitters may be dysfunctional in persons
with anxiety disorders.
Severe Trouble thinking and reasoning; muscles tighten; Psychodynamic Theories
Anxiety vital signs increase; pacing; restless, irritable, and ➔ Overuse of defense mechanisms; results from
angry; uses other emotional-psychomotor means
to release tension. problems in interpersonal relationships; as “learned”
behavioral response.
Panic Fight, flight, or freeze responses; cognitive
Anxiety process focuses on the person’s defense. Neurochemical Theories
➔ (GABA) is the amino acid neurotransmitter believed to
When Working With Anxious Clients: be dysfunctional in anxiety disorders. GABA, an
● Be aware of the nurse’s own anxiety level. inhibitory neurotransmitter, functions as the body’s
● Assess the person’s anxiety level. natural anti-anxiety.
● Speaking in short, simple, and easy to understand ● Serotonin is believed to play a distinct role in
sentences. OCD, panic disorder, and generalized anxiety
● Lower the person’s anxiety level to moderate or mild disorder. An excess of norepinephrine is
before proceeding with anything else. suspected in panic disorder, generalized
● Talk to the client in a low, calm, and soothing voice. anxiety disorder, and posttraumatic stress
● Walk while talking if the patient cannot sit still. disorder.
● Ensure safety during panic-level anxiety.
● Remain with the client until the panic recedes. Interpersonal Theory
● Short term use of anxiolytics ➔ Viewed anxiety as being generated from problems in
interpersonal relationships.
ANXIETY DISORDERS
A group of conditions that share a key feature of excessive Behavioral Theory
anxiety with ensuing behavioral, emotional, and physiologic ➔ Anxiety as being learned through experiences and
responses. response.
● Agoraphobia with or without panic disorder
● Panic Disorder Cultural Considerations
● Specific Phobia Asian Cultures often express anxiety through somatic
● Social Phobia symptoms such as headaches, backaches, fatigue,
● Obsessive-Compulsive Disorder (OCD) dizziness, and stomach problems.
● Generalized Anxiety Disorder (GAD)
● Post traumatic Stress Disorder (PTSD)
27
Hispanics experience high anxiety as sadness, agitation, ● Treated with cognitive-behavioral techniques, deep
weight loss, weakness, and heart rate changes. The breathing and relaxation, and medications
symptoms are believed to occur because supernatural (benzodiazepines, SSRI antidepressants, tricyclic
spirits or bad air from dangerous places and cemeteries antidepressants, and antihypertensives).
invades the body. ● Symptoms persist for at least 1 month.
● Attacks have a sudden onset of intense anxiety.
Treatment ● Profound fear or sense of imminent danger.
Treatments usually involve a combination of medication ● Women are 2-3 times more likely to suffer from panic
(anxiolytics and antidepressants) and therapy. disorder than men.
Cognitive-Behavioral Therapy APPLICATION OF THE NURSING PROCESS

● Positive reframing - Turning negative messages into Assessment
positive ones. ● Reports of several panic attacks.
● Decatastrophizing - Making a more realistic appraisal ● May appear “normal” or may have signs of anxiety.
of the situation. ● Anxious, worried, tense, depressed, serious, or sad.
● Assertiveness training - Learn to negotiate ● Fears losing control or going insane.
interpersonal situations and foster self assurance ● Confused and disoriented.
● Judgment is poor during an attack.
Elder Considerations ● Self-blaming statements.
Late-life anxiety disorders are often associated with another ● Alterations in his or her social occupation, or family life.
condition, such as depression, dementia, physical illness, or ● Problems sleeping and eating.
medication toxicity or withdrawal. Phobias, particularly
agoraphobia, and generalized anxiety disorders (GAD) are
the most common late-life anxiety disorders. Diagnosis
Nursing diagnosis may include the following:
The treatment of choice for anxiety disorders in the elderly ● Risk for injury
is SSRI antidepressants. ● Anxiety Situational low self-esteem (panic attacks)
● Ineffective coping
MENTAL HEALTH PROMOTION ● Powerlessness
● Goal is effective management, not total elimination of ● Ineffective role performance
anxiety. ● Disturbed sleep pattern
● Keep a positive attitude and believe in yourself.
● Accept that there are events you cannot control. Planning/Outcomes
● Communicate assertively with others. The client will:
- Talk about your feelings with others. ● Be free of injury.
- Express your feelings through laughing, crying and ● Verbalize feelings.
so forth. ● Use effective coping techniques.
● Learn to relax. ● Manage his own anxiety response.
● Exercise regularly. ● Verbalize a sense of personal control.
● Eat well-balanced meals. ● Reestablish adequate nutritional intake.
● Limit intake of caffeine and alcohol. ● Sleep at least 6 hours per night.
● Get enough rest and sleep.
● Set realistic goals and expectations. Intervention
● Find an activity that is personally meaningful. ● Provide a safe environment and ensure client’s privacy
● Learn stress management techniques. during a panic attack.
● Remain with the client during a panic attack.
PANIC DISORDER ● Help the client to focus on deep breathing.
● Involves 15- to 30-minute episodes of intense, ● Talk to the client in a calm reassuring voice.
escalating anxiety with emotional fear and physiologic ● Teach the client to use relaxation techniques.
discomfort. ● Help the client to use cognitive restructuring
● Peaks in late adolescence and the mid-30s. techniques.
● Can lead to avoidance behavior or agoraphobia. ● Engage with the client to explore how to decrease
stressors and anxiety-provoking situations.
28
Evaluation
ENOCHLOphobia Crowds
● Does the client understand the prescribed medication
regimen, and is he or she committed to adhering to it? FRIGOphobia Cold or cold things
● Has the client’s episodes of anxiety decreased in
frequency or intensity? GAMOphobia Marriage
● Does the client understand various coping methods
GERASCOphobia Getting old
and when to use them?
● Does the client believe that his or her quality of life is GLOSSOphobia Speaking in public
satisfactory?
GYNEphobia Women
PHOBIA
HELIOphobia Sun
Phobia is a logical intense, persistent fear of a specific
object or social situation that causes extreme distress and HETEROphobia Opposite sex
interferes with normal life functioning.
HIPPOphobia Horses
Onset and Clinical Course
HYPSIphobia Height
● Specific phobias usually occur in childhood or
adolescence.In some cases, merely thinking about or IATROphobia Doctors
handling a plastic model of the dreaded object can
create fear. ICHTHYOphobia Fish
● Specific phobias that persist into adulthood are lifelong
80% of the time. IOphobia Poison
Types of Phobia
KAINOphobia Novelty
1. Agoraphobia - Fear of being outside.
2. Specific Phobia - An irrational fear of an object or KAKORRHAPHIOphobia Failure
situation.
3. Social Phobia - Anxiety provoked by certain social or LEVOphobia Objects to the left
performance situations.
LILAPSOphobia Hurricanes
SPECIFIC PHOBIA Fear of… MACROphobia Long waits
ABLUTOphobia Washing MAGEIROCOphobia Cooking
ACHLUOphobia Darkness MAIEUSIOphobia Childbirth
AILUROphobia Cats MEDOMALACUphobia Losing an erection
ARACHNOphobia Spiders MYCTOphobia Darkness
ASTRAPOphobia Lightning NEOPHOphobia Anything new
BATHMOphobia Stairs NEPHOphobia Clouds
BROMIDROSIphobia Body smells NOCTIphobia Night
CACOphobia Ugliness OCHLOphobia Crowds or mobs
CATAGELOphobia Being ridiculed OCHOphobia Vehicles
DEMOphobia Crowds OENOphobia Wines
DIDASKALEINOphobia Going to school PAGOphobia Ice or frost
DOMATOphobia Houses PANphobia Everything
EISOPTROphobia Mirrors PHALACROphobia Becoming bald
29
OBSESSIVE-COMPULSIVE DISORDER
POTAMOphobia Rivers
Obsessions are recurrent, persistent, intrusive, and
PYROphobia Fire unwanted thoughts, images, or impulses that cause marked
anxiety and interfere with interpersonal, social or
RANIDAphobia Frogs occupational functioning.
RHYPOphobia Defecation
Compulsions are ritualistic or repetitive behaviors or
RHYTIphobia Getting wrinkles mental acts that a person carries out continuously in an
attempt to neutralize anxiety.
RUPOphobia Dirt
Common Rituals
SCIOphobia Shadows
The person knows the rituals are unreasonable but feels
SCOLECIphobia Worms forced to continue them in an attempt to relieve anxiety
caused by obsessions.
SELACHOphobia Sharks ● Checking rituals
● Counting rituals
SIDERODROMOphobia Trains
● Washing and scrubbing until the skin is raw
SYNGENESOphobia Relatives ● Praying or chanting
● Touching, rubbing, or tapping
THANATOPhobia Death ● Hoarding items
● Ordering (arranging and rearranging items on a desk,
THALASSOphobia Sea shelf, or furniture, into a prefect order; vacuuming the
rug pile in one direction).
TRISKAIDEKAphobia Number 13
TRYPANOphobia Injections Treatment and Prognosis

● Treatment is the most successful with behavior therapy
VESTIphobia Clothing and medication.
- SSRI antidepressants, fluvoxamine, clomipramine,
XANTHOphobia Color yellow or the
word “Yellow” buspirone, clonazepam
XENOphobia Strangers ● Behavior Therapy Techniques:

- Exposure (confronting anxiety-provoking stimuli).
XYROphobia Razors
- Response prevention (delaying or avoiding ritual
ZELOphobia Jealousy performance
ZOOphobia Animals APPLICATION OF THE NURSING PROCESS

Assessment
● Yale-Brown Obsessive Compulsive Scale
Treatment and Prognosis
● Reports of obsession becoming too overwhelming,
● Psychopharmacology
compulsions interfere with daily life.
- Anxiolytics, SSRI antidepressants, beta blockers to
● Tense, anxious, worried, and fretful.
slow heart rate and lower blood pressure.
● Ongoing, overwhelming feelings of anxiety.
● Intact intellectual functioning with difficulty
● Behavioral Therapies
concentrating.
- Systematic desensitization - One behavioral
● Recognizes that the obsessions are irrational, but he
therapy often used to treat phobias is systematic
or she cannot stop them.
(serial) desensitization in which the therapist
● Powerlessness
progressively exposes the client to the threatening
● Relationships suffer.
object in a safe setting until the client’s anxiety
● Trouble sleeping or loss of appetite.
decreases.
- Flooding - Is an abrupt exposure to the feared
Diagnosis
object. It is a form of rapid desensitization in which
Nursing diagnosis may include the following:
a behavioral therapist confronts the client with the
● Anxiety
phobic object until it no longer produces anxiety.
30
● Ineffective coping ● Sleep disturbances, recurrent intrusive dreams of the

● Fatigue event, nightmares, difficulty in falling or staying asleep;
● Situational low self-esteem hypersomnia (intrusive thoughts, flashbacks, and/or
● Impaired skin integrity (if scrubbing or washing rituals). nightmares are trial symptomatic of PTSD).
Planning/Outcomes Nursing Priorities

The client will: 1. Provide safety for clients/others.
● Complete daily routine within a realistic time frame. a. Identify development of phobic reactions to
● Demonstrate effective use of relaxation techniques. ordinary articles (e.g., knives), situations
● Discuss feelings with others. (e.g.,strangers ringing doorbells, walking in
● Demonstrate effective use of behavior therapy. crowds of people).
● Spend less time performing rituals. b. Note signs of increasing anxiety (e.g., silence
stuttering, inability to sit still/pacing).
Intervention c. Develop a trusting relationship with the client.
● Using therapeutic communication.
● Teaching relaxation and behavioral techniques. 2. Assist the client to enhance self-esteem and regain a
● Completing a daily routine. sense of control over feelings/actions.
● Providing client and family education a. Identify whether the incident has reactivated
preexisting or coexisting situations
(physical/psychological).
Evaluation b. Evaluate social aspects of trauma/incident (e.g.,
● Do the symptoms no longer interfere with the client's disfigurement, chronic conditions, permanent
ability to carry out responsibilities? disabilities).
● When obsessions occur, does the client manage c. Encourage the client to keep a journal about
resulting anxiety without engaging in complicated or feelings, precipitating factors, associated
time consuming rituals? behaviors.
● Does the client report regain control over his or her d. Explore actions that can be used during periods
life? of stress (e.g., deep breathing, counting to 10,
● Does the client report the ability to tolerate and reviewing the situation, reframing).
manage anxiety with minimal disruption? e. Stay with the client, maintaining a calm,
confident manner. Speak in brief statements,
GENERALIZED ANXIETY DISORDER (GAD) using simple words.
● Excessive worry and anxiety that is unwarranted more f. Provide a nonthreatening, consistent
days than not. environment or atmosphere.
● Symptoms include uneasiness, irritability, muscle
tension, fatigue, difficulty thinking, and sleep ACUTE STRESS DISORDER (DISSOCIATIVE
alterations. DISORDER)
● Seen most often by family physicians. ● A dissociative response develops following the
● Treated with SSRI antidepressants and buspirone. experience of a traumatic situation.
● The person has a sense that the event was unreal,
POST TRAUMATIC STRESS DISORDER (PTSD) thinks he or she is unreal, and forgets some aspects of
● An anxiety disorder resulting from exposure to a the event through amnesia, emotional detachment,
traumatic event in which the individual has and muddled obliviousness to the environment.
experienced, witnessed, or been confronted with an ● Blocks off part of his or her life from consciousness
event or events that involve actual or threatened during periods of intolerable stress. Stressful emotion
death/serious injury or a threat to the physical integrity becomes a separate entity, as the individual “splits”
of the self or others. from it and mentally drifts into a fantasy state.
● New behaviors develop related to the trauma such as
sleep difficulty, hypervigilance, thinking difficulty,
DISSOCIATIVE DISORDERS
severe startle response, and agitation.
Disorders in which consciousness, behavior, and identity are
APPLICATION OF THE NURSING PROCESS split or altered, typically involve some degree of memory loss.
Assessment
31
Loss of memory for threatening or

Dissociative anxiety-producing events with no
Amnesia biological cause, cannot be explained
by ordinary forgetfulness.
Disorder in which a person forgets

Dissociative Fugue identity and wanders far from home,
may take on a new identity, may later
regain memory of original identity, but
have no memory of fugue experiences.
Dissociative
Identity Disorder Disorder in which two or more identities
(Formerly Multiple exist within the same person.
Personality
Disorder or MPD)
Nursing Priorities
1. Provide a safe environment; protect clients/others from
injury.
a. Provide a calm environment; minimize
external stimuli. Identify individual
causes/precipitators of stress.
2. Assist clients to recognize anxiety.
a. Maintain a neutral approach when
confronted by an alternate personality or
dissociative state.
3. Promote insight into the relationship between anxiety
and development of dissociative/other personalities.
a. Discuss relationship between severe
anxiety and depersonalization behaviors.
b. Explore past experiences and painful
situations (e.g., trauma, abuse) that may be
repressed.
4. Support client/family in developing effective coping
skills and participating in therapeutic activities.
SELF-AWARENESS ISSUES
● Stress and anxiety are common experiences for all
people.
● People with anxiety disorder often “look well enough”
to control their behavior.
● Avoid trying to “fix” the client’s problems.
The Advanced-Practice Psychiatric Nurse

● Incorporates the role of the generalist nurse.
● Applies advanced clinical skills.
● Determines differential diagnosis.
● Major interventions include:
○ Psychotherapy
○ Prescribing medications
○ Case management
○ Evaluation of outcomes measures
32

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PSYCHIATRIC NURSING (PRELIM) NCM 117 LECTURE

CONCEPTS OF MENTAL HEALTH AND MENTAL Mental Health-Illness Continuum

Psychiatric nursing is a specialized area of nursing

Characteristics of a Mentally Healthy Person

Basic Needs in Development of Personality

Factors Influencing Personality

Factors Involved inPersonality Development

LEVELS OF CONSCIOUSNESS BY SIGMUND FREUD

A. Part of the mind which functions when the person is

Example: A nurse working in an emergency room is

Example: A teenage boy dresses and behaves like his

THEORY OF PSYCHOSEXUAL DEVELOPMENT BY ERIKSON’S STAGES OF PSYCHOSOCIAL

● Greatest need: Security. STAGE VIRTUE TASK

● Primary source of pleasure is elimination Initiative vs. Beginning development

● These models use a cognitive approach based on Interpersonal Process (Peplau)

● Crying LAZARUS INTERACTIONAL MODEL

HUMANISTIC MODEL (MASLOW) Primary parts:

Cerebellum - Overlies the pons and medulla.

● Necessary in just the right proportions to relay

Limbic System SEROTONIN Inhibitory Food intake, sleep &

HISTAMINE Neuro-modulator Alertness, gastric secretions,

NEUROPEPTIDES Neuro-modulator Enhance, prolong, inhibit, or

BRAIN IMAGING TECHNIQUE

Positron Emission Tomography (PET) & Single Photon PHASES OF CRISIS

FDDNP with PET

Key Element of Management PHASES OF CRISIS INTERVENTION

Planning Therapeutic Intervention Factors Influencing Assessment

Resolution and Anticipatory Planning

Components of a Psychosocial Assessment

● Facial expressions COMMON SIGNS AND SYMPTOMS OF MENTAL

● Grandiosity: False belief that one is superior and FLIGHT OF IDEAS

WORD SALAD Catatonic Stupor

Rigidity ● The client finds it difficult to remember things that

Tics and Spasm Assessment of Schizophrenia

● Disorganized Behavior brain physiology. Recent researchers have been

○ Behavioral Pattern: Withdrawn Defense ➢ Disorganized catatonic behavior.

● Encourage family/significant other to become involved Related Disorders

● Social Skills Education Somatic Patient believes that he has a physical

Current Trends in Schizophrenia Research MOOD DISORDERS

MOOD DISORDERS AND SUICIDE Biological Theories

ego and acting as an undisciplined hedonistic Treatment

personal business of others, can become hostile to SUICIDE

Intervention ANXIETY AND STRESS RELATED ILLNESS

behaviors. If the person adapts to the stress,

Categories Related Disorders

Moderate Feeling that something is definitely wrong; Etiologies

Cognitive-Behavioral Therapy APPLICATION OF THE NURSING PROCESS

SPECIFIC PHOBIA Fear of… MACROphobia Long waits

ABLUTOphobia Washing MAGEIROCOphobia Cooking

ACHLUOphobia Darkness MAIEUSIOphobia Childbirth

AILUROphobia Cats MEDOMALACUphobia Losing an erection

ARACHNOphobia Spiders MYCTOphobia Darkness

ASTRAPOphobia Lightning NEOPHOphobia Anything new

BATHMOphobia Stairs NEPHOphobia Clouds

BROMIDROSIphobia Body smells NOCTIphobia Night

CACOphobia Ugliness OCHLOphobia Crowds or mobs

CATAGELOphobia Being ridiculed OCHOphobia Vehicles

DEMOphobia Crowds OENOphobia Wines