PSYCHIATRIC NURSING
Counseling
Benchmark Period in Psychiatric History
Historical Perspective of the Treatment of Mental Illness
Benchmark V: Decade of the Brain
▪ The 1990s – declared the Decade of the Brain
▪ During this decade, a steep increase in brain research
occurred that coincided with an increased interest in biologic
explanations for mental disorders
▪ The Decade crystallized the fact that some behaviors are
caused by biologic irregularities and not willful contraries, or
worse
▪ The Decade brought back nursing into the mainstream of
psychiatric care
Psychiatric Nursing Practice
Linda Richards
▪ Graduated in 1873 from New England Hospital for Women
and Children in Boston
▪ Improved nursing care in psychiatric hospitals and organized
educational programs in state mental hospitals in Illinois
▪ First psychiatric nurse
▪ Believed the mentally sick should be at least as well cared for
as the physically sick
Harriet Bailey
- published the first psychiatric nursing textbook, Nursing Mental
Diseases in 1920
Hildegard Peplau
– described the therapeutic nurse-client relationship with its phases and
tasks and wrote extensively about anxiety
The interpersonal dimension forms the foundation of nursing practice
today
June Mellow
– focuses on clients’ psychosocial needs and strengths
- argued that the nurse as the therapist is particularly suited to working
with those with severe mental illness in the context of daily activities,
focusing on the here and now to meet each person’s psychosocial needs
Psychiatric Nursing in the Philippines
• The National Center for Mental Health (NCMH) was
established thru Public Works Act 3258.
• It was first known as INSULAR PSYCHOPATHIC
HOSPITAL, situated on a hilly piece of land in Barrio
Mauway, Mandaluyong, Rizal and was formally opened on
December 17, 1928.
• This hospital was later known as the NATIONAL MENTAL
HOSPITAL, given on November 12, 1986, it was given its
present name thru Memorandum Circular No. 48 of the Office
of the President.
• On January 30, 1987, NCMH was categorized as a Special
Research Training Center and hospital under Department of
Health.
• Today, NCMH has an authorized bed capacity of 4,200 and a
daily average of 3,400 in-patients.  It sprawls on a 46.7
hectare compound with a total of 35 Pavilions/Cottages and
52 Wards.
• The NCMH is a special training and research hospital
mandated to render a comprehensive (preventive, promotive,
curative and rehabilitative) range of quality mental health
services nationwide.
Standards of Mental Health Clinical Nursing Practice
Standards of Care
Standard I. Assessment
⬥ The psychiatric-mental health nurse collects health data
Standard II. Diagnosis
⬥ The psychiatric-mental health nurse analyzes the data in
determining diagnoses
Standard III. Outcome Identification
⬥ The psychiatric-mental health nurse identifies expected
outcomes individualized to the client
Standard IV. Planning
⬥ The psychiatric-mental health nurse develops a plan of care
that prescribes interventions to attain expected outcomes
Standard V. Implementation
⬥ The psychiatric-mental health nurse implements the
interventions identified in the plan of care
Standard Va.
⬥ The psychiatric-mental health nurse uses counseling
interventions to assist clients in improving or regaining their
previous coping abilities, fostering mental health, and
preventing mental illness and disability
Standard Vb. Milieu Therapy
⬥ The psychiatric-mental health nurse provides, structures, and
maintains a therapeutic environment in collaboration with the
client and other health care providers
Standard Vc. Self-Care Activities
⬥ The psychiatric-mental health nurse structures interventions
around the client’s activities of daily living to foster self-care
and mental and physical well-being
Standard Vd. Psychobiologic Interventions
⬥ The psychiatric-mental health nurse uses knowledge of
psychobiologic interventions and applies clinical skills to
restore the client‘s health and prevent further disability
Standard Ve. Health Teaching
⬥ The psychiatric-mental health nurse, through health teachings
assists clients in achieving satisfying, productive, and healthy
patterns of living
Standard Vf. Case Management
⬥ The psychiatric-mental health nurse provides case
management to coordinate comprehensive health services and
ensure continuity of care
Standard Vg. Health Promotion and Maintenance
⬥ The psychiatric-mental health nurse employs strategies and
interventions to promote and maintain mental health and
prevent mental illness
Standard VI. Evaluation
⬥ The psychiatric-mental health nurse evaluates the client’s
progress in attaining expected outcomes
MENTAL HEALTH
• State in the relationship of the individual and his environment
in which the personality structure is relatively stable, and
environmental stresses are within its absorptive
capacity.(WHO)
• A positive state in which one is responsible, displays
self-awareness, is self-directive, is worry-free and can cope
with usual daily tension
• A state of complete physical, mental and social well-being
and not merely the absence of disease
• Relative and dynamic concept. Not the same to all people
• Changes at different point in time. It is not static
FACTORS THAT AFFECT MENTAL HEALTH
 • Inherited characteristics – genetic make-up ⮚ Cope and tolerate anxiety CONCEPT of PERSONALITY – all behavior have meaning and is not
• Nurturing during childhood ⮚ Resolve conflicts, stress and anxiety determined by chance
• Life circumstances ⮚ Believes that crises is temporary
SIGMUND FREUD (1856 – 1939)
FACTORS INFLUENCING A PERSON’S MENTAL HEALTH CHARACTERISTICS OF A PERSON WITH GOOD MENTAL • Believed that vast majority of mental disorder were due to
• Individual factors – vitality, finding meaning to life, HEALTH unresolved issues that originate in childhood
biological make-up, emotional resilience, spirituality, sense of • Have positive self-concept & relate well to people & their
harmony in one’s life environment LEVELS OF AWARENESS
• Interpersonal factors – Intimacy, helping others, effective • Form close relationship with others Conscious – aware at any time
communication, maintaining a balance of separateness and • Make decision pertaining to reality rather than fantasy Pre-conscious – can be retrieved rather easily through conscious part
connection • Be optimistic & appreciate & enjoy life Unconscious – repressed memories, passion, unacceptable urges
• Social, Cultural factors – access to adequate resources, • be independent or autonomous in thought and action
sense of community, intolerance of violence • Be creative, using varying approaches as they perform task or
solve problem
COMPONENTS OF MENTAL HEALTH • Consistent as they appreciate and respect the rights of others PERSONLITY STUCTURE
• Autonomy and Independence • Displays willingness to listen and learn from others ID – source of all drives, instincts, reflexes, needs, genetic inheritance
⮚ Individual follows guiding values and rules to live and capability to respond to wishes that motive us
by SELF - AWARENESS • Present at birth
⮚ Engage in independent action and thinking • Process by which the individual gains recognition of his or • Unlearned selfish source of libidal energy
⮚ Consider the opinions and wishes of others her own feelings, beliefs and attitudes • Operates on pleasure principle through the use of fantasy and
⮚ Can work interdependently or cooperatively with • The ability to recognize the nature of one’s own behavior, images
others without losing his autonomy attitude and emotion • Compulsive with no sense of right or wrong
• Key to self-understanding • Demands immediate satisfaction
• Maximizing one’s potential • Help understand and accept the difference of others • SIGNIFICANCE – if id is not controlled effectively the
⮚ Keep aiming individual function in antisocial; lawless manner or ways
⮚ Keep going SELF – CONCEPT because his primitive drives or impulses are freely express
⮚ Use talents – part of self that lies within conscious awareness depends on how a
⮚ Continually strive to grow person thinks he or she is viewed by others EGO – begins during the first 8 months of life and is fairly develop when
⮚ Self-actualization the child reaches 2 years
• Self – esteem Good self-concept leads to self-acceptance • The self or the I
⮚ Accept strength and limitations • Problem solver and reality tester
⮚ Awareness of abilities and limitations SELF-ACCEPTANCE – regards of oneself with realistic concept of • Able to differentiate subjective experience, memory images
strength and weakness, accept others easily and object reality
• Tolerating life’s uncertainties • Attempts to negotiate a solution with the outside world
⮚ Positive outlook in life Behaviors of a self-accepting person: • Controls and guides the action of individual
⮚ Face challenges life has to offer • Perserving • Part of the personality that experiences anxiety and uses
⮚ Optimism • Trusting and accepting others defense mechanism for protection
⮚ Have the courage to rise after falling • Seeing reality • Influenced by heredity, environmental factors and maturation
• Minimizing weakness • SIGNIFICANCE – if the individual does not develop a strong
• Mastering the environment • Increase strengths ego to arbitrate effectively between id and superego the
⮚ Learn to adopt or cope and relate • Learning from mistakes individual will surely develop intrapersonal and interpersonal
⮚ Can deal with the environment • Reaching out to others conflict
⮚ Can influence the environment • Continuing growth towards self-actualization
⮚ Being competent and creative SUPEREGO – moral component of personality
PSYCHODYNAMICS OF PERSONLITY • Consists of “conscience” (“should-nots”) and ego ideal
• Reality Orientation PERSONALITY – is the sum total of or whole being (“should”)
⮚ Distinguished real world from a dream – Aggregate of the physical and mental qualities of • Operates both in the conscious and unconscious but operates
⮚ Distinguished facts from fantasy individual as it interacts in characteristic fashion mostly on the unconscious level
⮚ Behave appropriately – Sum total of the person’s distinctive character, • Develops around 3-4 years and fairly develop at age 10
⮚ Act accordingly behavior, attitude • Formed and influence from the internalization of what parents
– The way one carries himself teach their children regarding right or wrong through rewards
• Stress management – Express through behavior and punishments
⮚ Tolerate life stresses – Complex, dynamic and unique • SIGNIFICANCE – if superego is so strong the life of the
⮚ Experience failure without devastation individual is dominated by its restriction on behavior, he or
 she is likely to be unhappy, inhibited and anxiety-guilt ridden.
Individuals become inferior if he/she cannot live up to
parental standards
FREUD’S PSYCHOSEXUAL STAGES OF DEVELOPMENT
ERIK ERICKSON’S DEVELOPMENTAL THEORY
• Each stage of development is an emotional crisis involving
positive and negative experiences
• Growth/mastery of critical task results from having more
positive experience than negative experience
• Allows for corrective emotional experience beyond 5 yrs of
life
JEAN PIAGET’S COGNITIVE THEORY
• Views intellectual development as result of constant
interaction between environmental influences and genetically
determined attributes
4 STAGES OF COGNITIVE DEVELOPMENT
1. SENSORIMOTOR STAGE (0 – 2 yr)
– Learns by exploring objects and events and by
imitating
– Infants develop SCHEMATA (assimilation and
accommodations incoming information)
2. PREOPERATION STAGE (2 – 7 yr)
– Preconceptual phase (2-4 yr)
• Learns by thinking images
• Develop expressive language and
symbolic play
– Intuitive phase (4-7)
• Egocentrism (seeing things from own
point of view)
3. CONCRETE OPERATIONAL STAGE (8 – 12 yr)
– Able to think more logically as concept of moral
judgment, numbers, spatial relationship
4. FORMAL OPERATION STAGE (12 – adulthood)
– Develops adult logic
– Able to reason, form conclusion, plan for the
future, think abstractly and builds ideas
HARRY STACK SULLIVAN’S INTERPERSONAL THEORY
PERSONALITY – behavior that can be observed within interpersonal
relationship
Personality development
Infancy – crying is used to establish contact with others
Childhood – language is used to assist with learning to delay the
gratification of needs
Juvenile period – competition, compromise and cooperation are tools
for developing relationship with others
Preadolescence – collaboration and the capacity for love assist in the
development of relationship with same gender
Early adolescence – with sexual desire, facilitate learning to establish
relationship with members of the opposite sex
Later adolescence – interdependence develop, learns to form lasting
sexual relationship
ANXIETY
– any painful feeling or emotion arising from social insecurity or blocks
to getting biological needs satisfied
SECURITY OPERATIONS
– a person uses to defend oneself against anxiety and ensure self-esteem
Somnolent detachment – use of sleep to avoid anxiety
Apathy – emotional detachment or numbing
Selective inattention – tuning out details associated with
anxiety-producing situation
Dissociation – prevents situation from integrating into conscious
awareness
Converting anxiety to anger – powerlessness is exchanged for a
temporary feeling of power associated with anger directed outward
3 TYPES OF TENSION
Tension of needs – stemming from physiochemical requirement of life
Tension of anxiety – from interpersonal situation
Tension of need for help
SELF-SYSTEM – develops relatively enduring patterns for avoiding or
minimizing anxiety during interpersonal encounters and the meeting of
biologic needs
– “good me” – needs are satisfied
– “bad me” – needs are unmet and anxiety persists
– “not me” – anxiety is severe and information is not
completely integrated into the personality on a
conscious level
Behavioral Theories
Key Concepts
• A behavioral framework is used to described a persons
functioning in terms of identified behaviors
– people learn to be who they are because of
environmental shaping
– behavior can be observed, described or recorded
– behavior is subject to reward or punishment
– changing one’s environment can modify behavior
• maladaptive behaviors are learned through classical and
operant conditioning; they may continue because they are
rewarding to the individual
• maladaptive behaviors can be change without developing
insight into the underlying concepts by altering the
environment
• behavioral models posit that personality consist of learned
behaviors and personality becomes synonymous with
behavior – if behavior changes, so does the personality
Classical conditioning (Pavlov’s theory)
• classical conditioning was developed by Ivan Pavlov
• he established that learning or conditioning can occur when a
stimulus is paired with an unconditioned response
– a conditioned response is pairing of a stimulus
with a response
– acquisition refers to the gaining of a learned
response (once a response is learned, it continues)
– Extinction is the loss of learned response
Operant conditioning (Skinner’s theory)
• developed by B. F. Skinner, operant conditioning involves the
use of reinforce consequences to change the behavior
• positive reinforcement is a reward given to help continue the
behavior
• negative reinforcement removes undesirable consequences to
help continue the behavior
• positive punishment involves the use of aversive
consequences to decrease a particular behavior
• negative punishment involves withdrawing the reward to
decrease a particular behavior
Behavioral treatments
• behavioral modification involves the use of various learned
techniques to change maladaptive behavior, it is commonly
used with clients who have anxiety disorders, substance abuse
problems or other specific behavioral problems
• modeling refers to new behaviors that are learned by
imitating the behavior of another person
• operant conditioning involves the use of tokens for desirable
behavior
• systemic desensitization involves gradually confronting a
stimulus that evokes intense anxiety, it is useful in treating
phobias
– the therapist initially teaches the client how to
relax and begins a stimulus that causes mild
anxiety
– the client learns to invoke the relaxation response
when confronted with a stimulus
– the process continues until an intensely anxiety
provoking stimulus no longer causes the client to
feel anxious
• aversive therapy operates on the principle that unpleasant
consequences result from undesirable behavior, it may be
used in treatment of paraphilias
• biofeedback involves training techniques used to control
physiologic responses such as stress response and its
physiologic manifestations
• relaxation techniques are training techniques used to
counteract anxiety symptoms
• assertiveness training incorporates techniques to overcome
passivity or aggression in interpersonal situation
Application to nursing
• In the behavioral framework, the nurse assesses both adaptive
and maladaptive behaviors.
• The nurse and the client collaborate to identify behaviors that
require change.
• As a member of the treatment team, the nurse uses various
behavioral modification techniques to help the client.
Cognitive Framework
Key concepts
• the cognitive framework focuses on distorted or negative
thought patterns that lead to maladaptive or symptomatic
feelings and behaviors
– distorted thinking leads to and perpetuates
maladaptive behaviors
– certain thought patterns can be identified as
misperceptions
• patterns of thinking leads to and perpetuates maladaptive
behaviors
• the amount of perceived control over a situation affects how
an individual responds to stressors and problems
Treatments
• Cognitive therapy, a form of therapy developed by Aaron
Beck, encompasses various treatment methods in which the
therapist and client work closely to identify maladaptive
thought patterns and develop alternate ways of thinking and
behaving.
– This is often used in depression that stems from
the individual’s negative self concept, or
exaggerated prolonged guilt, that result in
automatic thoughts of self deprecation.
– The goal of the therapy is to diminish depressive
symptoms by helping the client challenge and
invalidate distorted thoughts through series of
mental exercises and replace them with
appropriate, realistic thoughts.
• In Rational-Emotive therapy developed by Albert Ellis,
helps the client examine own irrational thoughts and behavior
through verbal discussion followed by activities that allows
the individuals to challenge the faulty beliefs by directly
confronting the feared situation. This is useful in mild to
moderate anxiety states
• In Gestalt therapy, based on the collective efforts of Fritz
Perls and Paul Goodman, the therapist promotes the client’s
self awareness and increased self responsibility for meeting
needs.
• In Beck’s Cognitive therapy, developed by Aaron Beck, the
therapist teaches the client to identify and correct
dysfunctional thoughts about the self, world and the future
Cognitive techniques may be used:
– Cognitive restructuring – change of maladaptive
beliefs through positive self statements and
refusing irrational beliefs
– Thought stopping – constantly say “STOP” to
maladaptive thoughts
 • Human motivation as a hierarchy of dynamic process or b. Biochemical – electrolyte imbalances, error in metabolism
needs that are critical for the development of all humans results in transposition of Sodium and Potassium within a
• Focused on human needs fulfilment, which is categorized into neuron, low levels of NE, dopamine and serotonin
6 incremental stages.
Dynamics of Behaviour
1. Behavior refers to the way in which an organism responds to
a stimulus
– All behaviors are meaningful and purposeful

Varieties of behavior
A. Reflex action – automatic response to a stimulus (blinking reflex,
gag reflex)
B. Goal oriented behavior – presence of two factors:
  ● Presence of need within the individual
Humanistic Framework ● Presence of goal outside the individual which is capable of
• Key Concepts producing a change in his internal condition and thus satisfying the
– Humanistic framework focuses on the “here and need (e.g.. Hunger, anxiety)
now” – current behaviors, issues and problems –
as well as spiritual values and meanings. – Need – an organismic condition which exist within
– human nature is viewed as positive and growth an individual and which demands certain activity.
Biomedical Framework It is a requirement for survival.
oriented, and existence involves search for
Key Concepts
meaning and authenticity
• Physiologic, social and environmental factors can predispose Sources of Need
– Abraham Maslow’s theory of human motivation
to mental illness. ● Those which arise as a direct result of metabolic process
theory describes human needs that are organized
• Mental illness can be classified as in the multi axial DSM (hunger and thirst)
according to levels in which individuals move on
IV-TR ● Those that results from a change in the person’s relationship
to higher needs as lower, more basic needs are met
– failure to develop one’s potential leads to poor with his external environment (drop in room temperature)
Treatments ● Symbolic behavior – talking, reading and thinking
coping
• Diagnostic work ups include detailed history and lab test as
– lack of self awareness and unmet needs interfere
well as careful observation of current behavior CONFLICT
with feelings of security as well as with
• Pharmacotherapy is a common treatment including g nurse • The result o f the presence of two opposing or incompatible
relationships
patient interaction and milieu management. drives wherein the person is required to make a choice
– fundamental human anxiety is fear of death which
leads to existential anxiety between the possible responses
Eclectic Theory
Eclectic DYNAMICS OF CONFLICT
Treatments
• varied; made up of parts from various sources
• Client centered therapy, developed by Carl Rogers is based
• choosing what is best or preferred from a variety of sources or Conflict → ↑ anxiety → feeling of hopelessness, helplessness
on the belief that mental illness results from an individuals
styles and isolation → ↑ perceived conflict increases → ↑ anxiety
failure to develop fully as human being.
– Psychotherapy fosters the process of learning to be
Schizophrenia
fully one’s own self
Possible causes:
– The therapist is genuine and without façade when
1. Genetic STRESS and ANXIETY
relating to the client
2. Organic
– The client’s behavior changes toward positive
3. Biomedical theories STRESS – a stimulus or situation that produces distress and create
functioning when the therapist conveys
4. Psychological theories – increased incidence among the lower physical and psychological demands on a person that requires coping and
acceptance, respect and genuine empathy for the
socio-economic groups adapting
client
5. Unknown
• Existential therapy – a form of talk therapy that focuses on
life issues of freedom, helplessness, loss, isolation, aloneness, CHARACTERISTICS OF STRESS
Mood Disorders • It is recurring
anxiety and death; through psychotherapy, the client discovers
Predisposing factors: • It is normal
his own meaning of existence.
1. Medical – Biological Theories • It cannot be avoided
a. Genetic – higher incidence among individuals with relatives • It is brought about by stressors
MASLOW’S HIERARCHY OF NEEDS
with the disorder
STRESSOR – any condition, agent, situation, feeling, thought or
behavior which demands an increase in any activity within the ANS &
CNS
ANXIETY – a response to internal conflict
- feeling of uncertainty; uneasiness, apprehension or tension
that a person experiences in response to an unknown object or
situation
Anxiety is describe as:
• Subjective experience
• Emotional pain
• Apprehension, fearfulness or a sense of powerlessness
• Warning signs of perceived danger or threat
• Emotional response that triggers behavior
• Alerting and individual to prepare for self-defense
• Occurring in degrees
• Contagious
• Part of a process, not an isolated phenomenon
LEVELS OF ANXIETY • Evaluate effective past useful coping mechanism
• Assist in developing alternative solution to a problem
• Provide outlets from working off excess energy
• Use non-verbal language to demonstrate interests
INTERVENTIONS FOR SEVERE TO PANIC LEVELS OF
ANXIETY
• Maintain a calm manner
• Always remain with the client
• Minimize environmental stimuli
• Use clear and simple statements and repetition
• Use a low pitched voice; speak slowly
• Reinforce reality
• Listen for themes in communication
• Attend physical and safety needs when necessary
• Set physical limit. Speak in a firm, authoritative voice.
• Provide opportunities for exercises
• Physical needs must be met to prevent exhaustion
• Assess need for medication or seclusion

CATEGORIES OF STRESS DEFENSE MECHANISM

• Normal anxiety • Protects people from painful awareness of feelings and
– healthy life force memories that can provoke anxiety
– Motivates people to make & survive change
– Proportionate to actual events 5 IMPORTANT PROPERTIES OF DEFENSE MECHANISM
• Acute anxiety 1. Defenses are major means of managing conflict and affect
– Precipitated by an imminent loss or change that 2. Defenses are relatively unconsciousness
threatens an individual’s sense of security 3. Defenses are discrete from one another
• Chronic anxiety 4. Although defenses are often the hallmark of major psychiatric
– the person has lived with the stress for a long time syndrome, they are reversible
5. Defenses are adaptive as well as pathological
PRECIPITATING FACTORS OF ANXIETY
• Threats to biological integrity – refers to the distortion in MOST HEALTH DEFENSES
homeostasis ----temperature control Altruism – emotional conflicts and stressors are dealt with by meeting
• Threat to self-esteem – threat towards maintaining the needs of others
established views of self, values and patterns of behavior he
uses to resists changes in self review Sublimation – unconscious process of substituting constructive and
– Sense of isolation (alienation) socially acceptable activity for strong impulses that are not acceptable in
– Sense of insecurity (threat to identity) the original form.
– Sense of helplessness
Humor – deals with emotional conflict or stress by emphasizing the
amusing or ironic aspects of the conflict or stressor.

Suppression – conscious denial of a disturbing situation or feeling

BEHAVIOR RESPONSE TO ANXIETY INTERMEDIATE DEFENSES

• Anger INTERVENTIONS FOR MILD TO MODERATE LEVELS OF Repression – exclusion of unpleasant or unwanted experiences,
• Crying ANXIETY emotions, or ideas from conscious awareness
• Withdrawal • Help client to focus and sole problems with the use of Displacement – transfer of emotion associated with a particular person,
• Forgetfulness communication techniques object, or situation to another person, object, or situation that is
• Quarrelling • Help client identify anxiety non-threatening
• Complaining • Provide a calm presence
• Defensive behavior • Recognize the anxious person’s distress Reaction formation – unacceptable feelings or behaviors are kept out of
• Be willing to listen awareness by developing the opposite behavior or emotion

Somatization – transforming anxiety on an unconscious level into a
physical symptoms that has no organic cause
Undoing – consciously doing something to counteract or make up for a
transgression or wrongdoing
Rationalization – justifying illogical or unreasonable ideas, actions, or
feelings by developing acceptable explanation that satisfy the teller as
well as the listener
Intellectualization – consciously or unconsciously using only logical
explanation without one’s feelings or an affective component
Compensation – consciously covering up for a weakness by
overemphasizing or making up a desirable trait
IMMATURE DEFENSES
Passive aggression – deals with emotional conflict or stressors by
indirectly and unassertively expressing aggression towards another
Acting-out behavior – deals with emotional conflict or stressors by
actions rather than reflections or feelings
Dissociation – unconscious separation of painful feelings and emotion
from an unacceptable idea, situation or object
Identification – conscious or unconscious attempt to model oneself after
a respected person
Introjection – unconsciously incorporating values & attitudes of others
as if they were your own
Devaluation – emotional conflict or stressors are dealt with by
attributing negative qualities to self or others
Idealization – attributing exaggerated positive qualities others
Splitting – the inability to integrate the positive and negative qualities of
oneself or others into a cohesive image.
Projection – person unconsciously rejects emotionally unacceptable
personal features and attributes to other people, objects or situation.
Denial – escaping unpleasant realities by ignoring their existence
Regression – unconscious return to an earlier and more comfortable
developmental level
ORGANIZATION OF THE NERVOUS SYSTEM
BRAINSTEM – regulates the internal organs and responsible for vital
functions such as regulation of blood gases and the maintenance of BP
attaching to the postsynaptic receptor. Once released, the
Hypothalamus – hunger, thirst and sex. transmitter is destroyed in one of two ways.
- thought & emotions One way is the immediate inactivation of the transmitter
at the postsynaptic membrane.
RAS – allows human to sleep and carry out conscious mental activity
🞂 After interacting with the postsynaptic receptor, the
Limbic system – crucial role in emotional status and psychological transmitter is released and taken back into the presynaptic
function (norepinephrine, serotonin, dopamine cell, the cell from which it was released. This process,
referred to as the reuptake of neurotransmitter. Once inside
CEREBELLUM the presynaptic cell, the transmitter is either recycled or
🞂 Coordinated muscle energy & activity inactivated by an enzyme within the cell. The monoamine
🞂 Maintenance of equilibrium transmitters norepinephrine, dopamine, and serotonin are all
🞂 Coordinates contraction inactivated in this manner by the enzyme monoamine
oxidase.
CEREBRUM – responsible for mental activities and a conscious
sense of being. Also responsible for language and the ability to A second method of neurotransmitter inactivation is a little
communicate more complex.
is a common target for drug action.
Cerebral cortex – responsible for conscious sensation and the
initiation of movement NEUROTRANSMITTERS AND RECEPTORS
◦ Parietal cortex – touch
◦ Temporal – sound
◦ Occipital – vision
◦ Frontal – initiation of skeletal muscle contraction
● Prefrontal cortex - responsible for
thoughts, goal-oriented oriented
behavior & inhibition
- Seat of Personality
◦ Basal ganglia – regulation of movements
◦ Limbic system
● Amygdala and hippocampus –
emotions, learning, memory and basic
drives
NEUROTRANSMITTERS AND RECEPTORS
🞂 Conduction along a neuron involves the inward movement of
sodium ions (Na) followed by the outward movement of
potassium ions (K). When the current reaches the end of the
cell, a neurotransmitter is released. The transmitter crosses the
synapse and attaches to a receptor on the postsynaptic cell.
The attachment of transmitter to receptor either stimulates or
inhibits the postsynaptic cell
🞂 the destruction of the action of the enzyme
acetylcholinesterase on the neurotransmitter acetylcholine.
Acetylcholinesterase is present at the postsynaptic membrane
and destroys acetylcholine shortly after it attaches to nicotinic
or muscarinic receptors on the postsynaptic cell.
A full explanation of the various ways in which psychotropic
drugs alter neuronal activity requires a brief review of the
manner in which neurotransmitters are destroyed after
attaching to the receptors.
To avoid continuous and prolonged action on the post-
synaptic cell, the neurotransmitter is released shortly after
 ● Listening to and understanding the 🞂 Clarifying techniques
person in the context of the social 1. Helps both participants identify major differences in
setting of his/her life their frame of references, giving them the opportunity to
● Listening for ‘false notes” correct misconception before these cause any serious
● Providing the client with feedback misunderstanding.
information about himself/herself of
which the client might not be aware 🞂 Degree of openness
◦ Clarifying techniques 1. Open-ended questions
● Paraphrasing 2. Close-ended question
● Restating 3. Indirect or implied question
● Reflecting
● Exploring Interference with therapeutic communication
1. Nurse’s fear and feelings
THERAPEUTIC RELATIONSHIP ● Avoid personalizing what the patients say or
🞂 Therapeutic relationship is consistently focused on the do
client’s problem & needs ● Ask question in a kind and matter-of-fact
manner, by conveying empathy, and by
Factors that enhances growth in others reiterating a desire to help
Therapeutic Communication
1. Genuineness – self-awareness of one’s feelings 2. Nurse’s lack of knowledge and insecurity
🞂 Clinical Interview - “The client leads”
2. Empathy – one understands the ideas expressed ● Patients are usually more accepting when the
How to begin
nurse is honest about not knowing an answer
◦ Setting – private, safe
5 concepts of empathy and expresses a willingness to find answers
◦ Seating – assume the same height, avoid face to
◦ Human trait 3. Ineffective responses
face, avoid sitting without ready access to a door,
◦ Professional state ● Nurses must avoid premature conclusions
avoid a desk barrier
◦ communication process ● Do not be preoccupied with what to say next,
◦ Introduction – name, school, purpose, time limit
◦ caring process rather, listen to patient or they might be
◦ How to start – use open-ended question
◦ special relationship listening to
◦ Guidelines:
● Speak briefly
3. Positive regard – ability to view another person as being THERAPEUTIC RELATIONSHIP
● When you do not know what to say,
worthy of caring about & as someone who has strength & ● Suspending value judgment
“SAY NOTHING”
achievement potential ● Recognize their presence
● When in doubt, focus on feelings
◦ Attitudes - the nurse takes the client & the ● Identify how or where you learned these response to client’s
● Avoid advice
relationship seriously behavior
● Avoid relying on questions
◦ Actions – ● Construct alternative ways to view the client’s thinking and
● Pay attention to non-verbal cues
behavior
● Keep focus on the client
Attending - foundation of interviewing ● Helping client develop resources – consistently encourage client to
- an intensity of presence or being with the client use their resources helps minimize the client’s feeling of
🞂 Dynamics of therapeutic communication
helplessness & dependency & also validates their potential for
◦ Interpretation of communication
Non-verbal behaviors the reflect degree of attending change
◦ Themes in patients communication
1. Nurse’s posture
● Content themes
2. Nurse’s degree of eye contact Establishing boundaries
● Mood themes
3. Nurse’s body language 🞂 Transference – the process whereby a person unconsciously
● Interaction themes
& inappropriately displaces onto individuals in his/her current
◦ Environmental consideration
Therapeutic techniques life those patterns of behavior & emotional reaction that
◦ Physical consideration
Therapeutic communication skills originated in relationship to significant figures in childhood
◦ Kinesis consideration
🞂 Use of silence
🞂 Active listening 🞂 Countertransference - the tendency of the nurse to displace
🞂 Effective tools in communicating
1. nurse carefully note what the client is saying verbally & onto the client feelings related to people in the nurse’s past
◦ The use of silence - a specific channel for
nonverbally, as well as monitoring their own nonverbal
transmitting and receiving messages
response 🞂 Common countertransference reaction
◦ Active listening
2. Helps strengthens the client’s ability to solve personal 1. Boredom (indifference)
● Observing the client’s non-verbal
problems 2. Rescue
behaviors
3. The nurse communicates that the client is not alone, 3. Overinvolvement
rather, the nurse is working along with the client 4. Overidentification misuse of honesty
 5. Anger
6. Helplessness or hopelessness
STAGES OF NURSE – PATIENT RELATIONSHIP
1. PREORIENTATION PHASE
◦ Goal: to establish a client database & assess own
feelings regarding the client
2. ORIENTATION PHASE
◦ Goal: develop mutual trust, establish role of the
nurse as significant other to the client
◦ Client recognizes needs & seek help
◦ Trustworthiness is built when the nurse is honest
regarding intention, is consistent, and keeps
promises
◦ Assess the degree of patient’s awareness of
problems & the ability & motivation to change
◦ Talk about feelings directly then focus on coping
more effectively with them
◦ Provide structure by limit setting
3. WORKING PHASE
◦ Goal: identify & address client’s problem
◦ Reality testing helps patient see reality more
clearly & objectively compared with the past
◦ Limit setting – intervention designed to prevent
clients from harming themselves or others
◦ Nurse’s awareness of personal feelings & reaction
to the client is vital for effective interaction with
the client
4. TERMINATION PHASE
◦ Goal: assist client to review what was learned and
to transfer learning interaction with others
◦ Attempt to make termination official and state
feelings about the relationship
◦ Reasons for terminating the nurse-client
relationship
◦ Symptom relief
◦ Improved social functioning
◦ Greater sense of identity
◦ Development of more adaptive behavior
◦ Accomplishment of the client’s goals
◦ Impasses in therapy that the nurse is unable to
resolve
Interaction with client behaviors
🞂 Violent behavior
◦ Stay out of striking distance
◦ Avoid touching clients without approval
◦ Change topic temporarily
◦ Suggest time out with patient
◦ Avoid being alone with patient
◦ Leave temporarily if patient is agitated
◦ Call for staff assistance
🞂 Hallucinations
◦ Comment on behavior
◦ Provide reality but acknowledge behavior
◦ Assess the hallucination based on content of the
messages
◦ Do not focus on hallucination once content is
known
◦ Ignore the hallucination
🞂 Delusions
◦ Clarify the meaning of the delusions then ignore
🞂 Conflicting values
◦ Help client examine the effects or outcomes of
their beliefs on their lives, relationship, and
happiness
🞂 Severe anxiety & incoherent speech
◦ Spend frequent, brief time with patients, offer
support, and build trust
🞂 Manipulation
◦ Provide limit setting
◦ Help client express their needs directly to others
🞂 Crying
◦ Unless a form of manipulation, allow client to cry
◦ Provide privacy
◦ Be quiet and unobtrusive
🞂 Sexual innuendos or inappropriate touch
◦ Remind client these actions are inappropriate
🞂 Denial & lack of cooperation
◦ Reality testing & supportive confrontation with
denial
🞂 Depressed affect, apathy, & psychomotor retardation
◦ Patience, frequent contact, and empathy
◦ Encourage hygiene, proper nutrition and gradual
increase in activities
◦ Postponed major decisions until emotions have
subsided
🞂 Suspiciousness
◦ Communicate clearly, simply, and congruently.
◦ Clarify misinterpretation
◦ Provide simple rationale or explanations for rules,
activities, occurrences, noises and requests
🞂 Hyperactivity
◦ Patient should be in a quiet area, with minimal
auditory & visual stimulation
◦ Remain calm, speak slowly and softly & respect
patient’s personal space
◦ Give direction in a kind, simple but firm manner
🞂 Transference & countertransference
◦ Nurses must be open and clear
◦ State action that they cannot meet patient’s need
◦ Limit setting
Milieu Management
🞂 Consists of treatment by means of control modification of the
client’s environment to promote positive experiences
🞂 Purpose: helps patient recover from psychiatric & mental
health problem
Characteristics of milieu therapy
● Friendly, warm, trusting, secure, supportive, comforting
atmosphere throughout the unit
● An optimistic attitude about prognosis of illness
● Attention to comfort, food, and daily living needs; help with
resolving difficulties related to tasks of daily living
● Opportunity for client to take responsibility for themselves
and for the welfare of the unit in gradual steps
● Maximum individualization in dealing with clients
● Opportunity to live through & test out situations in a realistic
way
● Opportunity to discuss interpersonal relationship in the unit
among clients and between clients and staff
● Program carefully selected resocialization activities to prevent
regression
Elements of milieu therapy
1. Safety
◦ Physical protection – safety from physical harm
◦ Psychological safety – nurse’s active intervention
to prohibit verbal abuse, ridicule or harassment of
patient
2. Structure – the physical environment rules & daily schedules
of treatment activities
◦ Patient education lead by the nurse
◦ Opportunities for recreation
3. Norms – specific expectations of behavior that permeates the
treatment environment
◦ Promotes safety & trust
◦ To create an environment that is more predictable
& applicable to all who share the environment
4. Limit settings – should be set on acting-out behavior
 ◦ Reinforces the norms of making rules &
expectations clear & encourage the milieu therapy
concept---responsibility to self
5. Balance – the process of gradually allowing independent
behavior in a dependent situation
Activity therapy
🞂 Consists of a variety of recreational and vocational activities
(recreational therapy, occupational therapy, music, art, and
dance therapy) designed to test 7 examine social skills &
serve as adjunct therapies
Concept and principles
1. Socialization counters the regressive aspect of
illness
2. Activities needs to be selected for specific
psychosocial reason to achieve specific effects
3. Nonverbal means of expression as an additional
behavioral outlet add a new dimension to
treatment
4. Sublimation of sexual drives is possible through
activities
5. Indication for activity therapy: clients with low
self-esteem who are socially unresponsive
Goals
6. Encourage socialization in community & social
activities
7. Provide pleasurable activities
8. Help client release tension and express feelings
9. Teach new skills, help client find new hobbies
10. Offer graded series of experience, from passive
spectator role & vicarious experiences to more
direct and active experience
11. Free and/or strengthen physical & creative abilities
12. Increase self-esteem
ANXIETY DISORDERS
🞂 Group of conditions in which the affected person experiences
persistent anxiety that the person cannot dismiss and that
interferes with daily activities
🞂 Etiology:
1. Neurobiological – hereditary, brain chemistry,
developmental factors, disruption of the amygdala
2. Psychological - low self-esteem, shy or timid in
childhood, critical parents, discomfort with
aggression, abuse, violence, poverty
A. GENERAL ANXIETY DISORDER
● Characterized by excessive chronic anxiety or worry & might
concern everyday events
● Individuals have no control over anxiety & worrying becomes
habitual
● Cognitive restructuring
Characteristics: restlessness. Fatigue, poor concentration, irritability,
muscle tension, sleep disturbance, physical symptoms (dry mouth, upset Psychopharmacology:
stomach) ● SSRI
● Benzodiazepine (clonazepam, lorazepam) – immediate effect
Psychotropic mgt:
1. NPR – reduce level of anxiety Milieu mgt.: gross motor activities – diffuse energy
Goal: assist patient with developing adaptive, coping responses
🞂 Promote trust C. OBSESSIVE – COMPULSIVE DISORDER
🞂 Convey empathy Obsession – persistent thoughts, impulses, images or desires that maybe
trivial or morbid
Psychopharmacology - Recognize thoughts are irrational & senseless
◦ Antidepressants: SSRI. SSNRI
◦ Benzodiazepine – short-acting Compulsion – repetitive stereotyped behavior that are performed in a
particular manner in response to an obsession
- Performed to prevent discomfort & to bind or neutralized
Milieu mgt: anxiety
● Recreational activities - It interferes with normal routines, occupational & social
● Relaxation exercises, meditation & biofeedback functioning
● CBT - Interferes with patient’s interpersonal relationship
● Therapeutic touch & acupressure
Etiology: genetic, increase brain activity in the frontal lobe & basal
B. PANIC DISORDERS – recurrent panic attack & are worried about ganglia, serotonin dysregulation
having more attacks
● Panic attacks – sudden, intense fear or discomfort and peaks Psychotherapeutic mgt.:
at 10 minutes 1. NPR:
● Feelings of impending doom ● Accept rituals permissively
● Avoid criticism or punishment, making demands, showing
Types of panic disorder impatient – positive feedback
1. Panic disorder with agoraphobia ● Allow extra time for slowness & client’s action
● Feelings of terror that function is suspended, perceptual field ● Help client verbalize feelings, solve problem & make
is severely limited & misinterpretation of reality decisions
● Personality disorganization ● Protect from rejection by others & self-inflected harm
● Sign/symptoms: palpitations, chest pain, dyspnea, nausea,
feelings of choking, chills & hot flashes Psychopharmacology:
● Antidepressant:
2. Panic disorder without agoraphobia o Clomipromine (anafranil)
● Agoraphobia - intense, excessive anxiety or fear about being ● SSRI – fluoxetine (Prozac), setraline (Zoloft), fluovoxamine
in places or situations from which escape might be difficult or (Luvox) & paroxetine (Plaxil)
embarrassing or in which help might not be available if panic
attack occurs Milieu mgt.:
● Feared places are avoided e.g.. Outside, alone @ home, ● Relaxation exercises & stress mgt.
travelling in car, bus or plane, being on a bridge, riding in a ● Recreational or social skills
elevator ● CBT, problem-solving & communication or assertive training
groups
Etiology: hereditary, trauma, life stress or trauma, disruption in the
amygdala D. PHOBIC DISORDERS
- Intense, irrational, persistent fear responses to an external object
Psychotherapeutic mgt: activity or situation
1. NPR:
● Reduce immediate anxiety – stay physically close to patient, Phobia – response to experience anxiety & is characterized by a
use simple sentences, firm voice, remove to smaller quiet persistent fear of specific places or things
room to minimize stimuli
● Patient education 3 types of phobias
 1. Agoraphobia with history of panic disorders –
fear of being in public or open spaces places or
situations in which escape might be difficult or
help might not be available
2. Social phobia – fear of being humiliated,
scrutinized, or embarrassed in public
3. Specific phobia – fear of a specific object or
situation that is not either of the above
Etiology: environment, genetic predisposition
Psychotherapeutic mgt.:
1. NPR:
● Accept patient & their fears with a non-critical attitude
● Provide & involve patient in activities that do not increase
anxiety but increase involvement, rather that promote
avoidance
● Help client with physical safety and comfort
● Help patient recognize that their behavior is a method of
avoiding anxiety
Psychopharmacology:
SSRI – to reduce anxiety & depression & block panic attacks, if present
Milieu mgt:
● Assertive training & goal-setting groups
● Social skills group to help redevelop social skills and
decrease avoidance
● Behavior therapy – systemic desensitization, flooding,
exposure, and self-exposure
E. ACUTE STRESS DISORDER & POST TRAUMATIC STRESS
DISORDERS
- Develop after exposure to a clearly identifiable traumatic event that
threatens the self, others, resources, and/or sense of control or hope
ACUTE STRESS SYNDROME – symptoms occur within 1 month of
extreme stressor; includes dissociative symptoms (depersonalization,
emotional detachment., dazed appearance, amnesia)
POST STRESS DISORDER – severe traumatic event that is not an
ordinary occurrence e.g.. Rape, fire, flood, earthquake, tornado,
bombing, plane crash, war, torture, kidnapping
Diagnostic criteria
1. Dissociative symptoms & numbing
● Amnesia, depersonalization, derealization & awareness of
surrounding, numbing, detachment or lack of emotional
response
● Numbing of responses or reduced involvement with the
external world
● Persistent avoidance of situation, activities and people,
thoughts and feelings
● Denial, repression & suspension
● Feel detached or estrange from family & friends →
withdrawal → depression
● Lost interest in activities, hopelessness
● Change in sleep pattern
● Impulsive behavior, sudden life change
2. Reexperiencing the trauma & intrusive memories – hallucinations
(PTSD)
3. Arousal symptoms
● ↑ arousal, anxiety, restlessness, irritability, disturbance in
sleep, memory impairment or concentration
● PTSD – outburst of anger, rage, survivor guilt
4. Other symptoms
● Anxiety or panic attack
● PTSD – grief, depression, suicidal ideation or attempts,
impulsive self-destructive behavior, anxiety-relate disorders
& substance abuse
Psychotherapeutic mgt: prevent or minimize the symptoms
1. NPR: develop trust
● Nurse needs to be non-judgmental honest, emphatic, and
supportive
● Teach dynamics of ASD & PTSD
● Exposure therapy & systematic desensitization
● Expressive therapy (art, music, poetry) – facilitate
externalizing painful emotions that are difficult to verbalize
● Crisis counselling –
Psychopharmacology
● Benzodiazepine (clonazepam, lorazepam) – to reduce level
of anxiety and fear. Help with sleep disturbance
● Clonidine & propanolol – diminish the peripheral autonomic
response associated with fear, anxiety & nightmare
● Lithium carbonate – prescribed to patients experiencing
explosive outburst
● SSRI (paroxetine, setraline, fluoxetine) – decrease
repetitive behaviors, disturbing images & somatic states
● TCA – depression, adehonia & sleep disturbances
● Antipsychotic (respirodone) – psychotic thinking
Milieu mgt:
● Social activities
● Recreational & exercise program
● Group therapy
F. SOMATOFORM DISORDERS
- Characterized by the presence of physiologic complaints or symptoms,
which are not under voluntary control & no demonstrable organic finding
and physiologic bases
Types of somatoform disorders
1. Somatization disorder
◦ Conversion of mental states or experiences into
bodily symptoms associated with anxiety
◦ Recurrent, frequent & multiple somatic complaints
for several years without physiologic cause
◦ Client’s constantly seek medical attention, undergo
numerous tests; at risk for unnecessary surgery or
drug abuse
2. Pain disorder
◦ Associated with psychological factors like severe
pain in one or more of anatomical sites that causes
significant distress or impairment in functioning
◦ Pain is exaggerated or out of proportion
◦ Causes significant impairment in occupational or
social functioning or causes marked distress
◦ Symptoms not intentionally produced or feigned
3. Hypochrondiasis
◦ Worried & belief that they have serious disorders
base on the misinterpretation of bodily signs &
sensation for at least 6 months
◦ Preoccupation persists despite appropriate medical
tests & reassurances
◦ Causes significant impairment in occupational or
social functioning or causes marked distress
4. Conversion disorder
◦ Alteration in voluntary or motor sensory
functioning that suggest neurological or medical
condition
◦ Not due to malingering or factitious disorder and
not culturally sanctioned
◦ Cannot be explained by gen. medical condition or
effects of a substance
5. Body dysmorphic disorder
◦ Individual is preoccupied with an imagined defect
in appearance which are usually facial flaws.
◦ Dermatologist & plastic surgeon is often consulted
◦ May also exhibit obsessive compulsive traits &
depressive syndrome
◦ Controls relationship through physical complaints
Causes:
1. Inability of the CNS to regulate & interpret sensory input or
to decrease communication between right & left hemisphere
2. Hx of physical & sexual abuse witnessing violent acts in
childhood, poor nurturing from family, lack of job, and social
skills
3. Need to be sick to relieve oneself of obligations & to gain
attention
4. Dissociation
Psychotherapeutic mgt.
1. NPR:
● Use matter-of-fact caring approach
● Encourage patient to verbalize & describe feeling
● Use positive reinforcement & set limits
 ● Be consistent 4. Dissociative identity disorder – existence of 2 or more ● Markedly restricted, stereotypical
● Use diversion by including patient patients in milieu activities identities or personalities that take control of the person’s patterns of behavior, interest and
and recreational games behavior with its own patterns of relating, perceiving, and activities
● Do not push awareness of or insight into conflicts or problems thinking 🞂 Childhood & Adolescent psychiatric disorders
◦ The person or host us unaware of the other a. Asperger’s disorders – a severe developmental
Psychopharmacology: SSRI – to treat anxiety and depression personalities, but the other alters might be aware disorder characterized by major difficulties in
of each other to varying degrees social interaction & restricts & unusual interest &
Milieu mgt: ◦ Defense mechanism: repression behavior
● Relaxation exercises meditation and CBT ● Use monotone speech and rigid
● Family therapy Psychotherapeutic mgt. language
1. NPR: ● They cannot understand jokes and are
G. DISSOCIATIVE DISORDER ● Establish trust & support, provide caring and empathy taken advantage easily
– disturbances in the normally well-integrated continuum of ● Assist in gathering data about feelings, conflicts, or situations ● Inability to show empathy to others but
consciousness, memory, identity, and perception that patient experienced want to meet people & make friends
● Ensure client safety ● Have an obsession with facts about
🞂 Dissociation – the removal from conscious awareness of ● Provide nondemanding, simple routine circumscribed and odd topics
painful feelings, memories, thoughts, or aspects of identity ● Confirm identity of client and orientation to time & place b. Attention deficit/hyperactivity disorder – characterized by
◦ Unconscious defense mechanism that protects an ● Encourage client to do things for self and make decision inattention, impulsiveness, and overactivity in school 9before
individual from the emotional pain of experiences about routine tasks 7 years old)
or conflicts that have been repressed ◦ Causes:
🞂 Defense mechanism: repression Milieu mgt: ● Environmental exposure – perinatal
● Individual therapy insults, head injury, psychosocial
Causes: ● Task-oriented group adversity, lead poisoning, and diet
● Inability to recall important personal information usually of a ● OT and art therapy ● Genetic and hereditary factors
traumatic or stressful nature ● Cognitive therapy ● Dysfunction in the frontal lobe
● The disorder is often associated with exposure to traumatic ● Self-help groups ◦ Characteristics of ADHD
event common during disaster and wartime ● Inattention
● Sexual abuse during childhood Childhood & Adolescent psychiatric disorders ❖ Difficulty paying attention
● Psychopathology: an escape mechanism from memory of 🞂 Risk factors: in tasks or play
painful experiences or devoid of emotional satisfaction. ◦ Genetic factor ❖ Does not seem to listen,
There is little or no participation of the conscious personality ◦ Social & environment – severe marital discord, follow through or finish
so the person is unable to recall low socioeconomic status, large family & tasks
overcrowding, parental criminality maternal ❖ Does not pay attention to
Types of dissociative disorders psychiatric disorder, traumatic life event, details & makes careless
1. Dissociative amnesia sexual/physical abuse mistakes
◦ Sudden inability recall important information of ◦ Psychosocial factor – ❖ Is easily distracted, lose
one or more episodes not associated with organic ◦ Biochemical factors – alterations of things, & is forgetful in
disorders usually of a traumatic or stressful nature neurotransmitters (decrease in norephhinephrine & daily activities
● Localized amnesia serotonin 🞂 Childhood & Adolescent psychiatric disorders
● Selective amnesia ◦ Temperament – a style of behavior a child ● Hyperactivity
● General amnesia habitually uses to cope with the demands & ❖ Fidgets, is unable to sit still
expectations of the environment or stay seated in school or at
2. Dissocialise fugue – sudden, unexpected travel away from 🞂 Types of childhood mental disorders other times
home or some other location with the assumption of a new 1. Pervasive development disorders ❖ Runs & climbs excessively
identity or a confusion about one’s identity a. Autistic disorder in inappropriate situations
◦ Fugue states is characterized amnesia; b. Characterized by impairment in social interaction, ❖ Has difficulty playing
consequently, patients do not remember what communication and restricted repertoire of activity quietly in leisure activities
happened. & interest ❖ Acts as if “driven by a
c. Usually first observed before 3 years of age motor”, constantly on the go
3. Depersonalization disorder – involves an altered sense of d. Sign & symptoms ❖ Talks excessively
self, so that the individual feel unreal or strange or believe ● Impairment in communication & ● Impulsivity
that danger is not happening to then or to someone else imaginative activity ❖ Blurts out answer before
◦ Reality testing remains intact ● Impairment in social interaction question has been
completed
 ❖ Has difficulty waiting for
own turn
❖ Interrupts, intrudes in
others’ conversation &
games
◦ Nursing Dx
● Risk for injury
● Impaired social interaction
● Ineffective individual
● Risk for violence for self-directed or
directed to others
◦ Nursing intervention
● Establish trust
● Talk to client about safe & unsafe
behavior – use clear, honest
straightforward communication
● Assess the frequency & severity of
accidents
● Provide supervision for potentially
dangerous
● Assist the client, parent or caregivers to
make the distinction between
accidental & purposeful incident
◦ Childhood & Adolescent psychiatric disorders
● Give instruction slowly using simply
giving instruction
● Ask client to repeat exercise or
instruction before beginning a task
● Administer stimulant in the morning to
maximize effectiveness for daytime
activity
● Help parents decrease their feelings of
guilt & blame
● Maintain a safe environment at home &
in school
◦ Oppositional defiant disorder – enduring pattern
of disobedience, argumentative, explosive angry
outburst, low frustration tolerance, and a tendency
to blame others for quarrels or accidents
● Recurrent pattern of negativistic,
disobedient, hostile , defiant behavior
towards authority figures with serious
violation of basic rights of others
● Exhibit persistent testing of limits, an
unwillingness to give in or negotiate,
and a refusal to accept blame for
misdeeds
● Behavior do not violate the rights of
others
◦ Conduct disorder – characterized by persistent
pattern of behavior in which the rights of others &
age-appropriate societal norms or rules are
violated.
● Predisposing factors: ADHD,
oppositional child behaviors, parental
rejection, inconsistent parenting with
harsh discipline, early institutional
living, frequent shifting of parental
figures, large family size, absence of
father or alcoholic father, antisocial &
drug-dependent family members, &
association with a delinquent group
● Examples of behaviors: physically
aggressive, have poor peer
relationships & shows little concern for
others & lack of guilt or remorse
🞂 Childhood & Adolescent psychiatric disorders
c. Anxiety disorders
1. Separation anxiety disorders – excessively
anxious when separated from or anticipating a
separation from their home or parental figures
2. Most children will express worry about harm or
permanent loss of the mother or major attachment
figure
3. Characteristics:
● Excessive distress when separated from
or anticipating separation from home or
parental figure
● Excessive worries that one will be lost
or kidnapped or that parental figures
will be harmed
● Fear of being home alone or in
situation without other significant
adults
● Refusal to sleep unless near a parental
figure & refusal to sleep away from
home
● Refusal to attend school or other
activities without a parental figure
● Physical symptoms as a response to
anxiety
4. Nursing interventions:
● Assess the quality of the relationship
between child & parents or caregivers
for evidence of anxiety, conflicts or
difficulty of fit between child’s and
parent’s temperament
● assess the child’s previous & current
ability to separate from parents or
caregivers
● Protect the child from panic levels of
anxiety by acting as parental surrogate
● Accept regression but giving emotional
support to help child progress again
● Increase child’s self-esteem & feelings
of competence in the ability to perform
, achieve, influence the future
● Help child accept and work through
traumatic events or losses
5. Psychopharmacology: antihistamines, anxiolytics
and antidepressants
6. Cognitive therapy, behavior modification
🞂 PERSONALITY DISORDERS
🞂 Personality – sum total of the person’s distinctive character,
behavior, attitudes, the way one carries himself , the way one
communicate
◦ An enduring pattern of behavior that is considered
to be both conscious and unconscious and reflects
a means of adapting to a particular environment &
it cultural, ethnic and community standards
(Carson)
◦ Healthy personality:
◦ Sees his or her own strengths weaknesses
◦ Identifies his or her own boundaries
◦ Recognizes interaction & thoughts that lead to
strong emotions such as joy or anger
◦ Interacts with others without expecting them to
meet all needs
◦ Seeks a balance of work & play
◦ Accomplishes goals
◦ Defines & expresses spirituality
🞂 Personality disorder – “enduring pattern of inner experience
& behavior that deviates markedly from the expectation of the
individual’s culture, is pervasive & inflexible, has an onset in
adolescence or early adulthood, is stable over time, & lead to
distress or impairment “ (APA, 2000)
🞂 Etiology of PD
◦ Theorist – PD is related to unsuccessful mastery of
task in early stages of development that can lead to
anxiety
◦ Behaviorist – Developmentalist – believe that PD
originates in early childhood experiences (negative
experiences)
◦ Genetic cmponents
◦ Stressful environment
🞂 PERSONALITY DISORDERS
🞂 CRITERIA FOR A PERSONALITY DISORDER
1. CLUSTER A DISORDERS (ODD, ECCENTRIC)
a. Paranoid personality disorder
● These individuals interpret other
people's motives as threatening
resulting in an increase in anxiety &
the need for vigilance
● Characterized by distrust &
suspiciousness toward others, based on
the belief (unsupported by evidence)
that others want to exploit, harm, or
deceive the person & often act in
defense of a fragile self-concept
● They demonstrate jealousy, controlling
behaviors, and unwillingness to forgive
 ● Common in men than women
● Irritable and stubborn – prejudice
● With ideas of reference
● Blunted affect , humorless and serious
● Fear in confiding in others
● Hold grudges towards others
● Easily get angry if they are threatened
● Emotionally cold in appearance but are
acceptable of close relationship to few
b. Nursing guidelines
c. – may carry or conceal weapons
🞂 PERSONALITY DISORDERS
b. Schizoid personality disorder
● Individuals with this disorder lacks
personal & social relationship. They
are detached from others & withdraws
from interaction – hypersensitive
● Introverted since childhood, rarely
have close friends
● Use autistic thinking, daydreaming are
more gratifying
● They respond with short answers to
questions & do not initiate spontaneous
conversation
● They are reality-oriented but maintain
fair contact with others
● They function in a solitary occupation
but shows indifference to praise or
criticism from others
● Can be a precursor to schizophrenia or
delusion disorder
● Defense mechanism:
INTELLECTUALIZATION
● DSM IV criteria
1. Lacks desire for close
relationship or friends
2. Choose to be alone
3. Lack sexual experience
4. Avoid activities
5. Appears cold and detached
● Nursing guideline:
1. Avoid being too “nice” or
“friendly”
2. Do not try to increase
socialization
🞂 PERSONALITY DISORDERS
b. Schizotypal personality disorder
● Individuals with this disorder may have
behavior similar to those of someone
with schizophrenia, however psychotic
episode are infrequent & less severe
● Characteristics:
1. Ideas of reference
2. With magical thinking/odd
beliefs leading to
interpersonal difficulties
3. Problems in thinking,
communicating and
perceiving
4. Has eccentric appearance
and shows evidence of
magical thinking or
perceptual distortion that
are not clear delusions or
hallucination
5. Sensitive to behavior of
other people especially
rejection & anger
6. Speech may be difficult to
follow – the individual
develops a personalized
style with vague association
7. Socially inept
● Nursing guideline
1. Offer support like kindness
2. Be calm, non-threatening in
all or approaches
3. Respect client’s need for
social isolation – cannot
tolerate group therapy
4. Speak in a gentle manner to
encourage to get involve in
group activities
5. Be aware of client’s
suspiciousness & employ
appropriate intervention
6. Assist & teach the client
about social skills &
appropriate behavior to
improve his interpersonal
relationship
🞂 PERSONALITY DISORDERS
2. CLUSTER B CRITERIA (DRAMATIC, EMOTIONAL,
ERRATIC)
a. Antisocial personality disorder
● Has consistent disregard for others with
exploitation & repeated unlawful
actions.
● Unable to postpone gratification,
selfish and irresponsible
● Generally manipulative, does not feel
guilty, sorrow & not loyal
● Charming, intellectual and smooth
talkers
● They repeatedly neglect
responsibilities, tell lies and perform
destructive or illegal acts, without
developing any insight into predictable
consequences
● Hostile, unable to follow rules
● Diagnose before age 15 as conduct
disorder
● Criteria for Antisocial PD
1. Violate rights of others
2. Engage in illegal activities
3. Aggressive behavior
4. Lack of guilt or remorse
5. Irresponsible in work &
with finances
6. Impulsiveness
7. Recklessness
● Etiology: genetics, environment,
family environment (unstable parent –
child realationship
🞂 PERSONALITY DISORDERS
● Nursing guidelines
1. Prevent or reduce untoward
effects of manipulation
(flattery, seductiveness,
instilling guilt) by setting
limits
2. Encourage client to
verbalize feeling
3. Be firm, steadfast and
consistent in dealing with
patient’s behavior and
reinforcing rules & policies
4. Help client be aware of the
consequences of their
behavior
5. Explain & point out the
effects of their behavior
towards others
6. Avoid moralizing
c. Borderline personality disorders
● Characterized by impulsiveness,
unpredictable, unstable moods
● Desperately seek relationship to avoid
feeling abandoned
● Chronic sense of boredom
● Overspending, promiscuity, overeating
● Problems with identity & self-image
● history of substance abuse & multiple
or dramatic suicidal gesture, risk of
suicide and mutilation
● Manipulative and dependent
● Emotional lability
● Defense mechanism: projection
● Etiology:
● Inadequate regulation of serotonin &
dopamine & other transmitters
 ● Parents may cling to the child and
prevent autonomy, individual or parent
withdraws support & attention making
the child confuse
🞂 PERSONALITY DISORDERS
● Pharmacologic mgt:
● Neuroleptic drugs (3-12 wks)
● Lithium
● Valporic acid
● Carbamazepine
● Benzodiazepine
● Nursing guidelines
● Set realistic goals, use clear action
word
● Be aware of manipulative behaviors
● Provide clear & consistent boundaries
& limits
● Use clear 7 straightforward
communication
● Avoid rejecting or rescuing
● Assess for suicidal & self-mutilating
behavior
c. Narcissistic personal disorder
● Individuals with this disorder display
grandiosity about his performance and
achievement
● Arrogant, extrovert
● Believe to be special with need to be
admired
● Feel intense shame & fear that if they
are “bad”, they will be abandoned
● Afraid of their own mistakes, as well as
the mistakes of others.
● Defense mechanism: rationalization
🞂 PERSONALITY DISORDERS
● Nursing guidelines:
● Supportive confrontation
● Remain neutral; avoid engaging in
power struggle or becoming defensive
in response to the client’s disparaging
remarks
● Convey unussuming self-confidence
● Point out reality
● Tell client no one is perfect
c. Histrionic personality disorder
● Individual with this disorder are
characterized by excessive emotional
attention seeking behavior and are
dramatic and ego-centric
● Seductive, flamboyant and shallow –
use speech to impress others
● Needs to be the center of attention
● Impulsive and melodramatic
●Demands “the best of everything” and
can be very critical
● Related factors: mother-child
relationship
● Nursing guidelines:
● Understand seductive behavior as a
response to distress
● Keep communication & interaction
professional, despite temptation to
collude with the client in a flirtatious &
misleading manner
● Encourage & model the use of concrete
& descriptive rather that vague &
impressionistic language
● Teach and role-model assertiveness
🞂 PERSONALITY DISORDERS
3. CLUSTER C DISORDERS (ANXIOUS, FEARFUL)
a. Dependent personality disorder
● “pervasive & excessive need to be
taken care of that leads to submissive
and clinging behavior & fears of
separation” (APA, 2000)
● Extreme dependency in a close
relationship, with an urgent search to
find a replacement when one
relationship ends - they are afraid to be
alone
● They want others to make decision for
them – they need direction and
reassurance
● They feel the need to be rewarded if
they do good deeds for others
● To avoid conflict they become passive,
conceal sexual feelings and anger
● Nursing guidelines:
● Increase responsibility for
self in daily livings
● Be assertive
● Encourage client to
verbalize feeling
● Be aware of
countertranference
b. Avoidant personality disorder
● These clients are timid, socially
uncomfortable, with self care and
withdrawn
● Social inhibition and avoidance of all
situation that require interpersonal
contact
● Hyeprsensitive to criticism
● Uncertain and lacks confidence and
afraid to ask question or speak in
public
● Nursing guidelines
● Be friendly, gentle,
reassuring approach
● Help client to confront fears
gradually
● Support & direct client in
accomplishing short-term
goals
● Relaxation techniques
● PERSONALITY DISORDERS
c. Obsessive-compulsive personality disorder
● Perfectionist and inflexible
● Overly strict & often set standards for
themselves that are too high
● Preoccupied with details, rules, trivial
and procedures
● Difficult to express emotions or
warmth
● They try to control partner in a
relationship
● Serious, affect is constricted and would
speak in monotone voice
● Defense mechanism:
intellectualization, rationalization,
reaction-formation
● Etiology: early parent-child
relationship
● Nursing guidelines:
● Help client make decision
encourage follow-through
behaviors
● Encourage leisure activities
● Guard against engaging in
power struggle with client
● Confront client’s
procastination and
intellectualization
● MOOD DISORDERS
🞂 Mood – a person’s state of mind exhibited through feeding &
emotions (APA, 2001)
🞂 Mood disorders – extreme change in mood that presents
problems in daily functioning
- alteration in effect or mood that occurs when an individual
experience exaggerated feeling for a prolong period of time that is
psychologically, physically & socially unacceptable
🞂 Causes:
◦ Genetics
◦ Biochemistry
◦ Personality
◦ Environment
🞂 Types of depression:
1. MAJOR DEPRESSIVE DISORDER (MDD)
◦ Characterized by 1 or more major depressive
episodes, which are defined as at least 2 weeks by
 depressive mood or less of interest accompanied e. Psychotic depression – delusions & 🞂 MANIC DISORDERS
by at least 4 additional symptoms of depression hallucination 🞂 STAGES OF MANIA
◦ Signs/behavior ● Delusion of guilt, delusions 1. Mild elation or hypomaniac (4 days)
a. Depressed mood most of the day of deserved punishment, ◦ Affect – feeling of happiness, confidence
b. Anhedonia somatic delusions, nihilistic ◦ Thought – flight of ideas, inflated self-esteem
c. Significant weight loss or gain (5% wt. delusion, & delusion of ◦ Behavior – always on the go, increase sexual drive
in month) poverty 2. Acute manic episodes
d. Insomia or hypersomia (2 hrs in 1 f. Seasonal affective disorder (SAD) – ◦ Intensified symptoms
month) occur in conjunction with a seasonal ◦ Mood disturbance & lability
e. Increase or decrease motor activities change ◦ Enthusiastic & intrusive
f. anergia 🞂 MOOD DISORDERS ◦ Hyperactivity
g. Feelings of worthlessness or ◦ Psychopharmacological mgt. ◦ Flight of ideas
inappropriate guilt (may be delusional) a. SSRIs ◦ Distractibility
h. Recurrent thoughts of death or suicidal b. Tricyclics ◦ Distortion of self-esteem
ideation c. Antidepressant 3. Delirium – state of extreme excitement
i. Decrease concentration or d. MAOIs ◦ Disorientation, incoherence
indecisiveness ◦ Nursing guidelines: ◦ Visual or olfactory hallucination
🞂 MOOD DISORDERS a. Establish trust ◦ Exhaustion, dehydration, injury even death
◦ Characteristics ● Nonjudgmental & friendly 🞂 MANIC DISORDERS
a. Disregards grooming, cleanliness & approach 🞂 Basic syndromes of bipolar disorders
personal appearance ● Use silence & stay with a. Manic episodes – elevated, expansive or irritable mood
b. Stooped posture & dejected facial patient b. Hypomanic episodes – less, severe level of impairment
expression ● Avoid challenging or testing c. Depressive episodes – hypersomia, hyperphagia, wt. gain,
c. Dishevelled, downcast, lacking eye the client leaden paralysis, little energy
contact & tearful ● Do not argue d. BIPOLAR DISORDER
d. Agitated ● Divert patient’s attention ◦ Bipolar I disorder – experiences swings between
◦ Specifiers: b. Bolster self-esteem manic episodes and major depression
a. Atypical depression – occurs in c. Be amphatic ◦ Bipolar II disorder – characterized by 1 or more
younger population d. Point out or reward small visible depressive episodes accompanied by at least one
● Increase appetite or wt. accomplishment hypomanic episodes
gain, hypersomnia, leaden e. Do not embarrass patient ◦ Cyclothymic disorders – a swing between a
paralysis & extreme f. Never reinforce hallucination, hypomanic and depressive symptoms
sensitivity to interpersonal delusions or irrational beliefs ◦ Behavior of bipolar disorder
rejection g. Encourage verbal expressions of anger ● Objective behavior
b. Melancholic depression – older adults h. Provide non-threatening one-to-one ● Disturbance of speech,
● Anhedonia & inability to be relationship social, interpersonal &
cheered up i. Guide patient to appropriate decisions occupational relationship,
● Depression worse in AM by using problem solving activity & appearance
● Early AM awakening 🞂 MOOD DISORDERS ● Speech – rapid, pressured,
● Psychomotor retardation or 2. DYSTHMIC DISORDER loud, easily distracted
agitation ▪ Patient is depressive mood for at least 2 years ● Altered social, interpersonal
● Significant anorexia or wt ▪ With poor appetite or over-eating & occupational relationship
loss ▪ Insomia or hypersomia ● Subjective behavior
● Excessive or inappropriate ▪ Low energy or fatigue ● Alteration of affect –
guilt ▪ Low self-esteem euphoric, grandiosity, labile
c. Catatonic features – psychomotor ▪ Poor concentration or difficulty making decisions ● Alteration of perception –
attraction including immobility, ▪ Feelings of hopelessness delusion & hallucination
excessive motor activities, mutism, ▪ Difference between MDD & DD (duration & 🞂 MANIC DISORDERS
echolalia or echopraxia, inappropriate severity) ◦ Nursing responsibilities
posturing ▪ Patient may engage in activities to generate ● Use matter of fact tone
● negativism excitement ● Clear, concise direction & comments –
d. Postpartum depression – mood ▪ may turn to substance abuse or food remarks should be simple & brief
disturbance that occurs during the first ▪ Patients do not readily recognize their symptoms ● Limit – setting
30 days post partum as abnormal ● Reinforcement of reality
 ● Respond to legitimate complaints ◦ Etiology ● Help patient reestablish appropriate
● Redirect patient into more healthy ● Biologic factors – increase serotonin eating behavior
activities ● A culture of thinness, relational ● Elevate self-esteem
● Provide for can be eaten easily orientation of women ● Medical treatment – IV lines & feeding
● Assess amount of sleep & rest ● Genetic component tubes
● Provide quiet place to sleep ● Family environment ◦ Nursing guidelines
● Structure activities during the day ● Odd eating habits & emphasis on ● Convey warmth & sincerity
● Do not drink caffeine at bedtime appearance ● Listen emphatically
◦ Psychopharmacology ● Rejection of food & wt. loss as a ● Be honest
● Lithium – positive reinforcement ● Set appropriate behavioral limit
● Anticonvulsant & atypical ● Childhood sexual abuse ● Assist patient in identifying their
antipsychotics ● Regression to a prepubertal state qualities
◦ Milieu mgt. ● Fear of being out of control ● Collaborate with patient
● Safety ● Defense mechanism: REACTION ● Teach patient about disorders
● Consistency among staff FORMATION ● Determine patient’s weight with their
● Reduction of environmental stimuli 🞂 BULIMIA NERVOSA back on the scale
● Dealing with patient who are escalating ◦ Intermittent binge period and periods of restrictive ● Initiate behavioral modification
● Reinforcement of appropriate hygiene eating ● Express emotions assertively
& dress ◦ Loss of control over eating ● Help patient identify & express bodily
● Nutrition & sleep issues ◦ Anxious & feeling of weakness – before eating sensation
🞂 EATING DISORDERS while binging ● identify non-weight related interest
🞂 ANOREXIA NERVOSA ◦ Angry & agitated or depressed ◦ Psychopharmacology
◦ Limit their intake or refuse to eat but do not lose ◦ Mood disorders ● Anxiolytics
their appetite ◦ Substance sbuse ● Atypical antipsychotics
◦ Perfectionist & introvert with self-esteem & peer ◦ Self-induce vomiting ● Antidepressants - SSRI
relationship problems 🞂 EATING DISORDERS 🞂 SCHIZOPHRENIA
◦ Clinical manifestation/behaviors ◦ Clinical manifestation/behavior 🞂 Schizophrenia – mental disorder characterized by
Restricters Vomiters-purgers ● Secretive about behavior disturdance in thought & sensory perception & deterioration
◦ Normal or slightly ↑ Induction of ● Binge eating in psychosocial functioning
vomiting 7 excessive use of laxative or diuretics ● F/E abnormalities 🞂 Psychotic – delusions, any prominent hallucinations,
◦ Avoids people ● Use of laxatives disorganized speech or disorganized catatonic behavior (APA,
denies concern ● Use of ipecac syrup 2000)
◦ Competitive, compulsive, obsessive ● Menstrual irregularities 🞂 Comorbidity
dental problems ● Dental carries 1. Substance abuse
◦ Rigid excersie program ● Russel’s sign 2. Depressive symptoms
uncontrollably eat large amounts of food ● Loss of control over eating 3. Anxiety disorders
◦ Hyperactive ● Anxious & feeling weakness 🞂 Theory
substance abuse ● Angry & agitated or depressed 1. Dopamine hypothesis
family conflict ● Mod disorders 2. Alternative biochemical hypothesis – structural cerebral
◦ Amenorrhea ● Substance abuse abnormalities, reduced gray matter, increase ventricular brain
◦ Hypotension, bradycardia, hyponatremia ● Self – induce vomiting ratio
◦ Dry skin with lanugo ◦ Etiology 3. Genetics
◦ Delayed gastric emptying ● Low serotonin activity 4. Autoimmune
◦ Slow peristalsis----constipation ● Inherited 5. Double bind communication – 2 messages that contradict
◦ Dehaydration ● Cycles of low self-esteem, extreme each other are sent causing the child to be confused on what
◦ Refeeding syndrome concerns about body shape & wt., strict action to engage in which immobilize the child & results to
◦ Pitting edema dieting, binge eating & compensatory anxiety
◦ Osteopenis or osteoporosis behavior 6. Birth & pregnancy complication, viral infxn, poor nutrition or
◦ Cardiac arrythmias ● Ambivalence starvation, exposure to toxin
◦ Bizaare behavior regarding fool & eating ● Feel unworthy of nurturing 7. Stress – development/family
◦ Feel abandoned or inadequate 🞂 EATING DISORDERS 8. Weak ego
◦ Depression, irritability, social withdrawal, lessened ◦ Psychotherapeutic mgt 9. Vitamin deficiency – vitamins B1, B6, B12, vit. C
sex drive & obsession symptoms ● Medical stabilization 🞂 SCHIZOPHRENIA
🞂 EATING DISORDERS ● Wt. restoration – 🞂 Precipitating factors
 1. Emotional - marital problem ◦ Reflects the presence of overt psychotic or ● Illusion
2. Somatic – pregnancy, physical illness distorted behavior ● Paranoid thinking
3. May be none 2. Negative symptoms – reflect a dimunition or loss of normal ● Thoiught disorder
🞂 4 A’s (Eugene Bleuler) function ● Delusions
Affect – outward manifestation of a person’s feelings & emotion – flat, 3. Disorganized symptoms – presence of confused thinking, ● Confusion, incoherent speech,
blunted, inappropriate bizarre affect incoherent or disorganized speech & disorganized behavior clouding, & a sense of going crazy
Associative looseness – haphazard & confused thinking manifested in 🞂 2 diagnostic categories ● Inappropriate, flattened, blunted, or
jumbled & illogical speech & reasoning Type I schizophrenia labile affect
Autism – thinking that is not bound to reality but reflects the private 🞂 Onset of positive symptoms is generally acute 🞂 SCHIZOPHRENIA
perceptual world of the individual – delusions, hallucination, neologism 🞂 Sx: delusions, excitement, feelings of persecution, 🞂 Psychopharmacology
Ambivalence – simultaneously holding 2 opposing emotions, attitudes, grandiosity, hallucination, hostility, ideas of reference, ◦ Stabilize acute symptoms
ideas, or wishes towards the same person situation or object illusions, insomia ◦ Maintain therapeutic plasma levels
🞂 Phases of schizophrenia Type II schizophrenia ◦ Typical antipsycotics
1. Acute phase – period of florid positive symptoms as well as 🞂 Slow onset of negative symptoms aused by viral infxn & ● Haloperidol (Haldol)
negative symptoms abnormalities in cholecystokinin ● Chlorpromazine (Thorazine)
2. Maintenance phase – period when acute symptoms decrease 🞂 Sx: dimunition or loss og normal function, anergia, ● Thiothixene (Navane)
in severity anhedonia, alogia, avolition, blunted affect or affective ◦ Atypical antipsychotics
3. Stabilization phase – patient is might still experience flattening, attention deficits, poor eye contact, asocial ● Clozapine (Clozaril)
hallucination & delusions but not as severe nor as disabling as behavior, difficulty in abstract thinking ● Respirodone (Respiradol)
they were during the acute phase 🞂 SCHIZOPHRENIA ● Olanzopine (Zyprexa)
Common symptoms of schizophrenia 🞂 SCHIZOPHRENIA SUBTYPES 🞂 Milieu mgt.
1. Delusions – false fixed beliefs that cannot be corrected by 1. PARANOID TYPE ◦ For disruptive patients:
reasoning ◦ Experience persecutory or grandiose delusion & ● Set limits
2. Hallucinations – sensory perception for which no external auditory hallucination ● Frequently observe escalating patients
stimulus exist 2. CATATONIC TYPE – psychomotor disturbances to intervene
3. Illusions – misinterpretation of environmental stimuli ◦ Motoric immobility, waxy flexibility or stupor ● Modify the environment to minimize
4. Depersonalization – feeling of the individual that the self has ◦ Excitement (excessive motor activity) objects that can be used as weapons
been changed or altered ◦ Extreme negativism or mutism ---- withdrawal ● Be careful in stating what the staff will
5. Affective flattening – absence of emotional response ◦ Peculiar movements do if a patient acts out
6. ambivalences ◦ Echolalia or echopraxia ● When using restraints, provide for
🞂 SCHIZOPHRENIA 3. DISORGANIZED TYPE – most severe prognosis, safety by evaluating the patient’s status
🞂 Common delusions in schizophrenia disintegration of personality & is withdrawn, disorganized of hydration, nutrition, elimination, &
1. Delusions of reference – everything that is occurring in the speech, disorganized behavior, flat or inappropriate affect circulation
environment has significance to oneself 4. UNDIFFERENTIATED TYPE – characterized by atypical 🞂 SCHIZOPHRENIA
2. Delusion of persecution – false belief that one is being singles symptoms that do not meet the criteria for other subtypes ◦ For withdrawn patients:
out for harm by others – someone is platting against him/her ◦ Characteristics symptoms ● Arrange non-threatening activities that
3. Somatic delusion – appearance or functioning of one’s body ◦ Prognosis is favorable involve these patient in doing
is altered 5. RESIDUAL TYPE something
4. Grandiose delusion – false belief that one is a very powerful ◦ Continuing evidence of negative symptoms ● Arrange furniture in a semicircle or
& important person without characteristic symptoms of schizophrenia around a table
5. Nihilistic delusion – “I am dead” 🞂 SCHIZOPHRENIA ● Help client to participate in decision
6. Delusions of influence – one is controlled by others or outside 🞂 Assessment making
force ◦ Objective Sx ● Reinforce appropriate grooming &
Jealousy – false belief that one’s mate in unfaithful; may have so-called ● Less concerned with their appearance hygiene
proof ● Introspection & apathy ● Provide psychosocial rehabilitation
🞂 Symptoms of loose association ● Anergia ◦ For suspicious patients:
1. Neologism ● Inadequate interpersonal ● Be matter-of-fact
2. Echolalia communication ● Staff members should not laugh or
3. Word salad ● Hostility whisper around patients unless patient
4. Clang association ● Withdrawal can hear what is being said
🞂 SCHIZOPHRENIA ● Psychomotor agitation or inactive or ● Do not touch suspicious patients
🞂 3 broad clinical symptoms catatonic without warning
1. Positive symptoms ◦ Subjective Sx ● Be consistent in activities
● Hallucnation ● Maintain eye contact
 ◦ For patient with impaired communication:
● Be patient & do not pressure patient to
make sense
● Do not place patient in group activities
that would frustrate them, damage
self-esteem, or over-tax their abilities
● Provide opportunities for purposeful
psychomotor activity
◦ SCHIZOPHRENIA
◦ For patient with hallucinations:
● Attempt to provide distracting activities
● Discourage situation in which patient
talk to others about their disordered
perception
● Monitor television selection
● Monitor for command hallucination
that might increase the potential for
patient to become dangerous
● Have staff members available in the
dayroom so that patient can talk to real
people about real people or real events
◦ For disorganized patients:
● Remove disorganized patient to a less
stimulating environment
● Provide a calm environment
● Provide safe & relatively simple
activities for these patients
🞂 Nursing guidelines
◦ Build a therapeutic alliance with patient
◦ Be calm
◦ Accept patient
◦ Keep promises
◦ Be honest
◦ Do not reinforce hallucinations or delusions
◦ Do not touch patient without warning
◦ Reinforce positive behaviors
◦ Avoid competitive activities
◦ Do not embarrass patient
◦ Allow & encourage verbalization of feelings
🞂 SCHIZOPHRENIA – LIKE DISORDERS
1. Schizoaffective disorders
◦ Uninterruptive period of illness during which at
some point the patient experiences a MDD, manic
or mixed episodes along with the negative
symptoms of schizophrenia
◦ In the absence of prominent mood symptoms,
patient exhibits delusion or hallucination
2. Schizophreniform disorder
◦ Patient exhibits features of schizopohrenia for
more than 1 month but fewer that 6 months
◦ No impaired social or occupational function
3. Brief psychotic disorder
◦ Onset of at least 1 or more positive symptoms of
psychosis
◦ Occur at least 1 day to less that an month then full
recovery
4. Psychotic disorder due to a general medical condition
◦ Presence of prominent hallucination or delusion
determined as resulting from the direct physiologic
effect of a specific medical condition
🞂 CRISIS
🞂 It is an overwhelming reaction to a threatening situation in
which an individual’s usual problem-solving skills and coping
responses are inadequate for maintaining psychological
equilibrium
🞂 General Consideration
1. Crisis occurs in all individuals at one time or another
2. Crisis is not necessarily pathological, it can provide stimulus
for growth & learning
3. Crisis is time limited and is usually resolve one way or
another in a brief period (4-6 weeks)
a. Successful crisis resolution occurs when
functioning is restored or enhanced through new
learning
b. Unsuccessful crisis resolution is when functioning
is not restored to pre-crisis level, and the
individual experiences decreased level of
functioning
4. Individual’s perception of the problem determine the crisis.
Each individual has unique response to the problem
5. Balancing factors are important in predicting outcomes for the
individual responding to a crisis
a. Perception of precipitating event is realistic rather
than destored
b. Situational supports (ex. Family, friends)
c. Coping mechanism that alleviate anxiety
🞂 CRISIS
Type of Crisis
🞂 Developmental crisis - occurs from transition from one
stage of maturation to another in the life cycle
🞂 Situational crisis – occurs to a sudden, unexpected event in
an individual life. These events is all about experiences of
loss.
🞂 Adventitious crisis – occurs in response to severe trauma or
natural disaster. These crisis can affect individuals,
communities and even nation
Sequence of Crisis Development
1. Pre-Crisis period – individual has emotional equilibrium
2. Crisis period – individual has the subjective experience of
being upset, failure of usual coping mechanism, symptoms
are expereinced
3. Post-Crisis period – resolution of crisis
Symptoms common in individual experiencing crisis
🞂 Physical symptoms – somatic complaints
🞂 Cognitive symptoms – confusion, difficulty concentrating,
racing thoughts, inability to make decisions
🞂 Behavioral symptoms – disorganization, impulsive, angry
outburst, withdrawal from social interaction
🞂 Emotional symptoms – anxiety, anger, guilt, sadness,
depression, paranoia, suspicion, helplessness, powerlessness
🞂 CRISIS
Management of Crisis: Crisis Intervention
1. Assistance
◦ Assistance for an individual affected by a crisis
◦ Assistance for groups or communities affected by
crisis
● Mobile crisis team – interdisciplinary
teams provide services to groups of
communities affected by crisis
● Disaster response team – teams have an
organized plan to provide help to large
segments of the population affected by
natural disaster
● Critical incident stress debriefing –
assistance is directed at groups of
professional such as hospital personnel,
police and firemen, who have been
involved in a crisis situation.
2. Role of the Nurse
🞂 Nurse provides direct services to people in crisis and serve as
members of crisis intervention teams
◦ In acute and chronic hospital setting assist
individuals and families responding to the crisis of
serious illness, hospitalization and death
◦ In community setting provide assistance to
individuals and families in developmental and
situational crisis
◦ Nurses working with a particular group of client
should anticipate situations in which crisis may
occurs. They also collaborate with other health
team members to help an individual resolve crisis
🞂 CRISIS
Principles of crisis intervention
🞂 the goal of crisis intervention is to return the individual to
pre-crisis level of functioning
🞂 Emphasis is on strengthening and supporting healthy aspects
of individual’s functioning
🞂 A problem-solving approach is use in a systematic manner
◦ Assessing the individual’s perception to problem
assessing strengths and weaknesses of the
individual and family support system
◦ Planning specific outcomes or goals based on
priorities
◦ Providing direct intervention
◦ Evaluation outcome and results of intervention
🞂 Use the framework of Maslow’s hierarchy of needs to
determine the priorities for intervention
◦ Physical resources – necessary for survival
◦ Social resources – necessary for regaining sense of
belonging
◦ Psychological resources – necessary for regaining
self-esteem
Role of crisis intervention worker includes:
🞂 Establishes rapport and communities hope and optimism
🞂 Assumes an active, directive role if necessary
🞂 Make suggestions and offer alternatives