NCM 117j - PSYCHIATRIC

NEURO ANATOMY AND NUROPHYSIOLOGY Cerebellum

The Central Nervous System (CNS) is composed It is located below the cerebrum and is the
of the brain, the spinal cord, and associated center for the coordination of movements and
nerves that control voluntary acts. Structurally, postural adjustments. It inhibited transmission
the brain is divided into the cerebrum, of dopamine, a
cerebellum, brain stem, and limbic system. neurotransmitter,
in this area is
associated with
the lack of smooth
coordinated
movements in
diseases such as
Parkinson’s
diseases and dementia.
Brain Stem
Cerebrum
The brain stem includes the midbrain, pons, and
Is divided into two hemispheres; all lobes and
medulla oblongata and the nuclei.
structures are
Midbrain
found in both
- Connects the pons and cerebellum
halves except for
with the cerebrum. It measures only
the pineal body or
0.8 inches (2cm) in length and includes
gland, which is
most of the reticular system. It
located between
includes, motor activity sleep,
the hemispheres.
consciousness, awareness, relays
4 Lobes: information about movement and
coordination.
Pons
- Bridges the gap both structurally and
functionally, serving as a primary
motor pathway.
Medulla Oblongata
- Located at the top of the spinal cord,
contains vital centers for respiration
and cardiovascular functions.
Nuclei
Lobes Function
- For cranial nerves III and XII
Frontal Lobe The organization of
Limbic System
thought, body movement
An area of the brain located above the brain
working memory, emotion,
stem that includes the thalamus, hypothalamus,
(problem solving, decision-
hippocampus, and amygdala.
making)
Thalamus
Parietal Lobe the taste and touch, spatial
- Regulates activity, sensation, and
orientation.
emotion
Temporal The smell and hearing,
Hypothalamus
Lobe emotional expression, and
- Involved in temperature regulation,
remember emotions
appetite control, endocrine function,
Occipital Lobe The coordinating language
sexual drive, and impulsive behavior.
generation, visual
interpretation

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Hippocampus and Amygdala
- Involved in emotional arousal and
memory
Neurotransmitters
The chemical substances manufactured, in the
neuron that aid in the transmission of
information throughout the body. They either
excite or stimulate an action in the cells
(excitatory) or inhibit or stop an action
(inhibitory). Studies are beginning to show
differences in the amount of some
neurotransmitters available in the brains of
people with certain mental disorders compared
with people who have no signs of mental illness.
Major Neurotransmitters
Dopamine
- neurotransmitter located primarily in
the brain stem
- Control of complex movements,
motivation, cognition, and regulation
of emotional responses
- Mechanism of action: excitatory
- Synthesized from tyrosine, a dietary
amino acid
- Implicated in Schizophrenia, other
psychoses, movement disorders
(Parkinson's Disease)
- Antipsychotic medication: blocks
dopamine receptors; reducing
dopamine activity
Norepinephrine and Epinephrine
- Norepinephrine (noradrenaline|- most
prevalent in the nervous system,
located primarily in the brain stem
- Plays a role in changes in attention,
learning, memory, sleep, wakefulness
NCM 117j - PSYCHIATRIC
- Excess=anxiety disorders
- Deficit=memory loss, social
withdrawal, and depression
- Epinephrine (adrenaline) - fight or
flight response
- Antidepressants- block re-uptake of
norepinephrine or inhibit MAO from
metabolizing it
- Mechanism of action: excitatory
Serotonin
- Derived from tryptophan, a dietary
amino acid
- Mechanism of action: Inhibitory
- Control of food intake, sleep
wakefulness, temperature regulation,
pain control, sexual behavior, and
regulation of emotions
- Antidepressants: bock serotonin re-
uptake, leaving it available longer in
the synapse, which result in improved
mood
- Serotonin levels are reduced in
depression
Histamine
- Role in mental illness is under
investigation
- Involved in peripheral allergic
response, control of gastric secretions,
cardiac stimulation, alertness
- Psychotropic drugs: block histamine
resulting in weight gain, sedation,
hypotension
- Mechanism of action: neuromodulator
Acetylcholine
- Neurotransmitter found in brain, spinal
cord and PNS
- Mechanism of action: excitatory or
inhibitory
- Synthesized from dietary choline found
in red meat and vegetables
- Affects sleep-wake cycle, signals
muscle to become active
- People with Alzheimer's disease have
decreased acetylcholine-secreting
neurons and people with myasthenia
gravis have reduced acetylcholine
receptors
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Glutamate
- Excitatory amino acid that can have
major neurotoxic effects at high levels
- Implicated in the brain damage caused
by stroke, hypoglycemia, sustained
hypoxia or ischemia and some
degenerative diseases
- Mechanism of action: excitatory
Gamma – Aminobutyric Acid
- major inhibitory neurotransmitter in
the brain and has been found to
modulate other neurotransmitter
systems rather than to provide a direct
stimulus.
- slows down your brain by blocking
specific signals in your CNS.
- Drugs that can increase GABA function,
such as benzodiazepines, are used to
treat anxiety and to induce sleep.
- Mechanism of action: excitatory or
inhibitory
Family Dynamics
Family building block of our society functioning
not only for procreation but also to transmit
values, protection, and nurturing needed for our
survival. The definition of family has changed
over the years; focused on roles and functions
of family rather than the relationships between
its members
Illness family supplies the needed care and
support. Nurses who care for mentally ill
individuals need to understand family
functioning
Family dynamics are the patterns of relating, or
interactions, between family members. Each
family system and its dynamics are unique,
although there are some common patterns.
Family Systems Theory
Traditional individual therapy -focus on
problems in a linear manner, that is, ‘event’ A
caused problem B.
- Family systems theory: views
problems in a more circular manner,
using what is called a 'systemic
perspective’
- assessment of patterns of interactions
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Family Roles
Roles Function
Peacekeeper Mediating and reducing
tension between conflicting
parents.
The problem Young person’s problems,
as the “role” for example drug use, may
play a ‘role’ in the family
system distracting the
family from other problems
Scapegoat The visible ‘symptom’ of a
troubled family system,
while the other children are
seen as the good ones
emphasis on what is happening, rather than
why
emphasizes the bidirectional nature of
relationships, moves away from blaming one
person for the dynamic
Symptomatic behavior is seen as arising out
of the interrelated behavior of all family
members
Symptomatic behavior is seen as arising out
of the interrelated behavior of all family
members
focus is on the pattern of dynamics within a
young person's family system, including the
effect of the young person's behaviors
Family “Roles”
Ascribed characteristics
- A family's attitude towards a young
person has an important influence on
their self-identity and self-worth. A
young person's behavior may, at times,
be in response to labeling or being
ascribed characteristics by the family.
- For example, a young person may be
called a 'sook' in a family where
emotional toughness is valued. This
may lead to certain responses by the
young person, such as toughening up'
or managing low self-worth in a
destructive manner. The young person
will benefit greatly from a worker who
will assist them to identify their
strengths and emphasize the value of
their attributes.
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The Filipino Family
- “mag-anak” or “pamilya”
- Household = “magkakasambahay”
- Filipino Values: “hiya”,“utang na loob”
and “pakikisama”
- “Karangalan” – maintain the morality
of the family
Stages of Family Development
By: Duvall and Miller (1985)
Beginning family
Early child-bearing family
Families with school children
Families with teenagers
Launching center families
Families in Midlife (the empty nest)
Families in retirement
Working with the Family
Assessment:
- Family characteristics in both the
family of origin and the present family
- Developmental stage of family at the
present time
- Family's accomplishment of
developmental and daily tasks
- Patient's and family’s reasons for
seeking treatment and reactions to
care
- Effects of mental illness on family
members and on the family as a whole
- Family strengths
- Family's understanding of the illness
and current coping skills for managing
the illness and its attendant behaviors
- Other health problems of the patient,
family members that may affect care
Family Assessment Guidelines
Family membership and development
- Tell me about the members of your
immediate family. including ages and
gender.
Family strengths and Needs
- What do you think is strength of your
family?
Family Coping
- Describe a problem that your family
has dealt with successfully.
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Family Problem Identification
- What is your perception of the current
family problem?
Family Use of Resources
- What does your family do to stay
healthy? What does your family do to
treat or control mental, emotional, and
physical illness?
Application of the Nursing Process to the
Family
Assessment: (nurse – patient – relationship)
- Discuss how problems are viewed
- Take into consideration living
arrangements
- Consider other physical and mental
health problems within the family
(stress-related physical problems)
Nursing Diagnosis: (NANDA international
classification system)
- Ineffective family therapeutic regimen
maintenance, impaired parenting,
interrupted family processes and risk
for caregiver role strain.
Outcome identification
- Goals for the individual
- Goals for the family as a whole or both
- Specific, measurable, and achievable
within a time frame
Planning and Implementation
Key nursing interventions for working with families:
- Provide respect, empathy, support,
and acceptance
- Advocate for patients and families in
their interactions with provider,
institutions, and organizations
- Help the family build the patient's self-
esteem
- Resolution of normal developmental
problems
- Use more adaptive coping skills
- Referrals to support groups and
resources
- teaching problem-solving, limit-setting,
and conflict resolution skills
- help families validate, clarify,
negotiate, and communicate feelings
appropriately
- recognizing and coping with abuse
issues
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- feedback to the patient and families
concerning their progress
- negotiate role flexibility between
patients and their families
- support for families through referral to
brief, problem-focused and psycho-
educational groups
- be honest with patients and families if
abuse must be reported
Teach
- communication and parenting skills
- causes, manifestations, and treatment
of psychiatric illnesses
- desired effects and side-effects of
medications = REPORT
- management of difficult behavior of
patients
- goal setting and treatment planning
- practice self-care as well as care for the
patient
Evaluation
- outcomes are measured
determining whether treatment goals
have been met.
Patterns of Behavior
What is a behavioral pattern?
- "The characteristic way in which a
person or animal acts"
- a chain of actions /thoughts that have
occurred in certain patterns within
your life, often repeated.
Different types of behavioral patterns can
vary but include:
- Passive Aggressive tendencies
- Hostility
- Codependency Traits
- Quick Tempered
- Acting on Impulse
- Self- sabotage
- Being attracted to the same sort of
person each time.
Actions can occur with a behavior pattern
- Gambling
- Retail therapy
- Sex addiction
- Codependency
- Change in your relationship with food
- Self-harming
- Toxic relationship (friends or partner)
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- Alcohol/drug dependence
Effects of Cyclical Behavior Patterns
- affect many different areas of your life
- barriers within relationships (outbursts
of aggression, defensive, isolate from
others)
- competitive in certain areas of your life
(work or fitness)
- Day to day tasks can start to become
difficult (alcoholism, gambling, retail
therapy or even your relationship with
food)
Concept of Human Behaviors
BEHAVIORISM
- school of psychology that focuses on
observable behaviors and what one
can do externally to bring about
behavior changes.
- does not attempt to explain how the
mind works
- behavior can be changed through a
by system of rewards and punishments
Pavlov Classical Conditioning
Behavior can be changed through conditioning
with external or environment conditions or
stimuli.
BF Skinner: Operant Conditioning
- (1904-1990)
- people learn behaviors from their
history or past experiences
- Some criticize his theories for not
considering the role that thoughts,
feelings, or needs play in motivating
behavior
- his work still used today
- did not deny the existence of feelings
and needs in motivation but viewed
behavior as only that which could be
observed, studied, and learned or
unlearned.
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- if the behavior could be changed, so
could the accompanying thoughts or
feelings
The following principles of operant
conditioning described by Skinner form the
basis for behavior techniques in use today:
1. All behavior is learned.
2. Consequences result from behavior.
3. Behavior that is rewarded with
reinforcers tends to recur.
4. Positive reinforcers that follow a
behavior increase the likelihood that
the behavior will recur.
5. Negative reinforcers that are removed
after a behavior, increase the
likelihood that the behavior will recur.
6. Continuous reinforcement is the
fastest way to increase that behavior,
but the behavior will not last long after
the reward ceases.
7. Random intermittent reinforcement is
slower to produce an increase in
behavior, but the behavior continues
after the reward ceases.
Negative reinforcement = removing a stimulus
immediately after a behavior occurs so that the
behavior is more likely to occur again.
Example: If a client becomes anxious
when wailing to talk in a group, he or
she may volunteer to speak first to
avoid the anxiety.
Stimulus=anxiety caused by waiting to talk
behavior=volunteer to speak
Behavior that will occur again- volunteer to
speak
Systematic Desensitization
Conditioned responses: fears or phobias
Overcome irrational fears and anxiety
associated with phobias.
1. Make a list of situations involving
phobic object, from least to most
anxiety-provoking.
2. Learns and practices relaxation
techniques to decrease and manage
anxiety.
3. Exposed to least anxiety-provoking
situation
4. Uses relaxation techniques to manage
resulting anxiety.
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5. Client is gradually exposed to more and
more anxiety-provoking situations until
he or she can manage most anxiety-
provoking situation.
Behavioral Technique
- Anorexia Nervosa
- goal is weight gain
- behavioral contract between the client
and the therapist or physician is
initiated when treatment begins.
- client has little unsupervised time and
is restricted to the hospital unit
- contract may specify that if the client
gains a certain amount of weight, such
as 0.2 ka/day, in return, he or she will
get increased unsupervised lime or
lime off the unit if the weight gain
progresses.
- When working with children with
attention-deficit/hyperactivity
disorder
- goals include task completion for
homework, hygiene tasks, fur-taking
when talking, and so forth
- child is given a "star" or sticker when
tasks are completed.
- Upon reaching a specified number of
stars, the child receives a reward.
Behavioral Therapy
Considers how reinforcement influences
behavior. Through reinforcement, a person
learns to perform a certain response either to
receive a reward or to avoid a punishment.
Anxiety
Peplau defined anxiety as the initial response to
psychic threat.
4 Levels of Anxiety
Mild positive state of heightened
Anxiety awareness/ sharpened senses;
learn new behaviors; solve
problems; can take in all
available stimuli (perceptual
field)
Moderate -decreased perceptual field
Anxiety (focus on immediate task only):
can learn new behavior or solve
problems only with assistance;
another person can redirect
person to the task
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Severe feelings of dread or terror;
Anxiety cannot be redirected to a task;
focuses only on scattered
details and has physiologic
symptoms of tachycardia,
diaphoresis, and chest pain;
may go to an emergency
department, believing he or
she is having a heart attack.
Panic - loss of rational thought,
Anxiety delusions, hallucinations,
complete physical immobility,
and muteness; may bolt and
run aimlessly, often exposing
him or herself to injury
Concepts of Mental Health & Mental Illness
Humanistic Theories
Humanism -shift away from psychoanalytic view
of individual as neurotic, impulse-driven person
with repressed psychic problems and away from
examination of client's past experiences.:
- It focuses on person's positive
qualities, his or her capacity to change
(human potential), and promotion of
self-esteem.
- It consider the person's past
experiences, but they direct more
attention toward the present and
future.
Abraham Maslow: Hierarchy of Needs
Carl Rogers: Client – Centered Therapy
- (1902-1987) humanistic American
psychologist
- focused on therapeutic relationship
- first to use client rather than patient
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- focuses on role of client, rather than
therapist
- believed each person experiences the
world differently and knows his or her
own experience best
- clients do "the work of healing"
- supportive /nurturing client-therapist
relationship > clients cure themselves
(best position to know their own
experiences and make sense of them) >
regain self-esteem > self-actualization
- person-centered approach = client as
the expert
therapist must promote client's self-esteem
through 3 central concepts:
1. Unconditional positive regard -
nonjudgmental caring
2. Genuineness- realness between what
therapist feels and says
3. Empathetic understanding- senses
feelings and personal meaning from
the client
Unconditional positive regard> self-esteem >
Decreased defensive behavioral self >
acceptance grows > self-actualization
- basic nature of humans is to become
self-actualized
- We are born with a positive self-regard;
natural inclination to become sell
actualized.
o Supportive and nurturing - self-worth -
self-actualization
o Repeated conflicts/non supportive
relationships - loses self-esteem-
defensive - no longer inclined toward
self-actualization
Crisis
a turning point in an individual's life that
produces an overwhelming emotional response.
- life circumstance or stressor that
cannot be effectively managed through
use of customary coping skills.
Caplan (1964) identified the stages of crisis:
1. exposure to a stressor - anxiety - tries
to cope in a customary manner
2. anxiety increases when customary
coping skills are ineffective
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3. makes all possible efforts to deal with Resolved in 1 of 3 ways:
stressor, including attempts at new 1. person either returns to pre-crisis level
methods of coping of functioning
4. coping attempts fail, experiences 2. begins to function at a higher level
disequilibrium, significant distress *Both are positive outcomes for the individual
3 Categories: 3. person's functioning stabilizes at a level
Maturational crises (developmental crises) lower than pre-crisis functioning
- predictable events in the normal *Negative outcome for the individual
course of life Positive outcomes
Situational crises = problem is clearly thoroughly defined early
- unanticipated or sudden events that intervention
threaten individual's integrity
Adventitious crises (social crises)
- Natural disasters like floods,
earthquakes, or hurricanes; war,
terrorist attacks; riots; violent crimes
Crisis Intervention
- Not all events that result in crisis are
"negative" in nature.
- Events like marriage, retirement, and
childbirth are often desirable for the
individual but may still present
overwhelming challenges.
Aguilera (1998) identified three factors that
influence whether or not an individual
experiences a crisis:
1. individual's perception of the event
2. emotional supports
3. adequate coping mechanisms.
Directive interventions are designed to:
1. assess health status
2. promote problem solving, such as
offering new information. knowledge,
or meaning
3. raising self-awareness by providing
feedback about behavior
4. directing behavior by offering
suggestions or courses of action
Supportive interventions aim at dealing with
needs for empathetic understanding
1. encouraging identification and
discussion of feelings
2. serving as a sounding board for the
person
3. affirming self-worth
Crisis
- self-limiting (4 to 6 weeks)

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