Textbook Ebook Psychiatric Mental Health Nursing Seventh North American Edition Version Revised Version All Chapter PDF

Psychiatric Mental Health Nursing
Seventh, North American Edition ■

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Barbara J. Goldberg, MS, RN, CNS
Assistant Professor
Onondaga Community College
Syracuse, New York
Judith E. Gunther, MSN, RN

Associate Professor of Nursing
Northern Virginia Community College
Springfield, Virginia
Lois Harder, RN
Senior Lecturer
West Virginia University
Morgantown, West Virginia
Tina L. Kinney, MSN, RNC, FNP-BC, WHNP-BC

Nursing Instructor
Lutheran School of Nursing
St. Louis, Missouri
Lynne S. Mann, MN, RN, CNE

Assistant Professor
Charleston Southern University
Charleston, South Carolina
J. Susan G. Van Wye, MSN, RN, ARNP, CPNP

Adjunct Nursing Faculty
Kirkwood Community College
Cedar Rapids, Iowa
8
The seventh edition of Psychiatric–Mental Health Nursing maintains a strong student focus, presenting sound
nursing theory, therapeutic modalities, and clinical applications across the treatment continuum. The chapters
are short, and the writing style is direct in order to facilitate reading comprehension and student learning.
This text uses the nursing process framework and emphasizes therapeutic communication with examples
and pharmacology throughout. Interventions focus on all aspects of client care, including communication,
client and family education, and community resources, as well as their practical application in various clinical
settings.
In this edition, all DSM-5 content has been updated, as well as the Best Practice boxes, to highlight current
evidence-based practice. New special features include Concept Mastery Alerts, which clarify important
concepts that are essential to students’ learning, and Watch and Learn icons that alert students to important
video content available on . Cultural and Elder Considerations have special headings to help call
attention to this important content. The nursing process sections have a new design to help highlight this
content as well.
ORGANIZATION OF THE TEXT

Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses current issues in
psychiatric nursing as well as the many treatment settings in which nurses encounter clients. It thoroughly
discusses neurobiologic theories, psychopharmacology, and psychosocial theories and therapy as a basis for
understanding mental illness and its treatment.
Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practice of mental
health nursing. Chapters on therapeutic relationships and therapeutic communication prepare students to
begin working with clients both in mental health settings and in all other areas of nursing practice. The
chapter on the client’s response to illness provides a framework for understanding the individual client. An
entire chapter is devoted to assessment, emphasizing its importance in nursing.
Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental health settings.
These include legal and ethical issues; anger, aggression, and hostility; abuse and violence; and grief and loss.
Nurses in all practice settings find themselves confronted with issues related to these topics. Additionally,
many legal and ethical concerns are interwoven with issues of violence and loss.
Unit 4: Nursing Practice for Psychiatric Disorders covers all the major categories of mental disorders. This
unit has been reorganized to reflect current concepts in mental disorders. New chapters include trauma and
9
stressor-related disorders; obsessive–compulsive disorder and related disorders; somatic symptom disorders;
disruptive disorders; and neurodevelopmental disorders. Each chapter provides current information on
etiology, onset and clinical course, treatment, and nursing care. The chapters are compatible for use with any
medical classification system for mental disorders.
PEDAGOGICAL FEATURES
Psychiatric–Mental Health Nursing incorporates several pedagogical features designed to facilitate student
learning:
• Learning Objectives focus on the students’ reading and study.

• Key Terms identify new terms used in the chapter. Each term is identified in bold and defined in the text.
• Application of the Nursing Process sections, with a special design in this edition, highlight the assessment
framework presented in Chapter 8 to help students compare and contrast various disorders more easily.
• Critical Thinking Questions stimulate students’ thinking about current dilemmas and issues in mental
health.
• Key Points summarize chapter content to reinforce important concepts.
• Chapter Study Guides provide workbook-style questions for students to test their knowledge and
understanding of each chapter.
SPECIAL FEATURES
• Clinical Vignettes, provided for each major disorder discussed in the text, “paint a picture” of a client
dealing with the disorder to enhance understanding.
• Nursing Care Plans demonstrate a sample plan of care for a client with a specific disorder.
• Drug Alerts highlight essential points about psychotropic drugs.
• Warning boxes are the FDA black box drug warnings for specific medications.
• Cultural Considerations sections highlight diversity in client care.
• Elder Considerations sections highlight the key considerations for a growing older adult population.
• Therapeutic dialogues give specific examples of the nurse–client interaction to promote therapeutic
communication skills.
• Client/Family Education boxes provide information that helps strengthen students’ roles as educators.
• Nursing Interventions provide a summary of key interventions for the specific disorder.
• DSM-5 Diagnostic Criteria boxes include specific diagnostic information for the disorder.
• Best Practices boxes highlight current evidence-based practice and future directions for research on a wide
variety of practice issues.
• Self-Awareness features encourage students to reflect on themselves, their emotions, and their attitudes as a
way to foster both personal and professional development.
• Concept Mastery Alerts clarify important concepts that are essential to students’ learning and practice.
• Watch and Learn icons alert the reader to important resources available on to enhance student
understanding of the topic.
10
ANCILLARY PACKAGE FOR THE SEVENTH EDITION
Instructor Resources
The Instructor Resources are available online at http://thepoint.lww.com/Videbeck7e for instructors who
adopt Psychiatric–Mental Health Nursing. Information and activities that will help you engage your students
throughout the semester include:
• PowerPoint Slides
• Image Bank
• Test Generator
• Pre-Lecture Quizzes
• Discussion Topics
• Written, Group, Clinical, and Web Assignments
• Guided Lecture Notes
• Case Studies
Student Resources
Students who purchase a new copy of Psychiatric–Mental Health Nursing gain access to the following learning
tools on using the access code in the front of their book:
• , highlighting films depicting individuals with mental health disorders, provide students the
opportunity to approach nursing care related to mental health and illness in a novel way.
• NCLEX-Style Review Questions help students review important concepts and practice for the NCLEX
examination.
• Journal Articles offer access to current research available in Wolters Kluwer journals.
• Online video series, Lippincott Theory to Practice Video Series includes videos of true-to-life clients
displaying mental health disorders, allowing students to gain experience and a deeper understanding of
these patients.
• Internet Resources provide relevant weblinks to further explore chapter content.
Practice Makes Perfect, and This Is the Perfect Practice.

PrepU is an adaptive learning system designed to improve students’ competency and mastery and provide
instructors with real-time analysis of their students’ knowledge at both a class and individual student level.
PrepU demonstrates formative assessment—it determines what students know as they are learning, and
focuses them on what they are struggling with, so they don’t spend time on what they already know. Feedback
is immediate and remediates students back to this specific text, so they know where to get help in
understanding a concept.
Adaptive and Personalized

No student has the same experience—PrepU recognizes when a student has reached “mastery” of a concept
11
before moving him/her on to higher levels of learning. This will be a different experience for each student
based on the number of questions he/she answers and whether he/she answers them correctly. Each question
is also “normed” by all students in PrepU around the country—how every student answers a specific question
generates the difficulty level of each question in the system. This adaptive experience allows students to
practice at their own pace and study much more effectively.
Personalized Reports
Students get individual feedback about their performance, and instructors can track class statistics to gauge the
level of understanding. Both get a window into performance to help identify areas for remediation. Instructors
can access the average mastery level of the class, students’ strengths and weaknesses, and how often students
use PrepU. Students can see their own progress charts showing strengths and weaknesses—so they can
continue quizzing in areas where they are weaker.
Mobile Optimized
Students can study anytime, anywhere with PrepU, as it is mobile optimized. More convenience equals more
quizzing and more practice for students!
There is a PrepU resource available with this book! For more information, visit
http://thepoint.lww.com/PrepU.
This leading content is also incorporated into Lippincott CoursePoint, a dynamic learning solution that
integrates this book’s curriculum, adaptive learning tools, real-time data reporting, and the latest evidence-
based practice content into one powerful student learning solution. Lippincott CoursePoint improves the
nursing students’ critical thinking and clinical reasoning skills to prepare them for practice. Learn more at
www.NursingEducationSuccess.com/CoursePoint.
12
Many years of teaching and practice have shaped my teaching efforts and this textbook.
Students provide feedback and ask ever-changing questions that guide me to keep this text useful, easy to
read and understand, and focused on student learning. Students also help keep me up to date, so the text can
stay relevant to their needs. I continue to work with students in simulation lab experiences as nursing
education evolves with advances in technology.
I want to thank the people at Wolters Kluwer for their valuable assistance in making this textbook a reality.
Their contributions to its success are greatly appreciated. I thank Natasha McIntyre, Dan Reilly, Zach
Shapiro, Helen Kogut, and Cynthia Rudy for a job well done once again.
My friends continue to listen, support, and encourage my efforts in all endeavors. My brother and his
family provide love and support in this endeavor, as well as in the journey of life. I am truly fortunate and
grateful.
13
Unit 1
Current Theories and Practice
1. Foundations of Psychiatric–Mental Health Nursing
Mental Health and Mental Illness
Diagnostic and Statistical Manual of Mental Disorders
Historical Perspectives of the Treatment of Mental Illness
Mental Illness in the 21st Century
Cultural Considerations
Psychiatric Nursing Practice
2. Neurobiologic Theories and Psychopharmacology
The Nervous System and How it Works
Brain Imaging Techniques
Neurobiologic Causes of Mental Illness
The Nurse’s Role in Research and Education
Psychopharmacology
3. Psychosocial Theories and Therapy
Psychosocial Theories
Treatment Modalities
The Nurse and Psychosocial Interventions
4. Treatment Settings and Therapeutic Programs
Treatment Settings
Psychiatric Rehabilitation and Recovery
Special Populations of Clients with Mental Illness
Interdisciplinary Team
Psychosocial Nursing in Public Health and Home Care
Unit 2
Building the Nurse–Client Relationship
14
5. Therapeutic Relationships
Components of a Therapeutic Relationship
Types of Relationships
Establishing the Therapeutic Relationship
Avoiding Behaviors that Diminish the Therapeutic Relationship
Roles of the Nurse in a Therapeutic Relationship
6. Therapeutic Communication
What is Therapeutic Communication?
Verbal Communication Skills
Nonverbal Communication Skills
Understanding the Meaning of Communication
Understanding Context
Understanding Spirituality
The Therapeutic Communication Session
Assertive Communication
Community-Based Care
7. Client’s Response to Illness
Individual Factors
Interpersonal Factors
Cultural Factors
8. Assessment
Factors Influencing Assessment
How to Conduct the Interview
Content of the Assessment
Assessment of Suicide or Harm Toward Others
Data Analysis
Unit 3
Current Social and Emotional Concerns
9. Legal and Ethical Issues

Legal Considerations
Ethical Issues
10. Grief and Loss

Types of Losses
The Grieving Process
Dimensions of Grieving
15
Disenfranchised Grief
Complicated Grieving
Application of the Nursing Process
11. Anger, Hostility, and Aggression

Onset and Clinical Course
Related Disorders
Etiology
Treatment
Workplace Hostility
12. Abuse and Violence

Clinical Picture of Abuse and Violence
Characteristics of Violent Families
Intimate Partner Violence
Child Abuse
Elder Abuse
Rape and Sexual Assault
Community Violence
Unit 4
Nursing Practice for Psychiatric Disorders
13. Trauma and Stressor-Related Disorders
Posttraumatic Stress Disorder
Etiology
Treatment
Elder Considerations
Mental Health Promotion
14. Anxiety and Anxiety Disorders

Anxiety as a Response to Stress
Overview of Anxiety Disorders
Incidence
16
Related Disorders
Etiology
Treatment
Panic Disorder
Application of the Nursing Process: Panic Disorder
Phobias
Generalized Anxiety Disorder
15. Obsessive–Compulsive and Related Disorders

Obsessive–Compulsive Disorder
16. Schizophrenia
Clinical Course
Related Disorders
Etiology
Treatment
17. Mood Disorders and Suicide

Categories of Mood Disorders
Related Disorders
Etiology
Major Depressive Disorder
Application of the Nursing Process: Depression
Bipolar Disorder
Application of the Nursing Process: Bipolar Disorder
17
Suicide
18. Personality Disorders

Personality Disorders
Etiology
Treatment
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Application of the Nursing Process: Antisocial Personality Disorder
Borderline Personality Disorder
Application of the Nursing Process: Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive–Compulsive Personality Disorder
19. Addiction
Types of Substance Abuse
Related Disorders
Etiology
Types of Substances and Treatment
Treatment and Prognosis
18
Substance Abuse in Health Professionals
20. Eating Disorders

Overview of Eating Disorders
Categories of Eating Disorders
Etiology
Anorexia Nervosa
Bulimia
21. Somatic Symptom Illnesses

Overview of Somatic Symptom Illnesses
Related Disorders
Etiology
22. Neurodevelopmental Disorders

Autism Spectrum Disorder
Related Disorders
Attention Deficit Hyperactivity Disorder
Application of the Nursing Process: Attention Deficit Hyperactivity Disorder
23. Disruptive Behavior Disorders

Related Disorders
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Related Problems
Application of the Nursing Process: Conduct Disorder
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24. Cognitive Disorders

Delirium
Application of the Nursing Process: Delirium
Dementia
Related Disorders
Application of the Nursing Process: Dementia
Role of the Caregiver
Answers to Chapter Study Guides
Appendix A
Disorders of Sleep and Wakefulness
Appendix B
Sexual Dysfunctions and Gender Dysphoria
Appendix C
Drug Classification Under the Controlled Substances Act
Appendix D
Canadian Drug Trade Names
Appendix E
Mexican Drug Trade Names
Glossary of Key Terms

Index
20
Key Terms
• asylum
• boarding
• case management
• deinstitutionalization
• Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
• managed care
• managed care organizations
• mental health
• mental illness
• phenomena of concern
• psychotropic drugs
• self-awareness
• standards of care
• utilization review firms
Learning Objectives
After reading this chapter, you should be able to:
1. Describe characteristics of mental health and mental illness.
2. Discuss the purpose and use of the American Psychiatric Association’s Diagnostic and Statistical Manual of
21
Mental Disorders (DSM-5).
3. Identify important historical landmarks in psychiatric care.
4. Discuss current trends in the treatment of people with mental illness.
5. Discuss the American Nurses Association (ANA) standards of practice for psychiatric–mental health
nursing.
6. Describe common student concerns about psychiatric nursing.
AS YOU BEGIN THE STUDY OF psychiatric–mental health nursing, you may be excited, uncertain, and even
somewhat anxious. The field of mental health often seems a little unfamiliar or mysterious, making it hard to
imagine what the experience will be like or what nurses do in this area. This chapter addresses these concerns
and others by providing an overview of the history of mental illness, advances in treatment, current issues in
mental health, and the role of the psychiatric nurse.
MENTAL HEALTH AND MENTAL ILLNESS

Mental health and mental illness are difficult to define precisely. People who can carry out their roles in
society and whose behavior is appropriate and adaptive are viewed as healthy. Conversely, those who fail to
fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The culture of
any society strongly influences its values and beliefs, and this, in turn, affects how that society defines health
and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive
and inappropriate.
Mental Health
The World Health Organization defines health as a state of complete physical, mental, and social wellness,
not merely the absence of disease or infirmity. This definition emphasizes health as a positive state of well-
being. People in a state of emotional, physical, and social well-being fulfill life responsibilities, function
effectively in daily life, and are satisfied with their interpersonal relationships and themselves.
No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his
or her mental health. Because each person can have a different view or interpretation of behavior (depending
on his or her values and beliefs), the determination of mental health may be difficult. In most cases, mental
health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive self-concept, and emotional stability.
Mental health has many components, and a wide variety of factors influence it. These factors interact; thus,
a person’s mental health is a dynamic, or ever-changing, state. Factors influencing a person’s mental health
can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a
person’s biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to
find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or
stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to
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help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental,
factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity
among people, mastery of the environment, and a positive, yet realistic, view of one’s world. Individual,
interpersonal, and social/cultural factors are discussed further in Chapter 7.
Mental Illness
Mental illness includes disorders that affect mood, behavior, and thinking, such as depression, schizophrenia,
anxiety disorders, and addictive disorders. Mental disorders often cause significant distress, impaired
functioning, or both. Individuals experience dissatisfaction with self, relationships, and ineffective coping.
Daily life can seem overwhelming or unbearable. Individuals may believe that their situation is hopeless.
Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural
categories. Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to
distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of
meaning in one’s life. Interpersonal factors include ineffective communication, excessive dependency on or
withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control.
Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view
of the world, and discrimination such as stigma, racism, classism, ageism, and sexism.
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

DISORDERS
The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) is a taxonomy published by
the American Psychiatric Association and is revised as needed. The current edition made some major
revisions and was released in 2013. The DSM-5 describes all mental disorders, outlining specific diagnostic
criteria for each based on clinical experience and research. All mental health clinicians who diagnose
psychiatric disorders use this diagnostic taxonomy.
The DSM-5 has three purposes:
• To provide a standardized nomenclature and language for all mental health professionals
• To present defining characteristics or symptoms that differentiate specific diagnoses
• To assist in identifying the underlying causes of disorders
The classification system allows the practitioner to identify all the factors that relate to a person’s condition:
• All major psychiatric disorders such as depression, schizophrenia, anxiety, and substance-related disorders
• Medical conditions that are potentially relevant to understanding or managing the person’s mental disorder
as well as medical conditions that might contribute to understanding the person
• Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental
disorders. Included are problems with the primary support group, the social environment, education,
occupation, housing, economics, access to health care, and the legal system.
Although student nurses do not use the DSM-5 to diagnose clients, they will find it a helpful resource to
23
understand the reason for the admission and to begin building knowledge about the nature of psychiatric
illnesses.
HISTORICAL PERSPECTIVES OF THE TREATMENT OF

MENTAL ILLNESS
Ancient Times
People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a
punishment for sins and wrongdoing. Those with mental disorders were viewed as being either divine or
demonic, depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as
demonic were ostracized, punished, and sometimes burned at the stake. Later, Aristotle (382–322 BC)
attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood,
water, and yellow and black bile in the body controlled the emotions. These four substances, or humors,
corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to
cause mental disorders; so treatment was aimed at restoring balance through bloodletting, starving, and
purging. Such “treatments” persisted well into the 19th century (Baly, 1982).
Possessed by demons
In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were
again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exorcisms to rid
evil spirits. When that failed, they used more severe and brutal measures, such as incarceration in dungeons,
flogging, and starving.
In England during the Renaissance (1300–1600), people with mental illness were distinguished from
criminals. Those considered harmless were allowed to wander the countryside or live in rural communities,
but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547,
the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind. By
24
1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who
were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the
United States), the mentally ill were considered evil or possessed and were punished.Witch hunts were
conducted, and offenders were burned at the stake.
Period of Enlightenment and Creation of Mental Institutions

In the 1790s, a period of enlightenment concerning persons with mental illness began. Philippe Pinel in
France and William Tuke in England formulated the concept of asylum as a safe refuge or haven offering
protection at institutions where people had been whipped, beaten, and starved just because they were mentally
ill (Gollaher, 1995). With this movement began the moral treatment of the mentally ill. In the United States,
Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit to Tuke’s
institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the
suffering. Dix believed that society was obligated to those who were mentally ill; she advocated adequate
shelter, nutritious food, and warm clothing (Gollaher, 1995).
The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state
hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of hospitals
were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a
negative connotation.
Sigmund Freud and Treatment of Mental Disorders

The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856–1939) and
others, such as Emil Kraepelin (1856–1926) and Eugen Bleuler (1857–1939). With these men, the study of
psychiatry and the diagnosis and treatment of mental illness started in earnest. Freud challenged society to
view human beings objectively. He studied the mind, its disorders, and their treatment as no one had done
before. Many other theorists built on Freud’s pioneering work (see Chapter 3). Kraepelin began classifying
mental disorders according to their symptoms, and Bleuler coined the term schizophrenia.
Development of Psychopharmacology
A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic
drugs, or drugs used to treat mental illness. Chlorpromazine (Thorazine), an antipsychotic drug, and lithium,
an antimanic agent, were the first drugs to be developed. Over the following 10 years, monoamine oxidase
inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety
agents, called benzodiazepines, were introduced. For the first time, drugs actually reduced agitation, psychotic
thinking, and depression. Hospital stays were shortened, and many people became well enough to go home.
The level of noise, chaos, and violence greatly diminished in the hospital setting.
Move toward Community Mental Health

The movement toward treating those with mental illness in less restrictive environments gained momentum in
25
1963 with the enactment of the Community Mental Health Centers Construction Act.
Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities,
began. Community mental health centers served smaller geographic catchment, or service, areas that provided
less restrictive treatment located closer to individuals’ homes, families, and friends. These centers provided
emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education.
Thus, deinstitutionalization accomplished the release of individuals from long-term stays in state institutions,
the decrease in admissions to hospitals, and the development of community-based services as an alternative to
hospital care.
In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled
persons: Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). This allowed
people with severe and persistent mental illness to be more independent financially and to not rely on family
for money. States were able to spend less money on care of the mentally ill than they had spent when these
individuals were in state hospitals because this program was federally funded. Also, commitment laws changed
in the early 1970s, making it more difficult to commit people for mental health treatment against their will.
This further decreased the state hospital populations and, consequently, the money that states spent on them.
MENTAL ILLNESS IN THE 21ST CENTURY

The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that more than
18.6% of Americans aged 18 years and older have some form of mental illness—approximately 43.7 million
persons. In the past year, 20.7 million people or 18.6%, had a substance use disorder. Of these, 8.4 million
had co-occurring mental illness and substance use disorder, or dual diagnosis (2015). Furthermore, mental
illness or serious emotional disturbances impair daily activities for an estimated 15 million adults and 4 million
children and adolescents. For example, attention deficit hyperactivity disorder affects 3% to 5% of school-aged
children. More than 10 million children younger than 7 years grow up in homes where at least one parent
suffers from significant mental illness or substance abuse, a situation that hinders the readiness of these
children to start school. The economic burden of mental illness in the United States, including both health-
care costs and lost productivity, exceeds the economic burden caused by all kinds of cancer. Mental disorders
are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age. Yet only
one in four adults and one in five children and adolescents requiring mental health services get the care they
need.
Some believe that deinstitutionalization has had negative as well as positive effects. Although
deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those
beds correspondingly increased by 90%. Such findings have led to the term revolving door effect. Although
people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals
more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general
hospital psychiatric units. In some cities, emergency department (ED) visits for acutely disturbed persons have
increased by 400% to 500%. Patients are often boarded or kept in the ED while waiting to see if the crisis de-
escalates or till an inpatient bed can be located or becomes available.
26
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tolerably firm brick-red mass adherent to surrounding brain, and
showing in the centre a softened clot about the size of a pea.
Twenty-eight to thirty-five days—soft, brownish, and semifluid. Forty-
one days—spot of softening filled with brownish material. One
hundred days—somewhat darker, and a little more distinctly marked
from surrounding tissues; by microscope granular corpuscles,
groups of fatty granules along the swollen vessels, granules of
pigment. Eighty-three years—old hemorrhagic focus in right optic
thalamus, color yellowish, and areolar structure.
The thirtieth day is given as about the time at which the walls of the
cyst become more firm and distinct. The following statement is
prepared from a considerable number of cases given by Durand-
Fardel: From four to six weeks, the clot is dark-colored, from black to
ochrey or reddish-yellow. It varies in firmness. The capsule is
tolerably firm. From two to four months, it seems to be generally
softer, pultaceous, grumous, or the clot still remaining swimming in
serum; in some cases lighter in color. In six months it has lost more
in color, and the cavity may be smaller. In a year there is still
considerable color left. In a few cases after some years the blood
has been found in the form of a dried mass, not changed or darker in
color.
Hemorrhages of several months' standing may be indicated either by

a brownish-red patch somewhat firmer in texture than the
surrounding brain-substance, or by a cavity with firm walls, which
often has strings and septa of connective tissue running across it, so
as to convert it into a kind of spongy mass filled with brownish fluid.
The most important changes which are found in most if not all cases
of ordinary hemorrhages (i.e. such as do not depend upon violence
or cachexia) are those of the blood-vessels. They are not, however,
visible in the ordinary inspection of the brain at an autopsy, but
require to be carefully sought for, either with the microscope or a
somewhat tedious process of washing. For this reason there are no
trustworthy statistics of large numbers to determine in how large a
proportion of all the cases alterations in the blood-vessels are to be
found, and in what form. There can be but little doubt, however, that
those cases in which no form of arterial disease is present (if, with
the reservation just noted as to violence or cachexia, such exist) are
to be looked upon as rare exceptions.
The presence of miliary aneurisms in the brain had been noted in

some cases, and even in cerebral hemorrhage, without the great
importance of the observation having been perceived; but the
extended and careful observations of Charcot and Bouchard first
showed how extremely common their presence is, while in many
instances they were found actually ruptured. These aneurisms are
present in the largest numbers in the regions of the brain where
hemorrhage is most frequent, and at the age when death from
apoplexy is most likely to occur. They have been found at the age of
twenty, but very rarely at early ages, while after forty they are not
uncommon. It is of course not always that they have gone on to
rupture, but may occasionally be found where no hemorrhages have
taken place. It is not going far, however, to infer that in such cases
the hemorrhage was not very distant.
These aneurisms are dependent upon a periarteritis which is

diffused more or less widely over the cerebral arteries, but not over
those of the rest of the body. The larger arteries get a thin and
shining appearance, compared by Charcot and Bouchard to the skin
of an onion, while the smaller ones present besides distinct
aneurisms, bulgings and irregularities of outline. This condition may
be—and, as would be at once suggested from the age at which both
lesions are met with, is—very likely to be associated with atheroma,
but it is not the same thing, since the development of the aneurisms
depends upon a periarteritis, and that of atheroma upon an
endarteritis. It may be remarked, also, that atheroma usually does
not affect the very small arteries which bear the aneurisms and give
rise to the hemorrhage.
These aneurisms are visible to the naked eye, being from two-tenths
to one millimeter, or a little more, in diameter, while the artery to
which they are attached can be seen by the naked eye or with a lens
magnifying two or three diameters. They may be strung along a
small artery like beads or be found in groups like a bunch of grapes.
Charcot and Bouchard found them in every case of cerebral
hemorrhage which they examined, and, although the possibility of
other sources was admitted, concluded that in by far the greater
number of cases, excluding those dependent upon traumatism or
hemorrhagic diseases, the blood effused in the brain has its origin in
one of these aneurisms. The presence of these aneurisms has been
abundantly established by other observers, and the fact that they are
not usually demonstrated proves nothing except the amount of care
and time necessary to find them. One does, however, find
occasionally noted that they were sought for and not found. The
statements of Charcot and Bouchard relate, so far as their own
observations are concerned, and as they themselves remark, chiefly
to aged persons, but in their first series of 66 cases there is found 1
of twenty and 1 of forty years of age. The patient of twenty was a
semi-imbecile and a drunkard. Extensive cerebral hemorrhage, with
atheroma, in the circle of Willis has been found in an apparently
healthy and well-nourished boy of fifteen.2
2 Baker, Annals of Anat. and Surg. Soc. Brooklyn, 1879, p. 40.
Larger aneurisms, often multiple, are not very infrequent upon the
arteries at the base of the brain. They may before their rupture give
rise to symptoms of pressure like any other tumor, and may also be
the source of hemorrhage, which is usually meningeal. They are not
infrequently symmetrical, and a place of election is one of the early
bifurcations of the middle cerebral.
Coats3 states that aneurism of the larger arteries is the most frequent
source of hemorrhage in persons under fifty. They may be due to
embolism, producing, when the occlusion is not complete,
mechanical injury to the walls of the vessels by the constant
hammering upon them of the embolus under the impulse of the
blood. If this etiology is a common one, it accounts for the frequent
situation of these aneurisms in the middle cerebral arteries.
3 Glasgow Med. Journ., 1882, xvii. 109.
Small vessels in a condition of fatty degeneration are often found in
the neighborhood of a cerebral hemorrhage. In some cases,
undoubtedly, the degeneration is a consequence of the injury to
which the cerebral substance has been subjected, but they have
also been found too soon after the hemorrhage for this explanation
to hold; and in cases where no aneurisms are present the older
supposition, that hemorrhage results from this kind of degeneration,
seems to have a certain foundation, even if only in a minimum of
cases.
In several cases of cerebral hemorrhage in purpura, where the

general character of the disease was shown by hemorrhages in
other organs, fatty degeneration of the cerebral vessels has been
found, together with extensive steatosis of the liver, kidneys,
muscles, and heart.4 In a cerebral hemorrhage found in the brain of a
girl of eleven the walls of the vessels were dotted with fat-globules
and dark granules, and several of them studded with round and oval
nuclei closely resembling the nuclei (small cells?) commonly found in
tubercle. There was no trace of tubercle in any part of the body.5
4 Gazette hébdomadaire, May 12, 1876, p. 288.
5 Trans. Path. Soc., Cayley.
There is no possible means of determining in which way any given

bleeding has arisen, except a very minute search, and this may fail
to show the actual point of rupture. It seems highly probable, from
the connection of some cases of hemorrhage with valvular disease
of the heart, that embolism may give rise to effusions of blood,
especially capillary and multiple ones. In such cases the emboli may
be deposited in arteries far too small to be obvious in the ordinary
process of dissection. (See Capillary Embolism.)
Hemorrhage arises in some rare cases from the backing up of blood

in the veins when they are obstructed by thrombosis. A case has
been described where meningeal and ventricular hemorrhage
resulted from a rupture of the straight sinus at its juncture with the
torcular Herophili.6
6 Mullar, Lancet, 1849, i. 607.
In many diseases like purpura, idiopathic anæmia, and

leucocythæmia many hemorrhages may take place in the brain as
well as elsewhere throughout the body. Their importance under
these circumstances is usually not great.
The usual localities of cerebral hemorrhage are stated with much

minuteness in the following table from Durand-Fardel, which,
although not very recent (1854), is not the less accurate on that
account. No subsequent statistics have essentially altered its most
important conclusions. In 139 cases the hemorrhage was situated in
the hemispheres 119 times; in the protuberance (pons), 21; in the
cerebellum, 13; total, 153.
I have placed beside these a small number of cases from the

records of the Boston City Hospital and my own practice, and, to
avoid the multiplication of headings, have entered some multiple
hemorrhages under two or more heads, so that from the whole
number of cases (46) there are 81 entries:
Durand- B. C. H.
Fardel.
Corpus striatum and optic thalamus, together 22 4
Corpus striatum 13 10
Optic thalamus 5 3
Corpus striatum, optic thalamus, and middle lobe 2 1
Corpus striatum, optic thalamus, and a considerable portion, not well
defined, of the hemisphere 12 2
Corpus striatum, optic thalamus, with posterior lobe 1
Corpus striatum and middle lobe 3 3
Corpus striatum, with a considerable portion of hemisphere 5 1
Corpus striatum, with an extended portion of base of ventricle 1
Optic thalamus with middle lobe 2 1
Optic thalamus with posterior lobe 1
Middle (parietal) lobe 19 1
Sphenoidal horn of middle lobe (temporal) 2 4
Anterior (frontal) lobe 11 3
Posterior (occipital) lobe 11 5
A not well-determined extent of one hemisphere 4 3
The superficies of the convolutions (once with corpus callosum) 3 1
Insula — 2
Cortex (not further defined) — 1
Small multiple — 3
Meninges (secondarily) 31 6
Ventricles 66 8
In the cerebellum, right lobe 6
In the cerebellum, left lobe 5 4
In the cerebellum, middle lobe 2
In the protuberance (pons) 13 4
Protuberance and brain 8
Protuberance, crus cerebri, crus cerebelli, external capsule, fourth
ventricle — 1
It would not have been very difficult to increase these figures from
the large number of recorded cases, but there is nothing in later
statistics to invalidate the statement that the corpus striatum,
including both its nuclei, but especially the nucleus lentiformis, the
optic thalamus, and the white substance in their neighborhood, are
the portions of the brain by far the most frequently affected by
hemorrhage, and especially by hemorrhages of considerable size.
There is no essential difference in the frequency of hemorrhage on

the two sides. It may occur on both sides at once. Hughlings-
Jackson says that he saw a patient who escaped with life from the
effects of a clot which had paralyzed both sides of the face as well
as all four limbs. Charcot and Bouchard give the following localities
as containing in decreasing frequency the miliary aneurisms: optic
thalami, corpora striata, the convolutions, the protuberance, the
cerebellum, the centrum ovale, the middle peduncles of the
cerebellum, the cerebral peduncles, and the bulb. The close
correspondence of this list with the table of Durand-Fardel is in itself
a strong argument in favor of the importance of the miliary aneurisms
as the principal factors in determining cerebral hemorrhage.
The arteries supplying the nucleus lenticularis and external capsule

are small branches arising chiefly from the middle cerebral a short
distance from its origin, with some assistance from the anterior and
posterior cerebral. One of the larger of them runs along the outer
side of the nucleus lenticularis where it is covered by the external
capsule—a disposition which may have something to do with the
occurrence of the larger hemorrhages so likely to take place just
outside this nucleus and into the substance of the hemispheres.
The arteries of the optic thalamus arise from the posterior

communicating or the posterior cerebral. Why these two groups
should furnish, as they do, so large a part of cerebral hemorrhages it
is impossible to state, unless it be that from their origin so near to the
larger trunks before their division they are exposed to more
pressure, and hence a greater tendency to form aneurisms. The
functional activity of these regions is another possible reason. The
largest hemorrhages also seem to spring from these sources, and if
a table of large effusions were compiled it would probably show a
greater predilection for this locality than even the general one given
above, which includes those of all sizes.7
7 A very careful study of the form and size of foci of bleeding arising from the various
nutrient arteries of the brain will be found in the well-known elaborate papers of Duret
(Archives de Physiologie, 1874).
Before proceeding to a minute account of the symptoms

accompanying cerebral hemorrhage, a consideration of the relation
between extensive lesions and the most fully-developed clinical
phenomena will be of value—in other words, the pathology of
hemorrhagic or sanguineous apoplexy. This will naturally demand a
reference to the cases where the same symptoms are present with a
different lesion.
The most marked symptom, one which is essential to the definition

of apoplexy, is the sudden, or more frequently rapid, loss of
consciousness, and next, in a great proportion of cases, a unilateral
paralysis or paresis. The latter, in many cases, finds a sufficient
explanation in the rupture of fibres connecting the motor centres in
the brain with the spinal cord; but this does not cover all cases, for it
is well known that we may have paralysis without any laceration. In
fact, in many cases paralysis may disappear so rapidly as to put
aside at once any such explanation. Sufficient pressure upon
contracting fibres is entirely competent to arrest their conductivity,
and this pressure may be diffused over a considerably wider area
than that where total destruction of tissue has taken place.
Meningeal hemorrhage, where, of course, no laceration takes place,
may be attended by a well-marked hemiplegia when the effusion is
wholly or chiefly on one side.
The writer recalls a case of a man, of whose history little or nothing

was known, found unconscious with a very distinct difference in the
amount of motion to be provoked by irritation of the two sides. The
diagnosis naturally inclined to the more common causes of
hemiplegia, but the autopsy showed a purulent meningitis of the
vertex, with a layer of pus considerably thicker on the side opposed
to the paralysis.
A very similar statement may be made in regard to the symptom of

unconsciousness, which seldom occurs more rapidly and completely
than in cases of meningeal hemorrhage (not from injury), where, of
course, there is no question of laceration.
F. Pagenstecher8 succeeded in producing phenomena closely allied

to apoplexy by injecting at a known pressure, between the skull and
dura mater in dogs, masses of melted wax and tallow. In the first
group of cases the result was somnolence, great depression of the
psychical capacity, and general muscular weakness. The second
group showed, besides the condition of sopor, unilateral paralysis;
and the third contained cases in a part of which death followed in a
few hours after the setting in of coma, and in another part partial
recovery took place after scooping out the waxy mass. The
symptoms in these cases are referred to the pressure upon the
vessels; and it is stated that in order to destroy life the pressure had
to be equal to that of the blood. Convulsions were present in some
cases where the pressure was not steady. The temperature showed
a notable peculiarity in that, after the initial fall, in which it resembles
the course in human apoplexy, it kept on falling in the fatal cases,
instead of rapidly rising, as in man. After injection into the brain of
animals of sufficient quantities of water to produce great tension of
the occipito-atlantoid membrane, Duret9 found the respiration to
cease and the heart to be slowed. On tearing the membrane so as to
allow the water to escape, respiration began again, and the animals
gradually recovered consciousness. Similar effects could, however,
be produced by blows on the head.
8 Centralblatt f. d. Med. Wiss., 1871, p. 706.
9 Centralblatt f. d. Med. Wiss., 1878, p. 454.
Several cases are reported by P. R. Hoy10 where pressure upon the

brain produced an arrest of function, which was resumed when the
pressure was removed. In the first of these a piece of bone had been
removed, but the dura was intact. If the patient were asked a
question and the finger immediately pressed upon the dura, no
answer was made, but as soon as the finger was removed the reply
came. In two other cases, which are not without their parallels, the
patients resumed after trephining the mental attitude in which they
had been surprised by the injury—in one case hours, and in the
other years, before.
10 Journ. Nerv. and Ment. Dis., vol. iv. p. 288.
The natural generalization to be made from these cases and

experiments is, that pressure upon the brain-tissue suspends, for the
time, its function; but when we find exactly the same symptoms
arising from either sudden or gradual occlusion of the vessels where
we can hardly imagine increased pressure to exist, except perhaps
over a very small area of collateral hyperæmia, we must go a step
farther for a common factor; and it seems possible to find one which
will not only explain the several conditions spoken of, but also others
which closely resemble them. Simple anæmia will cover the cases of
hemorrhage and embolism, but certainly not narcotic poisoning and
certain other conditions where characteristic apoplectic symptoms
exist without discoverable lesion. If, however, we say that a
deprivation of a considerable portion of gray matter of its due supply
of arterialized and healthy blood suspends for a time its functional
activity, we can explain the similarity of results arising from very
different causes.
In a case of cerebral hemorrhage of considerable size the pressure

is distributed over a space much exceeding the area of the clot itself,
and renders a large part of at least one hemisphere anæmic. If the
blood finds its way into the ventricles, the conditions are most
favorable for compressing nearly the whole brain. The anæmic
appearance of the cerebral surface is often remarked at autopsies.
When an embolus lodges in an artery and produces complete

occlusion, the portion of brain supplied thereby becomes at once
entirely anæmic, since the arteries on the surface have so slight
anastomoses that they are entirely unable to supply the deficiency,
except to a slight extent around the edges of the vascular territory
involved. The anæmia, however, does not extend beyond the
territory originally affected, and consequently we may have extensive
paralysis from embolism without a marked apoplectic attack. In
extreme congestion of the brain the reverse may seem to be the
case.
In reality, the hindrance to the proper functions is nearly the same,

since blood which is not duly renovated and contains the products of
metamorphosis of tissue in excess is worth as little for healthy
nutrition as no blood at all. There is no reason to suppose that blood
in circulation, no matter in how great quantity, gives rise to
unconsciousness. It may cause over-action or disordered action, as
in mania, but not arrest of action.
The narcotic poisons also deprive the nerve-tissue of its healthy

food; whether by interference with oxygenation and depuration, or by
a direct action of the substance itself on the nerve-cells, it is not easy
to say. The fact that the completeness and duration of the
unconsciousness are not in proportion to the paralysis or anæsthesia
shows that they are to some extent independent of each other; and,
although it is possible to locate with some precision the lesion which
abolishes motor power and conscious sensation, yet we cannot say
how much or what part of the brain must be deprived of its function
in order to produce that cutting off of all conscious relation with the
external world and reduction of a feeling, thinking, remembering, and
acting organism to the level of a mere automatic breathing-machine,
which we designate as loss of consciousness.
In fact, in the present state of our knowledge as to what

consciousness is, any speculation as to its seat would be a waste of
time, and we must content ourselves with recognizing that
experience seems to show that a large part, rather than any
particular part of the brain, must be involved, not necessarily in the
primary lesion, but in the resulting pressure or anæmia.
Another theory of unconsciousness is simply that it is due to shock—

that the sudden irruption of blood acts like a blow, as it were, and
abolishes for a time the function of the nervous structure. This is
substituting something indefinite for something comparatively
definite; and it is certainly not true that the more sudden the shock
the more complete the unconsciousness. It may come on after the
paralysis is apparent, and in fact is more commonly gradual than
sudden in its onset. The classical instantaneous shock is the rare
exception. In the celebrated case where a tamping-iron was driven
completely through a man's skull and brain, he himself was able to
give a clear description of the accident to the surgeon who first
attended him. Several other instances of severe and sudden injury to
the brain without loss of consciousness have been recorded.
ETIOLOGY.—As regards the greater number of cases and the most

common pathology, the existence of so specific and peculiar lesion
as aneurism enables us to distinguish between predisposing and
exciting causes, or, in other words, the conditions which lead to the
localized periarteritis with its resulting aneurisms and those which
cause their rupture. Unfortunately, the aneurisms are not usually
looked for, and in the collection of statistics we are obliged to group
together cases the pathology of which is not always the same, and
which are usually collected under the name of apoplexy.
Age, however, is well known, both on clinical and anatomical

grounds, to be the most important factor. Among the predisposing
causes of apoplexy, all statistics, both of recent and older date,
agree in assigning the period of life beyond forty-five or fifty as that in
which the liability to apoplexy is greatly increased. There is no age,
however, below this, even to infancy, in which true cerebral
hemorrhage may not occur, although the intracranial hemorrhage of
children is more usually meningeal. It is probable, however, that in
many of these the rupture of the vessel does not depend upon a
previous aneurism, but on other lesions. The youngest case in which
aneurisms were found by Charcot and Bouchard was twenty.
If we speak of cerebral hemorrhage in general, without reference to

the presence of aneurisms, as we unfortunately are obliged to do in
the great majority of cases, we may often go much below this point.
In youth and childhood, however, it is possible, and often almost
proved, that other conditions must have been of greater importance
in determining the hemorrhage than aneurism.
In our own small series we find cases of eighteen, twenty-three,

twenty-five, twenty-six, twenty-seven years of age, and quite a
number from thirty to forty-five. A little further examination shows
many of them not to have been of the ordinary kind; thus the patient
of eighteen had valvular disease of the heart and advanced
parenchymatous nephritis; the one of twenty was, so far as could be
seen, typical, but no search was made for aneurisms; that of twenty-
five had many small hemorrhages and was a marked case of
idiopathic anæmia; that of twenty-six had valvular disease of the
heart, an embolus in the middle cerebral artery, which was not in the
immediate neighborhood of any hemorrhage, several old
hemorrhages, and hemorrhagic infarction in other organs. The case
aged twenty-seven had a very large clot in one hemisphere and
advanced interstitial nephritis.
Cayley11 describes the case of a girl of eleven with a large cavity in

the left middle cerebral lobe, where nothing was discovered
abnormal upon the left middle cerebral artery, but when the cerebral
matter was washed away with a stream of water, the walls of the
vessels were found to be dotted with oil-globules, and in several
places studded with round and oval nuclei. This was before miliary
aneurisms were known, but the process of preparation was exactly
suited to bring them to light had they been present, and they could
hardly have escaped observation and mention. Other cases of boys
have been reported where the hemorrhage was of the typical kind.
11 Trans. Path. Soc., vol. xx.
Meigs and Pepper speak of nine cases of hemorrhage into the

substance of the brain in children, but give none of their own. Of the
two cases mentioned by West as coming within his own observation,
in one the source of the blood was in the cerebral veins obstructed
by the formation of clots in the longitudinal sinus.
C. W. Dulles12 describes a case occurring in his own practice in a

child of six months, where a considerable amount of blood was
found in the lateral, third, and fourth ventricles. Nothing is said of
aneurisms in particular, but the brain was carefully examined without
the source of the hemorrhage being found, although it seemed to be
in some of the vessels of the velum interpositum. Dulles mentions
further a case reported in the books of the Philadelphia Hospital by
Joseph Berens, where in the brain of a child ten days old there were
found, besides a large meningeal hemorrhage, many points of
subarachnoid extravasation, a clot filling all the ventricles, and a clot
the size of a pea in the anterior portion of both corpora striata. In
addition to these there were scattered points of hemorrhage
throughout the brain-substance.
12 Philada. Med. Times, vol. vi. p. 507.
Cerebellar hemorrhage seems to show a certain preference for
younger ages than the more usual forms. In a list of 25 cases from
various sources I find the ages given thirty-two, twenty, nineteen,
sixteen, thirteen and a half, eight. In the seven cases detailed by
Hillairet there were two aged fifteen and twenty-six respectively.
These exceptions, however, do not invalidate the rule that cerebral

hemorrhage of the ordinary type is pre-eminently a disease of later
middle or advanced life.
The male sex is more liable than the female. Durand-Fardel gives 54
cases of men, 37 of women (old persons); our own list, 31 men, 15
women. Falret, cited by Rochoux and Durand-Fardel, gives 1670
cases of apoplexy among men and 627 among women. This,
however, is only a rough approximation as regards cerebral
hemorrhage, as it undoubtedly includes many cases not dependent
upon this lesion. The same remark applies to Lidell's statement that
there died in New York during three years, of apoplexy, 598 males
and 440 females. This moderate predominance is ascribable to
greater muscular effort, and probably also to the greater prevalence
of alcoholic intoxication. Greenhow, in a Parliamentary report,13
states that in England and Wales the number of deaths from
apoplexy in 100,000 of population is 46 males to 44 females. From
paralysis the figures are 42 and 44, so that the total from the
diseases registered under these two heads is alike for the two sexes
—viz. 88 to 88. In London alone the discrepancy is a little greater on
the male side—108 to 101; but in certain districts of England the
excess is on the other side. Race is of little influence. High altitudes
(7000 feet) favor the prevalence of apoplexy in the population,14 as
in Peru and Mexico. Warm climates are somewhat, but less
markedly, opposed to it.
13 Results of Inquiries into Different Proportions of Deaths, etc.
14 Hirsch, Handbuch der Hist. Geoqr. Pathologie, vol. ii.
Heredity seems to play an important part in the same sense as in

tuberculosis; that is, in the establishment of a tendency, which of
course means, anatomically speaking, periarteritis. Many deaths
from cerebral hemorrhage may sometimes be found among the
members of a single family. Dieulafoy has been able to trace this
disposition through several generations. Among several instances,
Mme. G—— died in three hours of paraplegia with loss of
consciousness. Her mother had hemiplegia at the age of fifty-two,
and two uncles and an aunt were also paralyzed at ages not stated.
A commercial traveller, aged thirty-nine, was in the hospital with left
hemiplegia, second attack; his mother, aged sixty-six, had an attack
a few weeks before, and his grandmother died at seventy-five of
fulminating apoplexy. A woman aged forty-six was hemiplegic for two
months. Her mother, her maternal aunt, and uncle are all hemiplegic,
and her son had a left hemiplegia at the age of seventeen. According
to the cases of Dieulafoy, it is especially through the female side that
the hemorrhagic disease is transmitted. Of course, the tendency may
remain, and usually does so, latent until the age at which in the
average of cases it becomes manifest by an apoplectic or paralytic
attack; but the last two series given above show that it may develop
at an earlier period of life in the younger than in the older generation.
Alcohol is universally stated by authorities to be one of the most

potent factors in different races in establishing the hemorrhagic
tendency: but it is not easy to get exact facts on this point, as so
large a share of hospital patients are more or less alcoholic, and in
private practice observations of this kind accumulate so slowly as not
to be readily available. The greater frequency of this affection among
the male sex may point in this direction. Two of the usual effects
produced by the long-continued use of alcoholic drinks in excess
probably combine to produce this result: first, the degeneration of
tissues and tendency to low forms of inflammation of the tissues in
general and arteries in particular; and secondly, the repeated
dilatations of vessels under its paralyzing influence on the vaso-
motor nerves, resulting in chronic congestion. This preparatory
influence is distinct from the effect an occasional debauch may have
in precipitating the attack.
Another highly important cause of cerebral hemorrhage is Bright's
disease of the kidneys, in the form known as chronic interstitial
nephritis, contracted, granular, cirrhotic, or atrophied kidney; or, as it
would be perhaps more correct to say, cerebral hemorrhage is one
of the results of the arterial lesion which almost invariably
accompanies interstitial nephritis. As to the supposed or possible
identity or relation of the arterio-capillary fibrosis of Gull and Sutton
with the periarteritis of Charcot and Bouchard, the writer does not
feel competent to express an opinion.
The connection between cerebral hemorrhage and hypertrophy of

the heart was noticed and commented on long before it was known
that the great majority of cases of hypertrophy, where no lesion of
valves or of the aorta was present, were really cases of Bright's
disease. The influence which might be exerted by the high arterial
tension in the rupture of an aneurism is obvious enough theoretically,
but it is far from certain that the effect of the renal disease, or rather
the common cause of renal and cerebral disease, is not a more
subtile one than this, and prepares the way for, as well as hastens
along, the impending catastrophe.
This result, however, is not an extremely common one. Among 43

fatal cases of interstitial nephritis, well-marked cerebral hemorrhage
was found in 4; in another, cysts and brownish indurations of small
size were found which might have been partly the results of
embolism. This patient had had a distinct paralytic attack. In a fifth
the symptoms pointed unequivocally to a large rapid hemorrhage,
although it was not demonstrated by an autopsy.
Looking at it from the other side, it was found that (in another series)
of 48 cases of cerebral hemorrhage with autopsy, contracted kidneys
were present in 17; and the writer is of the opinion, although he has
not at his command a sufficient number of facts to make such an
opinion conclusive, that if a series of cases were taken of persons
under forty or fifty, excluding those where a hemorrhagic disease or
a valvular disease of the heart might be present, the proportion of
interstitial nephritis to cerebral hemorrhage would be greatly
increased; and especially so if large hemorrhages into the great
ganglia or the interior of the cerebral lobes were alone considered.
The so-called apoplectic constitution should be mentioned here; that

is, the stout, thick-set build with short neck and florid complexion.
The popular notions as to the peculiar dangers of this condition
seem to have arisen rather from suppositions as to what might be
supposed to take place, from inferring a similar state of things to
exist in the brain to what exists in the countenance, than from any
observation as to what has actually occurred. Cerebral hemorrhage
may take place with any sort of complexion or any figure, and there
is no sufficient evidence that persons of the physique above
described are specially liable to it. Many recent writers distinctly deny
any such connection.
Intellectual pursuits have been considered a disposing cause—a

theory which it would be difficult to substantiate. It is not, of course,
the quality of the work, but its relation to the capacity of the individual
brain, which makes any amount of thought a special strain. The
cases of Dieulafoy, in which the hereditary tendency was so strongly
marked, were mostly hospital cases, among which class the so-
called intellectual occupations do not specially preponderate. A life of
constant cerebral excitement, like that of a speculator or stockbroker,
certainly seems more likely to give rise to overstrain of the vessels
than the more quiet and regular, but certainly more intellectual, labor
of the professional or literary man.
Thackrah15 speaks of affections of the head as frequent among

professional men, but does not advert to cerebral hemorrhage in
particular. He evidently considers a want of sufficient exercise in the
open air a far more potent factor than mental excitement.
15 Health and Longevity, p. 183.
It is very difficult to get statistics which bear upon the influence of

mental labor on the brain, since the recorded occupation of an
individual furnishes but a very rough estimate of the amount of
thought evolved from his brain, and a very much less accurate one
of what is probably of far greater importance—the amount of friction
and anxiety with which it is done.
Hemorrhagic diseases may, for the sake of completeness, be once

more mentioned as among the predisposing causes.
The exciting causes of cerebral hemorrhage are those which give

rise to rupture of the fragile walls either of the aneurisms or fattily
degenerated arterioles. They are to be found chiefly among such
conditions as increase the pressure in the cerebral vessels, chiefly,
though not wholly, from the arterial side. The connection of an attack
of apoplexy with hypertrophy of the heart means, as has already
been shown, in a great many cases, their mutual dependence upon
arterial disease, as in chronic interstitial nephritis, but it seems
probable also that an unusually powerful action of such a heart might
be the immediate cause of the rupture. An excited action of the
heart, connected with a dilatation of the cerebral vessels, naturally
increases the strain on the weak portions, and we have thus the
explanation of those instances where sudden or great excitement
brings on the attack.
Apoplexy is less frequent in summer than in the other seasons, and

it is especially remarked that sudden changes of temperature are
likely to be accompanied by an unusual number of cases. Changes
in the arterial tension consequent upon the varying amount of blood
circulating in the skin are the probable connecting link.
Obstruction to the venous outflow, either alone or in conjunction with

the preceding condition, has undoubtedly a marked effect. In
addition to the cases of hemorrhage from veins obstructed by
thrombi, already mentioned, instances of this method of production
are to be found in the effects of severe muscular effort, as in lifting, in
straining at stool, or, as has occasionally happened, in coitu. It has
been objected to the congestion theory of apoplexy that even in
severe paroxysms of whooping cough, where the face becomes
cyanosed and congested, nothing like unconsciousness or paralysis
occurs; but cases have been reported where aphasia and cerebral
hemorrhage into the optic thalamus and cortex have accompanied
whooping cough. Violent convulsions may be the cause of cerebral
hemorrhage, as in puerperal eclampsia.
Obstruction to the circulation in the neck by tight clothing may be a

means of increasing the back pressure from the veins. It is said that
deaths from apoplexy have been unusually frequent among soldiers
who have been obliged to wear tight stocks for the sake of imparting
what was supposed to be a more military bearing. Probably some of
the hemorrhages found with valvular disease of the heart are to be
explained by venous congestion, although others are due to
embolism.
Blows and shocks to the head, not producing fractures, are

occasional causes of cerebral and ventricular as well as of
meningeal hemorrhage. Important medico-legal questions are likely
to arise where both bruises externally and internal hemorrhage are
found. It is important to recollect that ecchymoses of the
pericranium16 have been found in cases of apoplexy where no
violence has been used. These may occur with occlusion of the
cerebral vessels, as well as with hemorrhage, and are most likely to
be situated on the paralyzed side, being sometimes distinctly limited
at the median line. They have been supposed to be due to the
general tendency of the blood toward the head, and to be of the
same pathological origin as the cerebral lesion they accompany; but
the fact that they may not be associated with hemorrhage proves
that this explanation is inadequate. Another explanation attributes
their causation to vaso-motor paralysis, together with some unknown
factor present in only a certain number of cases. They may be
compared to the subconjunctival hemorrhages seen after violent
convulsions.
16 Lepine, Archives de Physiologie, tome ii., 1869, p. 667.
Cerebral hemorrhage depending upon a blow is likely to be

accompanied by meningeal bleeding; to be situated at some point of
the cortex, and not in the regions more frequently affected; and to
consist of the effusion of no great amount of blood, mixed with
cerebral substance. There are also very often more than one. All the
circumstances should be carefully weighed when, as not infrequently
happens, there is doubt as to whether a blow was the cause of a
hemorrhage, or whether a person found insensible, with a bruise
upon his head, may have fallen down suddenly from an apoplectic
attack. In the following case it would be difficult to be sure of the
sequence: A negro man aged fifty fell backward from the first step of
a ladder. He got up and went to work again, but soon became
unconscious. He became partially conscious again in the accident-
room of the hospital, but died in a few hours. There was no sign of
injury to the head, but there was a rupture of an aneurism (not
miliary) of the left middle cerebral artery, and hemorrhage into the
meninges and all the ventricles. If the first fall had occurred in a
scuffle, and the autopsy had been made in such way as not to
disclose the aneurism, it might have been considered a case of
homicide.
Alcohol, besides not infrequently counterfeiting apoplexy, and

besides acting as one of the predisposing causes, is occasionally an
exciting cause. The dilatation of cerebral vessels, perhaps present
as an habitual condition, is added to by the effect of the temporary
narcotism and produces the rupture. In many cases these factors
have their activity much increased by heavy sleep, very likely in a
constrained posture, causing pressure on the veins of the neck and
consequent venous congestion, which is in its turn intensified by the
confined air of a station-house or the cold of the weather. The man
who has possibly a vessel ready to burst in his brain should have,
even if demonstrably drunk, the advantage at least of good air and
an unconstrained position.
Other poisons, less frequently taken, may perhaps have a similar

influence. In one case under the observation of the writer a number
of small hemorrhages were found in various parts of the brain of a
man who was found in his room some forty-eight hours after taking a
quantity of opium, and having had, of course, no treatment during
that time. He was aroused in the hospital without great difficulty, but
died after a day or two with his brain in the condition above
described, and bronchitis with inhalation pneumonia. There had

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Psychiatric Mental Health Nursing

Seventh, North American Edition ■

Judith E. Gunther, MSN, RN

Tina L. Kinney, MSN, RNC, FNP-BC, WHNP-BC

Lynne S. Mann, MN, RN, CNE

J. Susan G. Van Wye, MSN, RN, ARNP, CPNP

ORGANIZATION OF THE TEXT

• Learning Objectives focus on the students’ reading and study.

Practice Makes Perfect, and This Is the Perfect Practice.

Adaptive and Personalized

9. Legal and Ethical Issues

10. Grief and Loss

11. Anger, Hostility, and Aggression

12. Abuse and Violence

14. Anxiety and Anxiety Disorders

15. Obsessive–Compulsive and Related Disorders

17. Mood Disorders and Suicide

18. Personality Disorders

20. Eating Disorders

21. Somatic Symptom Illnesses

22. Neurodevelopmental Disorders

23. Disruptive Behavior Disorders

24. Cognitive Disorders

Answers to Chapter Study Guides

Glossary of Key Terms

1. Describe characteristics of mental health and mental illness.

3. Identify important historical landmarks in psychiatric care.

4. Discuss current trends in the treatment of people with mental illness.

6. Describe common student concerns about psychiatric nursing.

MENTAL HEALTH AND MENTAL ILLNESS

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

HISTORICAL PERSPECTIVES OF THE TREATMENT OF

Period of Enlightenment and Creation of Mental Institutions

Sigmund Freud and Treatment of Mental Disorders

Move toward Community Mental Health

MENTAL ILLNESS IN THE 21ST CENTURY

Hemorrhages of several months' standing may be indicated either by

The presence of miliary aneurisms in the brain had been noted in

These aneurisms are dependent upon a periarteritis which is

In several cases of cerebral hemorrhage in purpura, where the

5 Trans. Path. Soc., Cayley.

There is no possible means of determining in which way any given

Hemorrhage arises in some rare cases from the backing up of blood

In many diseases like purpura, idiopathic anæmia, and

The usual localities of cerebral hemorrhage are stated with much

I have placed beside these a small number of cases from the

There is no essential difference in the frequency of hemorrhage on

The arteries supplying the nucleus lenticularis and external capsule

The arteries of the optic thalamus arise from the posterior

Before proceeding to a minute account of the symptoms

The most marked symptom, one which is essential to the definition

The writer recalls a case of a man, of whose history little or nothing

A very similar statement may be made in regard to the symptom of

F. Pagenstecher8 succeeded in producing phenomena closely allied

9 Centralblatt f. d. Med. Wiss., 1878, p. 454.

Several cases are reported by P. R. Hoy10 where pressure upon the

The natural generalization to be made from these cases and

In a case of cerebral hemorrhage of considerable size the pressure

When an embolus lodges in an artery and produces complete

In reality, the hindrance to the proper functions is nearly the same,

The narcotic poisons also deprive the nerve-tissue of its healthy

In fact, in the present state of our knowledge as to what

Another theory of unconsciousness is simply that it is due to shock—