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Centro Escolar University

College of Nursing

Mendiola, Manila

In Partial Fulfilment of the Requirements

In

NCM 103

Mental Institution
National Center for Mental Health

MILD MENTAL RETARDATION WITH


UNDIFFERENTIATED
SCHIZOPHRENIA

Submitted by:

Gallos, Randell M.

BSN 3A /Group 3A

Submitted to:

Donie L. Brabante, RN, MAN

Clinical Instructor

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TABLE OF CONTENTS

CHAPTER I: INTRODUCTION
A. Introduction to Psychopathology
B. Theoretical Framework
C. Biographical Data
D. Nursing History
1. Chief Complaint
2. History of present Illness
3. Previous Illness
4. Past Personal History
5. Family History
6. Social History

CHAPTER II: Presentation, Interpretation & Analysis of Data


A. General Appearance
B. Motor Behavior
C. Sensorium & Cognition
D. Perception
E. Attitude
F. Defense Mechanisms
G. Affective States
H. Thought Process

CHAPTER III DIAGNOSIS


A. Predisposing Factors
B. Psychodynamics / Psychopathology
C. Related Literature
1. Summary
2. Reaction
D. Drug Study

CHAPTER IV: NURSING CARE PLAN

A. Process Recording
B. List of Prioritized Psychiatric Nursing Diagnosis
 5 prioritized nursing diagnosis with rationale
C. Psychiatric Nursing Care Plans
 First 3 highly prioritized nursing diagnosis

CHAPTER V: PSYCHOTHERAPY
A. Play Therapy
B. Music & Art Therapy
C. Bibliotherapy
D. Occupational Therapy
E. Remotivation Therapy

APPENDICES
A. MSA Tool used with the patient
B. Art Therapy Output
C. List of Reference Materials used
a. Title of the Book / website
b. Author
c. Date published/searched from the net

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CHAPTER

1
INTRODUCTION

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A. Introduction to Psychopathology

Psychopathology is a term which refers to either the study of mental illness or mental distress,
or the manifestation of behaviors and experiences which may be indicative of mental illness or
psychological impairment, such as abnormal, maladaptive behavior or mental activity.

Psychopathology is that branch of psychiatry which deals with the study of manifestation of
behaviours and experiences indicative of mental illness.

Psychopathology as the study of mental illness

Many different professions may be involved in studying mental illness or distress. Most notably,
psychiatrists and clinical psychologists are particularly interested in this area and may either be
involved in clinical treatment of mental illness, or research into the origin, development and
manifestations of such states, or often, both. More widely, many different specialties may be
involved in the study of psychopathology. For example, a neuroscientist may focus on brain
changes related to mental illness. Therefore, someone who is referred to as a psychopathologist,
may be one of any number of professions who have specialized in studying this area.

Psychiatrists in particular are interested in descriptive psychopathology, which has the aim of
describing the symptoms and syndromes of mental illness. This is both for the diagnosis of
individual patients (to see whether the patient's experience fits any pre-existing classification), or
for the creation of diagnostic systems (such as the Diagnostic and Statistical Manual of Mental
Disorders or International Statistical Classification of Diseases and Related Health Problems)
which define exactly which signs and symptoms should make up a diagnosis, and how
experiences and behaviours should be grouped in particular diagnoses (e.g. clinical depression,
paraphrenia, paranoia, schizophrenia).

Psychopathology should not be confused with psychopathy, which is a type of personality


disorder.

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Psychopathology as a descriptive term

The term psychopathology may also be used to denote behaviours or experiences which are
indicative of mental illness, even if they do not constitute a formal diagnosis. For example, the
presence of a hallucination may be considered as a psychopathological sign, even if there are not
enough symptoms present to fulfill the criteria for one of the disorders listed in the DSM or ICD.

In a more general sense, any behaviour or experience which causes impairment, distress or
disability, particularly if it is thought to arise from a functional breakdown in either the cognitive
and neurocognitive systems in the brain, may be classified as psychopathology.

Mental retardation is an idea, a condition, a syndrome, a symptom, and a source of pain and
bewilderment to many families. Its history dates back to the beginning of man's time on earth.
The idea of mental retardation can be found as far back in history as the therapeutic papyri of
Thebes (Luxor), Egypt, around 1500 B.C. Although somewhat vague due to difficulties in
translation, these documents clearly refer to disabilities of the mind and body due to brain
damage (Sheerenberger, 1983). Mental retardation is also a condition or syndrome defined by a
collection of symptoms, traits, and/or characteristics. It has been defined and renamed many
times throughout history. For example, feeblemindedness and mental deficiency were used as
labels during the later part of the last century and in the early part of this century. Consistent
across all definitions are difficulties in learning, social skills, everyday functioning, and age of
onset (during childhood). Mental retardation has also been used as a defining characteristic or
symptom of other disorders such as Down syndrome and Prader-Willi syndrome. Finally, mental
retardation is a challenge and potential source of stress to the family of an individual with this
disorder. From identification through treatment or education, families struggle with questions
about cause and prognosis, as well as guilt, a sense of loss, and disillusionment about the future.

The objective of this chapter is to provide the reader with an overview of mental retardation, a
developmental disability with a long and sometimes controversial history. Following a brief
historical overview, the current diagnostic criteria, epidemiological information and the status of
dual diagnosis will be presented. Comprehensive assessment and common interventions will also
be reviewed in some detail.

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Mental Retardation
Mental retardation is a generalized disorder, characterized by significantly impaired cognitive
functioning and deficits in two or more adaptive behaviors with onset before the age of 18. Once
focused almost entirely on cognition, the definition now includes both a component relating to
mental functioning and one relating to individuals' functional skills in their environment

Alternative terms

The term "mental retardation" is a diagnostic term denoting the group of disconnected categories
of mental functioning such as "idiot", "imbecile", and "moron" derived from early IQ tests,
which acquired pejorative connotations in popular discourse. The term "mental retardation"
acquired pejorative and shameful connotations over the last few decades due to the use of
"retarded" as an insult. This may have contributed to its replacement with euphemisms such as
"mentally challenged" or "intellectual disability". While "developmental disability" may be
considered to subsume other disorders (see below), "developmental disability" and
"developmental delay" (for people under the age of 18), are generally considered more
acceptable terms than "mental retardation".

* In North America mental retardation is subsumed into the broader term developmental
disability, which also includes epilepsy, autism, cerebral palsy and other disorders that develop
during the developmental period (birth to age 18.) Because service provision is tied to the
designation developmental disability, it is used by many parents, direct support professionals,
and physicians. However, in school-based settings, the more specific term mental retardation is
still typically used, and is one of 13 categories of disability under which children may be
identified for special education services under Public Law 108-446.

* The phrase intellectual disability is increasingly being used as a synonym for people with
significantly below-average cognitive ability.[1] These terms are sometimes used as a means of
separating general intellectual limitations from specific, limited deficits as well as indicating that
it is not an emotional or psychological disability. Intellectual disability may also used to describe
the outcome of traumatic brain injury or lead poisoning or dementing conditions such as
Alzheimer's disease. It is not specific to congenital disorders such as Down syndrome.

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The American Association on Mental Retardation continued to use the term mental retardation
until 2006.[2] In June 2006 its members voted to change the name of the organization to the
"American Association on Intellectual and Developmental Disabilities," rejecting the options to
become the AAID or AADD. Part of the rationale for the double name was that many members
worked with people with pervasive developmental disorders, most of whom do not have mental
retardation.[3]

In the UK, "mental handicap" had become the common medical term, replacing "mental
subnormality" in Scotland and "mental deficiency" in England and Wales, until Stephen Dorrell,
Secretary of State for Health for the United Kingdom from 1995-7, changed the NHS's
designation to "learning disability." The new term is not yet widely understood, and is often
taken to refer to problems affecting schoolwork (the American usage), which are known in the
UK as "learning difficulties." British social workers may use "learning difficulty" to refer to both
people with MR and those with conditions such as dyslexia.

In England and Wales between 1983 and 2008 the Mental Health Act 1983 defined "mental
impairment" and "severe mental impairment" as "a state of arrested or incomplete development
of mind which includes significant/severe impairment of intelligence and social functioning and
is associated with abnormally aggressive or seriously irresponsible conduct on the part of the
person concerned."[4] As behavior was involved, these were not necessarily permanent
conditions: they were defined for the purpose of authorizing detention in hospital or
guardianship. The term Mental Impairment was removed from the Act in November 2008, but
the grounds for detention remained. However, English statute law uses "mental impairment"
elsewhere in a less well-defined manner—e.g. to allow exemption from taxes—implying that
mental retardation without any behavioral problems is what is meant.

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Signs

Children with mental retardation may learn to sit up, to crawl, or to walk later than other
children, or they may learn to talk later. Both adults and children with mental retardation may
also exhibit the following characteristics:

* Delays in oral language development

* Deficits in memory skills

* Difficulty learning social rules

* Difficulty with problem solving skills

* Delays in the development of adaptive behaviors such as self-help or self-care skills

* Lack of social inhibitors

The limitations of cognitive functioning will cause a child with mental retardation to learn and
develop more slowly than a typical child. Children may take longer to learn language, develop
social skills, and take care of their personal needs such as dressing or eating. Learning will take
them longer, require more repetition, and skills may need to be adapted to their learning level.
Nevertheless, virtually every child is able to learn, develop and become participating members of
the community.

In early childhood mild mental retardation (IQ 50–69) may not be obvious, and may not be
identified until children begin school. Even when poor academic performance is recognized, it
may take expert assessment to distinguish mild mental retardation from learning disability or
emotional/behavioral disorders. As individuals with mild mental retardation reach adulthood,
many learn to live independently and maintain gainful employment.

Moderate mental retardation (IQ 35-49) is nearly always apparent within the first years of life.
Children with moderate mental retardation will require considerable supports in school, at home,
and in the community in order to participate fully. As adults they may live with their parents, in a
supportive group home, or even semi-independently with significant supportive services to help
them, for example, manage their finances.

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A person with a more severe mental retardation will need more intensive support and supervision
his or her entire life.

Diagnosis

According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV),[5] three criteria must be met for a diagnosis of mental retardation: an IQ below 70,
significant limitations in two or more areas of adaptive behavior (as measured by an adaptive
behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and
evidence that the limitations became apparent before the age of 18.

It is formally diagnosed by professional assessment of intelligence and adaptive behavior.

IQ below 70

The first English-language IQ test, the Terman-Binet, was adapted from an instrument used to
measure potential to achieve developed by Binet in France. Terman translated the test and
employed it as a means to measure intellectual capacity based on oral language, vocabulary,
numerical reasoning, memory, motor speed and analysis skills. The mean score on the currently
available IQ tests is 100, with a standard deviation of 15 (WAIS/WISC-IV) or 16 (Stanford-
Binet). Sub-average intelligence is generally considered to be present when an individual scores
two standard deviatons below the test mean. Factors other than cognitive ability (depression,
anxiety, etc.) can contribute to low IQ scores; it is important for the evaluator to rule them out
prior to concluding that measured IQ is "significantly below average".

The following ranges, based on Standard Scores of intelligence tests, reflect the categories of the
American Association of Mental Retardation, the Diagnostic and Statistical Manual of Mental
Disorders-IV-TR, and the International Classification of Diseases-10:

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Class IQ

Profound mental retardation Below 20

Severe mental retardation 20–34

Moderate mental retardation 35–49

Mild mental retardation 50–69

Borderline intellectual functioning 70–80

Since the diagnosis is not based only on IQ scores, but must also take into consideration a
person's adaptive functioning, the diagnosis is not made rigidly. It encompasses intellectual
scores, adaptive functioning scores from an adaptive behavior rating scale based on descriptions
of known abilities provided by someone familiar with the person, and also the observations of
the assessment examiner who is able to find out directly from the person what he or she can
understand, communicate, and the like.

Significant limitations in two or more areas of adaptive behavior

Adaptive behavior, or adaptive functioning, refers to the skills needed to live independently (or
at the minimally acceptable level for age). To assess adaptive behavior, professionals compare
the functional abilities of a child to those of other children of similar age. To measure adaptive
behavior, professionals use structured interviews, with which they systematically elicit
information about persons' functioning in the community from people who know them well.
There are many adaptive behavior scales, and accurate assessment of the quality of someone's
adaptive behavior requires clinical judgment as well. Certain skills are important to adaptive
behavior, such as:

* daily living skills, such as getting dressed, using the bathroom, and feeding oneself;

* communication skills, such as understanding what is said and being able to answer;

* social skills with peers, family members, spouses, adults, and others.

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Evidence that the limitations became apparent in childhood

This third condition is used to distinguish it from dementing conditions such as Alzheimer's
disease or due to traumatic injuries with attendant brain damage.

Causes

Down syndrome, fetal alcohol syndrome and Fragile X syndrome are the three most common
inborn causes. However, doctors have found many other causes. The most common are:

* Genetic conditions. Sometimes disability is caused by abnormal genes inherited from


parents, errors when genes combine, or other reasons. The most prevalent genetic conditions
include Down syndrome, Klinefelter's syndrome, Fragile X syndrome, Neurofibromatosis,
congenital hypothyroidism, Williams syndrome, Phenylketonuria (PKU), and Prader-Willi
syndrome. Other genetic conditions include Phelan-McDermid syndrome (22q13del), Mowat-
Wilson syndrome, genetic ciliopathy,[6] and Siderius type X-linked mental retardation (OMIM
300263) as caused by mutations in the PHF8 gene ((OMIM 300560).[7][8] In the rarest of cases,
abnormalities with the X or Y chromosome may also cause disability. 48, XXXX and 49,
XXXXX syndrome affect a small number of girls worldwide, while boys may be affected by 47,
XYY, 49, XXXXY, or 49, XYYYY.

* Problems during pregnancy. Mental disability can result when the fetus does not develop
properly. For example, there may be a problem with the way the fetus' cells divide as it grows. A
woman who drinks alcohol (see fetal alcohol syndrome) or gets an infection like rubella during
pregnancy may also have a baby with mental disability.

* Problems at birth. If a baby has problems during labor and birth, such as not getting enough
oxygen, he or she may have developmental disability due to brain damage.

* Exposure to certain types of disease or toxins. Diseases like whooping cough, measles, or
meningitis can cause mental disability if medical care is delayed or inadequate. Exposure to
poisons like lead or mercury may also affect mental ability.

* Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading


preventable cause of mental disability in areas of the developing world where iodine deficiency
is endemic. Iodine deficiency also causes goiter, an enlargement of the thyroid gland. More
common than full-fledged cretinism, as retardation caused by severe iodine deficiency is called,
is mild impairment of intelligence. Certain areas of the world due to natural deficiency and
governmental inaction are severely affected. India is the most outstanding, with 500 million

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suffering from deficiency, 54 million from goiter, and 2 million from cretinism. Among other
nations affected by iodine deficiency, China and Kazakhstan have instituted widespread
iodization programs, whereas, as of 2006, Russia had not.

* Malnutrition is a common cause of reduced intelligence in parts of the world affected by


famine, such as Ethiopia.

* Absence of in the brain of the arcuate fasciculus.

Treatment and assistance

By most definitions mental retardation is more accurately considered a disability rather than a
disease. MR can be distinguished in many ways from mental illness, such as schizophrenia or
depression. Currently, there is no "cure" for an established disability, though with appropriate
support and teaching, most individuals can learn to do many things.

There are thousands of agencies in the United States that provide assistance for people with
developmental disabilities. They include state-run, for-profit, and non-profit, privately run
agencies. Within one agency there could be departments that include fully staffed residential
homes, day rehabilitation programs that approximate schools, workshops wherein people with
disabilities can obtain jobs, programs that assist people with developmental disabilities in
obtaining jobs in the community, programs that provide support for people with developmental
disabilities who have their own apartments, programs that assist them with raising their children,
and many more. The Burton Blatt Institute at Syracuse University works to advance the civic,
economic, and social participation of people with disabilities. There are also many agencies and
programs for parents of children with developmental disabilities.

Although there is no specific medication for mental retardation, many people with
developmental disabilities have further medical complications and may take several medications.
Beyond that there are specific programs that people with developmental disabilities can take part
in wherein they learn basic life skills. These "goals" may take a much longer amount of time for
them to accomplish, but the ultimate goal is independence. This may be anything from
independence in tooth brushing to an independent residence. People with developmental
disabilities learn throughout their lives and can obtain many new skills even late in life with the
help of their families, caregivers, clinicians and the people who coordinate the efforts of all of
these people.

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Archaic Terms

* Idiot indicated the greatest degree of intellectual disability, where the mental age is two
years or less, and the person cannot guard himself or herself against common physical dangers.
The term was gradually replaced by the term profound mental retardation.

* Imbecile indicated an intellectual disability less extreme than idiocy and not necessarily
inherited. It is now usually subdivided into two categories, known as severe mental retardation
and moderate mental retardation.

* Moron was defined by the American Association for the Study of the Feeble-minded in
1910, following work by Henry H. Goddard, as the term for an adult with a mental age between
eight and twelve; mild mental retardation is now the term for this condition. Alternative
definitions of these terms based on IQ were also used. This group was known in UK law from
1911 to 1959/60 as "feeble-minded".

* Mongolism was a medical term used to identify someone with Down syndrome. For obvious
reasons, the Mongolian People's Republic requested that the medical community cease use of the
term as a description of mental retardation. Their request was granted in the 1960s, when the
World Health Organization agreed that the term should cease being used within the medical
community.

* In the field of special education, educable (or "educable mentally retarded") refers to MR
students with IQs of approximately 50-75 who can progress academically to a late elementary
level. Trainable (or "trainable mentally retarded") refers to students whose IQs fall below 50 but
who are still capable of learning personal hygiene and other living skills in a sheltered setting,
such as a group home. In many areas, these terms have fallen out of favor in favor of "severe"
and "moderate" mental retardation. While the names change, the meaning stays roughly the same
in practice.

* Retarded comes from the Latin retardare, "to make slow, delay, keep back, or hinder." The
term was recorded in 1426 as a "fact or action of making slower in movement or time." The first
record of retarded in relation to being mentally slow was in 1895. The term retarded was used to
replace terms like idiot, moron, and imbecile because it was not a derogatory term. By the 1960s,
however, the term had taken on a partially derogatory meaning as well.

Perhaps the negative connotations associated with these numerous terms for mental retardation
reflect society's ambivalent attitude about the condition. There are competing desires among
elements of society, some of whom seek neutral medical terms, and others who want to use such
terms as weapons with which to abuse people.

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Today, the term "retarded" is slowly being replaced by new words like "special" or "challenged."
The term "developmental delay" is rapidly gaining popularity among caretakers and parents of
individuals with mental retardation. Using the word "delay" is preferred over "disability" by
many people, because that term (delay) encapsulates the core deficit that creates mental
retardation in the first place. Delay suggests that a person has been held back from their
potential, rather than someone who has been disabled.

Usage has changed over the years, and differed from country to country, which needs to be borne
in mind when looking at older books and papers. For example, "mental retardation" in some
contexts covers the whole field, but previously applied to what is now the mild MR group.
"Feeble-minded" used to mean mild MR in the UK, and once applied in the US to the whole
field. "Borderline MR" is not currently defined, but the term may be used to apply to people with
IQs in the 70s. People with IQs of 70 to 85 used to be eligible for special consideration in the US
public education system on grounds of mental retardation.

Along with the changes in terminology, and the downward drift in acceptability of the old terms,
institutions of all kinds have had to repeatedly change their names. This affects the names of
schools, hospitals, societies, government departments, and academic journals. For example, the
Midlands Institute of Mental Subnormality became the British Institute of Mental Handicap and
is now the British Institute of Learning Disability. This phenomenon is shared with mental health
and motor disabilities, and seen to a lesser degree in sensory disabilities.

Historical Perspective

The plight of individuals with developmental disabilities has been dependent on the customs and
beliefs of the era and the culture or locale. In ancient Greece and Rome, infanticide was a
common practice. In Sparta, for example, neonates were examined by a state council of
inspectors. If they suspected that the child was defective, the infant was thrown from a cliff to its
death. By the second century A.D. individuals with disabilities, including children, who lived in
the Roman Empire were frequently sold to be used for entertainment or amusement. The
dawning of Christianity led to a decline in these barbaric practices and a movement toward care
for the less fortunate; in fact, all of the early religious leaders, Jesus, Buddha, Mohammed, and
Confucius, advocated human treatment for the mentally retarded, developmentally disabled, or
infirmed (Sheerenberger, 1983).

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During the Middle ages (476 - 1799 A.D.) the status and care of individuals with mental
retardation varied greatly. Although more human practices evolved (i.e., decreases in infanticide
and the establishment of foundling homes), many children were sold into slavery, abandoned, or
left out in the cold. Toward the end of this era, in 1690, John Locke published his famous work
entitled An Essay Concerning Human Understanding. Locke believed that an individual was
born without innate ideas. The mind is a tabula rasa, a blank slate. This would profoundly
influence the care and training provided to individuals with mental retardation. He also was the
first to distinguish between mental retardation and mental illness; "Herein seems to lie the
difference between idiots and madmen, that madmen put wrong ideas together and reason from
them, but idiots make very few or no propositions and reason scarce at all (Doll, 1962 p. 23)."

A cornerstone event in the evolution of the care and treatment of the mentally retarded was the
work of physician Jean-Marc-Gaspard Itard (Sheerenberger, 1983) who was hired in 1800 by the
Director of the National Institutes for Deaf-Mutes in France to work with a boy named Victor.
Victor, a young boy, had apparently lived his whole life in the woods of south central France
and, after being captured and escaping several times, fled to the mountains of Aveyron. At about
age 12, he was captured once again and sent to an orphanage, found to be deaf and mute, and
moved to the Institute for Deaf-Mutes.

Based on the work of Locke and Condillac who emphasized the importance of learning through
the senses, Itard developed a broad educational program for Victor to develop his senses,
intellect, and emotions. After 5 years of training, Victor continued to have significant difficulties
in language and social interaction though he acquired more skills and knowledge than many of
Itard's contemporaries believed possible. Itard's educational approach became widely accepted
and used in the education of the deaf. Near the end of his life, Itard had the opportunity to
educate a group of children who were mentally retarded. He did not personally direct the
education of these children, but supervised the work of Edouard Seguin (Sheerenberger, 1983).
Seguin developed a comprehensive approach to the education of children with mental
retardation, known as the Physiological Method (Sheerenberger, 1983). Assuming a direct
relationship between the senses and cognition, his approach began with sensory training
including vision, hearing, taste, smell, and eye-hand coordination. The curriculum extended from
developing basic self-care skills to vocational education with an emphasis on perception,
coordination, imitation, positive reinforcement, memory, and generalization. In 1850, Seguin
moved to the United States and became a driving force in the education of individuals with
mental retardation. In 1876, he founded what would become the American Association on Metal
Retardation. Many of Seguin's techniques have been modified and are still in use today.

Over the next 50 years, two key developments occurred in the United States: residential training
schools were established in most states (19 state operated and 9 privately operated) by 1892, and

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the newly developed test of intelligence developed by Binet was translated in 1908 by Henry
Goddard, Director of Research at the training school in Vineland, New Jersey. Goddard
published an American version of the test in 1910. In 1935, Edgar Doll developed the Vineland
Social Maturity Scale to assess the daily living skills/adaptive behavior of individuals suspected
of having mental retardation. Psychologists and educators now believed that it was possible to
determine who had mental retardation and provide them with appropriate training in the
residential training schools.

During the early part of the 20th century, residential training schools proliferated and individuals
with mental retardation were enrolled. This was influenced by the availability of tests (primarily
IQ) to diagnose mental retardation and the belief that, with proper training, individuals with
mental retardation could be "cured". When training schools were unable to "cure" mental
retardation, they became overcrowded and many of the students were moved back into society
where the focus of education began to change to special education classes in the community. The
training schools, which were initially more educational in nature, became custodial living
centers.

As a result of the disillusionment with residential treatment, advocacy groups, such as the
National Association of Retarded Citizens and the President's Commission on Mental
Retardation, were established in the 1950's through the 1970's. The Wyatt-Stickney federal court
action, in the 1970's, was a landmark class action suit in Alabama establishing the right to
treatment of individuals living in residential facilities. Purely custodial care was no longer
acceptable. Concurrent with this case, the United States Congress passed the Education for the
Handicapped Act in 1975, now titled the Individuals with Disabilities Education Act. This Act
guaranteed the appropriate education of all children with mental retardation and developmental
disabilities, from school age through 21 years of age. This law was amended in 1986 to
guarantee educational services to children with disabilities age 3 through 21 and provided
incentives for states to develop infant and toddler service delivery systems. Today, most states
guarantee intervention services to children with disabilities between birth and 21 years of age.

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Definition/Diagnosis/Classification.

According to Sheerenberger (1983), the elements of the definition of mental retardation were
well accepted in the United States by 1900. These included: onset in childhood, significant
intellectual or cognitive limitations, and an inability to adapt to the demands of everyday life. An
early classification scheme proposed by the American Association on Mental Deficiency
(Retardation), in 1910 referred to individuals with mental retardation as feeble-minded, meaning
that their development was halted at an early age or was in some way inadequate making it
difficult to keep pace with peers and manage their daily lives independently (Committee on
Classification, 1910). Three levels of impairment were identified: idiot, individuals whose
development is arrested at the level of a 2 year old; imbecile, individuals whose development is
equivalent to that of a 2 to 7 year old at maturity; and moron, individuals whose mental
development is equivalent to that of a 7 to 12 year old at maturity.

Over the next 30 years, the definitions of mental retardation focused on one of three aspects of
development: the inability to learn to perform common acts, deficits or delays in social
development/competence, or low IQ (Yepsen, 1941). An example of a definition based on social
competence was proposed by Edgar Doll who proposed that mental retardation referred to
"social incompetence, due to mental subnormality, which has been developmentally arrested,
which obtains at maturity, is of constitutional origin, and which is essentially incurable" (Doll,
1936 p. 38). Fred Kuhlman, who was highly influential in the early development of intelligence
tests in the United States, believed mental retardation was "a mental condition resulting from a
subnormal rate of development of some or all mental functions" (Kuhlman, 1941 p. 213).

As a result of the conflicting views and definitions of mental retardation, a growing number of
labels used to refer to individuals with mental retardation, and a change in emphasis from a
genetic or constitutional focus to a desire for a function-based definition, the American
Association on Mental Deficiency (Retardation) proposed and adopted a three part definition in
1959. "Mental retardation refers to subaverage general intellectual functioning which originates
in the developmental period and is associated with impairment in adaptive behavior" (Heber,
1961). Although this definition included the three components of low IQ (<85), impaired
adaptive behavior, and origination before age 16, only IQ and age of onset were measurable with
the existing psychometric techniques. Deficits in adaptive behavior were generally based on
subjective interpretations by individual evaluators even though the Vineland Social Maturity
Scale was available (Sheerenberger, 1983).

In addition to the revised definition, a five level classification scheme was introduced replacing
the previous three level system which had acquired a very negative connotation. The generic

17
terms of borderline (IQ 67-83), mild (IQ 50-66), moderate (IQ 33-49), severe (16-32), and
profound (IQ <16) were adopted.

Due to concern about the over or misidentification of mental retardation, particularly in minority
populations, the definition was revised in 1973 (Grossman, 1973) eliminating the borderline
classification from the interpretation of significant, subaverage, general intellectual functioning.
The upper IQ boundary changed from <85 to < 70. This change significantly reduced the number
of individuals who were previously identified as mentally retarded impacting the eligibility
criteria for special school services and governmental supports. Many children who might have
benefitted from special assistance were now ineligible for such help. A 1977 revision (Grossman,
1977) modified the upper IQ limit to 70 - 75 to account for measurement error. IQ performance
resulting in scores of 71 through 75 were only consistent with mental retardation when
significant deficits in adaptive behavior were present.

The most recent change in the definition of mental retardation was adopted in 1992 by the
American Association on Mental Retardation. "Mental retardation refers to substantial
limitations in present functioning. It is characterized by significantly subaverage intellectual
functioning, existing concurrently with related limitations in two or more of the following
applicable adaptive skill areas: communication, self-care, home living, social skills, community
use, self-direction, health and safety, functional academics, leisure, and work. Mental retardation
manifests before age 18" (American Association on Mental Retardation, 1992). On the surface,
this latest definition does not appear much different than its recent predecessors. However, the
focus on the functional status of the individual with mental retardation is much more delineated
and critical in this definition. There is also a focus on the impact of environmental influences on
adaptive skills development that was absent in previous definitions. Finally, this revision
eliminated the severity level classification scheme in favor of one that addresses the type and
intensity of support needed: intermittent, limited, extensive, or pervasive. Practically, a child
under age 18 must have an IQ < 75 and deficits in at least 2 of the adaptive behavior domains
indicated in the definition to obtain a diagnosis of mental retardation.

18
Educational Classifications. While the medical and psychosocial communities were developing
an acceptable definition and classification system, the educational community adopted their own
system of classification. Their three level system separated school age children with mental
retardation into three groups based on predicted ability to learn (Kirk, Karnes, & Kirk, 1955).
Children who were educable could learn simple academic skills but not progress above fourth
grade level. Children who were believed to be trainable could learn to care for their daily needs
but very few academic skills. Children who appeared to be untrainable or totally dependent were
considered in need of long term care, possibly in a residential setting. Some form of this scheme
is still in use today in many school systems across the country.

DSM-IV. DSM-IV attempts to blend the 1977 and 1992 definitions put forth by the American
Association on Mental Retardation. It adopts the 1992 definition, but retains the severity level
classification scheme from the 1977 definition. The upper IQ limit is 70, and an individual must
have delays in at least two of the 10 areas outlined in the 1992 definition. In general, the
overview of mental retardation in DSM-IV is thorough and easy to follow. However, it should be
noted that comprehensive cognitive and adaptive skill assessment is necessary to make the
diagnosis; it should not be made on the basis of an office visit or developmental screening.

ICD-10. ICD-10 is the tenth revision of the International Classification of Diseases (World
Health Organization, 1993). It is currently in use in some countries around the world but will not
be adopted for use in the United States until after the year 2000. ICD-10 differs from ICD-9 in at
least two key ways. First, it includes more diagnoses and is, consequently, much larger. The
second major change is the coding scheme. The diagnostic codes have been changed from
numeric codes to codes that begin with an alphabet letter and are followed by two or more
numbers (e.g., mild mental retardation has changed from 317 to F70).

ICD-10 characterizes mental retardation as a condition resulting from a failure of the mind to
develop completely. Unlike DSM-IV and the Classification Manual of the AAMR, ICD-10
suggests that cognitive, language, motor, social, and other adaptive behavior skills should all be
used to determine the level of intellectual impairment. ICD-10 also supports the idea of dual
diagnosis, suggesting that mental retardation may be accompanied by physical or other mental
disorders.

Four levels of mental retardation are specified in ICD-10: F70 mild (IQ 50 - 69), F71 moderate
(IQ 35 - 49), F72 severe (IQ 20 - 34), and F73 profound (IQ below 20). IQ should not be used as
the only determining factor. Clinical findings and adaptive behavior should also be used to

19
determine level of intellectual functioning. Two additional classifications are possible: F78 other
mental retardation and F79 unspecified mental retardation. Other mental retardation (F78) should
be used when associated physical or sensory impairments make it difficult to establish the degree
of impairment. Unspecified mental retardation (F79) should be used when there is evidence of
mental retardation but not enough information to establish a level of functioning (e.g., a toddler
with significant delays in development who is too young to be assessed with an IQ measure).

Epidemiology

Over the past 50 years the prevalence and incidence of mental retardation have been affected by
changes in the definition of mental retardation, improvements in medical care and technology,
societal attitudes regarding the acceptance and treatment of an individual with mental
retardation, and the expansion of educational services to children with disabilities from birth
through age 21. The theoretical approach to determining the prevalence of mental retardation
uses the normal bell curve to estimate the number of individuals whose IQ falls below the
established criterion score. For example, 2.3% of the population of the United States has an IQ
score below 70, and 5.5% has an IQ score below 75. However, this estimate does not account for
adaptive behavior skills. Based on empirical sampling, Baroff (1991) suggested that only 0.9%
of the population can be assumed to have mental retardation. Following a review of the most
recent epidemiological studies, McLaren and Bryson (1987) reported that the prevalence of
mental retardation was approximately 1.25% based on total population screening. When school
age children are the source of prevalence statistics, individual states report rates from 0.3% to
2.5% depending on the criteria used to determine eligibility for special educational services, the
labels assigned during the eligibility process (e.g., developmental delay, learning disability,
autism, and/or mental retardation), and the environmental and economic conditions within the
state (U.S. Department of Education, 1994). It is estimated that approximately 89% of these
children have mild mental retardation, 7% have moderate mental retardation, and 4% have
severe to profound mental retardation. In addition, McLaren and Bryson (1987) report that the
prevalence of mental retardation appears to increase with age up to about the age of 20, with
significantly more males than females identified.

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Etiology. There are several hundred disorders associated with mental retardation. Many of these
disorders play a causal role in mental retardation. However, most of the causal relationships must
be inferred (McLaren & Bryson, 1987). The American Association on Mental Retardation
subdivides the disorders that may be associated with mental retardation into three general areas:
prenatal causes, perinatal causes, and postnatal causes. It should be noted that some causes can
be determined much more reliably than others. For example, chromosomal abnormalities such as
Down syndrome can be assumed to be causal with more certainty than some postnatal infections.
It should also be noted that mental retardation is both a symptom of other disorders as well as a
unique syndrome or disorder.

Causes associated with level of mental retardation. The most common factor associated with
severe mental retardation (including the moderate, severe, and profound levels of mental
retardation) has been chromosomal abnormality, particularly Down syndrome (McLaren &
Bryson, 1987). In approximately 20 to 30% of the individuals identified with severe mental
retardation the cause has been attributed to prenatal factors, such as chromosomal abnormality.
Perinatal factors such as perinatal hypoxia account for about 11%, and postnatal factors such as
brain trauma account for 3 to 12% of severe mental retardation. In 30 to 40% of cases, the cause
is reported to be unknown.

The etiology of mild mental retardation is much less delineated. Between 45 and 63% of the
cases are attributed to unknown etiology. Fewer cases of prenatal and perinatal causes are
reported, with the largest number attributed to multiple factors (prenatal) and hypoxia (perinatal).
Very few postnatal causes have been linked to mild mental retardation (McLaren & Bryson,
1987).

Associated disorders. A variety of disorders are associated with mental retardation. These
include: epilepsy, cerebral palsy, vision and hearing impairments, speech/language problems,
and behavior problems (McLaren & Bryson, 1987). The number of associated disorders appears
to increase with the level of severity of mental retardation (Baird & Sadovnick, 1985).

21
Psychopathology

Studies estimating the prevalence of mental health disorders among individuals with mental
retardation suggest that between 10 and 40% meet the criteria for a dual diagnosis of mental
retardation and a mental health disorder (Reiss, 1990). The range in prevalence rates appears to
be due to varying types of population sampling. When case file surveys are conducted, the
prevalence rates are consistently around 10%. The use of psychopathology rating scales in
institutional or clinic samples produces the much higher 40% prevalence rate (Reiss, 1990). The
actual prevalence may lie somewhere in between these two estimates. This may be the case due
to the tendency of mental health professionals to consider behavior disorders in individuals with
mental retardation as a symptom of their delayed development. Nevertheless, individuals with
mental retardation appear to display the full range of psychopathology evidenced in the general
population (Jacobson, 1990; Reiss, 1990). Individuals with mild cognitive limitations are more
likely to be given a dual diagnosis than children with more significant disabilities (Borthwick-
Duffy & Eyman, 1990).

Assessment

Assessment of a child suspected of having a developmental disability, such as mental retardation,


may establish whether a diagnosis of mental retardation or some other developmental disability
is warranted, assessing eligibility for special educational services, and/or aid in determining the
educational or psychological services needed by the child and family. At a minimum, the
assessment process should include an evaluation of the child's cognitive and adaptive or
everyday functioning including behavioral concerns, where appropriate, and an evaluation of the
family, home, and/or classroom to establish goals, resources, and priorities.

Globally defined, child assessment is the systematic use of direct as well as indirect procedures
to document the characteristics and resources of an individual child (Simeonsson & Bailey,
1992). The process may be comprised of various procedures and instruments resulting in the
confirmation of a diagnosis, documentation of developmental status, and the prescription of
intervention/treatment (Simeonsson & Bailey, 1992). A variety of assessment instruments have
been criticized for insensitivity to cultural differences resulting in misdiagnosis or mislabeling.
However, assessments have many valid uses. They allow for the measurement of change and the
evaluation of program effectiveness and provide a standard for evaluating how well all children
have learned the basic cognitive and academic skills necessary for survival in our culture. Given
that the use of existing standardized instruments to obtain developmental information as part of
the assessment process may bring about certain challenges, there does not appear to be a
reasonable alternative (Sattler, 1992). Thus, it becomes necessary to understand assessment and

22
its purpose so that the tools which are available can be used correctly, and the results can be
interpreted in a valid way.

The four components of assessment (Sattler, 1992), norm-referenced tests, interviews,


observations, and informal assessment, complement each other and form a firm foundation for
making decisions about children. The use of more than one assessment procedure provides a
wealth of information about the child permitting the evaluation of the biological, cognitive,
social and interpersonal variables that affect the child's current behavior. In the diagnostic
assessment of children, it is also important to obtain information from parents and other
significant individuals in the child's environment. For school-age children, teachers are an
important additional source of information. Certainly, major discrepancies among the findings
obtained from the various assessment procedures must be resolved before any diagnostic
decisions or recommendations are made. For example, if the intelligence test results indicate that
the child is currently functioning in the mentally retarded range, while the interview findings and
adaptive behavior results suggest functioning in a average range, it would become necessary to
reconcile these disparate findings before making a diagnosis.

Developmental Delay or Mental Retardation

In diagnosing infants or preschoolers, it is important to distinguish between mental retardation


and developmental delay. A diagnosis of mental retardation is only appropriate when cognitive
ability and adaptive behavior are significantly below average functioning. In the absence of
clear-cut evidence of mental retardation, it is more appropriate to use a diagnosis of
developmental delay. This acknowledges a cognitive or behavioral deficit, but leaves room for it
to be transitory or of ambiguous origin (Sattler, 1992). In practice, children under the age of 2
should not be given a diagnosis of mental retardation unless the deficits are relatively severe
and/or the child has a condition that is highly correlated with mental retardation (e.g., Down
syndrome).

23
Cognitive/Developmental Assessment Tools

Bayley Scales of Infant Development - Second Edition (Bayley, 1993): The Bayley Scales is an
individually administered instrument for assessing the development of infants and very young
children. It is appropriate for children from 2 months to 3½ years. It is comprised of three scales,
the Mental Scale, the Motor Scale, and the Behavior Rating Scale. The Mental Scale assesses the
following areas: recognition memory, object permanence, shape discrimination, sustained
attention, purposeful manipulation of objects, imitation (vocal/verbal and gestural), verbal
comprehension, vocalization, early language skills, short-term memory, problem-solving,
numbers, counting, and expressive vocabulary. The Motor Scale addresses the areas of gross and
fine motor abilities in a relatively traditional manner. The Behavior Rating Scale is used to rate
the child's behavioral and emotional status during the assessment. Performance on the Mental
and Motor Scales is interpreted through the use of standard scores (mean = 100; standard
deviation = 15). The Behavior Rating Scale is interpreted by the use of percentile ranks. The
Bayley Scales were standardized using a stratified sample of 1,700 infants and toddlers across 17
age groupings closely approximating the U.S. Census Data from 1988. The manual includes
validity studies and case examples. The Bayley Scales is one of the most popular infant
assessment tools. It can also be used to obtain the developmental status of children older than 3
½ who have very significant delays in development and cannot be evaluated using more age-
appropriate cognitive measures (e.g., a 6 year old with a developmental level of 2 years).

The Differential Ability Scales (DAS) (Elliott, 1990): The DAS consists of a battery of
individually administered cognitive and achievement tests subdivided into three age brackets:
lower preschool (2 ½ years to 3 years, 5 months), upper preschool (3 ½ years to 5 years, 11
months), and school age (6 years to 17 years, 11 months). The cognitive battery focuses on
reasoning and conceptual abilities and provides a composite standard score, the General
Conceptual Ability (GCA) score. Verbal and Nonverbal cluster standard scores and individual
subtest standard scores are also available. The DAS has several advantages over other similar
measures. It has a built-in mechanism for assessing significantly delayed children who are over
the age of 3 ½ years. It can also provide information comparable to other similar instruments in
about half the time. Finally, it is very well standardized and correlates highly with other
cognitive measures (i.e., the Wechsler Scales).

Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) (Wechsler, 1989):


The WPPSI-R can be utilized for children ranging in age from 3 years to 7 years, 3 months.
Though separate and distinct from the WISC-III (discussed below), it is similar in form and
content. The WPPSI-R is considered a downward extension of the WISC-III. These two tests
overlap between the ages of 6 and 7 years, 3 months. The WPPSI-R has a mean of 100 and
standard deviation of 15, with scaled scores for each subtest having a mean of 10 and a standard

24
deviation of 3. It contains 12 subtests organized into one of two major areas: the Verbal Scale
includes Information, Similarities, Arithmetic, Vocabulary, Comprehension, and Sentences
(optional) subtests; the Performance Scale includes Picture Completion, Geometric Design,
Block Design, Mazes, Object Assembly, and Animal Pegs (optional) subtests. The WPPSI
contains 9 subtests similar to those included in the WISC-III (Information, Vocabulary,
Arithmetic, Similarities, Comprehension, Picture Completion, Mazes, Block Design, and Object
Assembly) and 3 unique subtests (Sentences, Animal Pegs, and Geometric Design). Three
separate IQ scores can be obtained: Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ.
The WPPSI-R was standardized on 1,700 children equally divided by gender and stratified to
match the 1986 U.S. census data. This instrument cannot be used with severely disabled children
(IQ's below 40) and, with younger children, may need to be administered over two sessions due
to the length of time required to complete the assessment.

Wechsler Intelligence Scale for Children-III (WISC-III) (Wechsler, 1991): The WISC-III can be
utilized for children ranging in age from 6 years through 16 years of age. It is the middle
childhood to middle adolescence version of the Wechsler Scale series. It contains 13 subtests
organized into two major areas: the Verbal Scale includes Information, Similarities, Arithmetic,
Vocabulary, Comprehension, and Digit Span (optional) subtests; the Performance Scale includes
Picture Completion, Picture Arrangement, Block Design, Object Assembly, Coding, and the
optional subtests of Mazes, and Symbol Search. Three separate IQ scores can be obtained:
Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ. Each of these separate IQ's are
standard scores with a mean of 100 and a standard deviation of 15, with scaled scores for each
subtest having a mean of 10 and a standard deviation of 3. The WISC-III was standardized on a
sample of 2,200 American children selected as representative of the population on the basis of
1988 U.S. census data.

Wechsler Adult Intelligence Scale - Revised (WAIS-R) (Wechsler, 1981): The WAIS-R covers an
age range of 16 years, 0 months to 74 years, 11 months. The revised version contains about 80%
of the original WAIS and was modified mainly due to cultural considerations. There are 11
subtests: Verbal Scale - Information, Similarities, Arithmetic, Vocabulary, Comprehension, and
Digit Span; Performance Scale - Picture Completion, Picture Arrangement, Block Design, Object
Assembly, and Digit Symbol. The WAIS-R was standardized in the 1970's on a sample of 1,880
white and non-white Americans equally divided among gender. The WAIS-R has a mean of 100
and a standard deviation of 15 with the scaled scores for each subtest having a mean of 10 and a
standard deviation of 3.

Stanford-Binet:Fourth Edition (SB: FE) (Thorndike, Hagen, & Sattler, 1986): The SB: FE is
appropriate for use on individuals ranging in age from 2 to 23. It is comprised of 15 subtests,
though only 6 (Vocabulary, Comprehension, Pattern Analysis, Quantitative, Bead Memory, and

25
Memory for Sentences) are used in all age groups. The other 9 subtests (Picture Absurdities,
Paper Folding and Cutting, Copying, Repeating Digits, Similarities, Form-Board Items, Memory
for Objects, Number Series, and Equation Building) are administered on the basis of age. Unlike
previous editions, the SB: FE uses a point scale similar to that of the Wechsler Scales, is more
culturally sensitive, and includes some new items in the areas of memory for objects, number
series, and equation building.

Once administered, the SB: FE yields three types of scores: age scores (or scaled scores), area
scores (general intelligence, crystallized intelligence and short-term memory, specific factors,
and specific factors plus short-term memory), and a Composite Score (similar to the Full-Scale
IQ of the Wechsler). The SB: FE Composite Score has a mean of 100 and a standard deviation of
16 (unlike the Wechsler's standard deviation of 15).

Overlap between the WISC-III and the Stanford-Binet:Fourth Edition: The WISC-III is
appropriate between the ages of 6-16, while the Stanford-Binet: Fourth Edition is appropriate
between the ages of 2 and 23. While the child is between 6 and 16, either test is appropriate.
Correlations range from .66 to .83 between the WISC-R Full Scale IQ and the Fourth Edition
composite. Results from Thorndike, Hagen, and Sattler (1986) show that while the two tests
yield approximately equal scores, they are not interchangeable. This is partly due to the fact that
they operate on different standard deviations (Sattler, 1992).

Overlap between the WAIS-R and the Stanford-Binet:Fourth Edition: Results for individuals
with and without mental retardation are similar in that the WAIS-R yields higher scores than the
Stanford-Binet Fourth Edition.

Special Note: Assessment Tools for Individuals with Mental Retardation. The Stanford-Binet:
Fourth Edition and the Wechsler Scales are useful instruments in assessing mild mental
retardation; however, neither is designed to test individuals with severe/profound mental
retardation. In addition, due to the high floor on the Wechsler Scales the publisher recommends
that a child obtain raw score credit in at least 3 subtests of the Verbal Scale and the Performance
Scale before assuming they provide useful information. Raw score for 6 subtests, 3 Verbal and 3
Performance are recommended for a valid Full Scale IQ.

McCarthy Scales of Children's Abilities (McCarthy, 1972): The McCarthy Scales can be used
with children between the ages of 2 ½ years and 8 ½ years. It contains six scales: Verbal Scale,
Perceptual-Performance Scale, Quantitative Scale, Memory Scale, Motor Scale, and General
Cognitive Scale. In addition to yielding a General Cognitive Index (GCI), the McCarthy Scales
provide several ability profiles (verbal, non-verbal reasoning, number aptitude, short-term
memory, and coordination). The overall GCI has a mean of 100 and a standard deviation of 16
and is an estimate of the child's ability to apply accumulated knowledge to the tasks in the scales.

26
The ability profiles, in particular, make the McCarthy Scales useful for assessing young children
with learning problems. The GCI is not interchangeable with the IQ score rendered by the
Wechsler Scales; therefore, caution is advised in making placement decisions based on the GCI,
especially in the case of children with mental retardation (Sattler, 1992).

Assessing Adaptive Behavior

Adaptive behavior is an important and necessary part of the definition and diagnosis of mental
retardation. It is the ability to perform daily activities required for personal and social sufficiency
(Sattler, 1992). Assessment of adaptive behavior focuses on how well individuals can function
and maintain themselves independently and how well they meet the personal and social demands
imposed on them by their cultures. There are more than 200 adaptive behavior measures and
scales. The most common scale is the Vineland Adaptive Behavior Scales (Sparrow, Balla, &
Cicchetti, 1984).

Vineland Adaptive Behavior Scales (VABS) (Sparrow, Balla, & Cicchetti, 1984): The VABS is a
revision of the Vineland Social Maturity Scale (Doll, 1953) and assesses the social competence
of individuals with and without disabilities from birth to age 19. It is an indirect assessment in
that the respondent is not the individual in question but someone familiar with the individual's
behavior. The VABS measures four domains: Communication, Daily Living Skills,
Socialization, and Motor Skills. An Adaptive Behavior Composite is a combination of the scores
from the four domains. A Maladaptive Behavior domain is also available with two of the three
forms of administration. Each of the domains and the Composite has a mean of 100 and a
standard deviation of 15. Three types of administration are available: the Survey Form (297
items), the Expanded Form (577 items, 297 of which are from the Survey Form), and the
Classroom Edition (244 items for children age 3-13). The Survey and Expanded Forms were
standardized on a representative sample of the 1980 U.S. census data including 3,000 individuals
ranging in age from newborn to 18 years, 11 months. There are norms for individuals with
mental retardation, children with behavior disorders, and individuals with physical handicaps.
The Classroom Edition was standardized on a representative sample of the 1980 U.S. census data
including 3,0000 students, ages 3 to 12 years, 11 months. Caution is advised when using this
scale with children under the age of two because children with more significant delays frequently
attain standard scores that appear to be in the low average range of ability. In this case more
weight should be placed on the age equivalents that can be derived.

The American Association on Mental Retardation (AMMR) Adaptive Behavior Scale (ABS): The
ABS has two forms which address survival skills and maladaptive behaviors in individuals living
in residential and community settings (ABS-RC:2; Nihira, Leland, & Lambert, 1993) or school

27
age children (ABS-S:2; Lamber, Nahira, & Leland, 1993). It is limited in scope and should be
used with caution. A new scoring method has recently been devised that can generate scores
consistent with the 10 adaptive behavior areas suggested in the 1992 definition of mental
retardation (Bryant, Taylor, & Pedrotty-Rivera, 1996). The results of this assessment can be
readily translated into objectives for intervention.

Achievement Tests

Intelligence tests are broader than achievement tests and sample from a wider range of
experiences, but both measure aptitude, learning, and achievement, to some degree (Sattler,
1992). Achievement tests (such as reading and mathematics) are heavily dependent on formal
learning, are more culturally bound, and tend to sample more specific skills than do intelligence
tests. Intelligence tests measure one's ability to apply information in new and different ways,
whereas achievement tests measure mastery of factual information (Sattler, 1992). Intelligence
tests are better predictors of scholastic achievement contributing to the decision-making
processes in schools and clinics, and they are a better predictor of educability and trainability
than other achievement tests because they sample the reasoning capacities developed outside
school which should also be applied in school.

To determine if learning potential is being fully realized, results from an IQ test and standardized
tests of academic achievement can be compared. If there is a significant difference between IQ
and achievement, the child may benefit from special assistance in the academic area identified.

Achievement Assessment Tools That Can Be Used With Children With Mild Learning
Disorders.

Woodcock-Johnson Psycho-Educational Battery - Revised (Woodcock & Johnson, 1990): The


Woodcock-Johnson is comprised of 35 tests assessing cognitive ability (vocabulary, memory,
concept formation, spacial relations, and quantitative concepts) and achievement (reading,
spelling, math, capitalization, punctuation, and knowledge of science, humanities, and social
studies). Though the test batteries can be used with individuals from age 2 through adulthood,
not all tests are administered at every age. The Cognitive Ability Battery and the Achievement
Battery each have a recommended standard and supplemental batteries. The Achievement
Battery can be used with preschool children (4 or 5 year olds) through adults. They each provide
scores which can be converted into standard scores with a mean of 100 and a standard deviation
of 15. By comparing the Tests of Cognitive Ability and the Tests of Achievement, the
Woodcock-Johnson allows for the assessment of an Aptitude/achievment discrepancy. The
discrepancy reflects disparity between cognitive and achievement capabilities. The Woodcock-

28
Johnson was standardized on a representative sample of 6,359 individuals ranging in age from 2
to 95 from communities throughout the United States.

The Wide Range Achievement Test - Revised (WRAT-R) (Jastak & Wilkinson, 1984): The
WRAT-R is a brief achievement test and contains three subtests: Reading, Spelling, Arithmetic.
The WRAT-R is divided into two levels: Level One (ages 5 years, 0 months to 11 years, 11
months), and Level Two (ages 12 years, 0 months to 74 years, 11 months). The WRAT-R has a
mean of 100 and a standard deviation of 15. It also provides T scores, scaled scores, grade-
equivalent scores, and percentile ranks. It was standardized on a sample of 5,600 individuals in
28 age groups (5-74 years).

A variety of other achievement tests are available for assessing academic performance. These
include, but are not limited to, the Kaufman Test of Educational Achievement (Kaufman &
Kaufman, 1985) and the Wechsler Individual Achievement Test (1992).

Other Assessment Tools

Peabody Picture Vocabulary Test - Revised (PPVT-R) (Dunn & Dunn, 1981): The PPVT-R is
appropriate for individuals between the ages of 2½ and adulthood and measures receptive
knowledge of vocabulary. It is a multiple choice test requiring only a pointing response and no
reading ability, thus making it useful for hearing individuals with a wide range of abilities,
particularly children with language based disabilities. The revised edition is more sensitive to
gender-based stereotypes and cultural issues; in fact only 37% of the original items were
retained. The PPVT-R has two forms, L and M, with 175 plates in each form in ascending order
of difficulty. Each plate consists of four clearly drawn pictures, one of which is the correct
response to the word given by the experimenter. Standard scores have a mean of 100 with a
standard deviation of 15. The PPVT-R was standardized on a national sample of 4,200 children
(2½ - 18) and 828 adults (19 - 40) equally divided among gender and based on 1970 U.S. census
data. The PPVT-R was designed to assess breadth of receptive vocabulary and not as a screening
tool for measuring intellectual level of functioning. PPVT-R scores are not interchangeable with
IQ scores obtained via the Stanford-Binet: Fourth Edition or the Wechsler Tests.

Columbia Mental Maturity Scale: The Columbia Mental Maturity Scale (Burgemeister, Blum, &
Lorge, 1972) is a test of general reasoning ability that can be used with children who have
significant physical limitations. It is appropriate for children between the ages of 3 ½ years and 9
years, 11 months. The Columbia has a mean of 100, a standard deviation of 16, and can be
interpreted using age equivalents. When used in conjunction with the Peabody Picture

29
Vocabulary Test - Revised, it can provide reasonably accurate cognitive status information
comparable to the more common intelligence tests.

Leiter International Performance Scale: The Leiter International Performance Scale (Leiter,
1948) is a nonverbal assessment of intelligence. Although the norms are dated, it provides useful
information about the cognitive status of children with hearing impairments or severe language
disabilities. It can be used with children aged 2 through adults. It is currently under revision and
will likely be a useful tool in the future (Roid & Miller, 1997).

For a description of a wide range of other specialty tests, the reader is referred to the Assessment
of Children by Jerome Sattler (1992).

Dual Diagnosis

Appropriate assessment of psychopathology in people with dual diagnosis is important because:


a) it can suggest the form of treatment; b) it may ensure access to and funding for special
services; and c) it can be used to evaluate subsequent interventions (Sturmey, 1995). Brain
damage, epilepsy and language disorders are risk factors for psychiatric disorders and are often
associated with mental retardation (Rutter, Tizard, Graham, & Whitmore, 1976; Sturmey, 1995).
Social isolation, stigmatization, and poor social skills put individuals with mental retardation at
further risk for affective disorders (Reiss & Benson, 1985). The relationship between emotional
disorders and mental retardation has been noted by many researchers (Bregman,
1991;Menolascino, 1977; Reiss, 1982). Rates of emotional disorders are more prevalent in
children with mental retardation than children without mental retardation (Bregman, 1988; Lewis
& MacLean, 1982; Matson, 1982, Russell, 1985). As noted previously, epidemiological studies
of psychiatric disorders in individuals with mental retardation show that this population
experiences higher rates of psychopathology (Corbett, 1985; Gostason, 1985). Though children
with mental retardation are diagnosed with psychiatric disorders more often than children
without mental retardation, they are usually diagnosed with the same types of disorders.
However, uncommon psychiatric disorders may be found in children with severe and profound
levels of mental retardation (Batshaw & Perret, 1992).

An additional problem is the application of DSM-IV criteria to individuals with mental


retardation. Though the DSM has proven useful in diagnosing individuals with mild or moderate
mental retardation (especially when the criterion are modified in some way, leading to problems
in clearly operationalized definitions), many psychologists and psychiatrists rely more on
biological markers, observable signs, and patterns of family psychopathology to diagnose
individuals with severe and profound mental retardation thus implying that the DSM may not be

30
as useful with this population (Sturmey, 1995). The mismatch between behaviors scripted in the
DSM-IV and psychopathology presented in individuals with mental retardation can lead to under
diagnosing of these individuals (Sturmey, 1995). Because the DSM is so widely used by
psychiatrists, psychologists, health insurance companies, and because of the way it is
coordinated with the International Classification of Diseases (ICD), it will continue to be the
main diagnostic source. Practitioners should take care not to modify the DSM criteria for their
own use and instead should use the criteria as they are prescribed and document cases where the
criteria are inadequate to make a comprehensive diagnosis (Sturmey, 1995).

Most psychologists in the mental health field have little exposure to individuals with mental
retardation and are sometimes uncomfortable treating these individuals; in fact, many
professionals seem unaware that this group can experience mental health problems (Reiss &
Szyszko, 1983). Mental health and mental retardation systems have been separated in this
country for many years making it difficult to administratively serve people with both mental
retardation and mental health disorders (Matson & Sevin, 1994). Recently, there has been a
heightened awareness of need to pursue behavioral-psychiatric assessment, diagnosis, and
treatment of people with mental retardation and mental health problems (Bregman, 1991; Eaton
& Menolascino, 1982; Reiss, 1990).

A variety of behavioral assessment tools are available and provide key information for
practioners in this area. A few of the commonly used measures or checklists include: the Child
Behavior Checklist (Achenbach & Edelbrock, 1986), the Conners Parent (or Teacher) Rating
Scale (Conners, 1990), the Revised Behavior Problem Checklist (Quay & Peterson, 1987), and
the Social Skills Rating System (Gresham & Elliott, 1990). These measures are only as reliable
as the parent, guardian, or teacher completing them. However, they can provide useful
information about the nature of the behavioral problems or competencies of the child. All of the
scales noted above focus primarily on behavioral difficulties with the exception of the Social
Skills Rating System which includes items that address prosocial behaviors.

Interdisciplinary Approach

Because children with mental retardation often have other problems, it is necessary to involve a
team of practitioners from different areas (e.g., child psychiatrist, social worker, child
psychologist, special education teacher, speech and language specialist, and community
agencies), in the comprehensive diagnosis. This type of interdisciplinary team approach is
relatively new but is considered to be imperative for comprehensive assessment, treatment, and
management of children with mental retardation (Lubetsky, Mueller, Madden, Walker, & Len,
1995). A natural extension of the interdisciplinary approach is the involvement of the family in

31
the decision-making process. In fact, recent government and educational initiatives such as
Public Law 99-457 and Public Law 102-119 require the involvement of parents and
professionals in early intervention services (Lubetsky et al, 1995). A family-centered
interdisciplinary approach begins with an assessment of the child (including school history,
obtained from parents and school records), family (family marital and parenting history), and
community resources. Medical, developmental and psychiatric histories are obtained. Behavioral
analysis, psychoeducational, speech and language testing are completed. Medical and
neurological assessments are performed.

Intervention

Psychoeducational Intervention

As a result of federal legislation developed with the aid and encouragement of a number of
advocacy groups (i.e., the Individuals with Disabilities Education Act; Public Law 94-142,
Public Law 99-457, and Public Law 102-119), children and adolescents with mental retardation
or related developmental disorders are entitled to free and appropriate intervention. Appropriate
intervention should be based on the needs of the child as determined by a team of professionals,
address the priorities and concerns of the family, and be provided in the least restrictive most
inclusive setting (i.e., where they have every opportunity to benefit from interacting with
nondisabled peers and the community resources available to all other children).

Infant/Toddler Services

Services to infants and toddlers can be home-based, center-based, or some combination of the
two. The nature of the services should be determined based on the results of the child assessment
and family priorities for the child. These should be used to develop an Individual Family Service
Plan for the child which includes all parties participating in the intervention and is coordinated
by a Services Coordinator (case manager) who is available and acceptable to the family. The
services may include assistive technology, intervention for sensory impairments, family
counseling, parent training, health services, language services, nursing intervention, nutrition
counseling, occupational therapy, physical therapy, case management, and transportation to
services.

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Preschool and School Services

Services to preschool children, ages 3 through 5, and school-aged children, 6 through 21, can be
home-based, but are more frequently center-based. As in the case of infants and toddlers, a team
evaluation and parent input is used to develop an intervention plan. This plan, the Individualized
Education Plan (IEP), details the objectives for improving the child's skills and may include
family or parent focused activities. Services may include special education provided by a
certified teacher and focused on the needs of the child, child counseling, occupational therapy,
physical therapy, language therapy, recreational activities, school health services, transportation
services, and parent training or counseling. These services should be provided in the most
inclusive least restrictive setting (e.g., a regular preschool program, Headstart Center, child's
home).

Social/Interpersonal Intervention

Social and interpersonal interventions can be both preventative and therapeutic. As noted above,
children with mental retardation are at an increased risk for behavioral disorders. Therefore, a
variety of group social and recreational activities should be included in the child's educational
program. These activities should include nondisabled peers and may include participation at
birthday parties, attending recreational activities such as ball games and movies, participating in
youth sports activities, and visiting community sites such as the zoo. The goal of these activities
should be to teach appropriate social skills relevant to group participation and building self-
esteem.

Parents also may benefit from prevention activities. Respite care provided by trained individuals
can afford parents the opportunity to address their own needs (e.g., personal time, medical
appointments, socializing with peers, etc.). They can be much more effective in parenting when
their own needs have been met. Social or parent support groups can also be an outlet for parents
to discuss their feelings with individuals who have similar experiences. These groups may be
syndrome specific (e.g., Parent Advocates for Down Syndrome) or more generic in nature.

Therapeutic interventions with the children and families may include family therapy, individual
child behavior therapy, parent training, and group therapy with mildly mentally disabled children
and adolescents focusing on developing appropriate social skills. Child behavioral interventions
can be used to teach self-care, vocational, leisure, interpersonal, and survival skills (e.g., finding
a public restroom). Disruptive behaviors such as tantrumming, self-injury, noncompliance, and
aggression toward others can also be addressed through behavioral techniques. The most

33
frequent form of behavioral intervention for problematic behavior involves differential
reinforcement of incompatible and/or other behaviors (Batshaw & Perret, 1992).

Psychopharmacological Intervention

Treatment specifying the use of medication should only be considered when a particular
psychiatric condition know to benefit from a particular drug coexists with the mental retardation
or developmental disability. This may take the form of a severe depression, obsessive-
compulsive disorder, attention deficit-hyperactivity disorder, or a variety of other psychiatric
disorders. There are few well controlled studies of drug treatments with children who have
mental retardation. It should also be noted that the use of medication as a form of chemical
restraint should be avoided. In addition, when drug treatment is used, it should only be one
component of an overall treatment approach (Batshaw & Perret, 1992).

Final Comments

An invaluable resource in evaluating and treating children with mental retardation is the child's
family. Consequently, including the families of children with or at-risk for disabilities in every
phase of intervention, from identification to planning to implementation through monitoring
should be considered. However, including families in decisions about the treatment or
management of their children's problems presents new challenges. Nevertheless, trying to
understand and include families in the decision-making process can ultimately be rewarding and
beneficial for all involved.

Level of Family Involvement

How and when should families be included in decision making? There is no standard formula for
answering this question. Families, like individuals, vary tremendously. Nevertheless, there are
some issues that must be considered when involving families in team decisions about their child
with a disability. First, the team must be receptive to including families in the decision-making
process. This involves some effort on the part of the non-family team members to encourage
family participation. In addition, the team must decide what child and family concerns are related
to enhancing the development of the child. These should be the focus of generating family-
oriented service delivery alternatives.

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Second, the team must consider the level of knowledge and understanding of the family related
to the disability of the child and/or the service/treatment options. If families are to participate in
the decision-making process they must have the knowledge necessary to select appropriate
alternatives. It is unfair to assume that families will not understand or cannot make appropriate
decisions about the care of their child. They are the consumers and need to be given the chance
to make an informed choice.

Finally, once the family has an adequate understanding of the condition and service/treatment
alternatives, they may need to be nurtured through the team decision-making process. Most
families have never been faced with participating as a member of a team of professionals and
may initially be reticent or nonparticipatory in discussions unless they are specifically invited to
do so. Certainly, as a primary care provider the parent or family member has more at stake than
the other team members. Over time, however, the cautious or reticent family member may
become an active and vital team member.

Encouraging Parent Participation

Health and education professionals who participate as team members must actively pursue
parent-professional partnerships in the decision-making process. The logical first step is to
acknowledge the value of the parent-professional relationship. Parents should be viewed as equal
partners who can make important and necessary contributions in the planning, decision-making,
process. If professionals are reluctant to or refuse to acknowledge parents as partners in the
process, they run the risk of alienating them resulting in a lack of interest or participation in
necessary services. Once the non-family team members accept the parents or other relevant
family members as equal partners in the planning process, strategies to encourage continued
active participation should be developed and implemented.

35
Mild Intellectual Disability (MID) also
referred to as Mild Mental Retardation

Many of the characteristics of MID correspond to those of Learning Disabilities. The intellectual
development will be slow, however, MID students have the potential to learn within the regular
classroom given appropriate modifications and/or accommodations.Some MID students will
require greater support and/or withdrawal than others will. MID students, like all students
demonstrate their own strengths and weaknesses. Depending on the educational jurisdiction,
criteria for MID will often state that the child is functioning approximately 2-4 years behind or 2-
3 standard deviations below the norm or have an IQ under 70-75. The intellectual disability may
vary from mild to profound.

How are MID Students Identified?

Depending on the education jurisdiction, testing for MID will vary. Generally, a combination of
assessment methods are used to identify mild intellectual disabilities. Methods may or may not
include IQ scores or percentiles, adaptive skills cognitive tests in various areas, skills-based
assessments, and levels of academic achievement. Some jurisdictions will not use the term MID
but will use mild mental retardation.

Academic Implications

Students with MID may demonstrate some, all or a combination of the following characteristics:

• 2-4 years behind in cognitive development which could include math, language, short
attention spans, memory difficulties and delays in speech development.
• Social Relationships are often impacted. The MID child may exhibit behavior problems, be
immature, display some obsessive/compulsive behaviors and lack the understanding of
verbal/non verbal clues and will often have difficulty following rules and routines.
• Adaptive Skill Implications. (Everyday skills for functioning) These children may be clumsy,
use simple language with short sentences, have minimal organization skills and will need
reminders about hygiene - washing hands, brushing teeth (life skills). etc.

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• Weak Confidence is often demonstrated by MID students. These students are easily
frustrated and require opportunities to improve self esteem. Lots of support will be needed to
ensure they try new things and take risks in learning.
• Concrete to Abstract thought is often missing or significantly delayed. This includes the
lacking ability to understand the difference between figurative and literal language.

Best Practices

• Use simple, short, uncomplicated sentences to ensure maximum understanding.


• Repeat instructions or directions frequently and ask the student if further clarification is
necessary.
• Keep distractions and transitions to a minimum.
• Teach specific skills whenever necessary.
• Provide an encouraging, supportive learning environment that will capitalize on student
success and self esteem.
• Use appropriate program interventions in all areas where necessary to maximize success.
• Use alternative instructional strategies and alternative assessment methods.
• Help the MID student develop appropriate social skills to support friend and peer
relationships.
• Teach organizational skills.
• Use behavior contracts and reinforce positive behavior if necessary.
• Ensure that your routines and rules are consistent. Keep conversations as normal as possible
to maximize inclusion with peers. Teach the difference between literal/figurative language.
• Be patient! Assist with coping strategies.

Disabilities

• Learning Disabilities
• Physical Disabilities
• Mental Retardation

Teaching Strategies
• Inclusional Strategies
• Helping with Reading
• Teach Rules and Routines
37
Behavior
• 5-Step Behavior Plan
• Best Practices
• Behavior Plans

38
Schizophrenia
Schizophrenia occurs in about 1 percent of the general U.S. population. That means that more
than 3 million Americans suffer from the illness.

The disorder manifests itself in a broad range of unusual behaviors, which cause profound
disruption in the lives of the patients suffering from the condition and in the lives of the people
around them. Schizophrenia strikes without regard to gender, race, social class or culture.

One of the most important kinds of impairment caused by schizophrenia involves the person’s
thought processes. The individual can lose much of the ability to rationally evaluate his
surroundings and interactions with others.

There can be hallucinations and delusions, which reflect distortions in the perception and
interpretation of reality. The resulting behaviors may seem bizarre to the casual observer, even
though they may be consistent with the schizophrenic’s abnormal perceptions and beliefs.

Nearly one-third of those diagnosed with schizophrenia will attempt suicide. About 10 percent of
those with the diagnosis will commit suicide within 20 years of the beginning of the disorder.

Patients with schizophrenia are not likely to share their suicidal intentions with others, making
life-saving interventions more difficult. The risk of depression needs special mention due to the
high rate of suicide in these patients.

The most significant risk of suicide in schizophrenia is among males under 30 who have some
symptoms of depression and a relatively recent hospital discharge. Other risks include imagined
voices directing the patient toward self-harm (auditory command hallucinations) and intense
false beliefs (delusions).

The relationship of schizophrenia to substance abuse is significant. Due to impairments in insight


and judgment, people with schizophrenia may be less able to judge and control the temptations
and resulting difficulties associated with drug or alcohol abuse.

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In addition, it is not uncommon for people suffering from this disorder to try to “self-medicate”
their otherwise debilitating symptoms with mind-altering drugs. The abuse of such substances,
most commonly nicotine, alcohol, cocaine and marijuana, impedes treatment and recovery.

The chronic abuse of cigarettes among schizophrenic patients is well-documented and probably
related to the mind-altering effects of nicotine. Some researchers believe that nicotine affects
brain chemical systems that are disrupted in schizophrenia; others speculate that nicotine
counters some of the unwanted reactions tomedications used to treat the disease.

It is not uncommon for people diagnosed with schizophrenia to die prematurely from other
medical conditions, such as coronary artery disease and lung disease. It is unclear whether
schizophrenic patients are genetically predisposed to these physical illnesses or whether such
illnesses result from unhealthy lifestyles associated with schizophrenia.

Schizophrenia usually first appears in a person during their late teens or throughout their
twenties. It affects more men than women, and is considered a life-long condition which rarely is
"cured," but rather treated. The primary treatment for schizophrenia and similar thought
disorders is medication. Unfortunately, compliance with a medication regimen is often one of the
largest problems associated with the ongoing treatment of schizophrenia. Because people who
live with this disorder often go off of their medication during periods throughout their lives, the
repercussions of this loss of treatment are acutely felt not only by the individual, but by their
family and friends as well.

Successful treatment of schizophrenia, therefore, depends upon a life-long regimen of both drug
and psychosocial, support therapies. While the medication helps control the psychosis associated
with schizophrenia (e.g., the delusions and hallucinations), it cannot help the person find a job,
learn to be effective in social relationships, increase the individual's coping skills, and help them
learn to communicate and work well with others. Poverty, homelessness, and unemployment are
often associated with this disorder, but they don't have to be. If the individual finds appropriate
treatment and sticks with it, a person with schizophrenia can lead a happy and successful life.
But the initial recovery from the first symptoms of schizophrenia can be an extremely lonely
experience. Individuals coping with the onset of schizophrenia for the first time in their lives
require all the support that their families, friends, and communities can provide.

With such support, determination, and understanding, someone who has schizophrenia can learn
to cope and live with it for their entire life. But stability with this disorder means complying with
the treatment plan set up between the person and their therapist or doctor, and maintaining the
balance provided for by the medication and therapy. A sudden stopping of treatment will most
often lead to a relapse of the symptoms associated with schizophrenia and then a gradual
recovery as treatment is reinstated

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SYMPTOMS

Schizophrenia is characterized by at least 2 of the following symptoms, for at least one month:

• Delusions

• Hallucinations

• Disorganized speech (e.g., frequent derailment or incoherence)

• Grossly disorganized or catatonic behavior

• Negative symptoms (e.g., a "flattening" of one's emotions, alogia,


avolition; see below)

(Only one symptom is required if delusions are bizarre orhallucinations consist of a voice
keeping up a running commentary on the person's behavior or thoughts, or two or more voices
conversing with each other.)

For a significant portion of the time since the onset of the disturbance, one or more major areas
of functioning such as work, interpersonal relations, or self-care are markedly below the level
achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve
expected level of interpersonal, academic, or occupational achievement).

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been considered as
alternative explanations for the symptoms and have been ruled out. The disturbance must also
not be due to the direct physiological effects of use or abuse of a substance (e.g., alcohol, drugs,
medications) or a general medical condition.

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the


additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month (or less if successfully treated).

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DIAGNOSIS OF SCHIZOPHRENIA

DSM-IV diagnostic criteria for schizophrenia

In DSM-IV, the diagnosis of schizophrenia depends upon the presence of characteristic


symptoms, a minimum duration of those symptoms, a minimum duration of the disorder, the
presence of social/occupational dysfunction, and adifferentiation from mood, schizoaffective,
other psychotic disorders, general medical conditions, substance-induced disorders and pervasive
developmental disorder

According to DSM-IV, there are no strictly pathognomonic symptomsof schizophrenia.


Characteristic symptoms are conceptualized as falling into two broad categories: positive and
negative. There are four groups of positive symptoms—delusions, hallucinations, disorganized
speech, and grossly disorganized or catatonic behaviour—and one group of negative symptoms,
which includes affective flattening, alogia avolition.

A. Characteristic Symptoms

Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated);
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, that is, affective flattening, alogia, or avolition.
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist
of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or
more voices conversing with each other.

B. Social/occupational dysfunction

For a significant portion of the time since the onset of the disturbance, one or more major areas
of functioning such as work, interpersonal relations, or self-care are markedly below the level
achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve
expected level of interpersonal academic, or occupational achievement).

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C. Duration

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.
active phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form
(e.g. odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out
because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently
with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to the duration of the active and residual
periods.

E. Substance/general medical condition exclusion

The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse,
a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the


additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month (or less if successfully treated).

The DSM-IV diagnostic criteria for schizophrenia require the presence of symptoms from at
least two of the groups listed above. Symptoms from only one group are required if delusions are
bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s
behaviour or thoughts, or two or more voices conversing with each other. Each of the symptoms
must be present for a significant portion of time during a one-month period (or less if
successfully treated).

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According to DSM-IV, schizophrenia is accompanied by marked social or occupational
dysfunction for a significant portion of the time since the onset of the disturbance. The
dysfunction must be present in at least one major area such as work, interpersonal relations or
self-care.

DSM-IV requires that continuous signs of the disturbance persist for at least 6 months. This 6-
month period may include periods when only negative or less severe symptoms are present. Such
periods are referred to as prodromal or residual, depending on whether they precede or follow the
one-month period of characteristic symptoms described above. Classification of course can be
applied only after at least one year has elapsed since the initial onset of active-phase symptoms.
According to DSMIV, the course of schizophrenia is variable. The manual lists the following
course specifiers: episodic with inter-episode residual symptoms; episodic with no inter-episode
residual symptoms; continuous; single episode in partial remission; single episode in full
remission; other or unspecified pattern.

Concerning differential diagnosis, DSM-IV emphasizes the distinction between schizophrenia


and mood disorders. If psychotic symptoms occur exclusively during periods of mood
disturbance, the diagnosis is mood disorder with psychotic features. If mood episodes have
occurred during active-phase symptoms, and if their total duration has been brief relative to the
duration of active and residual periods, the diagnosis is schizophrenia. If a mood episode is
concurrent with the active-phase symptoms of schizophrenia, and if mood symptoms have been
present for a substantial portion of the total duration of the disturbance, and if delusions or
hallucinations have been present for at least 2 weeks in the absence of prominent mood
symptoms, the diagnosis is schizoaffective disorder.

The differentiation between schizophrenia, brief psychotic disorder and schizophreniform


disorder rests upon a criterion of duration: less than one month for brief psychotic disorder; more
than one month but less than 6 months for schizophreniform disorder; at least 6 months for
schizophrenia. The differential diagnosis between schizophrenia and delusional disorder rests on
the nature of the delusions (in delusional disorder they are nonbizarre) and the absence of other
characteristic symptoms of schizophrenia such as hallucinations, disorganized speech and
behaviour, or prominent negative symptoms.

Schizophrenia and pervasive developmental disorder are distinguished by a number of criteria,


including in particular the presence of prominent delusions and hallucinations in the former but
not in the latter.

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Finally, the diagnosis is not made if the disturbance is due to the direct physiological effects of a
substance or a general medical condition.

DSM-IV describes five subtypes of schizophrenia: paranoid, disorganized, catatonic,


undifferentiated and residual. Post-psychotic depressive disorder of schizophrenia and simple
deteriorative disorder or simple schizophrenia is described in Appendix B, among conditions
requiring further study. In both the ICD-10 and the DSM-IV there is a distinction between
positive and negative characteristic symptoms of schizophrenia. According to the definition
provided in DSM-IV, ‘‘the positive symptoms appear to reflect an excess or distortion of normal
functions, whereas the negative symptoms appear to reflect a diminution or loss in normal
functions’’.

In both ICD-10 and DSM-IV, positive symptoms include hallucinations and delusions,
disorganized thought and speech, as well as disorganized and catatonic behaviour. In both
systems, negative symptoms include affective flattening or blunting of emotional responses,
alogia or paucity of speech, and apathy or avolition.

The reliability and validity of psychiatric diagnoses that are based on explicit diagnostic criteria
have been investigated in a number of studies during recent decades. According to Kendell
[106], psychiatric diagnoses are now as reliable as the clinical judgements made in other
branches of medicine. High reliability does not, however, by itself predict high validity.

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Different Types of Schizophrenia:
Paranoid schizophrenia a person feels extremely suspicious, persecuted, grandiose, or
experiences a combination of these emotions.

Disorganized schizophrenia a person is often incoherent but may not have delusions.

Catatonic schizophrenia a person is withdrawn, mute, negative and often assumes very unusual
postures.

Residual schizophrenia a person is no longer delusion or hallucinating, but has no motivation or


interest in life. These symptoms can be most devastating.

Positive Symptoms Negative Symptoms


• Delusions • Lack of drive or
initiative
• Hallucinations
• Social withdrawal
• Disorganized
thinking • Apathy

• Agitation • Emotional
unresponsiveness

The kinds of symptoms that are utilized to make a diagnosis of schizophrenia differ between
affected people and may change from one year to the next within the same person as the disease
progresses. Different subtypes of schizophrenia are defined according to the most significant and
predominant characteristics present in each person at each point in time. The result is that one
person may be diagnosed with different subtypes over the course of his illness.

Paranoid Subtype

The defining feature of the paranoid subtype is the presence of auditory hallucinations or
prominent delusional thoughts about persecution or conspiracy. However, people with this
subtype may be more functional in their ability to work and engage in relationships than people
with other subtypes of schizophrenia. The reasons are not entirely clear, but may partly reflect
that people suffering from this subtype often do not exhibit symptoms until later in life and have
achieved a higher level of functioning before the onset of their illness. People with the paranoid
subtype may appear to lead fairly normal lives by successful management of their disorder.

46
People diagnosed with the paranoid subtype may not appear odd or unusual and may not readily
discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve around
some characteristic theme, and this theme often remains fairly consistent over time. A person’s
temperaments and general behaviors often are related to the content of the disturbance of
thought. For example, people who believe that they are being persecuted unjustly may be easily
angered and become hostile. Often, paranoid schizophrenics will come to the attention of mental
health professionals only when there has been some major stress in their life that has caused an
increase in their symptoms. At that point, sufferers may recognize the need for outside help or
act in a fashion to bring attention to themselves.

Since there may be no observable features, the evaluation requires sufferers to be somewhat open
to discussing their thoughts. If there is a significant degree of suspiciousness or paranoia present,
people may be very reluctant to discuss these issues with a stranger.

There is a broad spectrum to the nature and severity of symptoms that may be present at any one
time. When symptoms are in a phase of exacerbation or worsening, there may be some
disorganization of the thought processes. At this time, people may have more trouble than usual
remembering recent events, speaking coherently or generally behaving in an organized, rational
manner. While these features are more characteristic of other subtypes, they can be present to
differing degrees in people with the paranoid subtype, depending upon the current state of their
illness. Supportive friends or family members often may be needed at such times to help the
symptomatic person get professional help.

Disorganized Subtype

As the name implies, this subtype’s predominant feature is disorganization of the thought
processes. As a rule, hallucinations and delusions are less pronounced, although there may be
some evidence of these symptoms. These people may have significant impairments in their
ability to maintain the activities of daily living. Even the more routine tasks, such as dressing,
bathing or brushing teeth, can be significantly impaired or lost.

Often, there is impairment in the emotional processes of the individual. For example, these
people may appear emotionally unstable, or their emotions may not seem appropriate to the
context of the situation. They may fail to show ordinary emotional responses in situations that
evoke such responses in healthy people. Mental health professionals refer to this particular
symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular
or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral
service or other solemn occasion.

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People diagnosed with this subtype also may have significant impairment in their ability to
communicate effectively. At times, their speech can become virtually incomprehensible, due to
disorganized thinking. In such cases, speech is characterized by problems with the utilization and
ordering of words in conversational sentences, rather than with difficulties of enunciation or
articulation. In the past, the term hebephrenic has been used to describe this subtype.

Catatonic Subtype

The predominant clinical features seen in the catatonic subtype involve disturbances in
movement. Affected people may exhibit a dramatic reduction in activity, to the point that
voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically
increase, a state known as catatonic excitement.

Other disturbances of movement can be present with this subtype. Actions that appear relatively
purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often
to the exclusion of involvement in any productive activity.

Patients may exhibit an immobility or resistance to any attempt to change how they appear. They
may maintain a pose in which someone places them, sometimes for extended periods of time.
This symptom sometimes is referred to as waxy flexibility. Some patients show considerable
physical strength in resistance to repositioning attempts, even though they appear to be
uncomfortable to most people.

Affected people may voluntarily assume unusual body positions, or manifest unusual facial
contortions or limb movements. This set of symptoms sometimes is confused with another
disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other
symptoms associated with the catatonic subtype include an almost parrot-like repeating of what
another person is saying (echolalia) or mimicking the movements of another person
(echopraxia). Echolalia and echopraxia also are seen in Tourette’s Syndrome.

Undifferentiated Subtype

The undifferentiated subtype is diagnosed when people havesymptoms of schizophrenia that are
not sufficiently formed or specific enough to permit classification of the illness into one of the
other subtypes.

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The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty
as to the correct subtype classification. Other people will exhibit symptoms that are remarkably
stable over time but still may not fit one of the typical subtype pictures. In either instance,
diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

Residual Subtype

This subtype is diagnosed when the patient no longer displays prominent symptoms. In such
cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions
or idiosyncratic behaviors may still be present, but their manifestations are significantly
diminished in comparison to the acute phase of the illness.

Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of
impairment affect each patient’s life to varying degrees. Some people require custodial care in
state institutions, while others are gainfully employed and can maintain an active family life.
However, the majority of patients are at neither of these extremes. Most will have a waxing and
waning course marked with some hospitalizations and some assistance from outside support
sources.

People having a higher level of functioning before the start of their illness typically have a better
outcome. In general, better outcomes are associated with brief episodes of symptoms worsening
followed by a return to normal functioning. Women have a better prognosis for higher
functioning than men, as do patients with no apparent structural abnormalities of the brain.

In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in


childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure
to return to prior levels of functioning after acute episodes.

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are
not sufficiently formed or specific enough to permit classification of the illness into one of the
other subtypes.

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty
as to the correct subtype classification. Other people will exhibit symptoms that are remarkably
stable over time but still may not fit one of the typical subtype pictures. In either instance,
diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

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How Is It Diagnosed?

Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it


depends on establishing the slowly progressive development of the characteristic
“negative” symptoms of schizophrenia without any history of hallucinations, delusions, or other
manifestations of an earlier psychotic episode, and with significant changes in personal
behaviour, manifest as a marked loss of interest, idleness, and social withdrawal.

Psychotherapy

Psychotherapy is not the treatment of choice for someone with schizophrenia. Used as an adjunct
to a good medication plan, however, psychotherapy can help maintain the individual on their
medication, learn needed social skills, and support the person's weekly goals and activities in
their community. This may include advice, reassurance, education, modeling, limit setting, and
reality testing with the therapist. Encouragement in setting small goals and reaching them can
often be helpful.

People with schizophrenia often have a difficult time performing ordinary life skills such as
cooking and personal grooming as well as communicating with others in the family and at work.
Therapy or rehabilitation therapy can help a person regain the confidence to take care of
themselves and live a fuller life.

Group therapy, combined with drugs, produces somewhat better results than drug treatment
alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained
when group therapy focuses on real-life plans, problems, and relationships; on social and work
roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on
some practical recreational or work activity. This supportive group therapy can be especially
helpful in decreasing social isolation and increasing reality testing (Long, 1996).

Family therapy can significantly decrease relapse rates for the schizophrenic family member. In
high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time
in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below
10 percent. This therapy encourages the family to convene a family meeting whenever an issue
arises, in order to discuss and specify the exact nature of the problem, to list and consider
alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

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Medications

Schizophrenia appears to be a combination of a thought disorder, mood disorder, and anxiety


disorder. The medical management of schizophrenia often requires a combination of
antipsychotic, antidepressant, and antianxiety medication. One of the biggest challenges of
treatment is that many people don't keep taking the medications prescribed for the disorder. After
the first year of treatment, most people will discontinue their use of medications, especially ones
where the side effects are difficult to tolerate.

As a recent National Institute of Mental Health Study indicated, regardless of the drug, three-
quarters of all patients stop taking their medications. They stopped the schizophrenia
medications either because they did not make them better or they had intolerable side effects.
The discontinuation rates remained high when they were switched to a new drug, but patients
stayed on clozapine about 11 months, compared with only three months for Seroquel, Risperdal
or Zyprexa, which are far more heavily marketed -- and dominate sales. Because of findings such
as this, it's generally recommended that someone with schizophrenia begin their treatment with a
drug such asclozapine (clozapine is often significantly cheaper than other antipsychotic
medications). Clozapine (also known as clozaril) has been shown to be more effective than many
newer antipsychotics as well.

Antipsychotic medications help to normalize the biochemical imbalances that cause


schizophrenia. They are also important in reducing the likelihood of relapse. There are two major
types of antipsychotics, traditional and new antipsychotics.

Traditional antipsychotics effectively control the hallucinations, delusions, and confusion of


schizophrenia. This type of antipsychotic drug, such as haloperidol, chlorpromazine, and
fluphenazine, has been available since the mid-1950s. These drugs primarily block dopamine
receptors and are effective in treating the "positive" symptoms of schizophrenia.

Side effects for antipsychotics may cause a patient to stop taking them. However, it is important
to talk with your doctor before making any changes in medication since many side effects can be
controlled. Be sure to weigh the risks against the potential benefits that antipsychotic drugs can
provide.

Mild side effects: dry mouth, blurred vision, constipation, drowsiness and dizziness. These side
affects usually disappear a few weeks after the person starts treatment.

51
More serious side effects: trouble with muscle control, muscle spasms or cramps in the head and
neck, fidgeting or pacing, tremors and shuffling of the feet (much like those affecting people
with Parkinson's disease).

Side effects due to prolonged use of traditional antipsychotic medications: facial ticks, thrusting
and rolling of the tongue, lip licking, panting and grimacing.

There are many newer antipsychotic medications available since the 1990's, including Seroquel,
Risperdal, Zyprexa and Clozaril. Some of these medications may work on both the serotonin and
dopamine receptors, thereby treating both the "positive" and "negative" symptoms of
schizophrenia. Other newer antipsychotics are referred to as atypical antipsychotics, because of
how they affect the dopamine receptors in the brain. These newer medications may be more
effective in treating a broader range of symptoms of schizophrenia, and some have fewer side
effects than traditional antipsychotics. Learn more about the atypical antipsychotics used to help
treat schizophrenia.

Coping Guidelines For The Family

1. Establish a daily routine for the patient to follow.

2. Help the patient stay on the medication.

3. Keep the lines of communication open about problems or fears the patient may have.

4. Understand that caring for the patient can be emotionally and physically exhausting. Take
time for yourself.

5. Keep your communications simple and brief when speaking with the patient.

6. Be patient and calm.

7. Ask for help if you need it; join a support group.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical
profession because very few professionals are involved in them. Adjunctive community support
groups in concurrence with psychotherapy is usually beneficial to most people who suffer from
schizophrenia. Caution should be utilized, however, if the person's symptoms aren't under control
of a medication. People with this disorder often have a difficult time in social situations,
therefore a support group should not be considered as an initial treatment option. As the person

52
progresses in treatment, a support group may be a useful option to help the person make the
transition back into daily social life.

Another use of self-help is for the family members of someone who lives with schizophrenia.
The stress and hardships causes of having a loved one with this disorder are often overwhelming
and difficult to cope with for a family. Family members should use a support group within their
community to share common experiences and learn about ways to best deal with their
frustrations, feelings of helplessness, and anger.

Cause of Schizophrenia

There is no known single cause of schizophrenia. Many diseases, such as heart disease, result
from an interplay of genetic, behavioral and other factors, and this may be the case for
schizophrenia as well. Scientists do not yet understand all of the factors necessary to produce
schizophrenia, but all the tools of modern biomedical research are being used to search for genes,
critical moments in brain development, and other factors that may lead to the illness.

Can It Be Inherited?

It has long been known that schizophrenia runs in families. People who have a close relative with
schizophrenia are more likely to develop the disorder than are people who have no relatives with
the illness. For example, a monozygotic (identical) twin of a person with schizophrenia has the
highest risk -- 40 to 50 percent -- of developing the illness. A child whose parent has
schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia in the
general population is about 1 percent.

Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are
involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal
difficulties like intrauterine starvation or viral infections, perinatal complications, and various
nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet
understood how the genetic predisposition is transmitted, and it cannot yet be accurately
predicted whether a given person will or will not develop the disorder.

Several regions of the human genome are being investigated to identify genes that may confer
susceptibility for schizophrenia. The strongest evidence to date leads to chromosomes 13 and 6
but remains unconfirmed. Identification of specific genes involved in the development of

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schizophrenia will provide important clues into what goes wrong in the brain to produce and
sustain the illness and will guide the development of new and better treatments. To learn more
about the genetic basis for schizophrenia, the NIMH has established a Schizophrenia Genetics
Initiative that is gathering data from a large number of families of people with the illness.

Is It Caused by a Chemical Defect in the Brain?

Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly.
Neurotransmitters, substances that allow communication between nerve cells, have long been
thought to be involved in the development of schizophrenia. It is likely, although not yet certain,
that the disorder is associated with some imbalance of the complex, interrelated chemical
systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. This area
of research is promising.

Is It Caused by a Physical Abnormality in the Brain?

There have been dramatic advances in neuroimaging technology that permit scientists to study
brain structure and function in living individuals. Many studies of people with schizophrenia
have found abnormalities in brain structure (for example, enlargement of the fluid-filled cavities,
called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or
function (for example, decreased metabolic activity in certain brain regions).

It should be emphasized that these abnormalities are quite subtle and are not characteristic of all
people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic
studies of brain tissue after death have also shown small changes in distribution or number of
brain cells in people with schizophrenia. It appears that many (but probably not all) of these
changes are present before an individual becomes ill, and schizophrenia may be, in part, a
disorder in development of the brain.

Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have
found that schizophrenia may be a developmental disorder resulting when neurons form
inappropriate connections during fetal development. These errors may lie dormant until puberty,
when changes in the brain that occur normally during this critical stage of maturation interact
adversely with the faulty connections. This research has spurred efforts to identify prenatal
factors that may have some bearing on the apparent developmental abnormality.

54
In other studies, investigators using brain-imaging techniques have found evidence of early
biochemical changes that may precede the onset of disease symptoms, prompting examination of
the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile,
scientists working at the molecular level are exploring the genetic basis for abnormalities in brain
development and in the neurotransmitter systems regulating brain function.

55
B.

Theoretical
Framework

56
1. Freud’s Theories

a. Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the
development of personality. Freud’s Stages of Psychosexual Development are, like other stage
theories, completed in a predetermined sequence and can result in either successful completion
or a healthy personality or can result in failure, leading to an unhealthy personality. This theory
is probably the most well known as well as the most controversial, as Freud believed that we
develop through stages based upon a particular erogenous zone. During each stage, an
unsuccessful completion means that a child becomes fixated on that particular erogenous zone
and either over– or under-indulges once he or she becomes an adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures
(sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality
which is evidenced by a preoccupation with oral activities. This type of personality may have a
stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise,
these individuals may become overly dependent upon others, gullible, and perpetual followers.
On the other hand, they may also fight these urges and develop pessimism and aggression toward
others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on
eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has to
learn to control anal stimulation. In terms of personality, after effects of an anal fixation during
this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On
the opposite end of the spectrum, they may become messy and disorganized (anal expulsive).

Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that
during this stage boy develop unconscious sexual desires for their mother. Because of this, he
becomes rivals with his father and sees him as competition for the mother’s affection. During
this time, boys also develop a fear that their father will punish them for these feelings, such as by

57
castrating them. This group of feelings is known as Oedipus Complex ( after the Greek
Mythology figure who accidentally killed his father and married his mother).

Later it was added that girls go through a similar situation, developing unconscious sexual
attraction to their father. Although Freud Strongly disagreed with this, it has been termed the
Electra Complex by more recent psychoanalysts.

According to Freud, out of fear of castration and due to the strong competition of his father, boys
eventually decide to identify with him rather than fight him. By identifying with his father, the
boy develops masculine characteristics and identifies himself as a male, and represses his sexual
feelings toward his mother. A fixation at this stage could result in sexual deviancies (both
overindulging and avoidance) and weak or confused sexual identity according to psychoanalysts.

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and
children interact and play mostly with same sex peers.

Genital Stage (puberty on). The final stage of psychosexual development begins at the start of
puberty when sexual urges are once again awakened. Through the lessons learned during the
previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary
focus of pleasure is the genitals.

b. Freud's Structural and Topographical Models of Personality

Sigmund Freud's Theory is quite complex and although his writings on psychosexual
development set the groundwork for how our personalities developed, it was only one of five
parts to his overall theory of personality. He also believed that different driving forces develop
during these stages which play an important role in how we interact with the world.

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Structural Model (id, ego, superego)

According to Freud, we are born with our Id. The id is an important part of our personality
because as newborns, it allows us to get our basic needs met. Freud believed that the id is based
on our pleasure principle. In other words, the id wants whatever feels good at the time, with no
consideration for the reality of the situation. When a child is hungry, the id wants food, and
therefore the child cries. When the child needs to be changed, the id cries. When the child is
uncomfortable, in pain, too hot, too cold, or just wants attention, the id speaks up until his or her
needs are met.

The id doesn't care about reality, about the needs of anyone else, only its own satisfaction. If you
think about it, babies are not real considerate of their parents' wishes. They have no care for
time, whether their parents are sleeping, relaxing, eating dinner, or bathing. When the id wants
something, nothing else is important.

Within the next three years, as the child interacts more and more with the world, the second part
of the personality begins to develop. Freud called this part the Ego. The ego is based on the
reality principle. The ego understands that other people have needs and desires and that
sometimes being impulsive or selfish can hurt us in the long run. Its the ego's job to meet the
needs of the id, while taking into consideration the reality of the situation.

By the age of five, or the end of the phallic stage of development, the Superego develops. The
Superego is the moral part of us and develops due to the moral and ethical restraints placed on us
by our caregivers. Many equate the superego with the conscience as it dictates our belief of right
and wrong.

In a healthy person, according to Freud, the ego is the strongest so that it can satisfy the needs of
the id, not upset the superego, and still take into consideration the reality of every situation. Not
an easy job by any means, but if the id gets too strong, impulses and self gratification take over
the person's life. If the superego becomes to strong, the person would be driven by rigid morals,
would be judgmental and unbending in his or her interactions with the world. You'll learn how
the ego maintains control as you continue to read.

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c. Topographical Model

Freud believed that the majority of what we experience in our lives, the underlying emotions,
beliefs, feelings, and impulses are not available to us at a conscious level. He believed that most
of what drives us is buried in our unconscious. If you remember the Oedipus and Electra
Complex, they were both pushed down into the unconscious, out of our awareness due to the
extreme anxiety they caused. While buried there, however, they continue to impact us
dramatically according to Freud.

The role of the unconscious is only one part of the model. Freud also believed that everything
we are aware of is stored in our conscious. Our conscious makes up a very small part of who we
are. In other words, at any given time, we are only aware of a very small part of what makes up
our personality; most of what we are is buried and inaccessible.

The final part is the preconscious or subconscious. This is the part of us that we can access if
prompted, but is not in our active conscious. Its right below the surface, but still buried
somewhat unless we search for it. Information such as our telephone number, some childhood
memories, or the name of your best childhood friend is stored in the preconscious.

Because the unconscious is so large, and because we are only aware of the very small conscious
at any given time, this theory has been likened to an iceberg, where the vast majority is buried
beneath the water's surface. The water, by the way, would represent everything that we are not
aware of, have not experienced, and that has not been integrated into our personalities, referred
to as the nonconscious.

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d. Ego Defense Mechanisms

We stated earlier that the ego's job was to satisfy the id's impulses, not offend the moralistic
character of the superego, while still taking into consideration the reality of the situation. We
also stated that this was not an easy job. Think of the id as the 'devil on your shoulder' and the
superego as the 'angel of your shoulder.' We don't want either one to get too strong so we talk to
both of them, hear their perspective and then make a decision. This decision is the ego talking,
the one looking for that healthy balance.

Before we can talk more about this, we need to understand what drives the id, ego, and
superego. According to Freud, we only have two drives; sex and aggression. In other words,
everything we do is motivated by one of these two drives.

Sex, also called Eros or the Life force, represents our drive to live, prosper, and produce
offspring. Aggression, also called Thanatos or our Death force, represents our need to stay alive
and stave off threats to our existence, our power, and our prosperity.

Now the ego has a difficult time satisfying both the id and the superego, but it doesn't have to do
so without help. The ego has some tools it can use in its job as the mediator, tools that help
defend the ego. These are called Ego Defense Mechanisms or Defenses. When the ego has a
difficult time making both the id and the superego happy, it will employ one or more of these
defenses:

DEFENSE DESCRIPTION EXAMPLE

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denial arguing against an denying that your physician's
anxiety provoking diagnosis of cancer is correct and
stimuli by stating it seeking a second opinion
doesn't exist

displacement taking out impulses on slamming a door instead of hitting as


a less threatening person, yelling at your spouse after an
target argument with your boss

intellectualization avoiding unacceptable focusing on the details of a funeral as


emotions by focusing opposed to the sadness and grief
on the intellectual
aspects

projection placing unacceptable when losing an argument, you state


impulses in yourself "You're just Stupid;" homophobia
onto someone else

rationalization supplying a logical or stating that you were fired because


rational reason as you didn't kiss up the the boss, when
opposed to the real the real reason was your poor
reason performance

reaction taking the opposite having a bias against a particular race


formation belief because the true or culture and then embracing that
belief causes anxiety race or culture to the extreme

regression returning to a previous sitting in a corner and crying after


stage of development hearing bad news; throwing a temper
tantrum when you don't get your way

repression pulling into the forgetting sexual abuse from your


unconscious childhood due to the trauma and
anxiety

sublimation acting out unacceptable sublimating your aggressive impulses


impulses in a socially toward a career as a boxer; becoming
acceptable way a surgeon because of your desire to
cut; lifting weights to release 'pent up'
energy

suppression pushing into the trying to forget something that causes


unconscious you anxiety

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Ego defenses are not necessarily unhealthy as you can see by the examples above. In face, the
lack of these defenses, or the inability to use them effectively can often lead to problems in life.
However, we sometimes employ the defenses at the wrong time or overuse them, which can be
equally destructive.

2. Kohlberg’s Stages of Moral Development

Although it has been questioned as to whether it applied equally to different genders and
different cultures, Kohlberg’s (1973) stages of moral development is the most widely cited. It
breaks our development of morality into three levels, each of which is divided further into two
stages:

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Preconventional Level (up to age nine):

~Self Focused Morality~

1. Morality is defined as obeying rules and avoiding negative consequences. Children in this
stage see rules set, typically by parents, as defining moral law.

2. That which satisfies the child’s needs is seen as good and moral.

Conventional Level (age nine to adolescence):

~Other Focused Morality~

3. Children begin to understand what is expected of them by their parents, teacher, etc. Morality
is seen as achieving these expectations.

4. Fulfilling obligations as well as following expectations are seen as moral law for children in
this stage.

Postconventional Level (adulthood):

~Higher Focused Morality~

5. As adults, we begin to understand that people have different opinions about morality and that
rules and laws vary from group to group and culture to culture. Morality is seen as upholding the
values of your group or culture.

6. Understanding your own personal beliefs allow adults to judge themselves and others based
upon higher levels of morality. In this stage what is right and wrong is based upon the
circumstances surrounding an action. Basics of morality are the foundation with independent
thought playing an important role.

Piaget’s Theory of Cognitive Development

Piaget's four stages

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Sensorimotor period

The Sensorimotor Stage is the first of the four stages of cognitive development. "In this stage,
infants construct an understanding of the world by coordinating sensory experiences (such as
seeing and hearing) with physical, motoric actions." "Infants gain knowledge of the world from
the physical actions they perform on it." "An infant progresses from reflexive, instinctual action
at birth to the beginning of symbolic thought toward the end of the stage." "Piaget divided the
sensorimotor stage into six sub-stages"

Sub-Stage Age Description

"Coordination of sensation and action through reflexive


behaviors"[. Three primary reflexes are described by Piaget:
sucking of objects in the mouth, following moving or interesting
Birth-6
1 Simple Reflexes objects with the eyes, and closing of the hand when an object
weeks
makes contact with the palm (palmar grasp). Over the first six
weeks of life, these reflexes begin to become voluntary actions;
for example, the palmar reflex becomes intentional grasping.

"Coordination of sensation and two types of schemes: habits


(reflex) and primary circular reactions (reproduction of an event
2 First habits and that initially occurred by chance). Main focus is still on the infant's
6 weeks-
primary circular body." As an example of this type of reaction, an infant might
4 months
reactions phase repeat the motion of passing their hand before their face. Also at
this phase, passive reactions, caused by classical or operant
conditioning, can begin

3 Secondary circular 4-8 Development of habits. "Infants become more object-oriented,


reactions phase months moving beyond self-preoccupation; repeat actions that bring
interesting or pleasurable results." This stage is associated
primarily with the development of coordination between vision
and prehension. Three new abilities occur at this stage: intentional
grasping for a desired object, secondary circular reactions, and
differentiations between ends and means. At this stage, infants will
intentionally grasp the air in the direction of a desired object, often
to the amusement of friends and family. Secondary circular
reactions, or the repetition of an action involving an external
object begin; for example, moving a switch to turn on a light
repeatedly. The differentiation between means and ends also
occurs. This is perhaps one of the most important stages of a

65
child's growth as it signifies the dawn of logic

"Coordination of vision and touch--hand-eye coordination;


coordination of schemes and intentionality." This stage is
associated primarily with the development of logic and the
4 Coordination of
8-12 coordination between means and ends. This is an extremely
secondary circular
months important stage of development, holding what Piaget calls the
reactions stage
"first proper intelligence." Also, this stage marks the beginning of
goal orientation, the deliberate planning of steps to meet an
objective

"Infants become intrigued by the many properties of objects and


by the many things they can make happen to objects; they
5 Tertiary circular experiment with new behavior." This stage is associated primarily
12-18
reactions, novelty, with the discovery of new means to meet goals. Piaget describes
months
and curiosity the child at this juncture as the "young scientist," conducting
pseudo-experiments to discover new methods of meeting
challenges

"Infants develop the ability to use primitive symbols and form


6 Internalization of 18-24 enduring mental representations." This stage is associated
Schemes months primarily with the beginnings of insight, or true creativity. This
marks the passage into the preoperational stage.

"By the end of the sensorimotor period, objects are both separate from the self and permanent."
"Object permanence is the understanding that objects continue to exist even when they cannot be
seen, heard, or touched." "Acquiring the sense of object permanence is one of the infant's most
important accomplishments, according to Piaget."

Preoperational Period

The Preoperational stage is the second of four stages of cognitive development. By observing
sequences of play, Piaget was able to demonstrate that towards the end of the second year, a
qualitatively new kind of psychological functioning occurs.

(Pre)Operatory Thought is any procedure for mentally acting on objects. The hallmark of the
preoperational stage is sparse and logically inadequate mental operations. During this stage, the
child learns to use and to represent objects by images, words, and drawings. The child is able to
form stable concepts as well as mental reasoning and magical beliefs. The child however is still

66
not able to perform operations; tasks that the child can do mentally rather than physically.
Thinking is still egocentric: The child has difficulty taking the viewpoint of others. Two
substages can be formed from preoperational thought.

• The Symbolic Function Substage

Occurs between about the ages of 2 and 4. The child is able to formulate designs of
objects that are not present. Other examples of mental abilities are language and pretend
play. Although there is an advancement in progress, there are still limitations such as
egocentrism and animism. Egocentrism occurs when a child is unable to distinguish
between their own perspective and that of another person's. Children tend to pick their
own view of what they see rather than the actual view shown to others. An example is an
experiment performed by Piaget and Barbel Inhelder. Three views of a mountain are
shown and the child is asked what a traveling doll would see at the various angles; the
child picks their own view compared to the actual view of the doll. Animism is the belief
that inanimate objects are capable of actions and have lifelike qualities. An example is a
child believing that the sidewalk was mad and made them fall down.

• The Intuitive Thought Substage

Occurs between about the ages of 4 and 7. Children tend to become very curious and ask
many questions; begin the use of primitive reasoning. There is an emergence in the
interest of reasoning and wanting to know why things are the way they are. Piaget called
it the intuitive substage because children realize they have a vast amount of knowledge
but they are unaware of how they know it. Centration and conservation are both
involved in preoperational thought. Centration is the act of focusing all attention on one
characteristic compared to the others. Centration is noticed in conservation; the awareness
that altering a substance's appearance does not change its basic properties. Children at
this stage are unaware of conservation. They are unable to grasp the concept that a certain
liquid can stay the same regardless of the container shape. In Piaget's most famous task,
a child is represented with two identical beakers containing the same amount of liquid.]
The child usually notes that the beakers have the same amount of liquid. When one of the
beakers is poured into a taller and thinner container, children who are typically younger
than 7 or 8 years old say that the two beakers now contain a different amount of liquid.
The child simply focuses on the height and width of the container compared to the
general concept. Piaget believes that if a child fails the conservation-of-liquid task, it is a
sign that they are at the preoperational stage of cognitive development. The child also
fails to show conservation of number, matter, length, volume, and area as well. Another
example is when a child is shown 7 dogs and 3 cats and asked if there are more dogs than

67
cats. The child would respond positively. However when asked if there are more dogs
than animals, the child would once again respond positively. Such fundamental errors in
logic show the transition between intuitiveness in solving problems and true logical
reasoning acquired in later years when the child grows up.

Piaget considered that children primarily learn through imitation and play throughout these first
two stages, as they build up symbolic images through internalized activity.

Studies have been conducted among other countries to find out if Piaget's theory is universal.
Psychologist Patricia Greenfield conducted a task similar to Piaget's beaker experiment in the
West African nation of Senegal. Her results stated that only 50 percent of the 10-13 year olds
understood the concept of conservation. Other cultures such as central Australia and New Guinea
had similar results. If adults had not gained this concept, they would be unable to understand the
point of view of another person. There may have been discrepencies in the communication
between the experimenter and the children which may have altered the results. It has also been
found that if conservation is not widely practiced in a particular country, the concept can be
taught to the child and training can improve the child's understanding. Therefore, it is noted that
there are different age differences in reaching the understanding of conservation based on the
degree to which the culture teaches these tasks.

Concrete operational stage

The Concrete operational stage is the third of four stages of cognitive development in Piaget's
theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 12
years and is characterized by the appropriate use of logic. Important processes during this stage
are:

Seriation—the ability to sort objects in an order according to size, shape, or any other
characteristic. For example, if given different-shaded objects they may make a color gradient.

Transitivity- The ability to recognize logical relationships among elements in a serial order, and
perform 'transitive inferences' (for example, If A is taller than B, and B is taller than C, then A
must be taller than C).

Classification—the ability to name and identify sets of objects according to appearance, size or
other characteristic, including the idea that one set of objects can include another.

68
Decentering—where the child takes into account multiple aspects of a problem to solve it. For
example, the child will no longer perceive an exceptionally wide but short cup to contain less
than a normally-wide, taller cup.

Reversibility—the child understands that numbers or objects can be changed, then returned to
their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals t,
t−4 will equal 4, the original quantity.

Conservation—understanding that quantity, length or number of items is unrelated to the


arrangement or appearance of the object or items.

Elimination of Egocentrism—the ability to view things from another's perspective (even if they
think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box,
leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in
the concrete operations stage will say that Jane will still think it's under the box even though the
child knows it is in the drawer.

Children in this stage can, however, only solve problems that apply to actual (concrete) objects
or events, and not abstract concepts or hypothetical tasks.

Formal operational stage

The formal operational period is the fourth and final of the periods of cognitive development in
Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around
11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond
concrete experiences and begin to think abstractly, reason logically and draw conclusions from
the information available, as well as apply all these processes to hypothetical situations. The
abstract quality of the adolescent's thought at the formal operational level is evident in the
adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is
when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin
to think more as a scientist thinks, devising plans to solve problems and systematically testing
solutions. They use hypothetical-deductive reasoning, which means that they develop
hypotheses or best gueses, and systematically deduce, or conclude, which is the best path to
follow in solving the problem.[ During this stage the young adult is able to understand such
things as love, "shades of gray", logical proofs and values. During this stage the young adult
begins to entertain possibilities for the future and is fascinated with what they can be.
Adolescents are changing cognitively also by the way that they think about social matters.
Adolescent Egocentrism governs the way that adolescents think about social matters and is the

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heightened self-consciousness in them as they are which is reflected in their sense of personal
uniqueness and invincibility. Adolescent egocentrism can be dissected into two types of social
thinking, imaginary audience that involves attention getting behavior, and personal fable which
involves an adolescent's sense of personal uniqueness and invincibility.

Jung's Theory of Psychological Types and the MBTI®


Instrument

"The purpose of the Myers-Briggs Type Indicator® is to make the theory of psychological types
described by C. G. Jung (1921/1971) understandable and useful in people's lives. The essence of
the theory is that much seemingly random variation in behavior is actually quite orderly and
consistent, being due to basic differences in the way individuals prefer to use their perception
and judgment."

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Perception involves all the ways of becoming aware of things, people, happenings, or ideas.
Judgment involves all the ways of coming to conclusions about what has been perceived. If
people differ systematically in what they perceive and in how they reach conclusions, then it is
only reasonable for them to differ correspondingly in their interests, reactions, values,
motivations, and skills.

The MBTI instrument is based on Jung's ideas about perception and judgment, and the attitudes
in which these are used in different types of people. The aim of the MBTI instrument is to
identify, from self self-report of easily recognized reactions, the basic preferences of people in
regard to perception and judgment, so that the effects of each preference, singly and in
combination, can be established by research and put into practical use.

The MBTI instrument differs from many other personality instruments in these ways:

• It is designed to implement a theory; therefore the theory must be understood to


understand the MBTI instrument.
• The theory postulates dichotomies; therefore some of the psychometric properties are
unusual.
• Based on the theory, there are specific dynamic relationships between the scales, which
lead to the descriptions and characteristics of sixteen "types."

The MBTI instrument contains four separate indices. Each index reflects one of four basic
preferences which, under Jung's theory, direct the use of perception and judgment. The
preferences affect not only what people attend to in any given situation, but also how they draw
conclusions about what they perceive.

Extraversion–Introversion (E–I)

The E–I index is designed to reflect whether a person is an extravert or an introvert in the sense
intended by Jung. Jung regarded extraversion and introversion as "mutually complementary"
attitudes whose differences "generate the tension that both the individual and society need for the
maintenance of life." Extraverts are oriented primarily toward the outer world; thus they tend to
focus their perception and judgment on people and objects. Introverts are oriented primarily
toward the inner world; thus they tend to focus their perception and judgment upon concepts and
ideas.

Sensing–Intuition (S–N)

The S–N index is designed to reflect a person's preference between two opposite ways of
perceiving; one may rely primarily upon the process of sensing (S), which reports observable
facts or happenings through one or more of the five senses; or one may rely upon the less

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obvious process of intuition (N), which reports meanings, relationships and/or possibilities that
have been worked out beyond the reach of the conscious mind.

Thinking–Feeling (T–F)

The T–F index is designed to reflect a person's preference between two contrasting ways of
judgment. A person may rely primarily through thinking (T) to decide impersonally on the basis
of logical consequences, or a person may rely primarily on feelings (F) to decide primarily on the
basis of personal or social values.

Judgment–Perception (J–P)

The J–P index is designed to describe the process a person uses primarily in dealing with the
outer world, that is, with the extraverted part of life. A person who prefers judgment (J) has
reported a preference for using a judgment process (either thinking or feeling) for dealing with
the outer world. A person who prefers perception (P) has reported a preference for using a
perceptive process (either S or N) for dealing with the outer world.

The Four Preferences of the MBTI instrument

Index Preferences

Between E–I

E Extraversion or
I Introversion

Affects Choices as to
Whether to direct perception judgment mainly on the outer world (E) or mainly on the inner
world of ideas.

Between S–N

S Sensing perception or
N Intuitive perception

Affects Choices as to
Which kind of perception is preferred when one needs or wishes to perceive

Between T–F

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T Thinking judgment or
F Feeling judgment

Affects Choices as to
Which kind of judgment to trust when one needs or wishes to make a decision

Between J–P

J Judgment or
P Perception

Affects Choices as to
Whether to deal with the outer world in judging (J) attitude (using T or F) or in the perceptive (P)
attitude (using S or N)

The Sixteen Types

According to theory, by definition, one pole of each of the four preferences is preferred over the
other pole for each of the sixteen MBTI types. The preferences on each index are independent of
preferences for the other three indices, so that the four indices yield sixteen possible
combinations called "types," denoted by the four letters of the preferences (e.g., ESTJ, INFP).
The theory postulates specific dynamic relationships between the preferences. For each type, one
process is the leading or dominant process and a second process serves as an auxiliary. Each type
has its own pattern of dominant and auxiliary processes and the attitudes (E or I) in which these
are habitually used. The characteristics of each type follow from the dynamic interplay of these
processes and attitudes.

Processes and attitudes

Attitudes refer to extraversion (E) or introversion (I).

Processes of perception are sensing (S) and intuition (N).

Processes of judgment are thinking (T) and feeling (F).

The style of dealing with the outside world is shown by judgment (J) or perception (P).

In terms of the theory, people may reasonably be expected to develop greater skill with the
processes they prefer to use and with the attitudes in which they prefer to use these processes.
For example, if they prefer the extraverted attitude (E), they are likely to be more mature and
effective in dealing with the world around them than with the inner world of concepts and ideas.

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If they prefer the perceptive process of sensing (S), they are likely to be more effective in
perceiving facts and realities than theories and possibilities, which are in the sphere of intuition.
If they prefer the judgment process of thinking (T), they are likely to have better developed
thinking judgments than feeling judgments. And if they prefer to use judgment (J) rather than
perception (P) in their attitude to the world around them, they are likely to be better organizing
the events of their lives than they are to experiencing and adapting to them. On the other hand, if
a person prefers introversion, intuition, feeling, and the perceptive attitude (INFP), then the
converse of the description above is likely to be true.

Peplau’s Theory of Theory of Interpersonal Relations

• Identified four sequential phases in the interpersonal relationship:


1. Orientation

2. Identification

3. Exploitation

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4. Resolution

Orientation phase

• Problem defining phase

• Starts when client meets nurse as stranger

• Defining problem and deciding type of service needed

• Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and
expectations of past experiences

• Nurse responds, explains roles to client, helps to identify problems and to use available
resources and services

Factors influencing orientation phase

Identification phase

• Selection of appropriate professional assistance


• Patient begins to have a feeling of belonging and a capability of dealing with the problem
which decreases the feeling of helplessness and hopelessness

Exploitation phase

• Use of professional assistance for problem solving alternatives


• Advantages of services are used is based on the needs and interests of the patients
• Individual feels as an integral part of the helping environment
• They may make minor requests or attention getting techniques
• The principles of interview techniques must be used in order to explore ,understand and
adequately deal with the underlying problem

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• Patient may fluctuates on independence
• Nurse must be aware about the various phases of communication
• Nurse aids the patient in exploiting all avenues of help and progress is made towards the
final step

Resolution phase

• Termination of professional relationship


• The patients needs have already been met by the collaborative effect of patient and nurse
• Now they need to terminate their therapeutic relationship and dissolve the links between
them.
• Sometimes may be difficult for both as psychological dependence persists
• Patient drifts away and breaks bond with nurse and healthier emotional balance is
demonstrated and both becomes mature individuals

Interpersonal theory and nursing process

• Both are sequential and focus on therapeutic relationship


• Both use problem solving techniques for the nurse and patient to collaborate on, with the
end purpose of meeting the patients needs
• Both use observation communication and recording as basic tools utilized by nursing

Assessment Orientation

Data collection and analysis Non continuous data collection


[continuous]
Felt need
May not be a felt need
Define needs

Nursing diagnosis Identification

Planning Interdependent goal setting

Mutually set goals

Implementation Exploitation

Plans initiated towards Patient actively seeking and


achievement of mutually set drawing help
goals
Patient initiated
May be accomplished by
patient , nurse or family

Evaluation Resolution

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Based on mutually expected
behaviors
Occurs after other phases are
May led to termination and completed successfully
initiation of new plans
Leads to termination

3. Carl Roger’s Humanistic Theory

The Person-Centered Approach

While Maslow was more of a theorist, Carl Rogers was more of a therapist. His professional
goal was more on helping people change and improve their lives. He was a true follower of
humanistic ideation and is often considered the person who gave psychotherapy it's basic
humanistic undertones.

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Rogers believed in several key concepts that he believed must be present in order for healthy
change to take place. His approach to treatment is called Client or Person-Centered-Therapy
because it sees the individual, rather than the therapist or the treatment process as the center of
effective change. These basic concepts include:

1. Unconditional Positive Regard: The therapist must believe that people are basically good
and must demonstrate this belief to the client. Without unconditional positive regard, the
client will not disclose certain information, could feel unworthy, and may hold onto
negative aspects of the self. Accepting the client as innately worthwhile does not mean
accepting all actions the client may exhibit.

2. Non-Judgmental Attitude: Along with seeing the person as worthy, the therapist should
never pass judgment on the individual. Roger's believed that people are competent in
seeing their mistakes and knowing what needs to change even if they may not initially
admit it. He also believed that by judging a person, you are more likely to prevent
disclosure.

3. Disclosure: Disclosure refers to the sharing of personal information. Unlike


Psychoanalysis and many other approaches to therapy, Roger's believed that in order for
the client to disclose, the therapist must do the same. Research has shown that we share
information at about the same level as the other person. Therefore, remaining secretive
as a therapist, encourages the client to hold back important information.

4. Reflection: Rogers believed that the key to understanding the self was not interpretation,
but rather reflection. By reflecting a person's words in a different manner, you can
accomplish two things. First, it shows the client that you are paying attention, thinking
about what he or she is saying, and also understanding the underlying thoughts and
feelings. Second, it allows the client to hear their own thoughts in a different way. Many
people have said that their beliefs become more real once they are presented back to them
by someone else.

By following these concepts, therapy becomes a self-exploration where the therapist is the guide
rather than the director. The client, according to Rogers, has the answers and the direction. It is
the therapist's job to help them find it.

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4. Alfred’s Adler’s Theory Of Personality

Inferiority

According to Adler's theory, each of us is born into the world with a sense of inferiority. We
start as a weak and helpless child and strive to overcome these deficiencies by become superior
to those around us. He called this struggle a striving for superiority, and like Freud's Eros and
Thanatos, he saw this as the driving force behind all human thoughts, emotions, and behaviors.

For those of us who strive to be accomplished writers, powerful business people, or influential
politicians, it is because of our feelings of inferiority and a strong need to over come this

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negative part of us according to Adler. This excessive feeling of inferiority can also have the
opposite effect. As it becomes overwhelming and without the needed successes, we can develop
an inferiority complex. This belief leaves us with feeling incredibly less important and deserving
than others, helpless, hopeless, and unmotivated to strive for the superiority that would make us
complete.

Parenting and Birth Order

Parenting Styles. Adler did agree with Freud on some major issues relating to the parenting of
children and the long term effects of improper or inefficient child rearing. He identified two
parental styles that he argued will cause almost certain problems in adulthood. The first was
pampering, referring to a parent overprotecting a child, giving him too much attention, and
sheltering him from the negative realities of life. As this child grows older, he will be ill
equipped to deal with these realities, may doubt his own abilities or decision making skills, and
may seek out others to replace the safety he once enjoyed as a child.

On the other extreme is what Adler called neglect. A neglected child is one who is not protected
at all from the world and is forced to face life's struggles alone. This child may grow up to fear
the world, have a strong sense of mistrust for others and she may have a difficult time forming
intimate relationships.

The best approach, according to this theory, is to protect children form the evils of the world but
not shelter them from it. In more practical terms, it means allowing them to hear or see the
negative aspects of the world while still feeling the safety of parental influence. In other words,
don't immediately go to the school principal if your child is getting bullied, but rather teach your
child how to respond or take care of herself at school.

Birth Order. Simply put, Adler believed that the order in which you are born to a family
inherently effects your personality. First born children who later have younger siblings may
have it the worst. These children are given excessive attention and pampering by their parents
until that fateful day when the little brother or sister arrives. Suddenly they are no longer the
center of attention and fall into the shadows wondering why everything changed. According to
Adler, they are left feeling inferior, questioning their importance in the family, and trying
desperately to gain back the attention they suddenly lost. The birth order theory holds that first
born children often have the greatest number of problems as they get older.

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Middle born children may have it the easiest, and interestingly, Adler was a middle born child.
These children are not pampered as their older sibling was, but are still afforded the attention.
As a middle child, they have the luxury of trying to dethrone the oldest child and become more
superior while at the same time knowing that they hold this same power over their younger
siblings. Adler believed that middle children have a high need for superiority and are often able
to seek it out such as through healthy competition.

The youngest children, like the first born, may be more likely to experience personality problems
later in life. This is the child who grows up knowing that he has the least amount of power in the
whole family. He sees his older siblings having more freedom and more superiority. He also
gets pampered and protected more than any other child did. This could leave him with a sense
that he can not take on the world alone and will always be inferior to others.

Adler stressed a positive view of human nature. He believed that individuals can control their
fate. They can do this in part by trying to help others (social interest). How they do this can be
understood through analyzing their lifestyle. Early interactions with family members, peers, and
teachers help to determine the role of inferiority and superiority in their lives.

View of Human Nature

A Person’s Perceptions are based on His or Her View of Reality (Phenomenology)

– Adler believed that we “construct” our reality according to our own way of
looking at the world.
– “I am convinced that a person’s behavior springs from this idea…because our
senses do not see the world, we apprehend it.” (Adler, 1933/1964)

Each person must be viewed as an individual from a holistic perspective.

– Adler suggested that dividing the person up into parts or forces (i.e., id, ego, and
superego) was counterproductive because it was mechanistic and missed the
individual essence of each person.
– In his view, understanding the whole person is different than understanding
different aspects of his life or personality.

Human Behavior is Goal Oriented (Teleological)

– People move toward self-selected goals. “The life of the human soul is not a
‘being’ but a ‘becoming.’” (Adler, 1963a)

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– This idea requires a very different way of viewing humans than the idea that
behavior is “caused” by some internal or external forces or rewards and
punishments.
– Understanding the causes of behavior is not as important as understanding the
goal to which a person is directed. Since we have evolved as social creatures, the
most common goal is to belong.

Determinism

– Moving through life, the individual is confronted with alternatives.


– Human beings are creative, choosing, self-determined decision-makers free to
chose the goals they want to pursue.

View of Human Nature

Conscious and unconscious are both in the service of the individual, who uses them to
further personal goals (Adler, 1963a)

Striving for superiority to overcome basic inferiority is a normal part of life.

– Mosak(2000) reports that Adler and others have referred to this central human
striving in a number of ways: completion, perfection, superiority, self-realization,
self-actualization, competence, and mastery.

Social Interest and a Positive involvement in the community are hallmarks of a healthy
personality.

– All behavior occurs in a social context. Humans are born into an environment
with which they must engage in reciprocal relations.
– Adler believed that social interest was innate but that it needed to be nurtured in a
family where cooperation and trust were important values.

Adlerian Core Concepts and Explanation of Behavior

Style of life or Lifestyle

– A way of seeking to fulfill particular goals that individuals set in their lives.
Individuals use their own patterns of beliefs, cognitive styles, and behaviors as a
way of expressing their style of life. Often style of life or lifestyle is a means for
overcoming feeling of inferiority.

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Four areas of lifestyle:

1. The self-concept

the convictions about who I am.

2. The self-ideal

convictions about what I should be.

3. The Weltbild, or “picture of the world”

convictions about the not-self and what the world demands of me.

4. The ethical convictions

The personal “right-wrong” code.

Adlerian explanation of Behavior


(Theory of Personality)

Family Constellation and Atmosphere:

– The number and birth order, as well as the personality characteristics of members
of a family. Important in determining lifestyle.
– The family and reciprocal relationships with siblings and parents determine how a
person finds a place in the family and what he learns about finding a place in the
world.
– Adlerian Theory of Personality

Social Interest:

– The caring and concern for the welfare of others that can serve to guide people's
behavior throughout their lives. It is a sense of being a part of society and taking
responsibility to improve it.

Superiority

– The drive to become superior allows individuals to become skilled, competent,


and creative.

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Superiority Complex:

– a means of masking feelings of inferiority by displaying boastful, self-centered, or


arrogant superiority in order to overcome feelings of inferiority.

Inferiority:

– Feelings of inadequacy and incompetence that develop during infancy and serve
as the basis to strive for superiority in order to overcome feelings of inferiority.

Inferiority complex:

– A strong and pervasive belief that one is not as good as other people. It is usually
an exaggerated sense of feelings of inadequacy and insecurity that may result in
being defensive or anxious.

Adlerian explanation of Behavior

Birth order:

– The idea that place in the family constellation (such as being the youngest child)
can have an impact on one's later personality and functioning.

Early recollections:

– Memories of actual incidents that clients recall from their childhood. Adlerians
use this information to make inferences about current behavior of children or
adults.

Basic mistakes:

– Self-defeating aspects of individuals' lifestyle that may affect their later behavior
are called basic mistakes. Such mistakes often include avoidance of others,
seeking power, a desperate need for security, or faulty values.

Assets:

– Assessing the strengths of individuals' lifestyle is an important part of lifestyle


assessment, as is assessment or early recollections and basic mistakes.

TECHNIQUES FOR CHANGE

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A lifestyle analysis helps the Adlerian therapist to gain insights into client problems by
determining the clients' basic mistakes and assets. These insights are based on assessing
family constellation, dreams, and social interest. To help the client change, Adlerians
may use a number of active techniques that focus to a great extent on changing beliefs
and reorienting the client's view of situations and relationships.

Life tasks:

– There are five basic obligations and opportunities: occupation, society, love, self
development, and spiritual development. These are used to help determine
therapeutic goals.

Interpretation:

– Adlerians express insights to their clients that relate to clients' goals.


Interpretations often focus on the family constellation and social interest.

Immediacy:

– Communicating the experience of the therapist to the client about what is


happening in the moment.

Encouragement:

– An important therapeutic technique that is used to build a relationship and to


foster client change. Supporting clients in changing beliefs and behaviors is a part
of encouragement.

Acting as if:

– In this technique, clients are asked to "act as if" a behavior will be effective.
Clients are encouraged to try a new role, the way they might try on new clothing.

Catching oneself:

– In this technique, patients learn to notice that they are performing behaviors
which they wish to change,. When they catch themselves, they may have an
"Aha" response.

Aha response:

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– Developing a sudden insight into a solution to a problem, as one becomes aware
to one's beliefs and behaviors.

Avoiding the tar baby:

– By not falling into a trap that the client sets by using faulty assumptions, the
therapist encourages new behavior and "avoids the tar baby" (getting stuck in the
client's perception of the problem).

The Question:

– Asking "what would be different if you were well?" was a means Adler used to
determine if a person's problem was physiological or psychological
– TECHNIQUES FOR CHANGE

Paradoxical intention:

– A therapeutic strategy in which clients are instructed to engage and exaggerate


behaviors that they seek to change. By prescribing the symptom, therapists make
clients more aware of their situation and help them seek to change. By prescribing
the symptom, therapists make clients more aware of their situation and help them
achieve distance from the symptoms. For example, a client who is afraid of mice
may be asked to exaggerate his fear of mice, or a client who hoards paper may be
asked to exaggerate that behavior so that living becomes difficult. In this way
individuals can become more aware of and more resistant from their symptoms.

Spitting in the client's soup:

– Making comments to the client to make behaviors less attractive or desirable.

Homework:

– Specific behaviors or activities that clients are asked to do after a therapy session

Push-button technique:

– Designed to show patients how they can create whatever feelings they what by
thinking about them, the push-button technique asks clients to remember a
pleasant incident that they have experienced, become aware of feelings connected

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to it, and then switch to an unpleasant image and those feelings. Thus clients learn
that they have the power to change their own feelings.

5. Karen Horney's Feminine Theory and Theory of


Neurosis

Feminine Psychology

Perhaps the most important contribution Karen Horney made to psychodynamic thought was her
disagreements with Freud's view of women. Horney was never a student of Freud, but did study
his work and eventually taught psychoanalysis at both the Berlin and New York Psychoanalytic
Institute. After her insistence that Freud's view of the inherent difference between males and
females, she agreed to leave the institute and form her own school known as the American
Institute for Psychoanalysis.

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In many ways, Horney was well ahead of her time and although she died before the feminist
movement took hold, she was perhaps the theorist who changed the way psychology looked at
gender differences. She countered Freud's concept of penis envy with what she called womb
envy, or man's envy of woman's ability to bear children. She argued that men compensate for
this inability by striving for achievement and success in other realms.

She also disagreed with Freud's belief that males and females were born with inherent
differences in their personality. Rather than citing biological differences, she argued for a
societal and cultural explanation. In her view, men and women were equal outside of the cultural
restrictions often placed on being female. These views, while not well accepted at the time, were
used years after her death to help promote gender equality.

Neurosis and Relationships

Horney was also known for her study of neurotic personality. She defined neurosis as a
maladaptive and counterproductive way of dealing with relationships. These people are unhappy
and desperately seek out relationships in order to feel good abut themselves. Their way of
securing these relationships include projections of their own insecurity and neediness which
eventually drives others away.

Most of us have come in contact with people who seem to successfully irritate or frighten people
away with their clinginess, significant lack of self esteem, and even anger and threatening
behavior. According to Horney, these individuals adapted this personality style through a
childhood filled with anxiety. And while this way of dealing with others may have been
beneficial in their youth, as adults it serves to almost guarantee their needs will not be met.

She identified three ways of dealing with the world that are formed by an upbringing in a
neurotic family: Moving Toward People, Moving Against People, and Moving Away From
People.

Moving Toward People. Some children who feel a great deal of anxiety and helplessness move
toward people in order to seek help and acceptance. They are striving to feel worthy and can
believe the only way to gain this is through the acceptance of others. These people have an
intense need to be liked, involved, important, and appreciated. So much so, that they will often
fall in love quickly or feel an artificial but very strong attachment to people they may not know

88
well. Their attempts to make that person love them creates a clinginess and neediness that much
more often than not results in the other person leaving the relationship.

Moving Against People. Another way to deal with insecurities and anxiety is to try to force
your power onto others in hopes of feeling good about yourself. Those with this personality
style come across as bossy, demanding, selfish, and even cruel. Horney argued that these people
project their own hostilities (which she called externalization) onto others and therefore use this
as a justification to 'get them before they get me.' Once again, relationships appear doomed from
the beginning.

Moving Away From People. The final possible consequence of a neurotic household is a
personality style filled with asocial behavior and an almost indifference to others. If they don't
get involved with others, they can't be hurt by them. While it protects them from emotional pain
of relationships, it also keeps away all positive aspects of relationships. It leaves them feeling
alone and empty.

6. Sullivan’s Interpersonal theory

Sam I am, good or bad

Harry Stack-Sullivan was trained in psychoanalysis in the United States, but soon drifted from
the specific psychoanalytic beliefs while retaining much of the core concepts of Freud.
Interestingly, Sullivan placed a lot of focus on both the social aspects of personality and
cognitive representations. This moved him away from Freud's psychosexual development and
toward a more eclectic approach.

Freud believed that anxiety was an important aspect in his theory because it represented internal
conflict between the id and the superego. Sullivan, however, saw anxiety as existing only as a
result of social interactions. He described techniques, much like defense mechanisms, that
provide tools for people to use in order to reduce social anxiety. Selective Inattention is one
such mechanism.
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According to Sullivan, mothers show their anxiety about child rearing to their children through
various means. The child, having no way to deal with this, feels the anxiety himself. Selective
inattention is soon learned, and the child begins to ignore or reject the anxiety or any interaction
that could produce these uncomfortable feelings. As adults, we use this technique to focus our
minds away from stressful situations.

Personifications

Through social interactions and our selective attention or inattention, we develop what Sullivan
called Personifications of ourselves and others. While defenses can often help reduce anxiety,
they can also lead to a misperception of reality. Again, he shifts his focus away from Freud and
more toward a cognitive approach to understanding personality.

These personifications are mental images that allow us to better understand ourselves and the
world. There are three basic ways we see ourselves that Sullivan called the bad-me, the good-
me and the not-me. The bad me represents those aspects of the self that are considered negative
and are therefore hidden from others and possibly even the self. The anxiety that we feel is often
a result of recognition of the bad part of ourselves, such as when we recall an embarrassing
moment or experience guilt from a past action.

The good me is everything we like about ourselves. It represents the part of us we share with
others and that we often choose to focus on because it produces no anxiety. The final part of us,
called the not-me, represents all those things that are so anxiety provoking that we can not even
consider them a part of us. Doing so would definitely create anxiety which we spend our lives
trying to avoid. The not-me is kept out of awareness by pushing it deep into the unconscious.

Developmental Epochs

Another similarity between Sullivan's theory and that of Freud's is the belief that childhood
experiences determine, to a large degree, the adult personality. And, throughout our childhood,
the mother plays the most significant role. Unlike Freud, however, he also believed that
personality can develop past adolescence and even well into adulthood. He called the stages in
his developmental theory Epochs. He believed that we pass through these stages in a particular
order but the timing of such is dictated by our social environment. Much of the focus in
Sullivan's theory revolved around the conflicts of adolescence. As you can see from the chart

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below, three stages were devoted to this period of development and much of the problems of
adulthood, according to Sullivan, arise from the turmoil of our adolescence.

Sullivan's Developmental Epochs

Infancy From birth to about age one, the child begins the process of
Age birth to 1 year developing, but Sullivan did not emphasize the younger years to
near the importance as Freud.

Childhood The development of speech and improved communication is key in


Ages 1 to 5 this stage of development.

Juvenile The main focus as a juvenile is the need for playmates and the
Ages 6 to 8 beginning of healthy socialization

Preadolescence During this stage, the child's ability to form a close relationship
Ages 9 to 12 with a peer is the major focus. This relationship will later assist the
child in feeling worthy and likable. Without this ability, forming
the intimate relationships in late adolescence and adulthood will be
difficult.

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Early The onset of puberty changes this need for friendship to a need for
Adolescence sexual expression. Self worth will often become synonymous with
Ages 13 to 17 sexual attractiveness and acceptance by opposite sex peers.

Late Adolescence The need for friendship and need for sexual expression get
Ages 18 to 22 or combined during late adolescence. In this stage a long term
23 relationship becomes the primary focus. Conflicts between parental
control and self-expression are commonplace and the overuse of
selective inattention in previous stages can result in a skewed
perception of the self and the world.

Adulthood The struggles of adulthood include financial security, career, and


Ages 23 on family. With success during previous stages, especially those in the
adolescent years, adult relationships and much needed socialization
become more easy to attain. Without a solid background,
interpersonal conflicts that result in anxiety become more
commonplace.

7. Maslow’s Humanistic Theory

King of the Mountain

Perhaps the most well known contribution to humanistic psychology was introduced by Abraham
Maslow. Maslow originally studied psychology because of his intrigue with behavioral theory
and the writings of John B. Watson.

Maslow grew up Jewish in a non-Jewish neighborhood. He spent much of his childhood alone
and reported that books were often his best friends. Despite this somewhat lonely childhood, he
maintained his belief in the goodness of mankind. After the birth of his first child, his devotion
to Watson's beliefs began a drastic decline. He was struck with the sense that he was not nearly
in control as much as Watson and other behaviorists believed. He saw more to human life than
just external reinforcement and argued that human's could not possibly be born without any
direction or worth.

At the time when he was studying psychology, behaviorism and psychoanalysis were considered
the big two. Most courses studies these theories and much time was spent determining which
theory one would follow. Maslow was on a different path.

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He criticized behaviorism and later took the same approach with Freud and his writings. While
he acknowledged the presence of the unconscious, he disagreed with Freud's belief that the vast
majority of who we are is buried deep beyond our awareness. Maslow believed that we are
aware of our motives and drives for the most part and that without the obstacles of life, we would
all become psychologically healthy individuals with a deep understanding of ourselves and an
acceptance of the world around us. Where Freud saw much negativity, Maslow focused his
efforts on understanding the positives of mankind. It could be said that psychoanalytic thought is
based on determinism, or aspects beyond our control, and humanistic thought is based on free
will.

Maslow's most well known contribution is the Hierarchy of Needs and this is often used to
summarize the belief system of humanistic psychology. The basic premise behind this hierarchy
is that we are born with certain needs. Without meeting these initial needs, we will not be able to
continue our life and move upward on hierarchy. This first level consists of our physiological
needs, or our basic needs for survival. Without food, water, sleep, and oxygen, nothing else in
life matters.

Once these needs are met, we can move to the next level, which consists of our need for safety

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and security. At this level we look seek out safety through other people and strive to find a
world that will protect us and keep us free from harm. Without these goals being met, it is
extremely difficult to think about higher level needs and therefore we can not continue to grow.

When we feel safe and secure in our world then we begin to seek out friendships in order to feel
a sense of belonging. Maslow's third level, the need for belonging and love, focuses on our
desire to be accepted, to fit in, and to feel like we have a place in the world. Getting these needs
met propels us closer to the top of this pyramid and into the fourth level, called esteem needs. At
this level we focus our energy on self-respect, respect from others, and feeling that we have
made accomplishments on our life. We strive to move upward in careers, to gain knowledge
about the world, and to work toward a sense of high self-worth.

The final level in the hierarchy is called the need for self-actualization. According to Maslow,
may people may be in this level but very few if anybody ever masters it. Self-actualization refers
to a complete understanding of the self. To be self-actualized means to truly know who you are,
where you belong in the greater society, and to feel like you have accomplished all that you have
set out to accomplish. It means to no longer feel shame or guilt, or even hate, but to accept the
world and see human nature as inherently good.
Application to Real Life

As you read through the section above, many likely tried to place themselves on one of the five
levels of the pyramid. This may be an easy task for some, but many struggle with the ups and
downs of life. For many of us, life is not that straight forward. We often have one foot in one
level, the other foot in the next level, and are reaching at times trying to pull ourselves up while
making sure we don't fall backward at other times.

As we climb the pyramid, we often make headway but also notice that two steps forward can
mean one step back. Sometimes it even feels like two steps forward means three steps back.
The goal of mankind, however, is to keep an eye on the top of the pyramid and to climb as
steadily as possible. We may stumble at times and we may leap forward at times. No matter
how far we fall backward, however, the road back up is easier since we already know the way.

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8. Glasser’s Control or Choice Theory

William Glasser, in his 'Control Theory' (later renamed to 'Choice Theory') detailed five needs
that are quite close to Maslow's Hierarchy, but with some interesting twists.

1. Survival

This is similar to Maslow's Physiological and Safety level. They are basic needs which are of
little interest unless they are threatened.

2. Love and belonging

This is the same as Maslow's Belonging need and recognises how important it is for us as a tribal
species to be accepted by our peers.

3. Power or recognition

This maps to some extent to Maslow's Esteem need, although the Power element focuses on our
ability to achieve our goals (which is perhaps a lower-level control need).

4. Freedom

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This is the ability to do what we want, to have free choice. It is connected with procedural justice
where we seek fair play.

5. Fun

An interesting ultimate goal. When all else is satisfied, we just (as Cyndi Lauper sang) 'want to
have fun'.

Relationships and our Habits:

Seven Caring Habits Seven Deadly Habits


1. Supporting 1. Criticizing
2. Encouraging 2. Blaming
3. Listening 3. Complaining
4. Accepting 4. Nagging
5. Trusting 5. Threatening
6. Respecting 6. Punishing
7. Negotiating differences 7. Bribing, rewarding to control

The Ten Axioms of Choice Theory

A. The only person whose behavior we can control is our own.


B. All we can give another person is information
C. All long-lasting psychological problems are relationship problems.
D. The problem relationship is always part of our present life.
E. What happened in the past has everything to do with what we are today,
but we can only satisfy our basic needs right now and plan to continue satisfying
them in the future.
F. We can only satisfy our needs by satisfying the pictures in our Quality
World.
G. All we do is behave.
H. All behaviors are Total Behaviors and are made up of four components:
acting, thinking, feeling and physiology. All Total Behaviors are chosen, but we
only have direct control over the acting and thinking components.
I. We can only control our feeling and physiology indirectly through how we
choose to act and think.
J. All Total Behavior is designated by verbs and named by the part that is the
most recognizable.Whoops that's ELEVEN?? - Glasser couldn't count!

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Fowler's Faith Stage Theory

James Fowler investigated and developed a stage theory for the development of religious faith.
In practice, it is also applicable to other areas of general beliefs.

Kirst-Ashman and Zastrow (2004) add a 'Primal or Undifferentiated' stage prior to stage 1. This
includes Lacan's early stages and entry into the Symbolic Register.

Level ~Ages Name Characteristics


Egocentric, becoming aware of time.
Stage 1 3-7 Intuitive-predictive Forming images that will affect their
later life.

Aware of the stories and beliefs of the


Stage 2 6-12 Mythical-literal local community. Using these to give
sense to their experiences.

Extending faith beyond the family and


Stage 3 12- Synthetic-conventional using this as a vehicle for creating a
sense of identity and values.

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The sense of identity and outlook on
early the world are differentiated and the
Stage 4 Individuative-reflective
adult person develops explicit systems of
meaning.

The person faces up to the paradoxes


of experience and begins to develop
Stage 5 adult Conjunctive
universal ideas and becomes more
oriented towards other people.

The person becomes totally altruistic


and they feel an integral part of an all-
Stage 6 adult Universalizing
inclusive sense of being. This stage is
rarely achieved.

C. Biographical Data

Patient is J. He is 22 years old, single. He is a Filipino and a Roman Catholic. He is the eldest
among 9 siblings. He lives at Sorsogon, Sorsogon. He was born on August 11, 1987 in Northern Samar.

J is currently hospitalized at National Center for Mental Health (NCMH) since November 6, 2009.

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D. Nursing History

1. Chief Complaint

“Hindi ko po alam,”, as verbalized by the patient.

“Mabuti naman.” , as verbalized by the patient.

As verbalized by the informant (patient’s mother):

“nambabato ng bahay”

“nananakit”

“nagwawala”

“tinadyakan ang lola”

2. History of present Illness

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While working as a plastic bag vendor in a market 12 days prior to admission, the patient
suddenly went home crying and anxious. He was restless, assaultive to his siblings when
apprehended. He sleeps poorly. He hides under the table. J became non-functional at home.

3. Previous Illness

J suffered from common illnesses like colds, cough, fever and flu.

4. Past Personal History

J was previously admitted at a Hospital in Sorsogon because of his mental illness. He


took up Grade 1 twice and repeated Grade 2 twice also. He is a former plastic bag vendor in a
market in their province. He is disoriented with time, place and person. He has no special
someone since birth. J is not sexually active. Eating gives him pleasure.

5. Family History

His mother is the most important person while he grows up. There is no concrete
evidence of sexual abuse or physical abuse but then, the patient verbalized that he was put into
“jail” by his mother, tied his hand, chained and was hit by a wood.

6. Social History

The patient belongs to a nuclear structured and patriarchal type of family. He is the eldest
among 9 siblings. J reached Grade 2. He has worked as a plastic bag vendor in a market at their
place.

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CHAPTER
II
Presentation,
Interpretation

101
&
Analysis
of
Data
(Daily Account of Observed
Behavior)
Psychiatric Nursing History and

Mental Status Assessment

GENERAL ADMISSION INFORMATION

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Name: “J”

Age/Gender: 22 y/o, Male Marital Status: Single

Racial and Ethnic Data: Filipino, Bisaya

Number and Ages of Children/Siblings: 9 siblings

Living Arrangements:

Educational Attainment: unfinished Grade 2

Occupation: none

Religious Affiliations: Roman Catholic

CONDITIONS OF ADMISSION

Voluntary: __________ Involuntary:

Accompanied to Facility by (Family Friend Police Other): mother

Route of Admission (ambulatory, wheelchair, stretcher): ambulatory

Admitted from: (home, other facility, street, place of destination): home

I. PRESENTING PROBLEM
A. Statement in the client’s own words of why he or she is hospitalized or seeking help
According to the Patient:

“mabuti naman”

According to the Informant:

“nambabato ng bahay”

“nananakit”

“nagwawala”

“tinadyakan ang lola”

B. Recent difficulties/alterations in
1. Relationships
2. Usual level of functioning
3. Behavior
4. Perceptions or cognitive abilities
C. Increased feelings of
1. Depression
2. Anxiety
3. Hopelessness
4. Being overwhelmed
5. Suspicious

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6. Confusion
D. Somatic changes, such as
1. Constipation
2. Insomnia
3. Lethargy
4. Weight loss or gain
5. Palpitations

II. RELEVANT HISTORY – PERSONAL:


A. Previous hospitalizations and illness: Provincial Hospital in Sorsogon/mental illness
B. Educational background : Grade 1 (2x), Grade 2 (2x)
C. Occupational background : former plastic bag vendor
1. if employed, where? : in a market at Sorsogon
2. How long at the job? ___________________________________________
3. Previous positions and reasons for leaving __________________________
4. Special skills _________________________________________________
D. Social patterns
1. Describe friends : disoriented with fellow patients
2. Describe a usual day __________________________________________
E. Sexual patterns
1. Sexually active? : not
2. Sexual orientation ___________________________________
3. Sexual difficulties ___________________________________
4. Practice safe sex or birth control ________________________
F. Interest and abilities
1. What does the client do in his or her spare time: sleep, rest
2. What is the client good at? ______________________________________
3. What gives the client pleasure? : eating
G. Substance use and abuse
1. What medication does the client take? : haloperidol
How often: once a day, at night How much? : 10mg

2. Any herbal or-the-counter medicati ons?__________________________


How often? ________________ How much? __________________

3. What psychotropic drugs does the client take? ____________________


How often? _______________ How much? ___________________

4. How many drinks of a alcohol does the client take? _______________


per day? ___________ Per week? _________________

5. Does the client identify use of drugs as a problem? _______________


H. How does the client cope with stress? ___________________________
1. What does the client do when he or she gets upset? ________________
_________________________________________________________

2. Whom can the client talk to? __________________________________


3. What usually helps to relieve stress? ____________________________
4. What did the client try this time? _______________________________

III. RELEVANT HISTORY – FAMILY


A. Childhood

1. Who was important to the client growing up? mother


2. Was there physical or sexual abuse? ________________________________
3. Did the parents drink or use drugs? _________________________________
4. Who was in the home when the client was growing up? Mother, father
B. Adolescence

1. How would be client describe his or her feelings in adolescence? ___________


_______________________________________________________________

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2. Describe the client’s peer group at the time. ___________________________

C. Use of drugs

1. Was there use or abuse of drugs by any family member? _________________


Prescription _________________ Street __________ By whom? _________

2. What was effect on the family? ______________________________________


D. Family physical or mental problems

1. Is there any family history of violence or physical/sexual abuse? ______________


2. Who in the family had physical or mental problems? _______________________
3. Describe the problem ________________________________________________
4. How did it affect the family? __________________________________________
E. Was there an unusual or outstanding event the client would like to mention ________

____________________________________________________________________

IV. SPIRITUAL ASSESSMENT


A. What importance does religion or spirituality have in your life? _______________

__________________________________________________________________

B. Do your religious or spiritual beliefs influence the way you take care of yourself or your illness?

How? __________________________________________________

C. Who or what supplies you with hope? ___________________________________

V. CULTURAL INFLUENCES
a. With what cultural group do you identify? Bisaya
a. Have you tried any cultural remedies or practices for your condition? If so, what?
________________________________________________________________

a. Do you use any alternative or complimentary medicines/herbs/practices?


_______________________________________________________________

/- observed

X- not observed

MENTAL STATUS EXAMINATION

General Appearance Day

1 2 3 4 5

Facial Expression

Animated x x x x /

Fixed or Immobile / / / / x

Sad or Depressed x x x x x

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Angry x x x x x

Pale / / / / /

Reddened x x x x x

Posture

Slouched / / / / /

Stooped / / / / /

Upright (erect) x x x x x

Stiff / / x / x

Gait

Smooth Rhythmic / / / / /

Shuffling x x x x x

Staggering x x x x x

Dress

Appropriately Dressed / / / / /

Inappropriately Dressed x x x x x

Pressed / / / / /

Wrinkled x x x x x

Grooming

Well Groomed / / / / /

Unkempt x x x x x

Hygiene

Clean / / / / /

Untidy x x x x x

Odor (Body / Breath)

None / / / / /

Alcohol x x x x x

Acetone x x x x x

Pungent x x x x x

Cigarette Smoke x x x x x

Foul Smelling x x x x x

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Physical Deformity: (specify)_____________________

Eye Contact

Maintains Good Eye Contact x / / / /

Poor Eye Contact (Lacks Eye Contact) / x x x x

Eye Cast (Client squints his eyes, pupils dilated) x x x x x

The patient has a fixed facial expression. He is 5’4” and weighs 56 kg. He has a stooped
posture. J has smooth rhythmic gait. He is appropriately dressed and well groomed. He is clean.
He has no body or breath odor. There is a scar on both patella and on both wrists. Eye contact
was established.

MOTOR BEHAVIOR Day

Gestures, stereotyped behavior, pacing, any purposeless 1 2 3 4 5


activity should be described.

Purposeful and Coordinated Movement x x x x x

Catatonia x x x x x

Echopraxia x x x x x

Tics x x x x x

Spasm x x x x x

Compulsive x x x x x

Waxy Flexibility / / / / /

Parkinson-like symptoms x x x x x

Akathisia x x x x x

Dyskinesia x x x x x

Apraxia x x x x x

Catatonic Stupor x x x x x

Catatonic Excitement x x x x x

Hyperkinesia x x x x x

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Catalepsy x x x x x

Cataplexy x x x x x

The patient at times has a waxy flexibility.

Speech Day

How the client is communicating, rather than what the 1 2 3 4 5


client is telling you. Rate, volume, modulation and flow

Rate

Rapid / / / / /

Slow x x x x x

Volume

Loud x x x x x

Soft/mumbled / / / / /

Quantity

Paucity / / / / /

Muteness x x x x x

Voluminous x x x x x

Quality

Articulate x x x x x

Congruent x x x x x

Spontaneous x x x x x

Monotonous / / / / /

Talkative x x x x x

Repetitious / / / / /

Pressured Speech x x x x x

J has somnolence. There is clouding and stupor. He is disoriented to time, place and person.
He is unrespondent to some querries. He has a difficulty to recall personal information and is
often confused.

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Perceptions Day

Process by which physical stimuli are brought to mental 1 2 3 4 5


awareness

Hallucinations

Auditory x x x x x

Visual x x x x x

Tactile x x x x x

Gustatory x x x x x

Olfactory x x x x x

Illusions x x x x x

Depersonalization x x x x x

Derealization x x x x x

Patient has an auditory hallucination.

Thinking Day
The waythe person functttions intellectually; the process 1 2 3 4 5
or way of thinking or analysis of the world: the way of
connecting or associating thoughts; the overall
organization of thoughts.

(1) Thought Content-What a client is thinking

1.1 Delusions
a. Delusions of Grandeur x x x x x
b. Delusions of Reference
x x x x x
c. Delusions of Persecution
d. Religious Delusion x x x x x
e. Somatic Delusion
x x x x x
f. Paranoid Delusion
1.2 Phobia: Specify _________________________

(2) Thought Process - How a person thinks


a. Flight of Ideas / / / / /

.b Looseness of Association / / / / /

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.c Blocking / / / / /
.d Confabulation / / / / /
.e Tangetiality x x x x x
.f Neologism x x x x x
.g Circumstantiality x x x x x
.h Perserveration / / / / /
.i Confabulation / / / / /
.j Word Salad / / / / /

Patient is mumbling to self. He has flight of ideas, looseness of association, blocking, and
perseveration. He has faulty judgment and has a poor insight to his illness. Echolalia can be
observed as well as mutism at times.

Emotional State (Mood/Affect) Day

Expression of emotion as seen by others;what examiner 1 2 3 4 5


infers from patient’s facial expression/behavior

Appropriate x x x x /

Inappropriate / / / / x

Flat / / / / x

Pleasurable Affect

Euphoria x x x x x

Exaltation x x x x x

Ecstacy x x x x x

Unpleasurable

Depression x x x x x

Anxiety / / / / /

Fear x x x x x

Agitation x x x x x

Ambivalence x x x x x

Aggression x x x x x

Mood Swings x x x x x

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Lability x x x x x

Panic x x x x x

Anger x x x x x

Mood is ethylic and has an inappropriate affect which in most of the times is flat. He is
anxious.

CHAPTER

111
3
DIAGNOSIS

E. Predisposing Factors

• Prenatal Alcohol Syndrome


• Traumatic injury to the brain
• Intrauterine malnutrition
• Central Nervous System Malignancy

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• fragile X syndrome
• Phenylketonuria (PKU)

F. Psychodynamics / Psychopathology

The mental retardation generally results from either of the two causes. The one is chromosomal
abnormality and the second is deficiency of certain bio chemicals or neurotransmitters due to the
lack of minerals required for that specific function and a third cause can be brain injuries.

The DSM (Diagnostic and Statistical Manual) divides the retardation into four categories as mild
MR, Moderate MR, severe MR, and profound MR. The level of mental retardation is usually
determined with reference to the IQ (Intelligence Quotient)

About 30% of cases of mental retardation are caused by hereditary factors. Mental retardation
may be caused by an inherited genetic abnormality such as fragile X syndrome, Phenylketonuria
(PKU), Down syndrome. etc.

Fetal alcohol syndrome (FAS), drug exposure, hyperthyroidism are some of the other causes.

Every mental activity involves a series of active involvement of the neurotransmitters, mental
waves, and other complex processes in the nervous system. Insufficient physiological process in
the nervous system results in the retarded mental functioning.

PKU

(enzyme phenylalanine hydroxylase normally converts the amino acid phenylalanine into the
amino acid tyrosine)

phenylalanine accumulates

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tyrosine is deficient

excessive phenylalanine

metabolism of phenylketones

transaminase pathway with glutamate

Metabolites formed

(phenylacetate, phenylpyruvate and phenethylamine)

Saturation of blood-brain barrier (BBB)

decreased levels of other large neutral amino acid (LNAAs) transporter in the brain

decreased synthesis of proteins and neurotransmitters

disrupts brain development

mental retardation

* Delays in oral language development

* Deficits in memory skills

* Difficulty learning social rules

* Difficulty with problem solving skills

* Delays in the development of adaptive behaviors such as self-help or self-care skills

* Lack of social inhibitors

G. Related Literature

DRUG REVERSES MENTAL RETARDATION CAUSED BY GENETIC DISORDER

Published: Sunday, June 22, 2008 - 12:35 in Health & Medicine


Source: University of California - Los Angeles

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UCLA researchers discovered that an FDA-approved drug reverses the brain dysfunction
inflicted by a genetic disease called tuberous sclerosis complex (TSC). Because half of TSC
patients also suffer from autism, the findings offer new hope for addressing learning disorders
due to autism. Nature Medicine publishes the findings in its online June 22 edition. Using a
mouse model for TSC, the scientists tested rapamycin, a drug approved by the FDA to fight
tissue rejection following organ transplants. Rapamycin is well-known for targeting an enzyme
involved in making proteins needed for memory. The UCLA team chose it because the same
enzyme is also regulated by TSC proteins.

"This is the first study to demonstrate that the drug rapamycin can repair learning deficits related
to a genetic mutation that causes autism in humans. The same mutation in animals produces
learning disorders, which we were able to eliminate in adult mice," explained principal
investigator Dr. Alcino Silva, professor of neurobiology and psychiatry at the David Geffen
School of Medicine at UCLA. "Our work and other recent studies suggest that some forms of
mental retardation can be reversed, even in the adult brain."

"These findings challenge the theory that abnormal brain development is to blame for mental
impairment in tuberous sclerosis," added first author Dan Ehninger, postgraduate researcher in
neurobiology. "Our research shows that the disease's learning problems are caused by reversible
changes in brain function -- not by permanent damage to the developing brain."

TSC is a devastating genetic disorder that disrupts how the brain works, often causing severe
mental retardation. Even in mild cases, learning disabilities and short-term memory problems are
common. Half of all TSC patients also suffer from autism and epilepsy. The disorder strikes one
in 6,000 people, making it twice as common as Huntington's or Lou Gehrig's disease.

Silva and Ehninger studied mice bred with TSC and verified that the animals suffered from the
same severe learning difficulties as human patients. Next, the UCLA team traced the source of
the learning problems to biochemical changes sparking abnormal function of the hippocampus, a
brain structure that plays a key role in memory.

"Memory is as much about discarding trivial details as it is about storing useful information,"
said Silva, a member of the UCLA Department of Psychology and UCLA Brain Research
Institute. "Our findings suggest that mice with the mutation cannot distinguish between
important and unimportant data. We suspect that their brains are filled with meaningless noise
that interferes with learning."

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"After only three days of treatment, the TSC mice learned as quickly as the healthy mice," said
Ehninger. "The rapamycin corrected the biochemistry, reversed the learning deficits and restored
normal hippocampal function, allowing the mice's brains to store memories properly."

In January, Silva presented his study at the National Institute of Neurological Disorders and
Stroke meeting, where he was approached by Dr. Petrus de Vries, who studies TSC patients and
leads rapamycin clinical trials at the University of Cambridge. After discussing their respective
findings, the two researchers began collaborating on a clinical trial currently taking place at
Cambridge to examine whether rapamycin can restore short-term memory in TSC patients.

"The United States spends roughly $90 billion a year on remedial programs to address learning
disorders," noted Silva. "Our research offers hope to patients affected by tuberous sclerosis and
to their families. The new findings suggest that rapamycin could provide therapeutic value in
treating similar symptoms in people affected by the disorder."

Title: Mental Retardation


Source: nih.com

Thirty Years Ago



Haemophilus Influenzae Type B (Hib) was the leading cause of acquired mental retardation. In
the mid-1970s, no means existed to prevent infection from Hib, the cause of meningitis — a

116
serious infection of the membrane surrounding the brain and spinal cord. The disease strikes
children under 7 years of age, with most cases occurring in children from six months to two
years old. By the late 1980s, roughly 15-20,000 cases of Hib meningitis occurred each year.
Antibiotics could treat Hib infection, but couldn’t prevent its devastating consequences. On
average, 1 in 10 infected children died from Hib meningitis, 1 in 3 became deaf, and 1 in 3 was
left with mental retardation.

More than 10 million children had blood lead levels high enough to affect their cognitive
functioning. It was not known in the early 1970s that exposure to even small amounts of lead in
the environment — from paint and from automobile exhaust — could have an adverse effect on
the developing brain.

Many children of women with the metabolic disorder phenylketonuria (PKU) were born with
severe mental retardation — even though they did not have PKU themselves. PKU is a genetic
inability to process the nutrient phenylalanine. The disorder occurs once in every 10,000 to
20,000 births, affecting 250 children each year in the United States. Without treatment, a child
will suffer irreparable brain damage and require a lifetime of care in a nursing home facility. In
the 1960s, a blood test for PKU was developed and children with the disorder were identified at
birth. A low phenylanine diet spared them from brain damage. Because the diet is difficult to
adhere to, many children, including those that would go on to be mothers, discontinued the low
phenylalanine diet at approximately age 7 when the dangers of retardation are past.
Unfortunately, by the late 1970s, it was
apparent that children carried by moms with PKU were born with mental retardation.
• Infants lacking thyroid hormone were destined to a life of mental retardation. In the mid 1970s,
more than 1000 U.S. children each year became mentally retarded shortly after birth, because of
hypothyroidism
— failure to produce sufficient amounts of thyroid hormone. Thyroid hormone is essential for
growth, especially of the brain. Although the hormone could be supplied artificially, diagnosis of
the condition was usually not made until after an infant’s brain was permanently damaged.

Today

Meningitis from Hib has virtually been eliminated. In the 1970s, the search began for a vaccine
to prevent Hib meningitis. The Hib bacterium could hide from a young child’s immature immune
system by means of a protective sheath, or capsule, which shields its outer surface. In their first
attempt at a vaccine to prevent the infection, researchers at NIH isolated a complex
polysaccharide — a sugar molecule — from the bacterium’s covering. By itself, the

117
polysaccharide was not enough to prime the immune system to eliminate the Hib bacterium. The
researchers then chemically combined, or conjugated, the sugar molecule to a protein that was
easily recognized by the immune system. The protein and sugar “conjugate” became the basis for
a new vaccine, which virtually eliminated Hib meningitis from the developed world. In the
United States, there are now fewer than 10 cases of Hib meningitis each year.

Lead is no longer an ingredient in paint and gasoline. In 1979, researchers funded by NIH
showed that children whose baby teeth contained relatively high amounts of lead fared poorly on
a standard intelligence test when compared to children whose teeth contained much lower
amounts of lead. The finding eventually led to Federal laws that banned lead as an ingredient in
paint in 1974 and as an additive in gasoline in 1978. As a result, the number of children
National Institutes of Health Mental Retardation – 1
with elevated blood lead levels fell from 10 million in the 1970s to 434,000 in 2001. Although
the two most common sources of environmental lead exposure have been eliminated, many
children are still exposed to such sources of lead as paint in older homes, and contaminated soils.

Children of women with PKU can be protected from brain damage. In the 1960s, children with
PKU typically discontinued the low phenylalanine diet by the time they reached 7 years of age.
The diet’s special protein formulations are expensive, and many find the diet difficult to stick
with. To test whether a low phenylalanine diet would prevent mental retardation in the children
of women with PKU, the NIH began a large study. The study, which took 18 years to complete,
enrolled women from more than 120 clinics in the United States, Canada, and three foreign
countries. The study was completed in 2003 and found that limiting phenylalanine in the diets of
women with PKU beginning before pregnancy and continuing through pregnancy nearly
eliminated mental retardation in their children. Subsequent studies have shown that people with
PKU score higher on intelligence tests if they remain on the low-phenylalanine diets throughout
their lifetimes, rather than discontinuing it in childhood.

Infants who lack thyroid hormone can be identified in time to help them. Researchers funded by
the NIH developed a test to identify newborns that have insufficient thyroid hormones. A large
study funded by NIH in the early 1970s showed that hypothyroidism could be easily detected,
and treated within two weeks, before any brain damage resulted. Soon, every State required
thyroid hormone screening along with PKU screening. Each year in the United States, roughly
1000 cases of mental retardation due to insufficient thyroid hormone are prevented.

Tomorrow

118
• The NIH is supporting the development of new DNA microarray chips and other technologies
for newborn screening. The goal is to develop a fast, reliable, cost effective means to screen
newborns for a multitude of genetic conditions, including not only causes of mental retardation,
but of immune deficiency, blood disorders, nervous system disorders and muscle disorders. Such
a screening test would make it possible to begin treatment early, when chances for success are
greatest. Large numbers of infants who have disorders lacking effective treatments could also be
identified easily. Although treatment might not yet be available for their conditions, they could
be offered a chance to participate in studies of new treatments, so that eventually new therapies
could be developed for their disorders as well.

NIH-funded researchers hope to develop a drug that may one day treat the symptoms of Fragile
X Syndrome. The condition affects one in 6000 births, resulting in mental retardation, sleep
problems, attention deficit disorder, aggression, and compulsive behavior. NIH-funded scientists
working with mice having the same genetic mutation found in Fragile X Syndrome learned that
the mice have increased activity in the metabotropic glutamate receptor (mGluR), which sits atop
brain cells. Studies in mice and fruit flies show that chemically blocking the mGluR receptor
results in the animals displaying more normal behaviors. Researchers hope that drugs that block
the mGluR receptor might one day be used to lessen the disorder’s effects in humans.

Researchers have prevented brain damage in newborn infants deprived of oxygen at birth by
lowering body temperature. Accidents of birth — compression of the umbilical cord, or rupture
of the uterus, for example — can deprive an infant’s brain of blood and oxygen. Survivors of
such accidents may suffer lifelong brain damage and disability. Known scientifically as hypoxic
ischemic encephalopathy, or HIE, oxygen deprivation during birth is estimated to occur from 0.5
to 1 times per every thousand births. Researchers in an NIH network were able to reduce the
amount of death and disability of a group of infants with HIE, by lowering the infants’ body
temperature. The cooling treatment, known as hypothermia therapy, consisted of placing the
infants on a soft plastic blanket through which cool water circulates. When the infants were
examined at 18 to 22 months of age, 44 percent of those given hypothermia treatment had
developed a moderate to severe disability or had died, as compared to 62 percent of infants
receiving standard treatment for HIE. Because minor fluctuations in an infant’s body temperature
could result in serious harm, the hypothermia treatment requires personnel trained in life support
and the use of the cooling blanket. Researchers in the network are working to refine the therapy
so that it may one day be used routinely in newborn intensive care units.

3. Summary

119
The literature discussed the causes of mental retardation from early years until these were
eradicated, prevented and resolved. The following factors that were considered are Haemophilus
Influenza Type B, products with lead content, PKU, fetal injury from oxygen deprivation and
deficient thyroid hormone.

4. Reaction

I just want to commend the works and studies of the National Institutes of Health (NIH),
an agency of the United States Department of Health and Human Services and the primary
agency of the United States government responsible for biomedical and health-related research.

NIH research of acquiring new knowledge to help prevent, detect, diagnose, and treat
mental retardation is of really huge help and contribution to the world’s wellness especially for
the mentally incapacitated patients

120
D. Drug Study – HALOPERIDOL

121
DOSE/
NURSING
DRUG CLASSIFICATION RATE/ ACTION CONTRAINDICATION SIDE EFFECTS
CONSIDERATIONS
ROUTE
Generic Antipsychotics / 10 mg , Haloperidol blocks • Severe toxic CNS Cardiovascular Effects:
Name: Anti-vertigo PO, HS postsynaptic • depression; Tachycardia, hypotension, and • Assess mental status prior to
haloperidol Drugs dopamine D1 and D2 • pre-existing coma; hypertension and periodically during
receptors in the • Parkinson's disease; CNS: therapy.
Brand INDICATION: mesolimbic system • Lactation Insomnia, restlessness, anxiety, • Monitor BP and pulse prior
Name: • Restlessness and decreases the
• Glaucoma
euphoria, agitation, drowsiness, to and frequently during the
Haldol • Confusion release of depression, lethargy, headache, period of dosage adjustment.
hypothalamic and • Seizures confusion, vertigo, grand mal May cause QT interval
• Schizophreni • Elderly
a hypophyseal seizures, exacerbation of psychotic changes on ECG.
• Psychosis hormones. It symptoms including hallucinations, • Observe patient carefully
• Organic produces calmness and catatonic-like behavioral states when administering
Psychoses and reduces Hematologic Effects: medication, to ensure that
aggressiveness with mild and usually transient medication is actually taken
• acute
disappearance of leukopenia and leukocytosis, and not hoarded.
psychotic
hallucinations and minimal decreases in red blood cell •Monitor I&O ratios and daily
symptoms
delusions. counts, anemia, or a tendency eight. Assess patient for signs
• Relieve Absorption: toward lymphomonocytosis. and symptoms of dehydration.
hallucination Readily absorbed Liver Effects: • Monitor for development of
s, delusions, from the GI tract Impaired liver function and/or neuroleptic malignant
disorganized (oral). jaundice syndrome (fever, respiratory
thinking Distribution: Dermatologic Reactions distress, tachycardia, seizures,
• severe Crosses the blood- Maculopapular and acneiform skin diaphoresis, hypertension or
anxiety brain barrier; enters reactions and isolated cases of hypotension, pallor, tiredness,
• seizures breast milk. Protein- photosensitivity and loss of hair. severe muscle stiffness, loss
binding: 92%. Endocrine Disorders of bladder control. Report
Metabolism: Lactation, breast engorgement, symptoms immediately. May
Hepatic via mastalgia, menstrual irregularities, also cause leukocytosis,
oxidative N- gynecomastia, impotence, increased elevated liver function tests,
dealkylation and libido, hyperglycemia, elevated CPK.
reduction of the hypoglycemia and hyponatremia. •Do not increase dose or
ketone group; Gastrointestinal Effects discontinue medication
undergoes Anorexia, constipation, diarrhea, without consulting health care
enterohepatic hypersalivation, dyspepsia, nausea professional. Abrupt
recycling. and vomiting. withdrawal may cause
Excretion: Urine Autonomic Reactions dizziness, nausea, and
and faeces; 12-38 hr Dry mouth, blurred vision, urinary vomiting, GI upset, trembling,
(elimination half- retention, diaphoresis and priapism. or uncontrolled movements of
life). Respiratory Effects mouth, tongue or jaw.
122 Laryngospasm, bronchospasm and
increased depth of respiration.
Special Senses
123
CHAPTER

IV

NURSING
CARE
PLAN

124
A.
Process
Recording

125
ORIENTATION PHASE

Description of Phase:

• Problem defining phase

• Starts when client meets nurse as stranger

• Defining problem and deciding type of service needed

• Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and
expectations of past experiences

• Nurse responds, explains roles to client, helps to identify problems and to use available
resources and services

Objectives:

After the orientation phase, the nurse will be able to:

 Determine why the patient sought help


 Establish trust, acceptance, and open communication
 Mutually formulate a contract with the patient
 Explore patient’s thoughts, feelings, and actions
 Identify patient’s problems
 Define goals with the patient

Date/ Time/ Venue: November 25, 2009 at National Center for Mental Health, Pavilion 1
Ward 9

RATIONALE OF THE ANALYSIS OF THE


NURSE’S PATIENT’S RESPONSE
NURSE-PATIENT
INTERACTION COMMUNICATION

126
TECHNIQUE

Nurse: Magandang umaga J. Therapeutic:


Ako si Ran. Estudyante ako
Giving Information
mula sa Centro Escolar
University, Manila. Student  Making available the facts
nurse mo ako ngayon. that the client needs
Magkikita at mag-uusap tayo Use names
simula Miyerkules hanggang
 Using a person's name
Biyernes sa susunod na
makes her feel more
linggo, mula alas-siyete
valued, and introducing
hanggang alas-tres ng hapon.
yourself is a basic step in
Mag-uusap ulit tayo bukas ha.
establishing a therapeutic
interaction.

Patient: Opo…Opo…Opo
(with nodding)

Nurse: Puwede ko bang


malaman ang buong pangalan  Patient is conscious and
Therapeutic:
mo? comprehending
Exploring

 Encourages the speaker to


expand upon their
Patient: (stated the name) remarks/ question

Nurse: Ano ulit ang pangalan


ko J?

 Patient is responsive

Patient: Ran po. (somnolence)

Nurse: Sige. Ako ang student


nurse mo tapos ikaw ang

127
pasyente. Therapeutic:  Patient is drowsy and
comprehending
Help to orient
 According to Jung,
 Illness and hospitalization perception involves all the
can be very disorienting ways of becoming aware
Patient: Opo.
for patients, especially the of things, people,
elderly. happenings, or ideas.
Judgment involves all the
Nurse: Mag-uusap tayo J ha.
ways of coming to
Magkukwentuhan lang tayo.
conclusions about what
has been perceived. If

Patient: Opo. Opo. people differ


systematically in what they
perceive and in how they

Nurse: Alam mo ba kung reach conclusions, then it

anong petsa at araw ngayon? is only reasonable for them


Therapeutic: to differ correspondingly
in their interests, reactions,
Help to orient
values, motivations, and
 Illness and hospitalization skills.
Patient: Sabado can be very disorienting  Patient is responsive
for patients.

Nurse: J Huwebes ngayon.


Therapeutic:
November 26, 2009.
Presenting Reality
 He is analyzing the
 When it is obvious that the information
patient is misinterpreting
Patient: (stares only) reality, the nurse can
indicate that which is real.  Patient had

He does this not by way of established/formed fixated


Nurse: Ano ulit ang petsa arguing with the patient or idea with regards
ngayon J? belittling his own

Patient: Sabado experiences, but rather by


 Patient is responsive
calmly and quietly
Nurse: Huwebes ngayon,
expressing her own
November 26, 2009 J.
perceptions or the facts

128
 He has a difficulty to recall
personal information and
Patient: Opo Therapeutic:
is often confused.
Asking Direct Questions:

Nurse: Ilang taon ka na pala J?  This allows the patient to


try answering a direct
question directly, briefly
Patient: Napulo and correctly  He has a difficulty to recall
Therapeutic: personal information and
is often confused.
Reframing the question:

 This allows the patient to


try answering a direct
Nurse: Anong taon nuong question directly, briefly
ipinanganak ka? and correctly
 Patient has difficulty in
Therapeutic:
memory skills
Asking Direct Questions:
Patient: Marso

 This allows the patient to


try answering a direct
question directly, briefly

Nurse: Ano ang birthday mo? and correctly

Kelan ka ipinanganak? Therapeutic:


 Disoriented to place
Help to orient

Patient: Hulyo, Agosto  Illness and hospitalization


can be very disorienting
for patients.

Nurse: alam mo ba J kung ano Therapeutic:


ang ginagawa mo dito?
Asking Direct Questions:  Misleading answer

 This allows the patient to


Patient: (looses eye contact, try answering a direct
tumingin sa malayo) question directly, briefly
and correctly

129
Nurse: Anong lugar to J? Therapeutic:

Asking Direct Questions:  Trying to recall personal


information
Patient: (silence. Spits saliva)..  This allows the patient to
Ambot try answering a direct
question directly, briefly
and correctly
Therapeutic:

Nurse: Saan ka pala nakatira Asking Direct Questions:


J?  Patient is responsive
 This allows the patient to
try answering a direct
question directly, briefly
Patient: sa bahay
and correctly
Therapeutic:

Asking Direct Questions:

Nurse: Saan ka galing na  This allows the patient to


probinsiya? try answering a direct
question directly, briefly
 Patient is responsive
and correctly
Patient: doon

Therapeutic:

Asking Direct Questions:

Nurse: Saan yung doon na


 This allows the patient to
sinasabi mo J? Yung lugar
try answering a direct
kung saan ka dati nakatira
question directly, briefly
bago ka napunta dito?  Patient is responsive
and correctly
Therapeutic:

Patient: Bitano Asking Direct Questions:

 This allows the patient to


try answering a direct
Nurse: Saan yung Bitano J?
question directly, briefly
and correctly

130
Patient: Sorsogon Therapeutic:

Using Broad Opening


Statements The use of a broad
opening statement allows the
patient to set the direction of
the conversation.
Nurse: alam mo ba kung
nasaan ang Sorsogon? Therapeutic:

Asking Direct Questions:

Patient: sa Mindanao  This allows the patient to


try answering a direct
question directly, briefly
and correctly
 Somnolence

Nurse: Naaalala mo pa ba ang


mga nangyari bago ka napunta
 The patient can’t justify
dito?
Piaget’s cognitive theory.

Therapeutic:
Patient: (looses focus, drowsy)  According to Piaget, the
Observation:
formal operational period
 To help with awareness of is the fourth and final of
Nurse: Sino ang kasama mo feelings, encourage the periods of cognitive
pagpunta mo dito? verbalization of feelings, development in Piaget's
conveys concern and theory. This stage, which
interest. follows the Concrete
Patient: (focus returned) Verbalizing Implied Thoughts Operational stage,
and Feelings commences at around 11
years of age (puberty) and
 The nurse voices what the
continues into adulthood.
patient seems to have
Nurse: J mag-usap pa tayo ha? In this stage, individuals
fairly obviously implied,
move beyond concrete
rather than what he has
experiences and begin to
actually said.
Patient: Opo. think abstractly, reason
Therapeutic:
logically and draw
Asking Direct Questions: conclusions from the

131
Nurse: Okay ka pa?  This allows the patient to information available, as
try answering a direct well as apply all these
question directly, briefly processes to hypothetical
Patient: Opo. and correctly situations.

Therapeutic:  It is observable that the


Nurse: Inaantok ka ba J?
patient has an
Exploring or delving further
inappropriate affect
into a subject or idea:
Patient: hindi po
 The nurse should
recognize when to delve
further. If the patient
Nurse: Napapagod ka na ba?
chooses not to elaborate,
the nurse should respect
the patient’s wishes.  Some questions with
Patient: Hindi po.
regards to personal
information can be
answered correctly by the
Nurse: Nag-enjoy ka ba knina
Therapeutic: patient.
J?

Focusing:

Patient: Opo (flat affect)  It will help the client


expand on a topic
Therapeutic:

Nurse: Nag-exercise ka rin ba?


Sequencing:

 Helps to identify cause and


Patient: Opo effect, recurring pattern of
interpersonal difficulties.
Therapeutic:
Nurse: Kamusta naman ang
Exploring or delving further
pag-ehersisyo mo kanina J?
into a subject or idea:
 Flight of ideas
 The nurse should  a nearly continuous flow
Patient: Okay lang po recognize when to delve of rapid speech that jumps
further – she should refrain from topic to topic, usually
from probing or prying. If based on discernible

132
Nurse: Sino pala ang kasama the patient chooses not to associations, distractions,
no J pagpunta mo dito? elaborate, the nurse should or plays on words, but in
respect the patient’s severe cases so rapid as to
wishes. Probing usually be disorganized and
Patient: Suseng occurs when the nurse incoherent.
introduces a topic because
she is anxious.
 Patient is fixated with
Nurse: Kaano-ano mo si Therapeutic:
certain numbers like 5 and
Suseng J?
Sequencing: 10.

 Helps to identify cause and


Patient: nanay effect, recurring pattern of  When we feel safe and
interpersonal difficulties. secure in our world then
we begin to seek out
Nurse: Nanay mo siya? friendships in order to feel
a sense of belonging.
Maslow's third level, the
Patient: Opo need for belonging and
love, focuses on our desire
Therapeutic: to be accepted, to fit in,
Nurse: Tapos ano ang and to feel like we have a
Exploring or delving further
nangyari? place in the world.
into a subject or idea:

 The nurse should


 Persons may be called both
Patient: may red na bag, blue recognize when to delve
mentally retarded and
further – she should refrain
learning disabled, meaning
from probing or prying. If
that their overall IQ is
Nurse: Tapos? the patient chooses not to
lower than average, but
elaborate, the nurse should
that they have strengths
respect the patient’s
and weaknesses on various
Patient: isang bag lang dala wishes. Probing usually
skills.
ko, namin occurs when the nurse
introduces a topic because
she is anxious.
Nurse: Ilang taon ka na dito?
Therapeutic:

Asking Direct Questions:

Patient: lima  Cognitive development is


 This allows the patient to
defined as thinking,

133
try answering a direct problem solving, concept
question directly, briefly understanding, and
Nurse: Si Suseng nasaan?
and correctly information processing
Therapeutic: and overall intelligence.
Many mentally retarded
Patient: Doon Asking Direct Questions:
clients have cognitive
 This allows the patient to weaknesses. Their overall
try answering a direct potential may be lower
Nurse: Saan yung nanay mo J?
question directly, briefly than that of their peers and
and correctly siblings. They still have
patterns of strengths and
Patient: sa bahay, dun
weaknesses in their
development and may do
very well with certain
Nurse: Sa Bitano?
types of learning.

Therapeutic:
Patient: Opo (nods)
Sequencing:

 Helps to identify cause and


Nurse: may mga gamot ka ba  Adaptive skills are the
effect, recurring pattern of
na iniinom? skills needed for daily life
interpersonal difficulties.
and include the ability to
produce and understand
Patient: oo, kanina language
(communication); home-
Therapeutic:
living skills; use of
Nurse: Ano daw yun J? Sequencing: community resources;
health, safety, leisure, self-
Helps to identify cause and
care, and social skills; self-
Patient: aspilit, isa lang effect, recurring pattern of
direction; functional
interpersonal difficulties
academic skills (reading,
writing, and arithmetic);
Patient: gamot, gamot, and work skills.
(showed both arms)

Therapeutic:

Nurse: may asawa ka naba J? Acknowledging the patient’s


Feeling:

134
 The nurse helps the patient
to know that his feelings
Patient: wala
are understood and
accepted and encouraged
him to continue expressing
them. If communication is
to be successful, it is
essential that the nurse
Nurse: Nakatapos ka na ba ng
accept the thoughts and
elementary o high school J?
feelings her patient is
expressing.

Patient: oo, elementary

Nurse: Hanggang anong grade


natapos mo?

Include the patient

Patient: Grade 1  You must remember that


patient care should be
collaborative and include
Nurse: ano pala palagi mo the patient in decision
ginagawa dito J? making whenever
possible. The patient often
feels at the mercy of the
Patient: Toothbrush (acting), system, but you can help
ligo, kain him find ways to feel in
control.

Nurse: Tuwing umaga?

Patient: kain

Nurse: kapag hapon?

135
Patient: tulog

Nurse: ano ang gusto mong


pagkain J?

Patient: monggo’

Nurse: ano ang kinain mo


kanina?

Patient: monggo

Nurse: Masarap ba J?

Patient: Opo

Nurse: ano ang mga ayaw mo


kainin?

Patient: monggo, kanin, apple

Nurse: Di ba sabi mo gusto


mo ng monggo knina?

Nurse: Usap ulit tayo bukas


ha!

136
Patient: Opo.

WORKING PHASE

Description of Phase:

At this point, the client’s problems are identified and solutions are explored,
applied and evaluated. The focus of the assessment and of the relationship is the client’s behavior
and the focus of the interaction is the client’s feelings.

Objective:

After the working phase, the nurse will be able to:

 Explore relevant stressors for the patient


 Promote patient’s development of insight and use of constructive coping
mechanisms
 Overcome resistance behavior

Date/ Time/ Venue: November 26, 2009 at National Center for Mental Health, Pavilion 1
Ward 9

RATIONALE OF THE
NURSE’S ANALYSIS OF THE
NURSE-PATIENT PATIENT’S RESPONSE
COMMUNICATION
INTERACTION
TECHNIQUE

Nurse: Magandang umaga sa Therapeutic:  Patient is disoriented to


yo J! time, place and person
Use names:

 Using a person's name


Patient: Magandang umaga makes her feel more
din po. valued, and introducing  MEMORY AND

137
yourself is a basic step in ATTENTION. Memory
establishing a therapeutic deficiencies interfere with
Nurse: Ano ulit ang pangalan
interaction. learning rote material such
ko J?
as days of the week,
months of the year, and
Therapeutic:
times tables. Basic facts
Patient: (Kran)
Help to orient are hard to remember and
there is a lack in
 Illness and hospitalization
knowledge of general
Nurse: Ran ako can be very disorienting
information. There are
for patients.
deficits in attention that
Therapeutic:
interfere with ability to
Patient: Ran
Using Broad Opening focus and concentrate on
Statements: tasks.

Nurse: Kamusta naman ang  The use of a broad


tulog mo J? opening statement allows
the patient to set the
direction of the
Patient: Maayos conversation. Give the
patient an opportunity to
begin expressing himself.
Nurse: eh ang gising? In using a broad opening
statement, the nurse
focuses the conversation
Patient: ayos directly on the patient and
communicates to him that
she is interested in him
Nurse: Anong araw pala
and his problems. Upon
ngayon J?
sensing that the patient
may have a need, the nurse
can use a broad opening
Patient: Martes
statement to initiate
discussion, while at the
same time allowing the
Nurse: J, Biyernes ngayon.
patient to determine what
Ang petsa ay November 27,
will be discussed.
2009.
Therapeutic:

138
Giving Information  The patient can’t justify
Piaget’s cognitive theory
Nurse: Anong araw ang  Studies have shown that a
sumunod sa Biyernes? major cause of anxiety or
discomfort in hospitalized  According to Piaget, the
patients is lack of formal operational period
Patient: Martes information or is the fourth and final of
misconceptions about their the periods of cognitive
condition, treatment, or development in Piaget's
Nurse: Kung Biyernes ngayon, hospital routines. When theory. This stage, which
ano ang araw bukas? Bukas the patient is in need of follows the Concrete
ay? information to relieve Operational stage,
anxiety, form realistic commences at around 11
conclusions, or make years of age (puberty) and
Patient: Martes decisions, this need will continues into adulthood.
often be revealed during In this stage, individuals
the interaction by move beyond concrete
Nurse: Sabado bukas J. statements he makes. By experiences and begin to
Sundan mo ko ha. providing such think abstractly, reason
information as she logically and draw
prudently can, admitting conclusions from the
Nurse: Lunes and finding out what she information available, as
doesn’t know, or referring well as apply all these
the patient to someone processes to hypothetical
Patient: Lunes who can assist him, the situations.
nurse can do much to
establish an atmosphere of
Nurse: Martes
helpfulness and trust in her
relationship with the
patient.
Patient: Martes

Nurse: Miyerkules

Patient: Miyerkules

Therapeutic:

139
Nurse: Huwebes Using Broad Opening
Statements:

 The use of a broad


Patient: Huwebes
opening statement allows
the patient to set the
direction of the
Nurse: Biyernes
conversation. Give the
patient an opportunity to
begin expressing himself.
Patient: Biyernes  Patient is responsive.
Therapeutic:

Sequencing:
Nurse: Sabado
 Helps to identify cause and
effect, recurring pattern of
interpersonal difficulties.  According to Piaget, the
Patient: Sabado
formal operational period
is the fourth and final of
the periods of cognitive
Nurse: Linggo
development in Piaget's
theory. This stage, which

Patient: Linggo follows the Concrete


Therapeutic: Operational stage,
Sharing Observations commences at around 11

Nurse: Anu-ano pala mga  The nurse shares with the years of age (puberty) and

ginawa mo ngayong umaga? patient observations continues into adulthood.


regarding behavior. The In this stage, individuals
patient who has a need is move beyond concrete

Patient: Kain, toothbrush, ligo often unaware of the experiences and begin to
source of this distress, or think abstractly, reason
reluctant to communicate logically and draw

Nurse: Ano yung mga kinain it verbally. However, the conclusions from the

mo? tension or anxiety created information available, as


by his need creates energy well as apply all these
which is transformed into processes to hypothetical
Patient: Spanish some kind of behavior, situations.

Therapeutic:

140
Nurse: Spanish bread? Sequencing:

 Helps to identify cause and


effect, recurring pattern of
Patient: Opo
interpersonal difficulties

Nurse: masarap ba?


Reflecting:  Patient is responsive and
answers questions with
In reflecting, all or part of comprehension.
Patient: Opo the patient’s statement is
repeated to encourage him
to go on. Reflecting can be
overused, and the patient
Nurse: pag-usapan natin ang is likely to become
annoyed if his own words
drawing mo kanina. or statements are
continually repeated to
him

Patient: iskindi (ice candy)

Nurse: ice candy yung


drawing mo?

 MEMORY AND

Patient: Opo. ATTENTION. Memory


deficiencies interfere with
learning rote material such

Nurse: Anong meron sa ice as days of the week,

candy at yun ang dinrawing months of the year, and

mo? Therapeutic: times tables. Basic facts


are hard to remember and
Ang ice candy ay? Exploring or delving further
there is a lack in
into a subject or idea:
knowledge of general
 The nurse should information. There are
Patient: matamis, lamig recognize when to delve
deficits in attention that
further – she should refrain
from probing or prying. If interfere with ability to
the patient chooses not to
focus and concentrate on
elaborate, the nurse should
Nurse: ano pa?
respect the patient’s tasks.
wishes. Probing usually
occurs when the nurse
introduces a topic because

141
Patient: tigas, tamis she is anxious

Nurse: may naalala ka ba sa


ice candy?
Therapeutic:
 MEMORY AND
Asking Direct Questions: ATTENTION. Memory
Patient: (silence) deficiencies interfere with
 This allows the patient to
learning rote material such
try answering a direct
as days of the week,
question directly, briefly
Nurse: paborito mo ba ang ice months of the year, and
and correctly
candy? times tables. Basic facts
are hard to remember and
there is a lack in
Patient: Opo. knowledge of general
information. There are
deficits in attention that
Nurse: ano ang paborito mo na interfere with ability to
lasa ng ice candy? focus and concentrate on
tasks.

Patient: monggo

Nurse: Anu-ano pala ang mga


kulay ng ice candy? Diyan sa
drawing mo J?

Patient: (Points on the lines


while identifying its colors,
with some mistakes)

Nurse: (corrects the mistakes)

Nurse: okay J, very well.

142
Magaling!

Nurse: Nagtitinda ka ba dati


ng ice candy J?

Patient: Hu..

Nurse: Pagod ka na ba J?

Patient: Opo.

Nurse: Okay sige. Pahinga ka


na J. Hintayin lana muna natin
ang iba na matapos ha.

Patient: Opo.

143
TERMINATION PHASE

Description of Phase:

The nurse terminates the relationship when the mutually agreed goals are met, the
patient is discharged or transferred or the rotation is finished. The focus of this stage is the
growth that has occurred in the client and the nurse helps the patient to become independent and
responsible in making his own decisions. The relationship and the growth or change that has
occurred in both the nurse and the patient is summarized.

Objective:

During the termination phase, the nurse will be able to:

 Establish reality of separation


 Review progress of therapy and attainment of goal
 Mutually explore feelings of rejection, loss, sadness, and anger and related
behaviors

Date/ Time/ Venue: December 3, 2009 at National Center for Mental Health, Pavilion 1
Ward 9

Nurse-Patient Interaction Rationale of the Nurse’s Analysis of the Patient’s


Communication Technique Response

Nurse: Magandang umaga sa Therapeutic:  The patient is conscious.


yo J.
Use names
Patient: Gandang umaga din  The patient talks rapidly.
po.  Using a person's name
makes her feel more  Adaptive skills are the

Nurse: Kumusta ang tulog valued, and introducing skills needed for daily life
mo? yourself is a basic step in and include the ability to
establishing a therapeutic produce and understand
Patient: Ok lang.
interaction. language

144
Therapeutic: (communication); home-

Nurse: Maayos ba naman ang living skills; use of


Using Broad Opening
gising? community resources;
Statements:
Patient: Opo. health, safety, leisure, self-
The use of a broad opening care, and social skills; self-
statement allows the patient to direction; functional
Nurse: Anu-ano ang mga set the direction of the
conversation. Give the patient academic skills (reading,
ginawa mo kanina?
an opportunity to begin writing, and arithmetic);
Patient: toothbrush, ligo, kain expressing himself. and work skills.

Nurse: Ano ang kinain mo J? Therapeutic:  Cognitive development is


Patient: tinapay Focusing: defined as thinking,
problem solving, concept
 It will help the client understanding, and
Nurse: masarap ba J?
expand on a topic information processing
Patient: Opo. Therapeutic: and overall intelligence.

Exploring or delving further Many mentally retarded

Nurse: nabusog ka ba? into a subject or idea: clients have cognitive


weaknesses. Their overall
Patient: (nods)
 The nurse should potential may be lower
recognize when to delve than that of their peers and
Nurse: Pag-usapan natin J further – she should refrain siblings. They still have
yung tungkol sa niyog. Ano from probing or prying. If patterns of strengths and
nga ang mga parte ng niyog?
the patient chooses not to weaknesses in their
Patient: dahon elaborate, the nurse should development and may do
respect the patient’s very well with certain
wishes. Probing usually types of learning.
Nurse: Ahh. Magbigay ka nga
ng isang gamit ng dahon. occurs when the nurse
introduces a topic because
Patient: bubong
she is anxious.

 MEMORY AND
Nurse: Ano pa J? Magsabi ka ATTENTION. Memory
pa nga ng isang parte pa ng
puno ng niyog? deficiencies interfere with
Therapeutic: learning rote material such
Patient: puno
Sequencing: as days of the week,
months of the year, and
Nurse: Anong gamit ng kahoy  Helps to identify cause and times tables. Basic facts
ng niyog J? effect, recurring pattern of

145
Patient: bahay. interpersonal difficulties. are hard to remember and
there is a lack in

Therapeutic: knowledge of general


Nurse: Oo. Ginagamit nga to
sa paggawa ng bahay. information. There are
Focusing: deficits in attention that

 It will help the client interfere with ability to


Nurse: Puwede ka bang expand on a topic focus and concentrate on
magkuwento ng tungkol sa
tasks.
mga magulang at mga kapatid
mo J? Therapeutic:

Patient: … Asking Direct Questions:

 This allows the patient to  According to Piaget, the


Nurse: Namimiss mo ba sila try answering a direct formal operational period
J?
question directly, briefly is the fourth and final of
Patient: … and correctly the periods of cognitive
development in Piaget's
theory. This stage, which
Nurse: Ano ulit pangalan nung
nanay mo? follows the Concrete
Operational stage,
Patient: Suseng
commences at around 11
years of age (puberty) and
Nurse: Ano naman ang continues into adulthood.
pangalan ng tatay mo J?
In this stage, individuals
Patient: Mario move beyond concrete
experiences and begin to
Therapeutic: think abstractly, reason
Nurse: Ang mga kapatid mo?
Naaalala mo ba mga pangalan logically and draw
Acknowledging the patient’s
nila? conclusions from the
Feeling:
Patient: Ricoy, Marichu information available, as
 The nurse helps the patient well as apply all these
to know that his feelings processes to hypothetical
Nurse: Nasaan na sila ngayon are understood and situations.
J?
accepted and encouraged
Patient: Ambot. him to continue expressing
them. If communication is

Nurse: Napaano pala yang to be successful, it is


mga sugat mo sa kamay J? essential that the nurse
accept the thoughts and

146
Patient: kadena feelings her patient is
expressing.

Nurse: Sino ang nagkadena sa


yo J?

Patient: nanay  MEMORY AND


ATTENTION. Memory
deficiencies interfere with
Nurse: Ano daw ang dahilan
ni Suseng dahil kinadena ka learning rote material such
nya? May nagawa ka ba na as days of the week,
kasalanan? months of the year, and
Patient: Ambot lang. times tables. Basic facts
are hard to remember and
there is a lack in
Nurse: Ano pa ang mga
knowledge of general
nangyari J. Sige magkuwento
ka pa. Makikinig ako. information. There are
deficits in attention that
Patient: Kinulong ako.
interfere with ability to
focus and concentrate on
Nurse: Kinulong ka J? tasks.
Patient: …

Nurse: Ano ang naramdaman


mo?

Patient: Nagalit.  According to Piaget, the


formal operational period
is the fourth and final of
Nurse: Kanino ka nagalit?
the periods of cognitive
Patient: Suseng development in Piaget's
theory. This stage, which
follows the Concrete
Nurse: Tapos ano na ang
nangyari? Operational stage,
commences at around 11
Patient: Ambot.
years of age (puberty) and
continues into adulthood.
Nurse: J huling beses na pala In this stage, individuals
kita makakausap ng ganito.
move beyond concrete
Patient: … experiences and begin to

147
think abstractly, reason

Nurse: Socialization na bukas logically and draw


at huling araw na rin na conclusions from the
pupunta ako dito bukas. information available, as
Patient: …. well as apply all these
processes to hypothetical
situations.
Nurse: May gusto ka pa ba na
sabihin o ikuwento sa akin?

Patient: Wala na.

Nurse: Sige J. Hintayin na


lang natin ang iba na matapos.

148
B. List of Prioritized Psychiatric Nursing Diagnosis

149
NURSING DIAGNOSIS RANK RATIONALE

Based on Carl Jung's Theory of Psychological


Types, perception involves all the ways of
becoming aware of things, people,
Disturbed Thought Processes happenings, or ideas. Judgment involves all
related to developmental delay of the ways of coming to conclusions about what
1
cognition as evidenced by has been perceived. If people differ
cognitive dissonance systematically in what they perceive and in
how they reach conclusions, then it is only
reasonable for them to differ correspondingly
in their interests, reactions, values,
motivations, and skills.

According to Karen Horney’s Theory on


Personality, moving away from people: The

Impaired Verbal Communication final possible consequence of a neurotic is a

related to impaired cognitive personality style filled with a social behavior


2 and an almost indifference to others. If they
abilities as evidenced by loose
association of ideas don't get involved with others, they can't be
hurt by them. While it protects them from
emotional pain of relationships, it also keeps
away all positive aspects of relationships. It
leaves them feeling alone and empty.

According to Sullivan’s Interpersonal Theory,


the need for friendship and need for sexual
Impaired Social Interaction expression get combined during late
related to impaired thought adolescence. In this stage a long term
processes as evidenced by 3 relationship becomes the primary focus.
dysfunctional interaction with Conflicts between parental control and self-
others expression are commonplace and the overuse
of selective inattention in previous stages can
result in a skewed perception of the self and
the world.

Self-Care Deficit, Bathing and Dorothea E. Orem's Self-Care Deficit Nursing


Hygiene related to mental delay Theory states that nursing is required because
4
as evidenced by inability to bathe of the inability to perform self-care as the
himself result of limitations.

150
151
PSYCHIATRIC NURSING CARE PLAN

Psychiatric Nursing Psychodynamics RATIONALE


Cues / Clues PLANNING Therapeutic Approach EVALUATION
Diagnosis (RATIONALE) (with Theories)

Subjective Cue:

When asked about the day, Disturbed Thought Risk factors are Short term outcome: A. INDEPENDENT:
the patient verbalized Processes related to socioeconomic & 1. Assess degree of
“Sabado”, mistaken it for developmental biochemical disorientation to Outcome Achieved:
time, place,
Thursday, even if initially delay of cognition as After 8 hours of person, and 1. This will determine the amount of
oriented. evidenced by situation regularly reorientation and intervention the
nursing intervention,
cognitive dissonance and frequently. patient will need to evaluate reality  The patient reduced
the pt will be able to
accurately. Based on Carl Jung's disorientation to
:
Neurologic Theory of Psychological Types, time, place, person,
Objective: perception involves all the ways of
developmental and situation.
 Reduce
becoming aware of things, people,  The patient
GA: failure disorientation to
happenings, or ideas. Judgment interacted with
time, place,
involves all the ways of coming to others
 Loosing eye contact person, and
conclusions about what has been appropriately.
 Inappropriate affect- situation.
perceived. If people differ  The patient assisted
flat  Interact with
systematically in what they perceive in assuming self-
Motor Behavior: others
Alteration of and in how they reach conclusions, care responsibilities
appropriately.
then it is only reasonable for them to to the limits of his
 Waxy flexibility function in  Assist in differ correspondingly in their ability.
Sensory & Cognition: cognitive and assuming self- interests, reactions, values,
care  The patient
perceptive fields motivations, and skills.
 Conscious but responsibilities participated in
disoriented to time, to the limits of social activities and
person & place his ability. group therapies
2. A calm approach helps to avoid
 Impaired memory on  Participate in distorting the client’s sensory
personal information social activities 2. Providing general perceptual field which helps could
 Poor focus regarding and group leads promote disturbed thoughts and
specific topic therapies a. Approach the client in perceptions. The client with
Inaccurate slow, calm, matter-of- disturbed thought process may have
Attitude: interpretation of fact manner difficulty in interpreting correct
incoming b. Maintain facial meanings if the nurse misrepresents

152
 handily cooperative information expression and intent with a conflicting or double
 Withdrawn behaviors that are message.
 Perplexed consistent with verbal Peplau defined Psychodynamic
 apathetic statements Nursing as being able to understand
Affect: one’s own behavior to help others
Disturbed identify felt difficulties and to apply
 Flat affect principles of human relations to the
thought process
 Anxious problems that arise at all levels of
Thought Process: experience.
 looseness of
association
 blocking 3. Clear direct explanations of
 perseveration environment events help to lessen
Altered perceptions of the client’s suspiciousness and fear
surrounding stimuli caused 3. Giving or mistrust of the surroundings and
by impairment in the information other. This can prevent aggressive
a. Offer the client clear, behavior. According to Sullivan, the
following cognitive
simple explanations of strand of interpersonal theory is the
processes: environmental events, principle of complementarities
activities and the which contends that people in dyadic
 Memory behaviors of other interactions negotiate the definition
 Judgment clients as necessary of their relationship through verbal
 Comprehension and non-verbal cues.
 Concentration
Inability to reason, problem
solve, calculate, and
B. COLLABORATIVE
conceptualize

1. Continue to Haloperidol may cause dehydration.


administer and
Assessing I/O is important.
monitor the effects
of the prescribed
medication
 haloperidol

153
PSYCHIATRIC NURSING CARE PLAN

Psychiatric Nursing Psychodynamics RATIONALE


Cues / Clues PLANNING Therapeutic Approach EVALUATION
Diagnosis (RATIONALE) (with Theories)

Subjective Cue:
(conversation between the
nurse and the patient) Impaired Verbal Risk factors are Short term C. INDEPENDENT:
Communication socioeconomic & outcome: 4. Assess degree of
Nurse: Ilang taon ka na pala related to impaired biochemical disorientation to 4. This will determine the amount of Outcome Achieved:
time, place, reorientation and intervention the
J? cognitive abilities as
person, and patient will need to evaluate reality
evidenced by loose situation accurately. Based on Carl Jung's
After 8 hours of
association of ideas regularly and Theory of Psychological Types,  The patient used a
nursing
Patient: Napulo intervention, the pt frequently. perception involves all the ways of form of
Neurologic becoming aware of things, people, communication to
will be able to :
developmental happenings, or ideas. Judgment get needs met and
involves all the ways of coming to to relate effectively
failure  Use a form of
Nurse: Anong taon nuong conclusions about what has been with persons and
communication his or her
ipinanganak ka? perceived. If people differ
to get needs environment.
systematically in what they perceive
met and to
and in how they reach conclusions,  The patient
relate
then it is only reasonable for them to demonstrated
effectively with
Patient: Marso Alteration of differ correspondingly in their congruent verbal
persons and his
function in interests, reactions, values, and non-verbal
or her
motivations, and skills. communication
cognitive and environment.
 The patient
perceptive fields  Demonstrate
Nurse: Ano ang birthday participated in
congruent 5. Clear direct explanations of
mo? Kelan ka ipinanganak? social activities and
verbal and non- environment events help to lessen the group therapies
verbal client’s suspiciousness and fear or
communication mistrust of the surroundings and other.
 Participate in This can prevent aggressive behavior.
Patient: Hulyo, Agosto Inaccurate social activities According to Sullivan, the strand of
interpretation of and group interpersonal theory is the principle of
incoming therapies 5. Giving
complementarities which contends that
information
Objective: information people in dyadic interactions negotiate
b. Offer the client clear,
the definition of their relationship

154
simple explanations through verbal and non-verbal cues.
of environmental
Sensory & Cognition: events, activities and
the behaviors of other 6. The nurse should set aside enough
 Conscious impaired cognitive clients as necessary time to attend to all of the details of
but disoriented to abilities patient care. Care measures may take
time, person & longer to complete in the presence of a
place communication deficit. Peplau defined
 Impaired Psychodynamic Nursing as being able
memory on to understand one’s own behavior to
personal help others identify felt difficulties and
information inability to recall 6. Anticipate patient to apply principles of human relations
 Poor focus familiar words, needs and pay to the problems that arise at all levels
regarding phrases, or names attention to of experience.
specific topic nonverbal cues.
of known persons,
objects, and places
Attitude:

 Withdrawn 7. It may be difficult for patients to


Thought Process: respond under pressure; they may need
extra time to organize responses, find
 looseness of the correct word, or make necessary
association language translations.
 blocking 8. 5to9. Humanistic Nursing
Communication Theory (Theorist:
 perseveration
Bonnie W. Duldt, Ph.D., R.N.) In an
 inability to recall interpersonal relationship of trust, self-
familiar words, disclosure, and feedback, to the degree
phrases, or names of that dehumanizing communication
known persons, 7. Give the patient
attitudes are expressed by another, to
objects, and places ample time to
that degree one tends to use
respond.
assertiveness as a pattern of
interaction. To the degree that
assertiveness tends not to re-establish
trust, self-disclosure, and feedback,
and to the degree that dehumanizing
8. Face the patient
when attitudes are expressed by another, to
that degree one tends to use
communicating

155
with them, listen assertiveness as a pattern of
and watch them
closely
9. Pay attention to
their voice
inflection and
body cues
10. Always speak to
the patient in a
calm even voice
11. Allow the patient
time to complete
what they are
saying
12. Provide
encouragement
and reassurance
to the patient at
all times when
they are
attempting to
communicate
with you

COLLABORATIVE

 Refer to speech
therapy for assistance
in understanding
patient's speech
patterns

 To promote wellness and assistance.

PSYCHIATRIC NURSING CARE PLAN

156
Psychiatric Psychodynamics RATIONALE
Cues / Clues Nursing PLANNING Therapeutic Approach EVALUATION
Diagnosis (RATIONALE) (with Theories)

Subjective Cue:

“Hindi ko sila kilala” Impaired Social Risk factors are Short term outcome: D. INDEPENDENT Outcome
(referring to his fellow Interaction socioeconomic & 1. Encourage client to verbalize Achieved:
patients), as verbalized related to biochemical feelings of discomfort about  According to Hildegard Peplau,
social situations. Identify psychodynamic nursing involves the
by the patient. impaired thought After 8 hours of causative factors, recurring use of one's (the nurse) knowledge and
processes as precipitation patterns, and
nursing intervention, understanding of one's own behavior to 1. The patient
evidenced by barriers to using support help others (patients) identify felt
the pt will be able to established a
dysfunctional systems difficulties, and the application of
Objective: : therapeutic
interaction with Neurologic human relations to problems that arise relationship with
others developmental failure 1. Establish a at all levels of experience (Carey, Noll,
Rasmussen, Searcy, and Stark, 1989, p. the nurse.
therapeutic
Sensory & Cognition: 205). This interpersonal process is
relationship with the 2. The patient
defined by Peplau in the context of
nurse. four phases of the nurse-patient identified barriers
 Conscious but
disoriented to relationship-orientation, identification, in interpersonal
2. Identify barriers exploitation, and resolution. Although relationships that
time, person & Alteration of function
in interpersonal each phase of this relationship is interfere with
place in cognitive and
 Impaired relationships that defined separately, Peplau recognized socialization.
perceptive fields
memory on interfere with that considerable overlap existed
personal socialization. between the phases. 3. The patient
information  Peplau: During the orientation phase of participated in
 Poor focus 3. Participate in the nurse-patient relationship, the social activities
regarding social activities and patient experiences a felt need and
and group
specific topic group therapies seeks professional assistance from the
nurse. During this phase, the nurse therapies
Attitude: Disturbed thought tries to help the patient in both
process recognizing and understanding the
 Withdrawn problem that he or she is experiencing.
Affect: During the orientation phase, also, the
2. Establish therapeutic nurse attempts to determine exactly
 Anxious relationship using positive what help is needed by the patient.
regard for the client, active

157
Thought Process: Dysfunctional listening and providing safe
interaction with environment for self-
 looseness of others disclosure  Ida Jean Orlando, The Dynamic Nurse-
association Patient Relationship:
 blocking The role of the nurse is to find out and
 perseveration meet the patient's immediate need for
help. The patient's presenting behavior
may be a plea for help; however, the
help needed may not be what it
appears to be. Therefore, nurses need
to use their perception, thoughts about
the perception, or the feeling
engendered from their thoughts to
3. Review/list behaviors explore with patients the meaning of
observed previously by their behavior. This process helps the
caregivers, care workers, and nurse find out the nature of the distress
so forth and what help the patient needs.
4. Provide positive reinforcement
for improvement in social
behaviors
5. Encourage classes, reading  There is a direct correlation between
materials, and lectures for self- the musical portion of the brain and the
help in alleviating negative language area, and the use of this
self-concepts that lead to programs may result in better
impaired social interaction communication skills

E. COLLABORATIVE
6. Involve client in a music-based
program, if available

158
CHAPTER

V
PSYCHOTHERAPY

159
A. Play Therapy

Definition Kahulugan

Play therapy refers to a method of Ang play therapy ay isang uri ng


psychotherapy in which a therapist uses the psychotherapy kung saan ang partisipasyon ng
symbolic meanings of his or her play as a pasyente ay maaring gawing isang obserbasyon
medium for understanding and communication ng nars at maaari din itong magsilbing tulay
with the client. upang makausap ng nars ang pasyente.

Purposes Mga Layunin

• To improve social and emotional • Mapaunlad ang pakikipagsalamuha ng


adjustment of the patient pasyente sa ibang tao.
• To reduce stress and anxiety
• To improve the self-concept
• Mabawasan ang stress at takot ng mga
• To learn to trust
pasyente.
• To learn to complete, cooperate and
collaborate
• Matulungan ang pasyente sa
pagpapabuti ng tingin sa sarili

• Matuto ang pasyente na magtiwala sa


sarili at sa ibang tao

• Matuto ang pasyente na


makipagtulungan sa iba

HOT POTATO

160
Standard Rules Mga Patakaran

1. It involves players gathering in a circle and


tossing a small object such as a beanbag or 1. Uupo ng paikot ang mga kasali ng laro.
tennis ball to each other while music plays Habang tumutugtog ang musika,
2. The player who is holding the "hot potato" pagpapasapasahan ng mga kasali ang
when the music stops is out. bola ng paikot.
2. Kung sino ang makakahawak ng bola
3. Play continues until only one player is left. sa pagtigil ng musika ay matatanggal sa
bilog.
3. Magpapatuloy ang laro hanggang sa isa
nalang ang matira. Ang natira ang
pangangalanang panalo.

Techniques Pamamaraan

1. The nurse must first explain to the 1. Dapat ipaliwanag muna ng nars kung
patient what particular activity they are anu-anong mga gawain ang kanilang
going to perform. Trust should be gagawin. Ang pagtitiwala ay dapat
developed during this stage. mabuo sa panahong ito.
2. The patient must be given an 2. Ang pasyente ay dapat mabigyan ng
opportunity to perform the activity. pagkakataong gawin ang gawain.
3. Huwag kalimutang kausapin ang
3. During the activity, never forget to talk
pasyente habang may gawain. Palaging
to your patient using therapeutic ways
gumamit ng mga therapeutic na
of communication.
pamamaraan ng pakikipag-usap.
ANALYSIS ANALISA

• Patient is interacting with other • Ang kliyente ay nakikipag-ugnayan


patients/playmates. sa ibang kalahok sa laro.
• Ang kliyente ay nagpakita ng hindi
• He has a flat affect during the
ukmang emosyon.
games’ implementation
INTERPRETATION INTERPRETASIYON

• Flat and inappropriate affect is • Ang hindi ukmang emosyon ng


really observable to patients with mukha ay normal na makikita sa
mental retardation. mga kliyenteng may kakulangan sa
pag-iisip.
• It is not obviously observed that the
• Hindi masasabing masaya ang

161
kliyente kahit na sinabi pa niya na
patient enjoys what he is playing
natututwa siya.
even if he told it so.

B. Music & Art Therapy

162
Definition Kahulugan

Music Therapy is a research-based health Ang music therapy ay isang propesyong


profession in which music activities are pangkalusugan na base sa pananaliksik
designed to accomplish non-musical kung saan ang mga pangmusikang gawain
therapeutic goals with clients of all ages ay idinisenyo upang magawa ang mga di-
and abilities in a non-threatening musika panterapeutikang hangarin sa mga
environment. kliyenteng may iba’t ibang edad at
kakayahan sa isang hindi mapanganib na
kapaligiran

Purposes Layunin

• cognitive stimulation • pagbibigay-buhay sa pag-unawa


• coping skills • kasanayan na makaya
• enhanced development • pinaghusay na pag-unlad
• mood elevation
• mapataas ang timpla ng damdamin
• to reduce pain and anxiety
• upang mabawasan ang sakit at
• increase compliance
pagkabalisa
• reinforce progress
• dagdagan ang pagsunod
• normalization of environment
• mapalakas ang pag-unlad
• reality orientation
• normalisasyon ng kapaligiran
• rehabilitation of physical and
• orientasyon sa realidad
cognitive abilities
• socialization • pagbabagong-tatag ng mga pisikal
na pag-unawa at mga kakayahan
• pagsasapanlipunan

Standard Rules Mga Patakaran

1. Provide planned schedule of 1. Magbigay ng mga pinlanong gawain


activities which aids patients in na makatutulong upang ang
dwelling personal problems. pasyente ay makaya ang kanyang
mga personal na problema.
2. Magbigay ng pagkakataong
makakuha ng atensyon sa
2. Provide opportunity for gaining katanggap-tanggap na paraan.
attention in acceptable ways. 3. Magbigay ng pagkakataong
makabuo ng malusog at maunlad na
interes.
3. Provide an opportunity for the

163
development of healthy and 4. Magbigay ng katanggap-tanggap na
productive interest. gawain kung saan kanilang
mailalabas ang kanilang mga sama
ng loob.
4. Provide planned acceptable outlet
for pension and hostility.

Technique Pamamaraan

1. The nurse must first explain to the 4. Dapat ipaliwanag muna ng nars
patient what particular activity they kung anu-anong mga gawain ang
are going to perform. Trust should kanilang gagawin. Ang pagtitiwala
be developed during this stage. ay dapat mabuo sa panahong ito.
2. The patient must be given an 5. Ang pasyente ay dapat mabigyan ng
opportunity to perform the activity. pagkakataong gawin ang gawain.
3. During the activity, never forget to 6. Huwag kalimutang kausapin ang
talk to your patient using pasyente habang may gawain.
therapeutic ways of Palaging gumamit ng mga
communication. therapeutic na pamamaraan ng
pakikipag-usap.

ART THERAPY

Definition Kahulugan

Art therapy is a form of expressive Ang art therapy ay isang anyo ng therapy
therapy that uses art materials, such as nagpapahayag na gumagamit ng mga
paints, chalk and markers. Art therapy materyal sa sining, tulad ng mga pintura,
combines traditional psychotherapeutic tisa at pang-marka. Ito ay nagsasanib ng

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theories and techniques with an tradisyonal na teoryang psychotherapeutic
understanding of the psychological aspects at pamamaraan ng pag-unawa sa sikolohikal
of the creative process, especially the na aspeto ng malikhaing proseso, lalo na sa
affective properties of the different art emosyonal na pag-aari ng iba’t ibang mga
materials. materyales na art.

Purposes Layunin

• Self-discovery • Madiskubre ang sarili


• Triggers an emotional catharsis • Nagsasanhi ng isang emosyonal na
• Personal fulfillment katarsis
• Empowerment • Pangsariling Katuparan
• Relaxation and stress relief • Empowerment
• Symptom relief and physical
• Nagdadala ng ginhawa at
rehabilitation
nagtatangal ng stress
• Can help people visually express
• Kaluwagan sa sintomas at pisikal na
emotions and fears that they cannot
rehabilitasyon
express through conventional
• Maaari matulungan nito ang mga tao
means, and can give them some
sa pamamagitan ng biswal na
sense of control over these feelings
pagpapahayag ng damdamin at takot
na hindi nila maaaring ipahayag sa
pamamagitan ng pakikipagtalastasan
at maaaring magbigay sa kanila ng
ilang pag-unawa at kontrol sa
kanilang mga damdamin
Standard Rules Mga Patakaran

1. Art materials and techniques should Ang materyales at pamamaraan ay dapat


match the age and ability of the client. na tumugma sa edad at kakayahan ng
mga kliyente.

Technique Pamamaraan

1. The therapist may have an 1. Ang therapist ay maaaring


introductory session with the client- magkaroon ng isang pambungad na
artist to discuss art therapy techniques introduksyon sa kliyente upang

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and give the client the opportunity to talakayin ang mga pamamaraan sa art
ask questions about the process. therapy at bigyan ang client ng
pagkakataon upang magtanong tungkol
sa proseso.
2. The therapist ensures that appropriate
materials and space are available for the
client-artist, as well as an adequate 2. Ang therapist ay tinitiyak na angkop
amount of time for the session. ang materyales at espasyo na gagamitin
ng kliyente. Sapat din dapat ang dami
3. An appropriate workspace should
ng oras para sa sesyon
be available for the creation of art.

4. The artist should have adequate


time to become comfortable with and 3. Isang sapat na espasyo ang dapat
explore the creative process. gamitin para sa paglikha ng sining.

4. Ang pintor ay dapat magkaroon ng


sapat na panahon upang maging
komportable at siyasatin ang mga
malikhaing proseso.

ANALYSIS ANALISA

• The patient draws straight • Gumuhit siya ng mga tuwid


lines with the colors of green, na linyang may mga kulay na
black, red, orange and yellow berde, itim, pula, dalandan, at
• He said that those are ice dilaw.
candies. • Sabi niya na ito raw ay mga
ice candies.
INTERPRETATION INTERPRETASIYON

• The patient may have a very • Maaaring mayroong isang


memorable experience with mahalagang pangyayari sa
regards to ice candies. buhay niya na kasama sa
• Red line indicates hostility, memorya ang ice candies.
black for anxiety, red and • Base sa iginuhit ng pasyente,
yellow for spontaneous form malalaman na siya ay balisa.
of expression and behaviour,
black represents repression,

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depression and regression
• The patient’s dominant
interpreted behaviour is being
anxious and depressed at that
moment

C. Bibliotherapy

ENGLISH TAGALOG

a. Definition a.Kahulugan

Bibliotherapy is a therapy Ang bibliotherapy ay ang paggamit ng


employed in which literature is used as a babasahin para makatulong sa pagpapalabas ng
stimulus to initiate expression of emotions. mga emosyon.

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b. Purpose

The printed word may be a means of


modifying or stimulating the emotions.
Ang babasahin ay pwedeng gamitin upang
Reading may help lift the spirit of a depressed
mabago o makapagpahayag ng emosyon. Ang
patient, improve the attention span of the
pagbabasa ay makakatulong sa pagpapataas ng
individual with limited power of concentration,
mababang emosyon ng tao, makatulong sa
relieve insomnia, stimulate the imagination,
pagkakaroon ng pokus, makakatulong kapag
and foster desirable attitudes and in patients.
hindi makatulog ang isang tao, mapalawak ang
imahinasyon at makatulong sa pagkakaroon ng
kanainis-nais na katangian ng isang pasyente.
c. Standard Rules

Principles in Selecting Reading


Materials for Psychiatric Patients:

a. Select literature in accordance


-sa pagpili ng babasahin:
with the patient's educational preparation,
intellectual capacity and interest. a. dapat pumili ng babasahin na angkop sa
kakayahang mental ng pasyente. Dapat ito
b. Size up the personality of the
ibatay sa kakayahan ng pasyenteng
patient and attempt to select materials which
maintindihan ang nilalaman ng babasahin.
you think may be interesting.
b. mamili ng babasahin na makakakuha ng
c. Avoid literature of
atensyon ng isang tao.
controversial nature or the type whose attempt
to stir up feeling of distress within the patient.
Literature concerning medicine, psychology,
c. huwag pilliin ang babasahin na magdudulot
psychiatric, politics, and tense murder
ng stress sa pasyente. Dapat ang nilalaman ay
mysteries may do patients more harm than
hidi tungkol sa pulitika, mga kalamidad, mga
good.
karahasan at iba pa dahil ito’y magdudulot ng
d. For educational reading, hindi maganda.
choose books recommended by reliable
authorities.

e. History, travel, art, science,


biography, and literature concerning hobbies d. sa mapagkakatiwalaan lamang kumuha ng

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are usually interesting subjects his most babasahing gagamitin sa therapy
patients.

e. kasaysayan, paglalakbay, art, siyensya, mga


istorya ng buhay ng mga tao at literatura ay
mga kanais-nais na babasahin na gusto
karaniwan ng mga pasyente.

Ang mga babasahin ay ibinibigay sa pasyente.


d. Techniques/Mechanics Tatanungin sa pasyente kung ano ang kanyang
pananaw at kung ano ang kanyang masasabi
tungkol doon. Ang therapist ay maaaring
Literature, such as magazines, books and other
maunawan at makilala ang pasyente sa
reading materials, is offered to the patient. Let
pamamagitan nito dahil nakapaglalabas ang
his view it and asks her what part catches his
pasyente ng kanyang emosyon.
attention most then the therapist to explore
more about the patient's emotions and feelings.

ANALYSIS ANALISA

• Not done • Hindi naisagawa


INTERPRETATION INTERPRETASIYON

• Not done • Hindi naisagawa

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D. Occupational Therapy

Definition: Kahulugan:

It is any productive, creative activity. Ito ay ang mga gawaing maunlad at


malikhain. Ang mga gawaing ito ay ibabase
These activities are individualized
sa pangangailangan ng pasyente at maaaring
depending on the client’s need and may
gawin ng mag-isa o ng grupo. Ang layunin
range from individual or group tasks. The
nito ay magamit ng indibidwal ang
major concern is the maximization of an
pinakamataas na antas ng kanyang
individual’s performance in relation to
makakaya na may relasyon sa kanyang
cultural, social and work environment.
kultura, pakikisama sa ibang tao at

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kapaligiran.

Purposes: Layunin:

1. To provide work training to the 1. Upang makapagbigay ng mapag-


patient. aaralang trabaho para sa pasyente.
2. Upang matutunan ang paghawak ng
2. To learn money management and pera at ng mga pang-araw-araw na
daily living skills. gawain.
3. Upang magkaroon ng panggrupong
3. To develop more positive group pag-eensayo ng kakayahan na
training skills. positibo.
4. Upang matulungan ang pasyenteng
umunlad sa kanyang napiling
4. To help the patient succeed in the
mapagkakakitaan.
chosen occupational role.
5. Upang mapanatiling aktibo at
malikhain ang pag-iisip.
6. Upang makabuo ng magandang
5. To keep mind active and creative at relasyon sa ibang pasyente.
any rate. 7. Upang madagdagan ang pagiging
6. To develop interpersonal bilib sa sarili, pagiging kontento at
relationships with other patients. ang pagpapalakad ng sariling buhay.
7. To increase sense of 8. Upang magkaroon ng malusog na
accomplishments, satisfaction and pagdepende sa iba.
control over one’s life.

8. To develop interdependence.
Standard Rules: Mga Patakaran:

5. Provide planned schedule of 5. Magbigay ng mga pinlanong gawain


activities which aids patients in na makatutulong upang ang
dwelling personal problems. pasyente ay makaya ang kanyang
mga personal na problema.
6. Magbigay ng pagkakataong
makakuha ng atensyon sa
6. Provide opportunity for gaining katanggap-tanggap na paraan.

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attention in acceptable ways. 7. Magbigay ng pagkakataong
makabuo ng malusog at maunlad na
interes.
7. Provide an opportunity for the
8. Magbigay ng katanggap-tanggap na
development of healthy and
gawain kung saan kanilang
productive interest.
mailalabas ang kanilang mga sama
8. Provide planned acceptable outlet
ng loob.
for pension and hostility.

Technique: Pamamaraan:

4. The nurse must first explain to the 7. Dapat ipaliwanag muna ng nars
patient what particular activity they kung anu-anong mga gawain ang
are going to perform. Trust should kanilang gagawin. Ang pagtitiwala
be developed during this stage. ay dapat mabuo sa panahong ito.
5. The patient must be given an 8. Ang pasyente ay dapat mabigyan ng
opportunity to perform the activity. pagkakataong gawin ang gawain.
6. During the activity, never forget to 9. Huwag kalimutang kausapin ang
talk to your patient using pasyente habang may gawain.
therapeutic ways of Palaging gumamit ng mga
communication. therapeutic na pamamaraan ng
pakikipag-usap.

ANALYSIS ANALISA

• The patient cooperates with the • Siya ay nakikipag-tulungan sa


task given to him with moderate studyante sa paggawa ng parol at
assistance. nakakagawa ng may sapat na
gabay ng studyante.
• He tried to process how the
• Sinubukan ng pasyente na
parts of the lantern will be
iproseso kung paano ang
made.
paggawa ng parol na gamit ay
papel.
INTERPRETATION INTERPRETASIYON

• It is clear, then, that there are • Makikita na mayroong


deficits in some aspects of kakulangangan sa ibang aspeto
information processing in ng pagproseso ng impormasyon
individuals with mental ang naobserbahan sa pasyente.

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retardation.

E. Remotivation Therapy

Definition: Kahulugan:

It is a simple group therapy which aims Isang simpleng gawaing panggrupo na


to bridge the fantasy world of the kung saan nilalayon nito na ipakita ang
psychotics to the real world. It is a realidad. Isa itong pamamaraan na
technique of simple group therapy, kadalasang napapatungkol sa kalikasan na
objective in nature, used with group of kung saan hindi nito naabala ang mga sugat
patients in an effort to reach the sa buhay ng isang tao bagkus ay pinapakita
unwounded areas of each patient’s nito ang realidad ng buhay.
personality and get them moving back into
reality

Purposes: Layunin:

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1. To stimulate patients to be fellow 9. upang mahikayat ang mga pasyente
explore the real world. na lakbayin ang tunay na mundo
2. *To develop their ability t 10. upang madebelop ang abilidad na
pagkilalao communicated and share makisalamuha sa mga tao at
ideas and experiences with the other maibahagi ang kanilang mga ideya
people. sa mga ito.
3. *To develop feelings of acceptance. 11. Upang madama ang pagtanggap
4. *To promote group harmony and 12. Para magkaroon ng maayos na
identification. pakikisama sa sriling grupo at
magkaroon ng pagkilala sa sarili.
Standard Rules: Mga Patakaran:

1. .climate acceptance 9. Pagtanggap sa klima


2. bridge to reality- questions must be 10. Tulay sa relidad-. Ang mga tanong
short and easy to understand ay nararapat na maikli at madaling
3. sharing the world we live in-explore intindihan.
the topic 11. Pagbabahagi sa kanila ng mundong
4. appreciation of the works of the ating tinitirhan – palawakin ang
world-application of the topic paksa.
5. Summarize the topic, subjects to be 12. Pagkagalak sa mnga gawa ng
covered: mundo- paggamuit ng paksa
Geography, history, Literature, Science, 13. Ibuod ang paksa , ang mga paksa na
Industry, Sports, Hobbies, Nature maaring gamitin ay ang mga
sumusunod:
6. Subjects not to be touched:Religion,
Heyograpiya, kasaysayan, panitikan ,
Politics, Family, Problem, Sex, love
siyensiyna , kapaligiran, laro, hilig.

14. Mga paksang hindi nararapat na


talakayin:
Relihiyon, politika, pamilya, problema,
pakikipagtalik at pag-ibig

Technique: Pamamaraan

7. The nurse must encourage clients 1. Nararapat na iengganyo ang


feeling about the topic pasyente sa paksang tatalakayin
8. The nurse must present the reality 2. Kailangang ipakita ang realidad sa
to the client. pasyente
9. Be natural• 3. Maging natural

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10. Approach in non-urging 4. Huwag silang pilitin
relationship• 5. Huwag makielam sa isang usapan.
11. Don’t side-track into individual
conversation
ANALYSIS ANALISA

• The patient is not paying • Hindi siya nakikinig minsan


attention to the speakers while • Inuulit ng pasyente ang anumang
they are speaking sometimes kakarinig niya lang kapag siya
• Echolalia was observed ay tinanong
• Inaantok ang pasyente
• Somnolence was observed
INTERPRETATION INTERPRETASIYON

 Memory deficiencies interfere with • Mahina ang memorya ng


learning rote material such as days of pasyente. May kakulangan din
the week, months of the year, and times sa pagtuon ng atensiyon at pokus
tables. Basic facts are hard to remember ang pasyente.
and there is a lack in knowledge of
general information. There are deficits
in attention and focus that interfere
with ability to focus and concentrate on
tasks.

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APPENDICES

176
National Center for Mental Health
Mandaluyong City
Pavilion 1

GRAND SOCIALIZATION DAY

Theme: “Building Bridges towards


Holistic
Nursing Care”

_________________

177
PROGRAMME...

Acknowledgement: Doxology …………Metropolitan


Medical Center
Food – Far Eastern University Philippine National
(Jay Nantin Ablao R.N) ……...Perpetual Help
Invitation- Centro Escolar University
Anthem University
(Dovie Brabante R.N) of Pangasinan
Calisthenics …………… Capitol
Sounds –Metropolitan Medical Center University
(Precy Samson R.N) Opening Remarks ……………
Ever C. Garcia,
Decorations and Aftercare – LORMA R.N.
Colleges MSN
(Ever C. Garcia Jr. R.N, MSN) Yell and Dance ……………… All
Schools
Games – Capitol University
(Honeylou Opanda R.N) Presentation
Games ……………………Capitol
Perpetual Help University of University
Pangasinan Dance for all……………….
(Ignacia Mogro R.N) Closing Remarks ……………Evelyn
Godines,
Nurse
177 Supervisor Pavilion 1