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

Sublimation – unconscious process of substituting constructive and

socially acceptable activity for strong impulses that are not acceptable in
the original form.

BEHAVIOR RESPONSE TO ANXIETY Humor – deals with emotional conflict or stress by emphasizing the
• Anger amusing or ironic aspects of the conflict or stressor.
• Crying
• Withdrawal Suppression – conscious denial of a disturbing situation or feeling
• Forgetfulness
• Quarrelling INTERMEDIATE DEFENSES
• Complaining Repression – exclusion of unpleasant or unwanted experiences,
• Defensive behavior emotions, or ideas from conscious awareness
Displacement – transfer of emotion associated with a particular person,
LEVELS OF ANXIETY INTERVENTIONS FOR MILD TO MODERATE LEVELS OF object, or situation to another person, object, or situation that is non-
ANXIETY threatening
• Help client to focus and sole problems with the use of
communication techniques Reaction formation – unacceptable feelings or behaviors are kept out of
• Help client identify anxiety awareness by developing the opposite behavior or emotion
• Provide a calm presence
• Recognize the anxious person’s distress Somatization – transforming anxiety on an unconscious level into a
• Be willing to listen physical symptoms that has no organic cause
• Evaluate effective past useful coping mechanism
• Assist in developing alternative solution to a problem
Undoing – consciously doing something to counteract or make up for a
transgression or wrongdoing
Rationalization – justifying illogical or unreasonable ideas, actions, or
feelings by developing acceptable explanation that satisfy the teller as
well as the listener
Intellectualization – consciously or unconsciously using only logical
explanation without one’s feelings or an affective component
Compensation – consciously covering up for a weakness by
overemphasizing or making up a desirable trait
IMMATURE DEFENSES
Passive aggression – deals with emotional conflict or stressors by
indirectly and unassertively expressing aggression towards another
Acting-out behavior – deals with emotional conflict or stressors by
actions rather than reflections or feelings
Dissociation – unconscious separation of painful feelings and emotion
from an unacceptable idea, situation or object
Identification – conscious or unconscious attempt to model oneself after
a respected person
Introjection – unconsciously incorporating values & attitudes of others
as if they were your own
Devaluation – emotional conflict or stressors are dealt with by
attributing negative qualities to self or others
Idealization – attributing exaggerated positive qualities others
Splitting – the inability to integrate the positive and negative qualities of
oneself or others into a cohesive image.
Projection – person unconsciously rejects emotionally unacceptable
personal features and attributes to other people, objects or situation.
Denial – escaping unpleasant realities by ignoring their existence
Regression – unconscious return to an earlier and more comfortable
developmental level
ORGANIZATION OF THE NERVOUS SYSTEM
BRAINSTEM – regulates the internal organs and responsible for vital
functions such as regulation of blood gases and the maintenance of BP
Hypothalamus – hunger, thirst and sex.
- thought & emotions
RAS – allows human to sleep and carry out conscious mental activity
Limbic system – crucial role in emotional status and psychological
function (norepinephrine, serotonin, dopamine  After interacting with the postsynaptic receptor, the
transmitter is released and taken back into the presynaptic
CEREBELLUM
cell, the cell from which it was released. This process,
 Coordinated muscle energy & activity referred to as the reuptake of neurotransmitter. Once inside
 Maintenance of equilibrium the presynaptic cell, the transmitter is either recycled or
 Coordinates contraction inactivated by an enzyme within the cell. The monoamine
transmitters norepinephrine, dopamine, and serotonin are all
CEREBRUM – responsible for mental activities and a conscious inactivated in this manner by the enzyme monoamine
sense of being. Also responsible for language and the ability to oxidase.
communicate
A second method of neurotransmitter inactivation is a little
Cerebral cortex – responsible for conscious sensation and the more complex.
initiation of movement is a common target for drug action.
◦ Parietal cortex – touch
NEUROTRANSMITTERS AND RECEPTORS
◦ Temporal – sound
◦ Occipital – vision
◦ Frontal – initiation of skeletal muscle contraction
 Prefrontal cortex - responsible for
thoughts, goal-oriented oriented
behavior & inhibition
- Seat of Personality
◦ Basal ganglia – regulation of movements
◦ Limbic system
 Amygdala and hippocampus –
emotions, learning, memory and basic
drives
NEUROTRANSMITTERS AND RECEPTORS
 Conduction along a neuron involves the inward movement of
sodium ions (Na) followed by the outward movement of
potassium ions (K). When the current reaches the end of the
cell, a neurotransmitter is released. The transmitter crosses
the synapse and attaches to a receptor on the postsynaptic
cell. The attachment of transmitter to receptor either
stimulates or inhibits the postsynaptic cell
 the destruction of the action of the enzyme
acetylcholinesterase on the neurotransmitter acetylcholine.
Acetylcholinesterase is present at the postsynaptic membrane
and destroys acetylcholine shortly after it attaches to nicotinic
or muscarinic receptors on the postsynaptic cell.
A full explanation of the various ways in which psychotropic
drugs alter neuronal activity requires a brief review of the
manner in which neurotransmitters are destroyed after
attaching to the receptors.
To avoid continuous and prolonged action on the post-
synaptic cell, the neurotransmitter is released shortly after
attaching to the postsynaptic receptor. Once released, the
transmitter is destroyed in one of two ways.
One way is the immediate inactivation of the transmitter
at the postsynaptic membrane.
  Listening to and understanding the 3. The nurse communicates that the client is not alone,
person in the context of the social rather, the nurse is working along with the client
setting of his/her life  Clarifying techniques
 Listening for ‘false notes” 1. Helps both participants identify major differences in
 Providing the client with feedback their frame of references, giving them the opportunity to
information about himself/herself of correct misconception before these cause any serious
which the client might not be aware misunderstanding.
◦ Clarifying techniques
 Paraphrasing  Degree of openness
 Restating 1. Open-ended questions
 Reflecting 2. Close-ended question
3. Indirect or implied question
 Exploring
Interference with therapeutic communication
THERAPEUTIC RELATIONSHIP 1. Nurse’s fear and feelings
 Therapeutic relationship is consistently focused on the  Avoid personalizing what the patients say or
client’s problem & needs do
Therapeutic Communication  Ask question in a kind and matter-of-fact
 Clinical Interview - “The client leads” Factors that enhances growth in others manner, by conveying empathy, and by
reiterating a desire to help
How to begin 1. Genuineness – self-awareness of one’s feelings 2. Nurse’s lack of knowledge and insecurity
◦ Setting – private, safe
◦ Seating – assume the same height, avoid face to 2. Empathy – one understands the ideas expressed  Patients are usually more accepting when the
face, avoid sitting without ready access to a door, nurse is honest about not knowing an answer
avoid a desk barrier 5 concepts of empathy and expresses a willingness to find answers
◦ Introduction – name, school, purpose, time limit ◦ Human trait 3. Ineffective responses
◦ How to start – use open-ended question ◦ Professional state  Nurses must avoid premature conclusions
◦ Guidelines: ◦ communication process  Do not be preoccupied with what to say next,
 Speak briefly ◦ caring process rather, listen to patient or they might be
 When you do not know what to say, ◦ special relationship listening to
“SAY NOTHING”
 When in doubt, focus on feelings 3. Positive regard – ability to view another person as being THERAPEUTIC RELATIONSHIP
worthy of caring about & as someone who has strength & • Suspending value judgment
 Avoid advice
achievement potential • Recognize their presence
 Avoid relying on questions
• Identify how or where you learned these response to client’s
 Pay attention to non-verbal cues ◦ Attitudes - the nurse takes the client & the
behavior
 Keep focus on the client relationship seriously
• Construct alternative ways to view the client’s thinking and
◦ Actions – behavior
 Dynamics of therapeutic communication
◦ Interpretation of communication Attending - foundation of interviewing • Helping client develop resources – consistently encourage client to
◦ Themes in patients communication - an intensity of presence or being with the client use their resources helps minimize the client’s feeling of
 Content themes helplessness & dependency & also validates their potential for
 Mood themes Non-verbal behaviors the reflect degree of attending change
 Interaction themes 1. Nurse’s posture
2. Nurse’s degree of eye contact Establishing boundaries
◦ Environmental consideration
3. Nurse’s body language  Transference – the process whereby a person unconsciously
◦ Physical consideration
◦ Kinesis consideration & inappropriately displaces onto individuals in his/her current
Therapeutic techniques life those patterns of behavior & emotional reaction that
Therapeutic communication skills originated in relationship to significant figures in childhood
 Effective tools in communicating
 Use of silence
◦ The use of silence - a specific channel for  Active listening
transmitting and receiving messages 1. nurse carefully note what the client is saying verbally &  Countertransference - the tendency of the nurse to displace
◦ Active listening nonverbally, as well as monitoring their own nonverbal onto the client feelings related to people in the nurse’s past
 Observing the client’s non-verbal response
behaviors 2. Helps strengthens the client’s ability to solve personal  Common countertransference reaction
problems 1. Boredom (indifference)
2. Rescue
 3. Overinvolvement
4. Overidentification misuse of honesty
5. Anger
6. Helplessness or hopelessness
STAGES OF NURSE – PATIENT RELATIONSHIP
1. PREORIENTATION PHASE
◦ Goal: to establish a client database & assess own
feelings regarding the client
2. ORIENTATION PHASE
◦ Goal: develop mutual trust, establish role of the
nurse as significant other to the client
◦ Client recognizes needs & seek help
◦ Trustworthiness is built when the nurse is honest
regarding intention, is consistent, and keeps
promises
◦ Assess the degree of patient’s awareness of
problems & the ability & motivation to change
◦ Talk about feelings directly then focus on coping
more effectively with them
◦ Provide structure by limit setting
3. WORKING PHASE
◦ Goal: identify & address client’s problem
◦ Reality testing helps patient see reality more
clearly & objectively compared with the past
◦ Limit setting – intervention designed to prevent
clients from harming themselves or others
◦ Nurse’s awareness of personal feelings & reaction
to the client is vital for effective interaction with
the client
4. TERMINATION PHASE
◦ Goal: assist client to review what was learned and
to transfer learning interaction with others
◦ Attempt to make termination official and state
feelings about the relationship
◦ Reasons for terminating the nurse-client
relationship
◦ Symptom relief
◦ Improved social functioning
◦ Greater sense of identity
◦ Development of more adaptive behavior
◦ Accomplishment of the client’s goals
◦ Impasses in therapy that the nurse is unable to
resolve
Interaction with client behaviors
 Violent behavior
◦ Stay out of striking distance
◦ Avoid touching clients without approval
◦ Change topic temporarily
◦ Suggest time out with patient
◦ Avoid being alone with patient
◦ Leave temporarily if patient is agitated
◦ Call for staff assistance
 Hallucinations
◦ Comment on behavior
◦ Provide reality but acknowledge behavior
◦ Assess the hallucination based on content of the
messages
◦ Do not focus on hallucination once content is
known
◦ Ignore the hallucination
 Delusions
◦ Clarify the meaning of the delusions then ignore
 Conflicting values
◦ Help client examine the effects or outcomes of
their beliefs on their lives, relationship, and
happiness
 Severe anxiety & incoherent speech
◦ Spend frequent, brief time with patients, offer
support, and build trust
 Manipulation
◦ Provide limit setting
◦ Help client express their needs directly to others
 Crying
◦ Unless a form of manipulation, allow client to cry
◦ Provide privacy
◦ Be quiet and unobtrusive
 Sexual innuendos or inappropriate touch
◦ Remind client these actions are inappropriate
 Denial & lack of cooperation
◦ Reality testing & supportive confrontation with
denial
 Depressed affect, apathy, & psychomotor retardation
◦ Patience, frequent contact, and empathy
◦ Encourage hygiene, proper nutrition and gradual
increase in activities
◦ Postponed major decisions until emotions have
subsided
 Suspiciousness
◦ Communicate clearly, simply, and congruently.
◦ Clarify misinterpretation
◦ Provide simple rationale or explanations for rules,
activities, occurrences, noises and requests
 Hyperactivity
◦ Patient should be in a quiet area, with minimal
auditory & visual stimulation
◦ Remain calm, speak slowly and softly & respect
patient’s personal space
◦ Give direction in a kind, simple but firm manner
 Transference & countertransference
◦ Nurses must be open and clear
◦ State action that they cannot meet patient’s need
◦ Limit setting
Milieu Management
 Consists of treatment by means of control modification of the
client’s environment to promote positive experiences
 Purpose: helps patient recover from psychiatric & mental
health problem
Characteristics of milieu therapy
• Friendly, warm, trusting, secure, supportive, comforting
atmosphere throughout the unit
• An optimistic attitude about prognosis of illness
• Attention to comfort, food, and daily living needs; help with
resolving difficulties related to tasks of daily living
• Opportunity for client to take responsibility for themselves
and for the welfare of the unit in gradual steps
• Maximum individualization in dealing with clients
• Opportunity to live through & test out situations in a realistic
way
• Opportunity to discuss interpersonal relationship in the unit
among clients and between clients and staff
• Program carefully selected resocialization activities to
prevent regression
Elements of milieu therapy
1. Safety
◦ Physical protection – safety from physical harm
◦ Psychological safety – nurse’s active intervention
to prohibit verbal abuse, ridicule or harassment of
patient
2. Structure – the physical environment rules & daily schedules
of treatment activities
◦ Patient education lead by the nurse
◦ Opportunities for recreation
3. Norms – specific expectations of behavior that permeates the
treatment environment
◦ Promotes safety & trust
◦ To create an environment that is more predictable
& applicable to all who share the environment
 4. Limit settings – should be set on acting-out behavior
◦ Reinforces the norms of making rules &
expectations clear & encourage the milieu therapy
concept---responsibility to self
5. Balance – the process of gradually allowing independent
behavior in a dependent situation
Activity therapy
 Consists of a variety of recreational and vocational activities
(recreational therapy, occupational therapy, music, art, and
dance therapy) designed to test 7 examine social skills &
serve as adjunct therapies
Concept and principles
1. Socialization counters the regressive aspect of
illness
2. Activities needs to be selected for specific
psychosocial reason to achieve specific effects
3. Nonverbal means of expression as an additional
behavioral outlet add a new dimension to
treatment
4. Sublimation of sexual drives is possible through
activities
5. Indication for activity therapy: clients with low
self-esteem who are socially unresponsive
Goals
6. Encourage socialization in community & social
activities
7. Provide pleasurable activities
8. Help client release tension and express feelings
9. Teach new skills, help client find new hobbies
10. Offer graded series of experience, from passive
spectator role & vicarious experiences to more
direct and active experience
11. Free and/or strengthen physical & creative
abilities
12. Increase self-esteem
ANXIETY DISORDERS
 Group of conditions in which the affected person experiences
persistent anxiety that the person cannot dismiss and that
interferes with daily activities
 Etiology:
1. Neurobiological – hereditary, brain chemistry,
developmental factors, disruption of the amygdala
2. Psychological - low self-esteem, shy or timid in
childhood, critical parents, discomfort with
aggression, abuse, violence, poverty
A. GENERAL ANXIETY DISORDER
• Characterized by excessive chronic anxiety or worry & might
concern everyday events
• Individuals have no control over anxiety & worrying becomes • Reduce immediate anxiety – stay physically close to patient,
habitual use simple sentences, firm voice, remove to smaller quiet
room to minimize stimuli
Characteristics: restlessness. Fatigue, poor concentration, irritability, • Patient education
muscle tension, sleep disturbance, physical symptoms (dry mouth, upset • Cognitive restructuring
stomach)
Psychopharmacology:
Psychotropic mgt: • SSRI
1. NPR – reduce level of anxiety • Benzodiazepine (clonazepam, lorazepam) – immediate effect
Goal: assist patient with developing adaptive, coping responses
 Promote trust Milieu mgt.: gross motor activities – diffuse energy
 Convey empathy
C. OBSESSIVE – COMPULSIVE DISORDER
Psychopharmacology Obsession – persistent thoughts, impulses, images or desires that maybe
◦ Antidepressants: SSRI. SSNRI trivial or morbid
◦ Benzodiazepine – short-acting - Recognize thoughts are irrational & senseless
Compulsion – repetitive stereotyped behavior that are performed in a
Milieu mgt: particular manner in response to an obsession
• Recreational activities - Performed to prevent discomfort & to bind or neutralized
• Relaxation exercises, meditation & biofeedback anxiety
• CBT - It interferes with normal routines, occupational & social
functioning
• Therapeutic touch & acupressure - Interferes with patient’s interpersonal relationship
B. PANIC DISORDERS – recurrent panic attack & are worried about Etiology: genetic, increase brain activity in the frontal lobe & basal
having more attacks ganglia, serotonin dysregulation
• Panic attacks – sudden, intense fear or discomfort and peaks
at 10 minutes Psychotherapeutic mgt.:
1. NPR:
• Feelings of impending doom
• Accept rituals permissively
• Avoid criticism or punishment, making demands, showing
Types of panic disorder
impatient – positive feedback
1. Panic disorder with agoraphobia
• Allow extra time for slowness & client’s action
• Feelings of terror that function is suspended, perceptual field
is severely limited & misinterpretation of reality • Help client verbalize feelings, solve problem & make
decisions
• Personality disorganization
• Protect from rejection by others & self-inflected harm
• Sign/symptoms: palpitations, chest pain, dyspnea, nausea,
feelings of choking, chills & hot flashes
Psychopharmacology:
2. Panic disorder without agoraphobia • Antidepressant:
o Clomipromine (anafranil)
• Agoraphobia - intense, excessive anxiety or fear about being • SSRI – fluoxetine (Prozac), setraline (Zoloft), fluovoxamine
in places or situations from which escape might be difficult or
(Luvox) & paroxetine (Plaxil)
embarrassing or in which help might not be available if panic
attack occurs
Milieu mgt.:
• Feared places are avoided e.g.. Outside, alone @ home, • Relaxation exercises & stress mgt.
travelling in car, bus or plane, being on a bridge, riding in a • Recreational or social skills
elevator • CBT, problem-solving & communication or assertive training
groups
Etiology: hereditary, trauma, life stress or trauma, disruption in the
amygdala
D. PHOBIC DISORDERS
- Intense, irrational, persistent fear responses to an external object
Psychotherapeutic mgt:
activity or situation
1. NPR:
Phobia – response to experience anxiety & is characterized by a
persistent fear of specific places or things
3 types of phobias
1. Agoraphobia with history of panic disorders –
fear of being in public or open spaces places or
situations in which escape might be difficult or
help might not be available
2. Social phobia – fear of being humiliated,
scrutinized, or embarrassed in public
3. Specific phobia – fear of a specific object or
situation that is not either of the above
Etiology: environment, genetic predisposition
Psychotherapeutic mgt.:
1. NPR:
• Accept patient & their fears with a non-critical attitude
• Provide & involve patient in activities that do not increase
anxiety but increase involvement, rather that promote
avoidance
• Help client with physical safety and comfort
• Help patient recognize that their behavior is a method of
avoiding anxiety
Psychopharmacology:
SSRI – to reduce anxiety & depression & block panic attacks, if present
Milieu mgt:
• Assertive training & goal-setting groups
• Social skills group to help redevelop social skills and
decrease avoidance
• Behavior therapy – systemic desensitization, flooding,
exposure, and self-exposure
E. ACUTE STRESS DISORDER & POST TRAUMATIC STRESS
DISORDERS
- Develop after exposure to a clearly identifiable traumatic event that
threatens the self, others, resources, and/or sense of control or hope
ACUTE STRESS SYNDROME – symptoms occur within 1 month of
extreme stressor; includes dissociative symptoms (depersonalization,
emotional detachment., dazed appearance, amnesia)
POST STRESS DISORDER – severe traumatic event that is not an
ordinary occurrence e.g.. Rape, fire, flood, earthquake, tornado,
bombing, plane crash, war, torture, kidnapping
Diagnostic criteria
1. Dissociative symptoms & numbing
• Amnesia, depersonalization, derealization & awareness of
surrounding, numbing, detachment or lack of emotional
response
• Numbing of responses or reduced involvement with the
external world
• Persistent avoidance of situation, activities and people,
thoughts and feelings
• Denial, repression & suspension
• Feel detached or estrange from family & friends →
withdrawal → depression
• Lost interest in activities, hopelessness
• Change in sleep pattern
• Impulsive behavior, sudden life change
2. Reexperiencing the trauma & intrusive memories – hallucinations
(PTSD)
3. Arousal symptoms
• ↑ arousal, anxiety, restlessness, irritability, disturbance in
sleep, memory impairment or concentration
• PTSD – outburst of anger, rage, survivor guilt
4. Other symptoms
• Anxiety or panic attack
• PTSD – grief, depression, suicidal ideation or attempts,
impulsive self-destructive behavior, anxiety-relate disorders
& substance abuse
Psychotherapeutic mgt: prevent or minimize the symptoms
1. NPR: develop trust
• Nurse needs to be non-judgmental honest, emphatic, and
supportive
• Teach dynamics of ASD & PTSD
• Exposure therapy & systematic desensitization
• Expressive therapy (art, music, poetry) – facilitate
externalizing painful emotions that are difficult to verbalize
• Crisis counselling –
Psychopharmacology
• Benzodiazepine (clonazepam, lorazepam) – to reduce level
of anxiety and fear. Help with sleep disturbance
• Clonidine & propanolol – diminish the peripheral autonomic
response associated with fear, anxiety & nightmare
• Lithium carbonate – prescribed to patients experiencing
explosive outburst
• SSRI (paroxetine, setraline, fluoxetine) – decrease
repetitive behaviors, disturbing images & somatic states
• TCA – depression, adehonia & sleep disturbances
• Antipsychotic (respirodone) – psychotic thinking
Milieu mgt:
• Social activities
• Recreational & exercise program
• Group therapy
F. SOMATOFORM DISORDERS
- Characterized by the presence of physiologic complaints or symptoms,
which are not under voluntary control & no demonstrable organic
finding and physiologic bases
Types of somatoform disorders
1. Somatization disorder
◦ Conversion of mental states or experiences into
bodily symptoms associated with anxiety
◦ Recurrent, frequent & multiple somatic complaints
for several years without physiologic cause
◦ Client’s constantly seek medical attention,
undergo numerous tests; at risk for unnecessary
surgery or drug abuse
2. Pain disorder
◦ Associated with psychological factors like severe
pain in one or more of anatomical sites that causes
significant distress or impairment in functioning
◦ Pain is exaggerated or out of proportion
◦ Causes significant impairment in occupational or
social functioning or causes marked distress
◦ Symptoms not intentionally produced or feigned
3. Hypochrondiasis
◦ Worried & belief that they have serious disorders
base on the misinterpretation of bodily signs &
sensation for at least 6 months
◦ Preoccupation persists despite appropriate medical
tests & reassurances
◦ Causes significant impairment in occupational or
social functioning or causes marked distress
4. Conversion disorder
◦ Alteration in voluntary or motor sensory
functioning that suggest neurological or medical
condition
◦ Not due to malingering or factitious disorder and
not culturally sanctioned
◦ Cannot be explained by gen. medical condition or
effects of a substance
5. Body dysmorphic disorder
◦ Individual is preoccupied with an imagined defect
in appearance which are usually facial flaws.
◦ Dermatologist & plastic surgeon is often consulted
◦ May also exhibit obsessive compulsive traits &
depressive syndrome
◦ Controls relationship through physical complaints
Causes:
1. Inability of the CNS to regulate & interpret sensory input or
to decrease communication between right & left hemisphere
2. Hx of physical & sexual abuse witnessing violent acts in
childhood, poor nurturing from family, lack of job, and social
skills
3. Need to be sick to relieve oneself of obligations & to gain
attention
4. Dissociation
 ◦ Fugue states is characterized amnesia; b. Characterized by impairment in social interaction,
Psychotherapeutic mgt. consequently, patients do not remember what communication and restricted repertoire of activity
1. NPR: happened. & interest
• Use matter-of-fact caring approach c. Usually first observed before 3 years of age
• Encourage patient to verbalize & describe feeling 3. Depersonalization disorder – involves an altered sense of d. Sign & symptoms
• Use positive reinforcement & set limits self, so that the individual feel unreal or strange or believe  Impairment in communication &
• Be consistent that danger is not happening to then or to someone else imaginative activity
• Use diversion by including patient patients in milieu activities ◦ Reality testing remains intact  Impairment in social interaction
and recreational games  Markedly restricted, stereotypical
• Do not push awareness of or insight into conflicts or 4. Dissociative identity disorder – existence of 2 or more patterns of behavior, interest and
problems identities or personalities that take control of the person’s activities

Psychopharmacology: SSRI – to treat anxiety and depression

behavior with its own patterns of relating, perceiving, and  Childhood & Adolescent psychiatric disorders
thinking
◦ The person or host us unaware of the other
a. Asperger’s disorders – a severe developmental
Milieu mgt: disorder characterized by major difficulties in
personalities, but the other alters might be aware
• Relaxation exercises meditation and CBT of each other to varying degrees
social interaction & restricts & unusual interest &
• Family therapy behavior
◦ Defense mechanism: repression  Use monotone speech and rigid
G. DISSOCIATIVE DISORDER language
– disturbances in the normally well-integrated continuum of Psychotherapeutic mgt.  They cannot understand jokes and are
consciousness, memory, identity, and perception 1. NPR: taken advantage easily
• Establish trust & support, provide caring and empathy  Inability to show empathy to others but
• Assist in gathering data about feelings, conflicts, or situations want to meet people & make friends
 Dissociation – the removal from conscious awareness of
that patient experienced
painful feelings, memories, thoughts, or aspects of identity  Have an obsession with facts about
• Ensure client safety circumscribed and odd topics
◦ Unconscious defense mechanism that protects an
• Provide nondemanding, simple routine b. Attention deficit/hyperactivity disorder – characterized by
individual from the emotional pain of experiences
or conflicts that have been repressed • Confirm identity of client and orientation to time & place inattention, impulsiveness, and overactivity in school 9before
• Encourage client to do things for self and make decision 7 years old)
 Defense mechanism: repression about routine tasks ◦ Causes:
Causes:  Environmental exposure – perinatal
Milieu mgt:
• Inability to recall important personal information usually of a insults, head injury, psychosocial
• Individual therapy adversity, lead poisoning, and diet
traumatic or stressful nature • Task-oriented group
• The disorder is often associated with exposure to traumatic  Genetic and hereditary factors
• OT and art therapy  Dysfunction in the frontal lobe
event common during disaster and wartime • Cognitive therapy
• Sexual abuse during childhood ◦ Characteristics of ADHD
• Psychopathology: an escape mechanism from memory of • Self-help groups  Inattention
painful experiences or devoid of emotional satisfaction.  Difficulty paying attention
There is little or no participation of the conscious personality Childhood & Adolescent psychiatric disorders in tasks or play
so the person is unable to recall  Risk factors:  Does not seem to listen,
◦ Genetic factor follow through or finish
Types of dissociative disorders ◦ Social & environment – severe marital discord, tasks
1. Dissociative amnesia low socioeconomic status, large family &  Does not pay attention to
◦ Sudden inability recall important information of overcrowding, parental criminality maternal details & makes careless
one or more episodes not associated with organic psychiatric disorder, traumatic life event, mistakes
disorders usually of a traumatic or stressful nature sexual/physical abuse  Is easily distracted, lose
 Localized amnesia ◦ Psychosocial factor – things, & is forgetful in
 Selective amnesia ◦ Biochemical factors – alterations of daily activities
neurotransmitters (decrease in norephhinephrine & 
 General amnesia serotonin
Childhood & Adolescent psychiatric disorders
 Hyperactivity
◦ Temperament – a style of behavior a child
2. Dissocialise fugue – sudden, unexpected travel away from  Fidgets, is unable to sit still
habitually uses to cope with the demands &
or stay seated in school or at
home or some other location with the assumption of a new expectations of the environment
other times
identity or a confusion about one’s identity  Types of childhood mental disorders
 Runs & climbs excessively
1. Pervasive development disorders
in inappropriate situations
a. Autistic disorder
  Has difficulty playing
quietly in leisure activities
 Acts as if “driven by a
motor”, constantly on the go
 Talks excessively
 Impulsivity
 Blurts out answer before
question has been
completed
 Has difficulty waiting for
own turn
 Interrupts, intrudes in
others’ conversation &
games
◦ Nursing Dx
 Risk for injury
 Impaired social interaction
 Ineffective individual
 Risk for violence for self-directed or
directed to others
◦ Nursing intervention
 Establish trust
 Talk to client about safe & unsafe
behavior – use clear, honest
straightforward communication
 Assess the frequency & severity of
accidents
 Provide supervision for potentially
dangerous
 Assist the client, parent or caregivers to
make the distinction between
accidental & purposeful incident
◦ Childhood & Adolescent psychiatric disorders
 Give instruction slowly using simply
giving instruction
 Ask client to repeat exercise or
instruction before beginning a task
 Administer stimulant in the morning to
maximize effectiveness for daytime
activity
 Help parents decrease their feelings of
guilt & blame
 Maintain a safe environment at home
& in school
◦ Oppositional defiant disorder – enduring pattern
of disobedience, argumentative, explosive angry
outburst, low frustration tolerance, and a tendency
to blame others for quarrels or accidents
 Recurrent pattern of negativistic,
disobedient, hostile , defiant behavior
towards authority figures with serious
violation of basic rights of others
 Exhibit persistent testing of limits, an
unwillingness to give in or negotiate,
and a refusal to accept blame for
misdeeds
 Behavior do not violate the rights of
others
◦ Conduct disorder – characterized by persistent
pattern of behavior in which the rights of others &
age-appropriate societal norms or rules are
violated.
 Predisposing factors: ADHD,
oppositional child behaviors, parental
rejection, inconsistent parenting with
harsh discipline, early institutional
living, frequent shifting of parental
figures, large family size, absence of
father or alcoholic father, antisocial &
drug-dependent family members, &
association with a delinquent group
 Examples of behaviors: physically
aggressive, have poor peer
relationships & shows little concern for
others & lack of guilt or remorse
 Childhood & Adolescent psychiatric disorders
c. Anxiety disorders
1. Separation anxiety disorders – excessively
anxious when separated from or anticipating a
separation from their home or parental figures
2. Most children will express worry about harm or
permanent loss of the mother or major attachment
figure
3. Characteristics:
 Excessive distress when separated from
or anticipating separation from home or
parental figure
 Excessive worries that one will be lost
or kidnapped or that parental figures
will be harmed
 Fear of being home alone or in
situation without other significant
adults
 Refusal to sleep unless near a parental
figure & refusal to sleep away from
home
 Refusal to attend school or other
activities without a parental figure
 Physical symptoms as a response to
anxiety
4. Nursing interventions:
 Assess the quality of the relationship
between child & parents or caregivers
for evidence of anxiety, conflicts or
difficulty of fit between child’s and
parent’s temperament
 assess the child’s previous & current
ability to separate from parents or
caregivers
 Protect the child from panic levels of
anxiety by acting as parental surrogate
 Accept regression but giving emotional
support to help child progress again
 Increase child’s self-esteem & feelings
of competence in the ability to
perform , achieve, influence the future
 Help child accept and work through
traumatic events or losses
5. Psychopharmacology: antihistamines, anxiolytics
and antidepressants
6. Cognitive therapy, behavior modification
 PERSONALITY DISORDERS
 Personality – sum total of the person’s distinctive character,
behavior, attitudes, the way one carries himself , the way one
communicate
◦ An enduring pattern of behavior that is considered
to be both conscious and unconscious and reflects
a means of adapting to a particular environment &
it cultural, ethnic and community standards
(Carson)
◦ Healthy personality:
◦ Sees his or her own strengths weaknesses
◦ Identifies his or her own boundaries
◦ Recognizes interaction & thoughts that lead to
strong emotions such as joy or anger
◦ Interacts with others without expecting them to
meet all needs
◦ Seeks a balance of work & play
◦ Accomplishes goals
◦ Defines & expresses spirituality
 Personality disorder – “enduring pattern of inner experience
& behavior that deviates markedly from the expectation of the
individual’s culture, is pervasive & inflexible, has an onset in
adolescence or early adulthood, is stable over time, & lead to
distress or impairment “ (APA, 2000)
 Etiology of PD
◦ Theorist – PD is related to unsuccessful mastery of
task in early stages of development that can lead to
anxiety
◦ Behaviorist – Developmentalist – believe that PD
originates in early childhood experiences (negative
experiences)
◦ Genetic cmponents
◦ Stressful environment
 PERSONALITY DISORDERS
 CRITERIA FOR A PERSONALITY DISORDER
1. CLUSTER A DISORDERS (ODD, ECCENTRIC)
a. Paranoid personality disorder
  These individuals interpret other 1. Avoid being too “nice” or  Has consistent disregard for others with
people's motives as threatening “friendly” exploitation & repeated unlawful
resulting in an increase in anxiety & 2. Do not try to increase actions.
the need for vigilance socialization  Unable to postpone gratification,
 Characterized by distrust & selfish and irresponsible
suspiciousness toward others, based on  PERSONALITY DISORDERS  Generally manipulative, does not feel
the belief (unsupported by evidence) b. Schizotypal personality disorder guilty, sorrow & not loyal
that others want to exploit, harm, or  Individuals with this disorder may have  Charming, intellectual and smooth
deceive the person & often act in behavior similar to those of someone talkers
defense of a fragile self-concept with schizophrenia, however psychotic
 They repeatedly neglect
 They demonstrate jealousy, controlling episode are infrequent & less severe
responsibilities, tell lies and perform
behaviors, and unwillingness to forgive  Characteristics: destructive or illegal acts, without
 Common in men than women 1. Ideas of reference developing any insight into predictable
 Irritable and stubborn – prejudice 2. With magical thinking/odd consequences
beliefs leading to
 With ideas of reference  Hostile, unable to follow rules
interpersonal difficulties
 Blunted affect , humorless and serious  Diagnose before age 15 as conduct
3. Problems in thinking,
 Fear in confiding in others disorder
communicating and
 Hold grudges towards others perceiving  Criteria for Antisocial PD
 Easily get angry if they are threatened 4. Has eccentric appearance 1. Violate rights of others
 Emotionally cold in appearance but are and shows evidence of 2. Engage in illegal activities
acceptable of close relationship to few magical thinking or 3. Aggressive behavior
b. Nursing guidelines perceptual distortion that 4. Lack of guilt or remorse
c. – may carry or conceal weapons are not clear delusions or 5. Irresponsible in work &
hallucination with finances
 PERSONALITY DISORDERS 6. Impulsiveness
b. Schizoid personality disorder 5. Sensitive to behavior of
other people especially 7. Recklessness
 Individuals with this disorder lacks
personal & social relationship. They rejection & anger  Etiology: genetics, environment,
are detached from others & withdraws 6. Speech may be difficult to family environment (unstable parent –
from interaction – hypersensitive follow – the individual child realationship
develops a personalized
 Introverted since childhood, rarely
style with vague association
 PERSONALITY DISORDERS
have close friends  Nursing guidelines
7. Socially inept
 Use autistic thinking, daydreaming are 1. Prevent or reduce untoward
 Nursing guideline
more gratifying effects of manipulation
1. Offer support like kindness
 They respond with short answers to (flattery, seductiveness,
questions & do not initiate spontaneous 2. Be calm, non-threatening in instilling guilt) by setting
conversation all or approaches limits
 They are reality-oriented but maintain 3. Respect client’s need for 2. Encourage client to
fair contact with others social isolation – cannot verbalize feeling
 They function in a solitary occupation tolerate group therapy 3. Be firm, steadfast and
but shows indifference to praise or 4. Speak in a gentle manner to consistent in dealing with
criticism from others encourage to get involve in patient’s behavior and
group activities reinforcing rules & policies
 Can be a precursor to schizophrenia or
5. Be aware of client’s 4. Help client be aware of the
delusion disorder
suspiciousness & employ consequences of their
 Defense mechanism: appropriate intervention behavior
INTELLECTUALIZATION 6. Assist & teach the client 5. Explain & point out the
 DSM IV criteria about social skills & effects of their behavior
1. Lacks desire for close appropriate behavior to towards others
relationship or friends improve his interpersonal 6. Avoid moralizing
2. Choose to be alone relationship c. Borderline personality disorders
3. Lack sexual experience  PERSONALITY DISORDERS  Characterized by impulsiveness,
4. Avoid activities unpredictable, unstable moods
2. CLUSTER B CRITERIA (DRAMATIC, EMOTIONAL,
5. Appears cold and detached  Desperately seek relationship to avoid
ERRATIC)
 Nursing guideline: a. Antisocial personality disorder feeling abandoned
 Chronic sense of boredom
  Overspending, promiscuity, overeating
 Problems with identity & self-image
 history of substance abuse & multiple
or dramatic suicidal gesture, risk of
suicide and mutilation
 Manipulative and dependent
 Emotional lability
 Defense mechanism: projection
 Etiology:
 Inadequate regulation of serotonin &
dopamine & other transmitters
 Parents may cling to the child and
prevent autonomy, individual or parent
withdraws support & attention making
the child confuse
 PERSONALITY DISORDERS
 Pharmacologic mgt:
 Neuroleptic drugs (3-12 wks)
 Lithium
 Valporic acid
 Carbamazepine
 Benzodiazepine
 Nursing guidelines
 Set realistic goals, use clear action
word
 Be aware of manipulative behaviors
 Provide clear & consistent boundaries
& limits
 Use clear 7 straightforward
communication
 Avoid rejecting or rescuing
 Assess for suicidal & self-mutilating
behavior
c. Narcissistic personal disorder
 Individuals with this disorder display
grandiosity about his performance and
achievement
 Arrogant, extrovert
 Believe to be special with need to be
admired
 Feel intense shame & fear that if they
are “bad”, they will be abandoned
 Afraid of their own mistakes, as well as
the mistakes of others.
 Defense mechanism: rationalization
 PERSONALITY DISORDERS
 Nursing guidelines:
 Supportive confrontation
 Remain neutral; avoid engaging in
power struggle or becoming defensive
in response to the client’s disparaging
remarks
 Convey unussuming self-confidence b. Avoidant personality disorder
 Point out reality  These clients are timid, socially
 Tell client no one is perfect uncomfortable, with self care and
withdrawn
c. Histrionic personality disorder
 Individual with this disorder are  Social inhibition and avoidance of all
characterized by excessive emotional situation that require interpersonal
attention seeking behavior and are contact
dramatic and ego-centric  Hyeprsensitive to criticism
 Seductive, flamboyant and shallow –  Uncertain and lacks confidence and
use speech to impress others afraid to ask question or speak in
public
 Needs to be the center of attention
 Impulsive and melodramatic  Nursing guidelines
 Demands “the best of everything” and  Be friendly, gentle,
can be very critical reassuring approach
 Help client to confront fears
 Related factors: mother-child
gradually
relationship
 Support & direct client in
 Nursing guidelines:
accomplishing short-term
 Understand seductive behavior as a goals
response to distress
 Relaxation techniques
 Keep communication & interaction
professional, despite temptation to  PERSONALITY DISORDERS
collude with the client in a flirtatious & c. Obsessive-compulsive personality disorder
misleading manner  Perfectionist and inflexible
 Encourage & model the use of concrete  Overly strict & often set standards for
themselves that are too high
& descriptive rather that vague &
impressionistic language  Preoccupied with details, rules, trivial
and procedures
 Teach and role-model assertiveness
 Difficult to express emotions or
 PERSONALITY DISORDERS warmth
3. CLUSTER C DISORDERS (ANXIOUS, FEARFUL)  They try to control partner in a
a. Dependent personality disorder relationship
 “pervasive & excessive need to be  Serious, affect is constricted and would
taken care of that leads to submissive speak in monotone voice
and clinging behavior & fears of
separation” (APA, 2000)  Defense mechanism:
 Extreme dependency in a close intellectualization, rationalization,
relationship, with an urgent search to reaction-formation
find a replacement when one  Etiology: early parent-child
relationship ends - they are afraid to be relationship
alone  Nursing guidelines:
 They want others to make decision for  Help client make decision
them – they need direction and encourage follow-through
reassurance behaviors
 They feel the need to be rewarded if  Encourage leisure activities
they do good deeds for others  Guard against engaging in
 To avoid conflict they become passive, power struggle with client
conceal sexual feelings and anger
 Confront client’s
 Nursing guidelines: procastination and
 Increase responsibility for intellectualization
self in daily livings
 Be assertive
 MOOD DISORDERS
 Mood – a person’s state of mind exhibited through feeding &
 Encourage client to
emotions (APA, 2001)
verbalize feeling
 Be aware of  Mood disorders – extreme change in mood that presents
countertranference problems in daily functioning
 - alteration in effect or mood that occurs when an individual  Significant anorexia or wt  Patient is depressive mood for at least 2 years
experience exaggerated feeling for a prolong period of time that is loss  With poor appetite or over-eating
psychologically, physically & socially unacceptable  Excessive or inappropriate  Insomia or hypersomia
 Causes: guilt  Low energy or fatigue
◦ Genetics c. Catatonic features – psychomotor  Low self-esteem
◦ Biochemistry attraction including immobility,  Poor concentration or difficulty making decisions
◦ Personality excessive motor activities, mutism,  Feelings of hopelessness
◦ Environment echolalia or echopraxia, inappropriate  Difference between MDD & DD (duration &
 Types of depression: posturing severity)
1. MAJOR DEPRESSIVE DISORDER (MDD)  negativism  Patient may engage in activities to generate
◦ Characterized by 1 or more major depressive
episodes, which are defined as at least 2 weeks by
d. Postpartum depression – mood excitement
disturbance that occurs during the first  may turn to substance abuse or food
depressive mood or less of interest accompanied
30 days post partum  Patients do not readily recognize their symptoms
by at least 4 additional symptoms of depression
e. Psychotic depression – delusions & as abnormal
◦ Signs/behavior
hallucination  MANIC DISORDERS
a. Depressed mood most of the day
b. Anhedonia  Delusion of guilt, delusions  STAGES OF MANIA
c. Significant weight loss or gain (5% wt. of deserved punishment, 1. Mild elation or hypomaniac (4 days)
in month) somatic delusions, nihilistic ◦ Affect – feeling of happiness, confidence
delusion, & delusion of
d. Insomia or hypersomia (2 hrs in 1 ◦ Thought – flight of ideas, inflated self-esteem
month) poverty
◦ Behavior – always on the go, increase sexual drive
e. Increase or decrease motor activities f. Seasonal affective disorder (SAD) – 2. Acute manic episodes
f. anergia occur in conjunction with a seasonal ◦ Intensified symptoms
g. Feelings of worthlessness or change ◦ Mood disturbance & lability
inappropriate guilt (may be delusional)  MOOD DISORDERS ◦ Enthusiastic & intrusive
h. Recurrent thoughts of death or suicidal ◦ Hyperactivity
◦ Psychopharmacological mgt.
ideation ◦ Flight of ideas
a. SSRIs
i. Decrease concentration or b. Tricyclics ◦ Distractibility
indecisiveness c. Antidepressant ◦ Distortion of self-esteem
 MOOD DISORDERS d. MAOIs 3. Delirium – state of extreme excitement
◦ Characteristics ◦ Nursing guidelines: ◦ Disorientation, incoherence
a. Disregards grooming, cleanliness & a. Establish trust
◦ Visual or olfactory hallucination
personal appearance  Nonjudgmental & friendly
b. Stooped posture & dejected facial approach ◦ Exhaustion, dehydration, injury even death
expression  Use silence & stay with  MANIC DISORDERS
c. Dishevelled, downcast, lacking eye patient  Basic syndromes of bipolar disorders
contact & tearful  Avoid challenging or testing
d. Agitated the client
a. Manic episodes – elevated, expansive or irritable mood
◦ Specifiers:  Do not argue b. Hypomanic episodes – less, severe level of impairment
a. Atypical depression – occurs in  Divert patient’s attention c. Depressive episodes – hypersomia, hyperphagia, wt. gain,
younger population b. Bolster self-esteem leaden paralysis, little energy
 Increase appetite or wt. c. Be amphatic d. BIPOLAR DISORDER
gain, hypersomnia, leaden d. Point out or reward small visible ◦ Bipolar I disorder – experiences swings between
paralysis & extreme accomplishment manic episodes and major depression
sensitivity to interpersonal e. Do not embarrass patient ◦ Bipolar II disorder – characterized by 1 or more
rejection f. Never reinforce hallucination, depressive episodes accompanied by at least one
b. Melancholic depression – older adults delusions or irrational beliefs hypomanic episodes
g. Encourage verbal expressions of anger ◦ Cyclothymic disorders – a swing between a
 Anhedonia & inability to be h. Provide non-threatening one-to-one hypomanic and depressive symptoms
cheered up relationship
 Depression worse in AM ◦ Behavior of bipolar disorder
 Early AM awakening i. Guide patient to appropriate decisions  Objective behavior
 Psychomotor retardation or by using problem solving  Disturbance of speech,
agitation  MOOD DISORDERS social, interpersonal &
2. DYSTHMIC DISORDER
 occupational relationship, ◦ Rigid excersie program  Use of ipecac syrup
activity & appearance  Menstrual irregularities
uncontrollably eat large amounts of
 Speech – rapid, pressured, food  Dental carries
loud, easily distracted ◦ Hyperactive  Russel’s sign
 Altered social, interpersonal substance abuse  Loss of control over eating
& occupational relationship family conflict  Anxious & feeling weakness
 Subjective behavior ◦ Amenorrhea  Angry & agitated or depressed
 Alteration of affect – ◦ Hypotension, bradycardia, hyponatremia  Mod disorders
euphoric, grandiosity, labile ◦ Dry skin with lanugo  Substance abuse
 Alteration of perception – ◦ Delayed gastric emptying  Self – induce vomiting
delusion & hallucination ◦ Slow peristalsis----constipation ◦ Etiology
 MANIC DISORDERS ◦ Dehaydration  Low serotonin activity
◦ Nursing responsibilities ◦ Refeeding syndrome  Inherited
 Use matter of fact tone ◦ Pitting edema  Cycles of low self-esteem, extreme
 Clear, concise direction & comments – ◦ Osteopenis or osteoporosis concerns about body shape & wt., strict
remarks should be simple & brief ◦ Cardiac arrythmias dieting, binge eating & compensatory
 Limit – setting ◦ Bizaare behavior regarding fool & eating behavior
 Reinforcement of reality ◦ Feel abandoned or inadequate  Ambivalence
 Respond to legitimate complaints ◦ Depression, irritability, social withdrawal,  Feel unworthy of nurturing
 Redirect patient into more healthy lessened sex drive & obsession symptoms
activities  EATING DISORDERS
 Provide for can be eaten easily  EATING DISORDERS ◦ Psychotherapeutic mgt
 Assess amount of sleep & rest ◦ Etiology  Medical stabilization
 Provide quiet place to sleep  Biologic factors – increase serotonin  Wt. restoration –
 Structure activities during the day  A culture of thinness, relational  Help patient reestablish appropriate
orientation of women eating behavior
 Do not drink caffeine at bedtime
 Genetic component  Elevate self-esteem
◦ Psychopharmacology
 Family environment  Medical treatment – IV lines & feeding
 Lithium –
 Odd eating habits & emphasis on tubes
 Anticonvulsant & atypical
antipsychotics
appearance ◦ Nursing guidelines
◦ Milieu mgt.  Rejection of food & wt. loss as a  Convey warmth & sincerity
positive reinforcement  Listen emphatically
 Safety
 Childhood sexual abuse  Be honest
 Consistency among staff
 Regression to a prepubertal state  Set appropriate behavioral limit
 Reduction of environmental stimuli
 Fear of being out of control  Assist patient in identifying their
 Dealing with patient who are escalating
 Defense mechanism: REACTION qualities
 Reinforcement of appropriate hygiene
FORMATION  Collaborate with patient
& dress
 BULIMIA NERVOSA  Teach patient about disorders
 Nutrition & sleep issues
◦ Intermittent binge period and periods of restrictive  Determine patient’s weight with their
 EATING DISORDERS eating back on the scale
 ANOREXIA NERVOSA ◦ Loss of control over eating  Initiate behavioral modification
◦ Limit their intake or refuse to eat but do not lose ◦ Anxious & feeling of weakness – before eating  Express emotions assertively
their appetite while binging  Help patient identify & express bodily
◦ Perfectionist & introvert with self-esteem & peer ◦ Angry & agitated or depressed sensation
relationship problems ◦ Mood disorders  identify non-weight related interest
◦ Substance sbuse ◦
◦ Clinical manifestation/behaviors Psychopharmacology
Restricters Vomiters-purgers ◦ Self-induce vomiting  Anxiolytics
◦  Atypical antipsychotics
Normal or slightly ↑ Induction of  EATING DISORDERS
vomiting 7 excessive use of laxative or diuretics ◦ Clinical manifestation/behavior  Antidepressants - SSRI
◦ Avoids people  Secretive about behavior
denies concern
 SCHIZOPHRENIA
 Binge eating
◦ Competitive, compulsive, obsessive  F/E abnormalities
dental problems
 Use of laxatives
  Schizophrenia – mental disorder characterized by 3. Illusions – misinterpretation of environmental stimuli 2. CATATONIC TYPE – psychomotor disturbances
4. Depersonalization – feeling of the individual that the self has
disturdance in thought & sensory perception & deterioration ◦ Motoric immobility, waxy flexibility or stupor
been changed or altered
in psychosocial functioning ◦ Excitement (excessive motor activity)
5. Affective flattening – absence of emotional response
 Psychotic – delusions, any prominent hallucinations, ◦ Extreme negativism or mutism ---- withdrawal
disorganized speech or disorganized catatonic behavior 6. ambivalences ◦ Peculiar movements
(APA, 2000)  SCHIZOPHRENIA ◦ Echolalia or echopraxia
 Comorbidity  Common delusions in schizophrenia 3. DISORGANIZED TYPE – most severe prognosis,
1. Substance abuse 1. Delusions of reference – everything that is occurring in the disintegration of personality & is withdrawn, disorganized
2. Depressive symptoms environment has significance to oneself speech, disorganized behavior, flat or inappropriate affect
3. Anxiety disorders 2. Delusion of persecution – false belief that one is being singles
 Theory out for harm by others – someone is platting against him/her
4. UNDIFFERENTIATED TYPE – characterized by atypical
1. Dopamine hypothesis symptoms that do not meet the criteria for other subtypes
3. Somatic delusion – appearance or functioning of one’s body
2. Alternative biochemical hypothesis – structural cerebral is altered ◦ Characteristics symptoms
abnormalities, reduced gray matter, increase ventricular brain 4. Grandiose delusion – false belief that one is a very powerful ◦ Prognosis is favorable
ratio & important person 5. RESIDUAL TYPE
3. Genetics
4. Autoimmune
5.
6.
Nihilistic delusion – “I am dead”
Delusions of influence – one is controlled by others or outside
◦ Continuing evidence of negative symptoms
5. Double bind communication – 2 messages that contradict without characteristic symptoms of schizophrenia
force
each other are sent causing the child to be confused on what Jealousy – false belief that one’s mate in unfaithful; may have so-called  SCHIZOPHRENIA
action to engage in which immobilize the child & results to proof  Assessment
anxiety  Symptoms of loose association ◦ Objective Sx
6. Birth & pregnancy complication, viral infxn, poor nutrition or 1. Neologism  Less concerned with their appearance
starvation, exposure to toxin 2. Echolalia  Introspection & apathy
7. Stress – development/family 3. Word salad
8. Weak ego  Anergia
9. Vitamin deficiency – vitamins B1, B6, B12, vit. C 4. Clang association  Inadequate interpersonal
communication
 SCHIZOPHRENIA  SCHIZOPHRENIA
 Hostility
 Precipitating factors  3 broad clinical symptoms
 Withdrawal
1. Positive symptoms
1. Emotional - marital problem
◦ Reflects the presence of overt psychotic or  Psychomotor agitation or inactive or
2. Somatic – pregnancy, physical illness distorted behavior catatonic
◦ Subjective Sx
3. May be none 2. Negative symptoms – reflect a dimunition or loss of normal  Hallucnation
 4 A’s (Eugene Bleuler) function
Affect – outward manifestation of a person’s feelings & emotion – flat,  Illusion
blunted, inappropriate bizarre affect 3. Disorganized symptoms – presence of confused thinking,  Paranoid thinking
Associative looseness – haphazard & confused thinking manifested in incoherent or disorganized speech & disorganized behavior  Thoiught disorder
jumbled & illogical speech & reasoning  2 diagnostic categories  Delusions
Autism – thinking that is not bound to reality but reflects the private Type I schizophrenia  Confusion, incoherent speech,
perceptual world of the individual – delusions, hallucination, neologism  Onset of positive symptoms is generally acute clouding, & a sense of going crazy
Ambivalence – simultaneously holding 2 opposing emotions, attitudes,  Sx: delusions, excitement, feelings of persecution,  Inappropriate, flattened, blunted, or
ideas, or wishes towards the same person situation or object grandiosity, hallucination, hostility, ideas of reference, labile affect
 Phases of schizophrenia illusions, insomia
Type II schizophrenia  SCHIZOPHRENIA
1. Acute phase – period of florid positive symptoms as well as  Psychopharmacology
 Slow onset of negative symptoms aused by viral infxn &
negative symptoms ◦ Stabilize acute symptoms
abnormalities in cholecystokinin
2. Maintenance phase – period when acute symptoms decrease ◦ Maintain therapeutic plasma levels
in severity  Sx: dimunition or loss og normal function, anergia, ◦ Typical antipsycotics
anhedonia, alogia, avolition, blunted affect or affective
3. Stabilization phase – patient is might still experience flattening, attention deficits, poor eye contact, asocial
 Haloperidol (Haldol)
hallucination & delusions but not as severe nor as disabling as  Chlorpromazine (Thorazine)
behavior, difficulty in abstract thinking
they were during the acute phase  Thiothixene (Navane)
Common symptoms of schizophrenia  SCHIZOPHRENIA ◦ Atypical antipsychotics
1. Delusions – false fixed beliefs that cannot be corrected by  SCHIZOPHRENIA SUBTYPES  Clozapine (Clozaril)
reasoning 1. PARANOID TYPE  Respirodone (Respiradol)
2. Hallucinations – sensory perception for which no external ◦ Experience persecutory or grandiose delusion &  Olanzopine (Zyprexa)
stimulus exist auditory hallucination  Milieu mgt.
 ◦ For disruptive patients:
 Set limits
 Frequently observe escalating patients
to intervene
 Modify the environment to minimize
objects that can be used as weapons
 Be careful in stating what the staff will
do if a patient acts out
 When using restraints, provide for
safety by evaluating the patient’s status
of hydration, nutrition, elimination, &
circulation
 SCHIZOPHRENIA
◦ For withdrawn patients:
 Arrange non-threatening activities that
involve these patient in doing
something
 Arrange furniture in a semicircle or
around a table
 Help client to participate in decision
making
 Reinforce appropriate grooming &
hygiene
 Provide psychosocial rehabilitation
◦ For suspicious patients:
 Be matter-of-fact
 Staff members should not laugh or
whisper around patients unless patient
can hear what is being said
 Do not touch suspicious patients
without warning
 Be consistent in activities
 Maintain eye contact
◦ For patient with impaired communication:
 Be patient & do not pressure patient to
make sense
 Do not place patient in group activities
that would frustrate them, damage self-
esteem, or over-tax their abilities
 Provide opportunities for purposeful
psychomotor activity
◦ SCHIZOPHRENIA
◦ For patient with hallucinations:
 Attempt to provide distracting
activities
 Discourage situation in which patient
talk to others about their disordered
perception
 Monitor television selection
 Monitor for command hallucination
that might increase the potential for
patient to become dangerous
 Have staff members available in the
dayroom so that patient can talk to real
people about real people or real events
◦ For disorganized patients:
 Remove disorganized patient to a less
stimulating environment
 Provide a calm environment
 Provide safe & relatively simple
activities for these patients
 Nursing guidelines
◦ Build a therapeutic alliance with patient
◦ Be calm
◦ Accept patient
◦ Keep promises
◦ Be honest
◦ Do not reinforce hallucinations or delusions
◦ Do not touch patient without warning
◦ Reinforce positive behaviors
◦ Avoid competitive activities
◦ Do not embarrass patient
◦ Allow & encourage verbalization of feelings
 SCHIZOPHRENIA – LIKE DISORDERS
1. Schizoaffective disorders
◦ Uninterruptive period of illness during which at
some point the patient experiences a MDD, manic
or mixed episodes along with the negative
symptoms of schizophrenia
◦ In the absence of prominent mood symptoms,
patient exhibits delusion or hallucination
2. Schizophreniform disorder
◦ Patient exhibits features of schizopohrenia for
more than 1 month but fewer that 6 months
◦ No impaired social or occupational function
3. Brief psychotic disorder
◦ Onset of at least 1 or more positive symptoms of
psychosis
◦ Occur at least 1 day to less that an month then full
recovery
4. Psychotic disorder due to a general medical condition
◦ Presence of prominent hallucination or delusion
determined as resulting from the direct
physiologic effect of a specific medical condition
 CRISIS
 It is an overwhelming reaction to a threatening situation in
which an individual’s usual problem-solving skills and coping
responses are inadequate for maintaining psychological
equilibrium
 General Consideration
1. Crisis occurs in all individuals at one time or another
2. Crisis is not necessarily pathological, it can provide stimulus
for growth & learning
3. Crisis is time limited and is usually resolve one way or
another in a brief period (4-6 weeks)
a. Successful crisis resolution occurs when
functioning is restored or enhanced through new
learning
b. Unsuccessful crisis resolution is when functioning
is not restored to pre-crisis level, and the
individual experiences decreased level of
functioning
4. Individual’s perception of the problem determine the crisis.
Each individual has unique response to the problem
5. Balancing factors are important in predicting outcomes for
the individual responding to a crisis
a. Perception of precipitating event is realistic rather
than destored
b. Situational supports (ex. Family, friends)
c. Coping mechanism that alleviate anxiety
 CRISIS
Type of Crisis
 Developmental crisis - occurs from transition from one
stage of maturation to another in the life cycle
 Situational crisis – occurs to a sudden, unexpected event in
an individual life. These events is all about experiences of
loss.
 Adventitious crisis – occurs in response to severe trauma or
natural disaster. These crisis can affect individuals,
communities and even nation
Sequence of Crisis Development
1. Pre-Crisis period – individual has emotional equilibrium
2. Crisis period – individual has the subjective experience of
being upset, failure of usual coping mechanism, symptoms
are expereinced
3. Post-Crisis period – resolution of crisis
Symptoms common in individual experiencing crisis
 Physical symptoms – somatic complaints
 Cognitive symptoms – confusion, difficulty concentrating,
racing thoughts, inability to make decisions
 Behavioral symptoms – disorganization, impulsive, angry
outburst, withdrawal from social interaction
 Emotional symptoms – anxiety, anger, guilt, sadness,
depression, paranoia, suspicion, helplessness, powerlessness
 CRISIS
Management of Crisis: Crisis Intervention
1. Assistance
◦ Assistance for an individual affected by a crisis
◦ Assistance for groups or communities affected by
crisis
 Mobile crisis team – interdisciplinary
teams provide services to groups of
communities affected by crisis
 Disaster response team – teams have an
organized plan to provide help to large
 segments of the population affected by
natural disaster
 Critical incident stress debriefing –
assistance is directed at groups of
professional such as hospital personnel,
police and firemen, who have been
involved in a crisis situation.
2. Role of the Nurse
 Nurse provides direct services to people in crisis and serve as
members of crisis intervention teams
◦ In acute and chronic hospital setting assist
individuals and families responding to the crisis of
serious illness, hospitalization and death
◦ In community setting provide assistance to
individuals and families in developmental and
situational crisis
◦ Nurses working with a particular group of client
should anticipate situations in which crisis may
occurs. They also collaborate with other health
team members to help an individual resolve crisis
 CRISIS
Principles of crisis intervention
 the goal of crisis intervention is to return the individual to
pre-crisis level of functioning
 Emphasis is on strengthening and supporting healthy aspects
of individual’s functioning
 A problem-solving approach is use in a systematic manner
◦ Assessing the individual’s perception to problem
assessing strengths and weaknesses of the
individual and family support system
◦ Planning specific outcomes or goals based on
priorities
◦ Providing direct intervention
◦ Evaluation outcome and results of intervention
 Use the framework of Maslow’s hierarchy of needs to
determine the priorities for intervention
◦ Physical resources – necessary for survival
◦ Social resources – necessary for regaining sense of
belonging
◦ Psychological resources – necessary for regaining
self-esteem
Role of crisis intervention worker includes:
 Establishes rapport and communities hope and optimism
 Assumes an active, directive role if necessary
 Make suggestions and offer alternatives