1 MDRN 7th Batch November 13, 2005/8-12 Mrs. Lucy Espinosa, RN PSYCHIATRIC NURSING Scope of Psychiatric Nursing: I.

Principles, Concepts and Theories II. Psychodynamics III. Mental Disorders based on DSM IV Revised Symptomatology Defense Mechanism: Example= Phobiadisplacement Obsessive Compulsive-undoing Psychopathology including Neurotransmitters and Brain Abnormalities Nursing Diagnosis emphasis in local board Nursing Interventions PRINCIPLES, CONCEPTS and THEORIES Definition of Psychiatric Nursing by the American Nursing Association (ANA): a specialized area of nursing which emphasizes the theories of human behavior as its scientific aspect and purposeful use of self as its art it is a SCIENCE because it deals with the use of knowledge, focused on human behavior and understand psychology & sociology Psychodynamic: it is understanding the motivation behind human behavior it deals with the whys, reasons and rationale of human behavior whether normal or abnormal (Example: Motivations why a lot of MDs are taking up nursing) according to Freud, psychiatric/mental cases should be studied from intrauterine stage of growth according to Leticia Kuan from the stage of courtship of the parents: 2 Types of Courtship 1. Over a stick of cigarette-woman had sex on the night she met the man 2. Bench shining method-advocated by Kuan that involves 2-3 years of courtship it involves therapeutic nurse-patient relationship (TNPR) and therapeutic nursepatient partnership (TNPP) giving the client a higher sense of autonomy or higher sense of direction Psychopathology: is understanding the motivation behind abnormal human behavior only there are 2 roles of psychopathology: 1. Role of Nature-biological & genetic influences 2. Role of Nurture-know psychodynamics (how a person is raised) and environmental influences (early childhood experiences)

2 Example: Patient with auditory hallucinations (false perceptual disturbance) ----------------------------------------------------- Nature Nurture Genetics and Biological: Environmental influences dopamine-a neurotransmitter Psychodynamics: history of loss which according to Keltner is a defensive coping mechanism against an overwhelming anxiety: Mild-Moderate=normal Severe=anxiety disorder etiology or cause is part of psychopathology while pathophysiology is abnormal functioning Example: AIDS is caused by HIV virus. How it enters the body? Whats the reason why immune system is low?

It is an ART because the essential tool used is the Self. A psychiatric nurse should be a role model, a change agent and employ the Therapeutic Use of the Self (TUS) which is the ability to use ones person consciously and with full awareness so as to establish relatedness and to structure nursing interventions, ability to use self deliberately and intentionally therapeutically A nurse should develop Self-awareness which according to Taylor, is the ability to experience genuine feelings of joy, anger and resentment as well as beliefs Example: A male nurse had a fight with his wife. He controlled his feelings, went to work and assigned to 3 patients on physical restraints. One patient while being fed, spewed his food on the male nurse. The latter reacted by kicking the patient resulting to rupture of bladder. As a consequence, he was relieved of his job. To demonstrate self awareness: if only the nurse was truthful to himself, he could ask his supervisor to assign him elsewhere doing difficult duties because he cant handle the stressful job due to his personal problem. BQ #1: What is the most difficult part in the therapeutic nurse-patient relationship? a. to remain professional at all times b. to establish trust-patient resistance due to experience c. to exhibit empathy d. self awareness Answer: D, self awareness BQ #2: Factor that strains therapeutic nurse-patient relationship? Answer: Counter transference-you see one person in another person

3 BQ #3: What will you do if you are affected by your patient? Answer: Go to your clinical specialist BQ #4: Client went to assaultive behavior, what should the nurse do? a. Call restraining team - practice in NCMH b. Call doctor - answer as MD c. Give neuroleptics - ideal answer d. Self awareness - local board answer Answer: D, according to Keltner, give the client the right to receive the least restrictive environment 3 Scopes of Psychiatric Nursing Practice: 1. Caring for psychologically ill client in general hospital or medical center Psychiatric nursing also have specialty areas such as adult and child Psychiatric nursing liaison is employed in medical centers to handle the psychosocial concern of psychologically ill clients Role of the nurse is as a facilitator bringing out the clients fears and anxieties 2. Community Mental Health Nursing (CMHN) The application of the principles of psychiatric care in communities & groups of people History of CMHN: Mental Health Nursing started in USA, where big mental institutions provide custodial care (physical care such as feeding and bathing only) of the clients. This resulted to develop Social Breakdown Syndrome, a complication of mental illness (BQ) wherein clients remained apathetic. Apathyis a complete absence of feelings or state of indifference in situations where in a normal person can elicit responses. In 1963, Community Mental Health Nursing was established by enactment of Community Mental Health Act which ordered the closure of big mental institution and the establishment of Community Mental Health Centers. 3. Caring for the Mental Health Consumers in a psychiatric institution 3 Levels of Prevention in CMH Centers: (BQ) Level of Prevention Clients Primary Well Secondary Tertiary Sick Recovered Aspect of Care Promotion of M. H. Prevention of M.I. Crisis Intervention Case Finding Institute Immediate Treatment Follow up Prevent further complications Job placement

a. b. c. a. b. a. b. c.

4 BQ #1: Which of the following aspects of care specifically focus on primary care? a. promotion of mental health b. prevention of illness c. crisis intervention d. teaching sex education among adolescent & old people Answer: D, all are correct but this is more specific BQ #2: To institute immediate treatment is this? a. Primary care b. Secondary care c. Tertiary care Answer: B, secondary care because patient is already sick PRIMARY Level of Prevention A. Promotion of Mental Health (MH): According to WHO, the Definition of Mental Health: 1. It is the ability to maintain an emotional well being 2. It is the ability to handle normal stresses of life 3. It is the ability to see self as others do and must fit in the society or culture where one belongs or lives 6 Concepts/Criteria of Positive Mental Health (according to Marie Jahoda): 1. Knowledge of Self ability to recognize and use God given talents/potentials and positive points (assets) & accepting negative points (liabilities) turning it into something positive healthy or normal narcissism is seen in infants & become pathologic if you reach adolescent years mentally healthy person will strive to avoid his liabilities through enhanced self-awareness by giving an opportunity to do the JOHARI Window by Joe Luft and Harry Ingham 4 Quadrants of Life or 4 Windows of Life I. Public Self II. Blind Spot Known to self and others Bad breath area because unknown to self but known to others Take the risk It brings anxiety to know the truth III. Private Self IV. Unconscious Secrets, masks, pretences & Unknown to self and others hypocrisy Known to self but unknown to others

5 Principles involved in the use of JOHARI Window to enhance self awareness: a. Change in any quadrant affects all the rest of the quadrants b. Bigger the Q III, poor communication/interpersonal relationships How to improve Johari Window? 1) Go into self disclosure by opening up to a friend 2) Feedback mechanism by constructive criticism c. Bigger the Q I, good communication/interpersonal relationships BQ: Can a nurse be self revealing? Answer: Yes, as long as it has a professional objective, refocus with empathy done only for 30 minutes 5 Levels of Communication in Johari Window: a. Clich (meaningless phrase) b. Gossip c. Ideas and judgment-trying to keep knowledgeable to compensate what is lacking like confidence d. Feelings-suppress feelings but never dies & come later as.. e. Guts-you should take the risk of blurting deep darkest secret

2. Perceptive Ability is awareness of our environment Example: A normal mentally well person who feels cold will get a blanket but a psychotic person is oblivious of the climate 3. Integrative Ability is the ability to harmonize the 3 Psychic Forces of Sigmund Freud: a. IDacts on pleasure, without morals, cant wait & impulsive b. EGO-acts on reality principle, the one deciding, can wait, can satisfy the needs of ID and restrictions of SE c. SUPEREGOacts on moral principle and the good conscience ID=Ego=Superego ID SE Ego Ego SE ID Mentally Healthy (Balanced) Strong ID (Antisocial PD) Strong Superego (Depression)

4. Autonomous Behavior is the ability to decide wisely 5. Desirous growth, development and self actualization is the ability to reach for the highest Example: Graduating, passing the licensure examinations and going to further studies 6. Mastery of ones environment is the ability to adjust and adapt how you do anything is how you do everything

6 B. Prevention of Mental Health: Etiology/General Causes of Mental Disorders I. Biological/Biomedical (BQ) Model involves organic pathology 4 Causes: 1. Genetic theory 4 illnesses that is genetic in origin: a. Mental Illness b. Cancer c. Cardiovascular d. Diabetes Method of transmission: ECG type Genograma multi-generative graphical presentation or schematic diagram of the family tree which includes up to the 3rd generation & take note of the following: a. Position in the family (2nd rank child syndrome)=unpleasant attitude b. Closeness among the family member 2. Brain abnormality theory It begun in 1990 in US as decade of the brain In all forms of mental illness, psychiatrist and neurologist appreciate the brain abnormality using diagnostic procedures showing brain activity such as: a. PET (Pulsitron Emission Tomography) b. SPECT (Single Photon Emission Computed Tomography) c. MRI and CT Scan PET and SPECT are sophisticated/innovative visual imaging techniques which provide the human brain activity by injection of radioisotope into patients bloodstream Examples: a. Depression-PET and SPECT shows hypofunctioning of the hypothalamus(a small structure of the brain with several blood supply which controls satiety center (thirst and hunger), sleep and wake cycle, sexual libido, concentration, learning and decision making causing pseudodementia (false dementia) b. AlzheimersPET shows increased senile plaques and neurofibrillary tangles c. Schizophrenicshows decreased blood flow to the frontal lobe 3. Neurotransmitter theory Neurons has two main parts: the axon and dendrites The terminal of an axon connects one neuron to another and has synaptic vesicles that stores and releases neurotransmitters Examples of neurotransmitters: a. Serotonin is proven to be a mood elevator and controls the sleep and wake cycle. It should stay at the receptor sites because if there is a reuptake or re-absorption of serotonin by the different synaptic vesicles, it causes depression

7 Nclex Q 1: Diet for depressed patients should be high in CHO and low in CHON intake. Answer: Food & beverages rich in serotonin are oatmeal, banana, chocolate and milk Nclex Q 2: What should be the first food & beverage given to insomniac clients? Answer: Give milk first because it contains L tryptophan, an enzyme precursor of serotonin and banana, potato and apple skin are rich in potassium which is a vehicle for serotonin b. Norepinephrine is a fight or flight neurotransmitter which is decreased on depressed patients c. Acetylcholine is a memory neurotransmitter which is decreased on Alzheimers d. Decreased GABAAnxiety e. Increased dopamineSchizophrenia f. Increased serotonin-Impulsive 4. Vitamin Deficiency theory a. Low in vitamin Capathy b. Low in vitamin Dmania c. Vitamin B1 deficiency seen in alcoholics where alcohol interferes with vitamin B1 absorption and thiamine serves as vehicle for glucose. Absence of glucose leads to Wernickes encephalopathy, a life threatening condition even when the client recovers, dementia of the Korsakoff type ensues (BQ). II. Cognitive Model A. Cognitive Model of Depression People who are vulnerable to depression shows a Triad of Depression Self Future World

In depression, the person 1) has negative perception of selfworthlessness, hopelessness poor self concept and low self esteem 2) faulty perception about the futurepessimism 3) faulty perception about the world-sees world as empty Self Concept cognitive view about the self (Pananaw sa pagkatao) Self Esteem affective view about the self (emotional) B. Cognitive Model of Anxiety Disorder Misinterpretation/misperception of danger

8 November 28, 2005/8-12 Mrs. Lucy Espinosa, RN Continuation of General Causes of Mental Disorders III. Psychosocial Model 2 Main Types: 1. Precipitating-most recent/immediate cause 2. Predisposing-causes that make a person vulnerable to mental illness Factors to consider: A. Age:3 vulnerable ages in life (BQ) connected with mental disorder 1. Adolescent: 17-25 years old-very fragile stage, period of storm and stress, vulnerable to Schizophrenia 2. Menopausal: midlife crisis-empty birds nest syndrome 3. Senility: mid 70s-80s-most painful part of our life B. Gender 1. Male-express feelings psychophysiologically; prone to schizophrenia 2. Female-express feeling symbolically; prone to depression, anxiety related disorders and somatoform disorders C. Nationality 1. Japanese-high suicide rate 2. Americans-vulnerable to Anxiety Disorder (well worried) 3. Filipinos-vulnerable to Schizophrenia (severely mentally ill) 4. Europeans-vulnerable to Mood Disorder particularly depression because they have everything and could not ask for more D. Intelligent Quotient (IQ) 1. High IQ-higher predisposition to Schizophrenia and Paranoia that started from oral stage because they didnt develop basic trust & as a compensatory act for lack of social warmth 2. Low IQ-mental retardation to experience psychosis E. Civil Status according to increasing incidence 1. Single-more vulnerable due to absence of support system 2. Widows 3. Separated 4. Married-last to have mental illness F. Four Classification of Body Built/Physique by Krethzner 1. Asthenic (malapalito)-80% has slender body with thin bone and oval face; vulnerable to Schizophrenia 2. Athletic (BQ)-has strong muscular development with bony prominence and square face; vulnerable to Anxiety Disorder 3. Pyknic (BQ)-has short & stocky (ex. natives of Baguio); vulnerable to Mood Disorder 4. Dysplastic-combination of the 3 body built and no vulnerability; common among Filipinos

9 G. Classification of Personality according to Temperament by Carl Jung 1. Introvert-very shy & sensitive; vulnerable to Schizophrenia 2. Extrovert-sociable & aggressive; vulnerable to Mood Disorder 3. Ambivert-possesses both qualities of introvert/extrovert; no vulnerability C. Crisis Intervention: BQ: In crisis intervention, one major focus is: a. To offer corrective emotional experiences b. To look into underlying cause c. To restore normal functioning of a person or assist him to pre-crisis level d. To improve social functioning of a person Answer: C 3 Normal Phenomena experienced by people: 1. Stress- a part of being alive; its a person & environment interaction; is something objective & can be seen; part of normal adaptation. a. Eutress-normal; motivates a person b. Distress-abnormal/pathological 2. Anxiety-vague unexplainable feelings of apprehension which disturbs the subjective life of a person & his relations with others; the internal state that stress produces 3. Crisis A minor event that produces stress, just like a straw that breaks a camels back minor event produces stress leading to series of events due to: a. lack of coping resources b. ineffective/dysfunctional coping comes from a Chinese word Krinein which is represented by: a. Face with horrified expression-a problem/danger b. Face with a smile-opportunity According to WHO, crisis is a psychological time wherein a person handles stress when he finds his old usual coping ways to be ineffective it differs from stress in that crisis results in a period of severe disorganization due to the failure of individuals usual coping mechanism &/or lack of their usual resources Crisis worker is a person who intervenes with crisis; he should be active & directive (BQ); experiences a secure level of decision making & problem solving the normal duration for a person to resolve a crisis is 4-6 weeks (BQ) but according to Mosby 1-6 weeks because it is self-limiting that goes either into (+) or (-) resolution: 1. Positive resolution-expected with a support system (family) crisis become an identified problem bringing growth, promoting potential & learning opportunity 2. Negative resolution-results when theres no support system thus crisis will set in with the preconscious level leading to: a. Psycho-physiologic disorder-when bad experience sets in the subconscious b. Anxiety related disorder c. Psychosis

10 3 Levels of Consciousness (psychoanalytical Theory of Freud): a. Conscious-is the here & now, operates when we are awake, can be compared to the tip of an ice cube in a glass of water, there is the knowledge of the problem thus the aim of crisis worker is to resolve crisis within this level b. Preconscious/Subconscious-watchman of the mind, partly forgotten/partly remembered memories, recalled with vigorous effort c. Unconscious-storage of all painful memories 2 Types of Crisis by Keltner: 1. Maturational/Developmental crisis-more predictable & easier to handle which happens all throughout developmental processes (ex. birth of baby, first day of school, menstruation, vacation) 2. Accidental/Situational crisis-less predictable & hard to manage; could be anticipated threat to ones self esteem (ex. physical health, accident, disastersnatural & man made) Psychotherapeutic Strategies: Psychotherapeutic Focus Strategies 1. Crisis Intervention Immediate present problem or present situation (ex. death, relationships) 2. Psychotherapy a. Individual (nurse-patient relationship) b. Group (small group meeting) 3. Psychoanalysis Major Goals Restore homeostatic level Normal functioning Normal equilibrium Assist the person to ones homeostasis (WB Cannon) Offer corrective emotional experiences

Here & now Conscious Immediate condition of person or the immediate concern Underlying cause Offer long term resolution Unconscious Old scars are unliquidated childhood experience stored in unconscious level

Nursing Diagnosis: 1. Ineffective coping 2. Risk for injury 3. Risk for violence 4. Family pattern disturbances

11 Roles of a Nurse in Crisis Intervention: 1. Assessment-determine the immediate precipitant or patient problem Intervene during the duration of crisis & not after crisis has abated because this is the time when: a. the client has mental block where decision making & problem solving are shot b. easier to intervene c. change is possible d. more effective & prevent ineffective coping styles e. prevent further violence & decompensation 2. Prevent Suicide-provide safety of client/family support system because: a. patients undertake suicide 2-3 months after the crisis has abated b. NE & Serotonin are highest during the crisis c. Critical time for a depressed patient is 7-9 months after crisis 3. Restore emotional security & stability Goals for Crisis Intervention: 1. Done in mentally well patients who are experiencing a crisis 2. Help the individual to go back to pre-crisis level or homeostatic state Technique in Crisis Intervention: Psychosocial Processing (PSP) a tool in transforming a victim to become a survivor by providing psychological relief Types of PSP: A. Critical Incident Stress Debriefing (CISD) pioneered by a fireman, Jeff Mitchell one shot deal (done only once); 2-3 hours Critical Incident is an event that causes an overwhelming reaction & disrupts normal functioning of a person 5 Steps of CISD: 1. Introduction-develop/establish trusting relationship & practice confidentiality; there must be respect & rules must be imposed; facilitator introduces self 2. Sharing experiences-involve10-12 persons/participants in circles; share their traumatic experiences; centered on facts & feelings 3. Expect for reactions-emotional, physical, behavioral & mental/cognitive reactions; tell clients that it is normal reaction in an abnormal situation (commonality, universality & normalcy); to lower tension do some breathing exercises 4. Identify coping styles-acceptance; among Filipinos prayers 5. Contingency plan-ex. community organization; BQ-Feeling tone of the client B. Multiple Intervention-in cases where crisis that continually occurs C. Psychosocial Processing (PSP) for children-children has shorter attention span: Color your life technique, music & art appreciation, murals & role playing

12 SECONDARY Level of Prevention Sick clients of the community Case Finding: early recognition early diagnosis early treatment recovery 1. Brief Psychotic Episode-symptoms lasting from few hours to one month 2. Schizophreniform Disorder-symptoms lasting 6 months 3. Schizophrenia-symptoms lasting more than 6 months Institute immediate treatment TERTIARY Level of Prevention Recovered clients of the community Prevent further complications Provide jobs & shelter to prevent Revolving Door Syndrome Services in a Community Health Center: 1. Out patient Service (OPS) 2. In-Patient Service-maximum stay of patient should be 72 hours in ER; if not recovered, client is admitted to acute psychiatric unit 3. Partial hospitalization a. Day care center: 8-5 pm b. Evening care center: offer administration of hypnosis, stress reduction techniques, sleep hygiene, music, proper sleeping pattern c. Weekend care center 4. 24 hour Emergency Service includes suicide prevention, equipped with mobile crisis unit (a department of community health center) 5. Consultation/Education Service Therapeutic Postures: 1. Therapeutic Community-Le Fortage Concept; a milieu therapy by which the total social structure of the treatment unit is involved in the helping process: Elements: a. People-client & relatives b. Organized activities c. Physical structures Therapeutic Meetings: a. Circle meeting-highlights of the 24 hours b. Small group-personal problems of clients c. Community meeting-problems of clients encountered in the ward of general interest d. Patient government meeting-officers of the clients discuss issue related to welfare 2. Attitude Therapy (BQ)-use of prescribed ways on how to handle clients according to the behavior symptoms they manifest Characteristics of Attitude Therapy: a. Consistency to reach the maximum therapeutic value b. Uniform attitude

13 Types: a. Matter of Fact-nurse must be objective, consistent, non-judgmental for manipulative, manic/elated, antisocial, demanding clients b. Active friendliness-nurse must have TLC for withdrawn, regressed, schizoid, fearful clients c. Passive friendliness for suspicious, paranoid clients d. Kind firmness (BQ)-gives boring menial tasks internalized hostilities for depressed clients e. No demand for highly assaultive, clients with rage/furious 3. Remotivation Technique assist a client to move again psychological movement involves 10-12 participants to reach the unwounded areas (sports, occupation, nature) of the client Steps: a. Introduction b. Bridge to reality c. Sharing the world to live in d. Sharing the works or jobs After remotivation therapy: a. Play therapy for children 0-5 years old allowing them the opportunity to express feelings in a safe environment b. Role therapy for 5-12 years old by mobilizing anger of the child c. Psychodrama for adolescent & adult Mental Health Consumers in a Psychiatric Hospital Members of a Psychiatric Team Responsibility 1. Psychiatrist Provides medical care, conducts mental status examination (MSE), gives diagnosis and prescribes medicines 2. Psychiatric Nurse Provides nursing care, Facilitates milieu therapy=scientific manipulation of clients environment aimed at producing changes in clients personality, Performs A. Play therapy for children 5 years and below=a therapeutic procedure by giving children the opportunity to express feelings in a safe environment B. Role Playing for children 6-12 years old C. Psychodrama for adolescents and adults 3. Psychologist Administers and interprets psychological tests A. Projective Test which reveals the unconscious, inner conflicts of the patient B. IQ test which determines the mental development of the patient 4. Case social worker Prepares family case work 5. Activity therapist Provides therapeutic activities

14 January 21, 2006/1-5 Mrs. Lucy Espinosa, RN Roles of a Psychiatric Nurse: 1. Mothering supervision of feeding & grooming that entails touching the client, so the nurse should be assessed first orchestrating the clinical activities in the area Example: Schizophrenia/Paranoid-mothering is CI, they may react violently Anti-social PD-mothering is CI, they have been smothered by too much mothering before, everything was given to them & they didnt experience any disappointments & frustrations 2. Teacher Example: Nurse teaches a manic client to wear make-up/clothes properly 3. Technician know the scientific principle behind nursing procedure develop systematic ways of doing nursing jobs Example: Nurse explains to client the importance of turning head to one side after a tonic clonic convulsion during ECT to prevent aspiration pneumonia 4. Socializing Agent 2 Types: a. Active socializing role-initiating social gatherings, presentations & dancing activities b. Passive socializing role-staying with mute patients 5. Counselor providing outlet for patients anxieties & hostilities nurse should avoid giving advices, suggestions & opinions nurse should assess the clients level of anxiety Mild-therapeutic; motivates an individual Moderate-give activities Severe-invite client into brisk walking Panic-nurse should stay put only & presence gives assurance to the client 6. Creator of Therapeutic Environment to produce a warm, homelike accepting atmosphere 3 Essential Skills of a Psychiatric Nurse: 1. Communication 2. Observation: to take notice of something which another person might miss a. Appearance-observe patient from head to foot, look at the eyes first (window of the soul) Example: Depressed client-sad facial expression, droopy posture, downcast eyes, slow movement & kyphotic=prevent suicide b. Behavior Example: Manic client-too happy, arms crossed & face sideways Paranoid-refuse to eat because of suspiciousness

15 Depressed-refuse to eat because of worthlessness c. Conversation-the manner the patient talks Example: Bipolar-client with pressured speech Depressed-monosyllabic Schizophrenia-incomprehensible responses 3. Recording & Reporting Official account of things done Avoid psychiatric terms, it should be per patients verbatim Charting Aides: a. Quotation marks-used to quote the exact verbatim of the client Example: may boses, papatayin ko sila b. Parenthesis-used to validate words preceding the parenthesis Example: sino sila? (ang mister ko at babae nya) c. Short dashes-used to validate words which were mumbled by the client Example: may boses..ingat sila d. Long dashes-used to complete an incomplete statement Example: masakit-----meaning the client didnt say anything else Communication defined as an exchange of my world of meaning with your world of meaning is the reciprocal or mutual exchange of ideas, feelings, values, beliefs, information & attitudes between 2 persons or among a group of persons clarify or validate first the clients feelings & expression before drawing a conclusion According to Davis, context (BQ) is the physical setting or constraints where communication took place Types of Communication: 1. Verbal-the transmission of a message using spoken or written word 2. Non-verbal actions or behaviors that communicate a message without speaking listen to what the other person is not saying more reliable of true feelings because less conscious reflective of ones attitude Subtypes of Non-verbal communication: a. Kinesis-the study of communication through body movement or body language; Kinesics-is a science of understanding body movement 3 Forms of Kinesis: 1) Facial expression-the eyes & the corner of the mouth are 2 areas of the face that are least susceptible to control Examples: Bipolar, manic-sizing up Schizophrenia-evasive Worried-knitted forehead 2) Eye contact Dimming of lights-looking at a stranger with an 8 feet distance and subsequently averting of our eyes as a sign of respect to the stranger (Hall)

16

Paranoid-poor eye contact Schizophrenia-empty looks Manic-super happy but eyes have no glow Depressed-sad looks, drooping eyes 3) Gestures: Examples a) Thumb pointing to the pocket-unconsciously telling you to look at his bulging penis b) Repetitive movement-according to Freud, doing repetitively is sexual in nature c) Semi-reclining position with crossed legs & both hands placed at napesuperiority d) Drawing pointed & straight object-phallic personality e) Black-represents penis like black cat at the lap of an old maid f) Hands on top of lap-ready to talk or discuss g) Crossed arms & legs-defensive h) Hands on pocket-ready to fight i) Applying lipstick in front of others-to look at my kissable lips b. Proxemics is the study of peoples use of interpersonal space is the law of space relationship or spatial relationship (BQ) 2 Forms of Proxemics: 1) Territoriality is the marking off & defending of certain areas as their own permanent space that we prevent from intrusion 2) Personal Space is a zone of space surrounding a person that is felt to belong to that person temporary space that we prevent from intrusion Interpersonal Distance Zones: a) Intimate=6-8 inches as in parents, children, lovers b) Personal=1.5-3 feet as in close friends; according to Hall, comfort zone is the arms length c) Business=4-12 feet as in gatherings, friends & work situations Persecutory Stance-exhibited by persons who were subjected to persecution (sarcasm or ridicule) by their loved ones d) Public=12 feet and beyond as in concerts & public performances; Ex. Paranoid clients-nearest distance is 4 feet c. Paralanguage refers to how something is said rather than what is said false language or beyond the language itself (BQ) 2 Forms: 1) Voice quality-tone of voice 2) Non language vocalization-crying, sobbing & moaning

Examples:

17 d. Touch-physical act & not always sexual in nature; according to Keltner, touch clients with warning e. Cultural artifacts Example: Wearing mustache & long beard-sign of depression Wearing dark glasses-hiding something Perfume-use mild for intimate contact preferably oil perfume (animalistic) 3. Symbolical-sending flowers to loved ones as an expression of love Therapeutic Communication Definition: The process in which the nurse consciously utilizes the principles of communication in a goal directed professional framework According to Kaplan, it involves active listening while understanding the client providing insight (awareness as to ones mental condition) & clarification (encourage the expression of feelings accurately) Therapeutic communication techniques has to have: respect, warmth, genuineness and empathy (entering into the life situation of the person or the objective understanding of how patients feel or how they see their situation) 4 Important Aspects of Therapeutic Communication: 1. Active Listening attentiveness to the client in a physical & psychological manner paying close attention to verbal & non-verbal communication 5 Aspects of Physical Attending according to Kozier: a. Face to face contact with the client-face client squarely b. Maintain eye contact c. Lean forward toward the client shows interest d. Relatively relaxed position e. Open posture BQ: The nurse must not interact with crossed arms & legs to the client because it decreases or loses attention on part of nurse & experiences the same feeling or situation from the client 2. Understanding impart to the client that you understood them by showing empathy (BQ)-entering into the life situation of client by perceiving his current situation or problem or putting oneself into the clients shoe avoid sympathy because it tends to push client into feelings of hopelessness & worthlessness; it has 2 elements: pity & condolence-nurse becomes subjective & emotional (introjection), so if nurse experienced nape pain, shes unconsciously absorbing the feelings of the client 3. Insight is the awareness to ones mental condition

18 the aim of the nurse is for the client to realize that he has a problem, thus the nurse should be truthful, compassionate & trustworthy 4. Clarification asking client to restate, elaborate or give examples of ideas or feeling encourage client to express feelings more accurately, elaborately & specifically Avoid the following Non Therapeutic Techniques: 1. Dont worry statements it gives client false reassurances it belittles his feelings expressed or connotes that feelings are non valid Example: Nurse-You dont need to worry 2. Why questions Dont use why as a universal rule because it seeks explanation or reasons that are subjective, conclusive, judgmental & threatening involving the client to thinking process wherein the client is already preoccupied with hallucinations & delusions Any question that puts the client to the defensive side Example: Nurse-What made you think about that? Except for this BQ: Scenario-Patient is standing in front of the window, Nurse asked-Why are you standing in front of the window? Answer: Nurse uses the nursing process of assessment-SEAS S-afety needs of client E-ncourage to express feelings A-ssist in solving problems S-olving problems=never solve problems for the client, nurse should assist only to avoid parasitic relationship 3. Exploratory statements (How) Avoid deep probing question by using how at a minimum level the psychiatrist can use how & why because their role is to determine the reason behind the clients feeling the nurse role is to allow the expression of clients feelings 4. Authoritarian remarks emphasizing the rules & regulations in the clinical area according to Kaplan, forget the real/actual world of nursing, when answering the board exam so stick with the ideal (Ivory tower of nursing), go back to the references Example: Nurse-Im sorry that smoking is not allowed but I understand that its difficult. 5. Nurse focus statement blocks the clients opportunity to express feelings by grabbing the limelight from the client Example: Client is telling the nurse about his problems then the nurse relates similar problems of her own 6. Close-ended questions questions answerable by yes or no

19 these questions can be used only during the orientation phase because the nurse is gathering the demographic data of client or when assessing the safety needs 7. Agreement with the client indicating accord with the client important to know the psychopathology of hallucinations & delusions a. its the client defensive coping mechanism against overwhelming anxiety, desires & inner conflicts which emanated from a loss, danger or threat b. these desires are serviceable or important to the client c. these desires are projected thoughts of the client (this is what they want in real) 8. Disagreeing with the client opposing the clients ideas Example: Nurse-Thats not true..youre wrong 9. Defending Attempting to protect someone or something from verbal attack Example: Nurse-This hospital has a fine reputation 10. Giving advice Telling the client what to do Example: Nurse-I think what you should do is or What dont you 11. Parroting Therapeutic Communication Techniques: 1. Reflecting verbalizing stated or implied clients feelings encourage to listen to ones feelings first, repeat what the client said but turn his statement from declarative to interrogatory Example: Client-Maam, hes breaking up from me. Nurse-Hes breaking up from you? What do you feel about this break up? 2. Presenting reality or giving correct information reporting events as they really are offering a view of what is real & what is not without arguing with the client Example: Client-My child, they said youre in Cebu but youre here. Nurse-Im the nurse of the clinical area. 3. Empathy entering into the life situation of the person objective understanding of how patient feel or how they see their situation Example: Nurse-I understand how you feel today. 4. Voice out doubts Expressing uncertainty about the reality of clients perception & conclusions Example: Nurse-I think that is very unusual. 5. Open-ended questions allowing client to tell his story without constraints

20 Example: Nurse-How can I help you

6. Confrontation (BQ) focuses the clients attention on the resistance by heightening his awareness & inviting an explanation Example: Client-This is the only time that I have peace of mind, now that we are divorced (but client is crying) Nurse-You said that..but I see that youre crying. 7. Suggesting collaboration (BQ) offering to work with client toward a goal making arrangement/agreement with the client Example: Nurse-Perhaps you & I can determine the source of your anxiety 8. Encouraging comparison asking client to verbalize similarities, differences & perceptions Example: Nurse-Was your experience similar to what had happened when you were 7 years old? 9. Formulating a plan of action (BQ) Example: Nurse-Next time you hear voices ordering you to kill, what will you do? 10. Giving recognition (BQ) Example: Nurse-Ive noticed you have combed your hair today. 11. Making observation commenting on what the nurse perceives Example: Nurse-Ive noticed that you are pacing the floor, you seem upset. 12. Role playing Example: Nurse-What will you tell me if I were your boss? 13. Focusing directing flow of interaction by pursuing a topic until its meaning is clear Example: Nurse-You were telling.. 14. Paraphrasing restating the content of message Example: Client-Maam, hes coming back Nurse-You mean that youre going to live together again 15. Offering general leads promotes freedom of response Example: Nurse-Where would you like to begin? 16. Summarizing pulling together the salient points of an interaction reviewing main points & conclusions Example: Nurse-For the last 30 minutes, we have been discussing. 17. Validation checking perception of clients verbalizations, remarks, feelings & plans

21 Example: Client-Something will happen soon, my husband & I are going to see each other soon Nurse-What you mean by saying that? Tell me about it Examination on Therapeutic Communication Techniques: 1. What makes you think the NBI is here? 2. Lets not talk about that now, just focus on getting.. 3. Is there something you would like to talk about? 4. Tell me when you feel anxious. 5. I think you should.. 6. Everything will be alright. 7. Have you had similar experiences? 8. This hospital has a fine reputation. 9. Who told you that you were Jesus? 10. Go on, I am listening, I hear what you are saying. 11. What do you mean by feeling sick inside? 12. Give an example of feeling lost. 13. You seem restless, I noticed you had trouble making decision about 14. I dont want to hear about it. 15. But Dr. R is very able Psychiatrist. 16. I will sit with you for a while. 17. Where would you like to begin? 18. Do you think I should tell the doctor? 19. Do you think you should..? 20. XXXXX N N T T N N T N N T T T T N N T T N T

Multiple Choice: 1. A patient says to the nurse, I want to tell you something but you must not tell anyone else. Which of the following responses by the nurse would be appropriate? Answer: I have to reveal anything that would be essential to your treatment 2. A patient who has Schizophrenia, Paranoid type says to the nurse, That guy over there is out to get me and you are one of them. Which of the following responses by the nurse would be therapeutic? Answer: You seem scared.. 3. Which of the following response by the nurse would be most appropriate when the patient states during admission interview on the psychiatric unit that she hears voices? Answer: What are the voices telling you.. 4. A patient was admitted to the psychiatric unit after she assaulted her landlord whom he believed was putting bad ideas in her head. When determining if the patient is ready for discharge, what would be most appropriate to ask the patient? Answer: What would you do if the situation comes up again? 5. XXXXX

22

January 22, 2006/1-5 Mrs. Lucy Espinosa, RN Principles of Psychiatric Nursing: 1. Acceptance: accept client unconditionally but reject maladaptive behavior 2. Anything which increases the clients anxiety should be avoided. Anxiety is a normal phenomenon and highly communicable & highly contagious that it can be transferred interpersonally (BQ) 3. Consistency can be used therapeutically to contribute to clients security Consistency means unchanging, uniformity or sameness Consistency & setting limits are building blocks of psychiatric nursing (BQ) Trust is the essential foundation of psychiatric nursing (BQ) According to Taylor, consistency is important because the client can anticipate the nurse decision Example: confused, manipulative or anti-social clients 4. Change in the clients behavior is not brought by reason but by emotional experience According to Mosby, change client by being the source of change, change agent by leading a good example or role model. Example: Social Learning Theory 5. Observation must be directed to the motivation of that particular behavior Know the reason/dynamics behind/pathology 6. Relationship with the client should be on the realistic basis Nurse should be honest and set limits Example: Client sad bad word, nurse should tell client that it is not accepted 7. Reassurance must be given subtly and in a manner acceptable to the client No false hopes and broken promises Simple presence shows assurance 8. Self understanding can be used as a therapeutic tool Joharis Window: sharing, listening and feedback Self-awareness Self acceptance Self understanding-longer process where nurse should know the whys & reasons behind clients feelings Example: Psychoanalysis and self disclosure 9. Unique personal contributions Example: Client holding thing or masturbating, nurse just leave him 10. Validate your observation Therapeutic Nurse-Patient Relationship (TNPR) Is a relationship between the nurse & client and the process, nursing needs of clients are met

23 BQ: Nursing need-a requirement on the part of the client which nurses are licensed to meet & it must be within the scope of nursing practice TNPR Social Relationship 1. Nurse to patient Friend to friend 2. Closeness to client but with limitation There is a degree of intimacy 3. Nurse cant select client Can select friends 4.Nurse is obliged to meet the nursing Not obliged to meet the needs of a friend needs of client but to a certain degree 4 Phases of Therapeutic Nurse-Client Relationship: 1. Orientation/Beginning Phase Aim: To establish trust The phase when the nurse establishes a contract (30 minutes to 4 days) regarding the duration of the relationship The phase when the nurse gives a realistic expectation, determines the immediate concern/problem/situation but to a broader scope or focus The phase when the start of introduction of termination. Termination is like a weaning process so it should done gradually, introduced/discussed every now and then during the interaction BQ: When do you start the termination phase of TNPR? Answer: Orientation phase BQ: Topics regarding the termination should be discussed in? a. Orientation b. Identifying c. Working d. All throughout the relationship Answer: D Expectations from the client during orientation phase: a. Silence-is the commonest among all forms of resistance; 200 or more meanings b. One word answer-client shows disinterest c. Tangential responses-client made a long story but no answer was given d. Circumstantial responses-client going around the bush BQ: During the orientation phase, you expect the client to be? Answer: all of the above, because all are forms of resistance BQ: What is the difference between tangential & circumstantial? Steps during Orientation Phase: a. Building trust warm, interest, concerns are conveyed with words and congruent body language confidentiality issues are explained b. Beginning assessment intake interviews, an assessment of clients needs, coping strategies, defenses and adaptation styles c. Management of emotions at the time of admission, the client typically experience painful emotions, so the nurse should talk about it directly to keep feelings from escalating

24 at first, the client may displace anger onto the nurse but if supportively confronted about the anger, the client is more likely to recognize the real source of his/her emotions d. Providing support like empathy e. Providing structure if client loses control of their thoughts, feelings or behavior, the nurse has the responsibility of taking temporary control by offering PRN medications directing the client to a quieter, less stimulating place and also includes spending time with him a major facet of providing structure is limit setting to decrease/stop dysfunctional behavior limit setting involves pointing out behavior and their negative effect and suggesting alternative behavior 2. Identifying Phase Aim: To maintain trust and relationship Client will test the nurses sincerity Client may fluctuate between dependence and independence Example: Client will come late, will never come or will never mind the presence of the nurse BQ: When can you tell the client establish trust? Answer: When the client calls you by your name, the client is accepting or acknowledging the relationship 3. Working Phase Aim: to identify coping styles There is clarification of perceptions and expectations about the relationship There is further definition of problems and identification of tentative solutions The client becomes more motivated to take advantage of available resources to resolve problems The phase that is hardest because trust was already established and client verbalized feelings Nurse should avoid giving advices instead use communication skills to encourage expression of feelings and interpersonal skills to maintain relationship The phase when the nurse evaluates, modify plans and handle issues of transference & counter transference BQ: During the working phase, the following are utilized except: a. remain supportive b. use observation skills c. identify coping styles d. give realistic expectation (orientation phase) Answer: D 4. Termination/Resolution Phase Aim: To prevent separation anxiety The phase that facilitates healthy closure of the relationship between the nurse and client The phase summarizes the gains of the relationship and the nurse endorses

25 Steps: a. Evaluation/Summary progress Reinforce the changes in and strengths of client Areas that need more work are outlined b. Synthesizing what has occurred Focuses on the more indirect outcomes of the NPR Clients are encouraged to form other relationships with future counselors and new friends c. Referrals d. Discussion of termination Process Recording a written record of encounters with clients that are as verbatim as possible and include situations that is actually based on previous experiences a documentation of the nurse-patient interaction that transpired during the establishment of TNPR a tool for the nurse to learn about working effectively with clients and establish the setting (interaction with the client) a learning tool that will facilitate professional growth usually done during the orientation phase set the objectives: 1. To meet/know the client 2. To introduce 3. To establish rapport/set a contract History: started in 1968 by Hildegard Peplau Purpose: 1. To identify the therapeutic communication techniques that were used 2. To describe the symptomatology including the defense mechanism that were exhibited/used by the client 3. To explain the nursing interventions Types of Process Recording: 1. Horizontal Name P.. Nursing inference CI remarks.. 2. Vertical Name of Patient (initials only). Pavilion General description (essay form): AG is a 14 y/o female adolescent admitted at Zonta Pavilion. She was wearing a pink hospital gown and was so eager in approaching me Learning objective (use SMART): At the end of 30 minutes of nurse-patient interaction, student nurse will be able to.. a. demonstrate a beginning rapport/trusting relationship with AG or

26 b. demonstrate the beginning skills in communication, observation.. c. describe/name/identify the behavioral symptoms including the defense mechanism that were exhibited by AG.. d. establish a contract e. specify the extent of the relationship f. use/apply nursing intervention through nursing process

Nurse-Patient Interaction

Student Nurse Inference/ Analysis & Interpretation N: Magandang umaga po Giving introduction made sincerely & coupled with the 5 aspects of physical attending such as.. will be very important in the beginning phase of the relationship Stuart 2000 said that the orientation phase can be challenging to the nurse because resistance will be obviously displayed by the client P: Did not answer, just Silence was chosen by the bowed his/her head patient

Clinical Instructor Remarks I agree with you in the same manner Taylor said..

I agree with you, I understand that the client was traumatized by previous incidence

Nurse Patient Verbal Non-verbal Verbal Non-verbal Nurse introduced herself and leads the way to the office, walking slowly but slightly ahead of the client. The client follows without looking at the nurse. In the office, the nurse sits in a chair at a desk and opens a folder of paper. The client sits at the side of desk; holding her purse with both hands on her lap. Would you prefer to Has pen in hand. (Pause) Anita Looking at the floor be called Mrs. Jarvis Other hand flat on or Anita? desk. Looking at patient. How long were you Writing and looking I dont know (same as above) feeling so tired? at patient (pause) a week. I guess What happen a Leans toward (Pause) My husband Tears in eyes week ago? patient. Move tissue (Pause) left

27 box Trust Fall Activity: emphasizes to develop empathy and trusting relationship Objective: To know that its difficult to develop trust and that its difficult to be entrusted with a mental patient Trust Walk: Team A (Blindfolded) Team B (Not blindfolded) 1. Gracie: fearful that I might fall Happy

PSYCHODYNAMICS Definition: understanding the motivations behind normal and abnormal human behavior Personality: comes from the word personane which means to sound through according to WHO, it is the sum total of ones physical, emotional, social, intellectual, spiritual and interpersonal well-being of a person it is the sum total of inherited (genetic) and acquired (environmental) traits (BQ) Two Portions of Human Personality: 1. Body/Soma-refers to tangible portion; can be seen and measured 2. Mind/Psyche-intangible portion; cant be seen or measured Example: IQ of Alfred Binet in 1904 According to parapsychologist, there is a 3rd portion of human personality which is the Soul or Spirit that remains upon the death of both body and mind. This theory is not accepted by psychiatrist. Three Levels of Consciousness based on the Psychoanalytical Theory of Freud: 1. Conscious compared to the tip of an ice cube in a glass of water according to Freud, it is compared to a dot it is a state of awareness, here and now, which operates only when awake material within an individuals awareness is only one small part of the mind 2. Preconscious/Subconscious watchman of the mind partly remembered/forgotten memories memories that can be recalled to consciousness with some effort and enough cue Example: Its at the tip of my tongue (BQ) 3. Unconscious material which is a large part of the mind

28 painful memories that could not be naturally recalled memories, conflicts, experiences and material that have been repressed and cannot be recalled at will storage of painful memories-selective recording of painful memories as early as prenatal stage of development Freud believed that uncovering unconscious material generate an understanding of behavior that enables the individual to make choices about the behavior and thus improve mental health

Three Methods of Recalling Unconscious: a. Psychoanalysis Sigmund Freud was the proponent and pioneered by Dr. Santiago in the Philippines a method of unlocking the unconscious from the past, unliquidated childhood experiences 4 Steps in Psychoanalysis: 1) Free association patient in a coach and analyst at the back of patient to prevent resistance in a dimly lit room in a therapeutic context, allow patient to say anything that comes to mind 2 things to be analyzed: word and dream analysis Evidences given by Freud to prove that there is free association/unconscious (BQ): a) Dreams are language of unconscious (unfulfilled), wish fulfillment , continuation of waking hours b) Freudian Slips are slip of the tongue or pen c) Jokes are unconscious intention d) Forgetting well-known names, phone #s, addresses e) Dropping objects 2) Transference is the clients feeling transferred to analyst which maybe (+)/(-) feeling intended to a significant person in the past (client-analyst) unconscious emotional reaction to a current situation that is actually based on previous experience if affected by client, terminate NPR during orientation phase if a basic RN and during working phase if a therapist then go to a clinical specialist 3) Counter transference is the feeling of the analyst transferred to the client due to empathy (a-c) 4) Catharsis-mental ventilation, sharing of repressed and unresolved memories, putting/unloading off the chest

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b. Hypnosis Anton Mesmer is the proponent and introduced by Fr. Jaime Bulatao in the Philippines A process of mesmerism and the suggested technique is mental trance c. Na Pentothal-truth serum in a process of narcosynthesis

3 Structures of Mind/Psychic Forces EGO SUPEREGO Man Angel Operates in conscious, Operates in conscious, preconscious, unconscious preconscious, unconscious but predominantly in but predominantly in conscious unconscious Operates in pleasure Operates in reality Operates in moral principle principle principle Untamed, uncultured and Mediator between ID & SE Censor/idealistic/perfectionist uncivilized (BQ), enjoys gratification provided by ID, decision making Present from birth until From erection to death resurrection Functions: operates on the Operates on secondary 2 Phases: primary process through process, a stabilizer 1. Ego-ideal=concept of right, hallucinations and culturally bounded (BQ: imagination another name for SE) 2. Conscience=concept of wrong ID Demon Operates in the unconscious BQ: Babies upon birth are purely ID, EGO evolves within the personality of 2 y/o (old concept) but Leticia Kwan new concept states that upon birth, baby must have both ID and EGO but ego is mostly affected by the babys significant adult. BQ: When can we have ID modified? a. when you are in elementary b. high school c. masteral d. never Answer: D, Id cant be modified

30 2 Stages in life Related in Superego Formation: 1. Anal (1 -3 y ears old) Child develops ambivalence=co-existing but contrasting feelings Start formation of superego (BQ) According to Mosby, ambivalence refers to independence vs. dependence According to Erikson, more on the adolescent stage of development Acoording to Freud, refers to love vs. hate 2. Phallic (3-6 years old) Superego becomes stronger Child loves parents of opposite sex and hates parents of same sex guilt SE The right time to tell an adopted child that he is an adopted At 7 years old, is called the age of reason where SE is fully developed Personality Theories: 1. Cognitive Theory Jean Piaget focused on the 4 major stages of cognitive development Highlight: knowing the world (BQ) 2. Psychosocial Theory Eric Erikson focused on the 8 stages of life cycle Highlight: focus on the different psychosocial crisis & developmental tasks During the early stage of life, we experienced psychosocial crisis (turning points) which should be resolved before moving on to the next stage, otherwise we develop fixation Fixation (BQ) is also known as developmental arrest (a stand still in the maturing process) Example: Stage 1-Basic Trust vs. Basic Mistrust, a child should develop this first before moving to Stage 2-Autonomy vs. Shame & Doubt 3. Moralistic Theory Karl Kohlberg focused on the 6 stages of moral development patterns a. Child-moral standards come from parents therefore parents should be role models because children are great imitators, takes in everything and it is longer for them to recover emotionally b. Adolescent-moral standards come from peer group c. Adult-his/her own discernment of what is right and wrong 4. Interpersonal Theory Harry Stack Sullivan: pioneered the theory Highlight: interpersonal relationships and anxiety facilitate development of the self system Mother and child relationship on the first year of life is the most important because early maternal loss is vulnerable to depression 5. Psychosexual/Libidinal Theory Sigmund Freud focused on the 8 stages of psychosexual development Highlight: focused on libido which is defined as sexual energy, itch, or where everything done repetitively is sexual in nature and its relationship to the development of personality

31

BQ: People with obsessive compulsive disorder had difficulty during: Answer: Anal phase BQ: Primary narcissism is seen during: Answer: Oral phase BQ: Period when family triangle is one: Answer: Latency

Age 0-18 months 1-3 years 3-6 years 6-12 years 12-18 years 18-25 years 25-45 years 45 years &

Different Stages of Personality Development PiagetEriksonSullivanCognitive Developmental Interpersonal Sensorimotor Trust vs. Need for Mistrust security & trust Pre-operational: Autonomy vs. Developing Pre-conceptual Shame and self-system Stage Doubt Pre-operational: Initiative vs. Development of Intuitive Stage Guilt body image and self perception Concrete Industry vs. Juvenile Era operational Inferiority Formal Identity vs. Early operational Role Diffusion Adolescent Era Formal Intimacy vs. Adulthood operational Isolation Formal Generativity vs. Maturity operational Isolation Formal Ego integrity Acceptance of operational vs. Despair responsibility for what life is

FreudPsychosexual Oral stage vs. Infancy Anal or Toddlerhood Phallic or Preschool Latency or School Age Genital or Adolescence Early Adulthood Middle Adulthood Old age

Kohlbergs Stages of Moral Development Pre-conventional: Emphasis Stage 1-might makes right Highlights/Significance: on avoiding punishments (punishment and obedience Children are egocentric & and getting rewards orientation) avoid punishment Stage 2-look out for number Recognition that others one (instrumental and have different points of relativist orientation views but childs own interest prevails

32 Conventional: Emphasis on social rules and conformity to social norms Stage 3-good girl and nice boy Stage 4-law and order Post-conventional: Emphasis on moral principles and values Stage 5-social contract and legalistic Stage 6-universal ethical principles Different Phases of Life: I. Intra-uterine Stage: 0 to Birth The start of life focused on the genetic influences and constitutional factors Highlights: The first trimester of pregnancy is the most important period because the intrauterine environment should be conducive for (+)/pleasant thoughts Communication should start early: talking to child while in the womb, listening to soft music that stimulates free flow of acetylcholine (Ach-a neurotransmitter for learning and memory) more intelligent child II. Oral Phase: Birth to 1 years old Also called as the Stage of Complete Dependence Infants should be given skin to skin contact 8 hours/day Chief Libidinal Areas are: mouth, lips and tongue Chief Libidinal Activities: 1. Sucking and swallowing: oral-passive phase 2. Chewing or biting: oral-aggressive phase Highlights: Narcissism is normal in this stage 1. If oral phase is overly gratified and infant is not weaned from breast to bottle feeding, it causes negative residuals such as: a. Alcoholism Psychopathology of alcoholism: 1) Emotional release 2) Emotional crutch-alcoholics are inadequate and insecure uses alcohol as substitute for the milk bottle Defense mechanisms: Substitution and Symbolism b. Over eating c. Talkativeness d. Gossiping e. Drug dependency/smoking/gum chewing 2. If oral phase is under gratified because (-) maternal-child bonding, it results to no basic trust Schizophrenia and Primary Narcissism (Self love) Living up to what people generally expect of one Child is oriented toward maintaining the society norm Fair procedures for interpreting and changing the law when unethical Recognition that some principles and values transcend laws

33

BQ: According to social learning theory, alcoholism is: a. learned behavior b. fixation at the oral phase Answer: A BQ: According to psychosexual theory, alcoholism is: Answer: B

III. Anal Phase: 1 to 3 years old (+)/(-) reinforcement, give love of understanding, To hold it on or let it go Chief Libidinal Areas: anus and urethra Chief Libidinal Activities: defecation and micturition Highlights: 1. If mother is too rigid/strict/perfectionist when imposing standards or during toilet training, it causes positive residuals. The child becomes ambivalent towards the mother but learns to accept mothers standards by letting it go. So, the child in adult life becomes obedient, reliable and responsible The child becomes overly neat, overly clean and very meticulous (BQ) When he grows up, he will develop obsessive compulsive trait obsessive compulsive personality disorder common among males and in USA Obsession is a repetitive abnormal/irrational thought though he knows that his thought is wrong while Compulsion is a repetitive abnormal act in response to obsession Obsessive compulsive disorder common among women and is worst than OCPD because social and occupational functions are affected Example: Wifes obsessive thought is the husband is a womanizer and her compulsion is to keep counting the pubic hair of her husband whenever hes late, hand washing, frequent fixing of bed and washing face 10 times before putting make up 2. If mother is too lax in imposing rules/no standard at all, it results to poor impulse control or no self control. The child shows negativism/resentment by feces retention or holding it on. Later in adult life, he becomes stubborn, unreliable and irresponsible. BQ #1: A child at anal phase will find gratification at what activity? a. definition of urination b. defecation and micturition c. defecation and voiding Answer: B, the term micturition is more scientific

34 BQ #2: What will you give a child for success in anal stage? a. give rewards for successful b. give punishment c. give love and understanding d. all of the above Answer: C BQ #3: According to Erikson, at the anal stage, the child experiences what? Answer: Struggle to hold it on or let it go

February 05, 2006/1-5 Mrs. Lucy Espinosa, RN Continuation of Different Phases of Life IV. Phallic Phase: 3 to 6 years old Came from the term phallus=penis; also known as the Period of Family Triangle because of a battle among the child, father and mother Chief Libidinal Areas: penis and clitoris Chief Libidinal Activity: normal infantile masturbation (BQ) which is a universal occurrence due to increase biological and sexual energy The child develops awareness, begins to examine and enjoys holding body and sexual parts. It is normal to see a child to experience voyeurism or peeping tom Sexual is ID so teach the child to sublimation: when you see a child playing with penis, turn negative to positive by doing constructive outlet such as play, sports activity or giving him toys This is a very crucial stage because resolution will determine future sexual role, whether becoming into a man or homosexual, woman or lesbian. Highlights: According to Freud, there are 3 Analytical Changes experienced normally by the child in this phase 1. Penis Envy for girls/Castration Fear or Anxiety for boys Penis Envy: a. At 2 years old, girl loves mother b. At 3 years old, girl loves the father because father has penis but girl hates mother because of fear that mother may cut the penis (the father) Castration Fear/Anxiety: a. The boy saw that his playmates were cut (through circumcision). He fears that he will be cut too, so he will develop the castration complex (BQ), a permanent idea. Seeing girls having no penis thinking that they were cut also results to continued threatening or adding up to his fear of being cut. Postpone circumcision between 3-6 years.

35 b. If castration complex still exist during adulthood, this leads to the psychopathology of exhibitionism where an exhibitionist is happy when he shocks women because it confirms he has penis 2. Oedipal/Electra Situation Oedipal Situation: The boy loves mother and hates father. Eventually, the boy admires attributes of father (according to Kuan, father should spend 10-15 minutes alone with boy) and identifies himself with his father so he gives up mother. In the absence of a father, the boy will become gay. Electra Situation The girl loves father and hates mother. Eventually, identifies with mother and gives up father. If unresolved, the girl will become lesbian Initially, both situations are experienced normally by the child but if it persists beyond adolescent stage it becomes a complex and considered abnormal. 3. Identification is the unconscious imitation of the feminine or masculine attributes unconscious attempt to model oneself after a respected person V. Latency Phase: 7 to 12 years old Also refers to as quiet or dormant period where the ID, Ego and SE are in equilibrium or stable; gone are the battle of Family Triangle Chief Libidinal Activity: tapering/lowering of the biological and sexual energy (BQ) The family triangle is gone because the focus of child is already with school The child introjects (to swallow) teachers ego-ideal Highlights: a. The child watches TV heroes and imitates what they do so hero worship is normal at this stage b. The child likes to interact with the peer of the same sex so homosexuality is also normally experienced VI. Genital Stage: 13 to 21 years old The first stormy period because the child is drawn towards and away from parents The child is fashion conscious, mirror reflex syndrome and has period of instability (thoughtful today, rude tomorrow) If he/she engaged in live-in relationships, its not love but more of lust The period when the child is vulnerable to mental disorders because of problems encountered: According to DSM IV, the age of onset for Schizophrenia=15-22 According to DSM IV-TR, the age of onset=10-25 years old Debut is a big celebration because it represents the victory of parents in guiding them: Female-18 years old; Male-21 years old Highlights: a. Social Status

36 A period of transition (too old to be a child, too young to be an adult): Who am I?; Where am I going? Parents should not be too strict or lax instead establish communication b. Gender Identification Period when you choose to be a man, homosexual, woman or lesbian The sexual preference is based on the experiences during the phallic stage Dyshomophilia: the guilt and anxiety after a homosexual practice (BQ) c. Ambivalence: Independence versus Dependence d. Oedipal/Electra Reactivation: it is normal to be close with the opposite parent until 17 years old VII. Vaginal Stage A non specific period and also known as high noon of life There is direct (+) feelings towards environment Also vulnerable to Schizophrenia Highlights: first sexual intimacy (#1 secret), selection of a mate/partner and psychosexual maturity is attained VIII. Menopausal: W=47; M=50 or gradual The second stormy period and also known as afternoon of life The period when mental illness also rises: depression Problem solving and decision making usually is a failure, unmatched sexual desire results to divorce (common in US) W=6 mcg progesterone; M=1000 mcg testosterone Highlights: Midlife crisis and empty nest syndrome BQ: Success of a menopausal stage is? Answer: Guide the next generation BQ: The following are considered normal menopausal signs except: a. Unreasonableness/irritability b. Hot flushes c. Palpitations d. Psychosis/Psychotic symptoms at times Answer: D IX. Senility: mid 70-80s according to Kuan Third stormy period and also known as the twilight years Most painful period of life Mental illness may also arise Defense Mechanisms: are psychological ways of resolving problems (BQ) used by both normal persons to avoid psychosis and by abnormal persons to cope with their mental disorder the ego uses these mental mechanisms unconsciously to reduce anxiety According to Taylor, one should avoid using defense mechanism because it leads to: a. Self deception b. You cant face the problem realistically

37 Taylor suggested: a. One should make use of coping mechanism which are conscious and healthy behaviors (ex. talk it out, pray it out, eat it out or sex it out) b. Use problem solving approaches or skills important in growth promoting potential and learning opportunities 2 Types of Coping Mechanism: a. Short term: suppression-conscious forgetting b. Long term-plan for any eventuality BQ: Defense mechanism for patients with phobia a. Denial b. Projection c. Displacement Answer: C

A. Narcissistic Defenses: 1. Denial Failure to accept an unpleasant reality Primary defense mechanism among alcoholics Example: A wife continuously sets the table despite the fact that her husband is already dead (BQ) 2. Projection Attributing ones thoughts, feelings, failures and frustrations towards others Initially, the person denies feelings then blames others Common defense mechanism among paranoids who manifest persecutory delusions (false beliefs that someone will harm/plot against him) BQ Example: You are the reason why I failed the examination because you frequently ask me to go with you in the mall B. Immature Defenses: 1. Identification Integrating attributes of an admired person to compensate perceived inadequacy Unconscious imitation of one idolized attribute of a person or admired attribute of a person Considered normal as long as it is something normal It becomes (+) if the idolized attribute is (+) Examples: A student nurse dresses like her teacher A student nurse acts like her previously admired chief nurse A 5 year old boy asks the barber to have a haircut like his father 2. Introjection Ingesting ego structure of another person becoming an extension of self

38 According to Keltner, it is incorporating the ideals & values of another person Common among depressed clients who commit suicide (70%) because depression is a pathological reaction to a loss (BQ) which may be real, imagined or symbolic (ex. a mother cant accept marriage of the son because she feels like not part of her life) Considered normal after a real loss when a person underwent the Stages of Grief Process by Elizabeth Kubler Ross completely: a. Denial-shock and disbelief few hours to few days only b. Anger-mad at God, to another person or at the world; acceptable and normal as long as it is sublimated c. Bargaining-asking for extension/something in exchange d. Depression-no longer interested with the environment e. Acceptance-accept the reality of the loss Allow the person with his own phasing in undergoing the grief process Sometimes the person can go back from one stage to another The person must undergo the experience of excruciating pain An unresolved/incomplete grief process leads to depression

A suicidal person is also a homicidal person (Suicide & Homicide-Siamese twins of Psychiatry) extended seaside Some people commit homicide first before committing suicide Example: A patient assumes the actions (emphasizes rules & regulations in the ward, beliefs, values) of the admired clinical nurse 3. Regression A return to an earlier stage of behavior when stress create problem at present stage where you find security Example: Assuming a fetal position when sleeping Sticking out the tongue during an embarrassing situation Hiding under the bed (like inside the uterus) Bed wetting (like an amniotic fluid) 4. Fantasy Dwelling into ones imagination Considered normal if can be recalled back to reality immediately and not excessive (if excessive, it results to delusions-false belief that cant be corrected by explanation) Example: Ministers wife daydreamed to become a rock star 5. Fixation Remaining stuck, failed to advance or arrest in developmental stage, standstill in the maturing process Example: Crying on ones father shoulder when faced a problem C. Neurotic Defenses: 1. Displacement Emotionally charged situation or object are shifted to a relatively safe substitute situation or object (pinagdidiskitahan)

39 Transferring of feelings to a safer object, person or situation Common among phobic where anxiety is detached from its original source and attached to a more specific activity 2. Dissociation An unconscious separation of painful feelings and emotions within an unacceptable object, idea or situation Anything that causes emotional problems and anxiety that are converted into psychological signs and symptoms Example: somnambulism (sleep walking), somniloquy (sleep talking) 3. Intellectualization Excessive use of logical reason/explanation to avoid painful situation instead of expressing the true emotions Also seen among OCD to avoid anxiety 4. Isolation Separating thoughts and emotions connected with an event to prevent undue anxiety (psychic numbing) Example: masking sadness by smiling at the funeral of a loved one 5. Rationalization Denial + Reason Justifying behavior by magnifying reasons that are publicly acceptable Attempts to explain behavior by logical reasoning or makes acceptable excuses for behavior and feelings If frequently used, one become a pathologic liar Example: Sorry class, I am late because its so traffic but the truth is she had a fight with husband BQ: A woman was window shopping and saw a beautiful dress but did not buy because she said it doesnt suit her complexion. The truth is she didnt have money to buy it 6. Reaction Formation Over compensation; what is involve is feeling Expressing the exact opposite of an unconscious feeling Unconsciously reverses unacceptable feeling and behaves in exact opposite manner Common among manic where they show happiness but deep inside they are sad Example: You say I love you but actually you wanted to kill him 7. Repression Involuntary exclusion from consciousness anxiety-producing thoughts, feelings and events Unconscious forgetting of painful ideas, events or conflicts According to Freud, most common defense mechanism used but others says rationalization 8. Conversion

40 Expressing unconscious emotional conflicts and anxiety into physical signs and symptoms Example: Hysterical fainting in funeral 9. Undoing Engaging in thoughts and actions to cancel out threatening thoughts and actions occurred in the past Involves a certain act-reverse re-enactment of a particular act Doing something that is opposite of a previous act with the involvement of guilt feelings Common among obsessive compulsive disorder Example: You have driven away your brother and now you accept visitors in your house with open arms 10. Withdrawal Pathologically isolating self away from others Example: Mental patients dont take a bath intentionally so that people wont get close to them to avoid a relationship, Husband left house for a while after a fight with wife

D. Mature Defenses: 1. Altruism Doing good for others with genuine desire, not waiting for reward, no guilt feeling Example: ABS-CBN/GMA Foundation 2. Sublimation Re-channeling socially unacceptable urges into socially acceptable manner Negative/undesirable things channeled into a desirable/positive Example: During sexual drive do sports instead Anger do gross manual outlet such as pulling out weeds in the garden 3. Suppression Voluntary exclusion from consciousness anxiety-producing ideas, feelings and situations Conscious/deliberately forgetting or intentionally avoiding discussing something Example: How is your husband? Answer: Please dont say bad words 4. Humor (Fun and Laughter) Laugh with the patient but not laughing at them Relaxation increases endorphins 5. Compensation Exaggerating a trait to mask up feelings of inadequacy and inferiority Emphasizing assets to fill up inadequacies Example: A young boy in college wants to be athlete but due to physical built he became a famous fashion designer

41 E. Other Defense Mechanisms: 1. Condensation Fusion of 2 or more ideals of ones idol into one totality Example: She sings like Nora Aunor but also includes attribute of her children 2. Substitution Taking in something in place of the original goal (panakip butas) Example: A girl spurned, so you take her best friend as a substitute 3. Resistance Instinctive opposition towards criticisms Ready answer to a negative feedback Commonest form of resistance-silence Example: Kahit ako mataba, hersheys chocolate naman kinakain ko. 4. Symbolism A mental short cut wherein a person attaches meanings to objects, colors, shapes and slogans Example: black butterfly-funeral; black letter-death; black cat-penis; red shirtlucky

February 11, 2006/1-5 Mrs. Lucy Espinosa, RN MENTAL DISORDERS based on DSM IV-TR prepared by American Psychiatric Association (APA) in 2002 Definition of Terms: 1. Symptomatology-the signs and symptoms of mental disorders 2. Psychopathology-defense mechanisms used Sisa-symbol of insanity in the Philippines Clifford Beers-symbol of insanity in the States St. Dymphna-Patron saint of the insane Signs and Symptoms of Mental Disorders: A. Sensory-Perceptual Disturbances Sensory stimuli are brought to awareness affecting the 5 senses Disturbances of Perception: 1. Hallucination-is a false perceptual disturbance without a stimulus a. Hypnagogic-happens when you are about to sleep b. Hypnopompic-happens when you are about to wake up Types of Hallucinations: a. Gustatory-experienced by patients with seizure disorder b. Olfactory-experience by patients with seizure disorder c. Visual-seen in Delirium tremens due to alcohol and Dementia

42 d. Auditory-common among Schizophrenics (BQ) e. Tactile-as in alcohol withdrawal (BQ) Reasons why we hallucinate: a. Psychosis-Schizophrenia b. Organic pathology-Seizure Disorder c. Chemical ingestion-when alcohol is taken for 7 days, non-stop & no food then suddenly stop, delirium tremens occurs: According to Taylor, DT occurs 16-36 hours According to Mosby, DT occurs 48-72 hours Ask patient when was his last drink (BQ) 2. Illusion-is a misinterpretation of a stimulus Example: Seeing small things as small rats because of anxiety to be late BQ: The following are not cognitive disorders except: Autism Delusion Persecution Apathy Answer: D, emotional disturbance

a. b. c. d.

B. Thought/Cognitive Disturbances goal directed flow of ideas, symbols & associations initiated by a problem or a task and leading toward a reality-oriented conclusion Disturbances in content of thought: 1. Delusions-false belief without stimulus which cant be corrected by evidences a. Persecutory-belief that someone will harm or kill him as in S. Paranoid b. Grandiose-belief of ones importance, wealth and power c. Somatic-belief of having misplaced organ or have a dreaded disease (Disorganized) d. Nihilistic-belief of non-existence or world is ending 2. Ideas of reference-false belief that behavior of others refers to oneself 3. Thought control-false feeling that one is being controlled by external forces Disturbances in form of thought: 1. Looseness of associations disorganized/fragmented flow of thought (sabog); no idea is derived seen among schizophrenia one of the 4 As of Schizophrenia: autism, ambivalence & affective disturbance (BQ) Example: Nurses are beautiful, cats are boastful , they are singing 2. Flight of ideas jumping from one topic to another spontaneously; you can derived an idea commonly observed among Bipolar patients on manic episode 3. Perseveration

43 repeating the same verbal response to various stimuli; patients can not detach one thought from another seen in schizophrenia Example: Saying the same thing to different questions; Sa labas, sa labas, sa labas 4. Neologism-coining of new words which has meaning to patient Example: Dethilating meaning death machine 5. Blocking-sudden stoppage of thought prominent in severe anxiety 6. Autism-thinking without conscious regard to reality, have their own world 7. Clang Association words are connected by sounds & not by meaning which include rhyming (poem-like) and punning (injecting witty/clever remark) 8. Echolalia-automatic obedience repeating the same words said by other (BQ) observed in dementia, autism & schizophrenia Example: Nurse says halika kumain ka and patient repeats halika kumain ka 9. Verbigeration-meaningless repetition of specific words or phrases; constant repetition of same words again & again Example: pangit, pangit, pangit 10. Volubility-increased thought seen among manic patients

C. Behavioral Disturbances Includes impulses, motivations, wishes, drives, instincts and cravings expressed by motor activity Behavioral disturbances: 1. Negativism-doing the exact opposite of what was told seen in Schizophrenia 2. Echopraxia-automatic obedience imitating the same act which were done by others seen in disorganized 3. Stereotypy-constant repetition of the same words and acts again and again (paulit ulit) even nobody said or did the act seen among autistic patients 4. Catalepsy-state of immobility (drama of death); pathological form of withdrawal; does not respond to stimulus Example: Patient dont eat, drink, move totally close, half close even in painful stimulus 5. Waxy Flexibility (Cerea flexibilitas)-maintaining the same position as positioned by others seen among Catatonic during stupor phase 6. Mannerism-habitual involuntary repetition of acts D. Affective Disturbances A complex feeling state with psychic, somatic, and behavioral components that is related to affect and mood 1. Mood-inner state of mind expressed through feelings; qualitative & subjective a. Dysphoric-unpleasant

44 b. c. d. e. Euthymic-normal range Mood swings Depress-sadness Euphoria-exaggerated feelings of well being Example: 2 bottles of beer f. Elation-inappropriate joyfulness with delusions of grandeur seen in manic (sobrang saya at yabang) g. Ecstacy-feeling of being in heaven; experienced in super sex with someone you love so dearly as in having orgasm 2. Affect-observed expression of emotions; external response to varied state of mood; measurable; quantitative & objective a. Apathy-state of indifference in situations wherein a normal person elicits a response (BQ); complete absence of emotion=scale 0 b. Flat-absence or near absence=scale 1 c. Blunt-severe reduction of emotion=scale 2 seen in post stroke patients Apathy, flat and blunt are seen in Schizophrenia & Depression d. Labile-mood swings or fast cycle of emotions seen in mania, dementia & intoxicated persons Example: Laughing at first then crying later e. Anxiety-a feeling of apprehension with a less identifiable cause (nababalisa) manifested like theres a lump in the throat (daga sa dibdib); chronic and hard to manage f. Fear-a feeling of apprehension coming from a more identifiable cause; acute and easy to manage Example: Fear at site of man g. Ataraxia-complete absence of anxiety in continuum seen in anti-social PD Example: Drink 1-2 bottles of beer gives you guts Drink 2-3 bottles of beer makes war h. Exaltation-a feeling of being glorified (BQ) Example: You worship me E. Memory function by which information stored in the brain is later recalled to consciousness Disturbances of Memory: 1. Amnesia: partial or total inability to recall past experiences a. Anterograde amnesia-forgetting recent events (kapapangyari lang-BQ); may have amnesia because of a traumatic event; seen in dementia Example: Wheres my ball pen? b. Retrograde amnesia-forgetting further events 2. Paramnesia: falsification of memory; telling false stories a. Confabulation-fabricating stories to fill gaps in memory because of anterograde amnesia seen in dementia but not in delirium b. Dj vu-familiarity with unfamiliar seen in neurotics Example: parang nakarating na ako dito

45 c. Jamais vu-unfamiliarity with the familiar d. Deja entendu-familiarity with sounds 3. Hypermnesia: exaggerated/excessive recall; detailed; seen among OCD Dementia: patient is usually disoriented to person, place & time (PPT) dementia due to head trauma is permanent symptoms last for more than 30 days Delirium: patient is usually disoriented to time and place only delirium due to head trauma is temporary symptoms is 30 days lesser disorientation to person is rare BQ: Tata Jose is known to be suffering from dementia was seen out of the clinical area by the nurse. Whats the nursing action? a. Orient him to time, place and person b. Hold him gently and guide him back to the clinical area Answer: B BQ: Tata Jose urinated on the floor. Whats the preventive measure? Answer: Instruct nurse to wipe wet floor for safety of patient

I. Disorders affecting Children, Infants and Adolescents Mental Retardation (MR): Is subnormal intellectual functioning which occurs before, during and after birth (less than 18 years old) Is not a mental illness but children with MR are susceptible to mental illness because of frustrations and failures resulting to depression A subnormal IQ, according to Alfred Binet (1904): Normal=90-110 Borderline=70 Mental Retardation=below 70 Multi-factorial/causal: 1. Before birth-mother takes teratogenic drugs like tetracycline, haloperidol and antimanic drugs (lithium carbonate); mother experiences emotional problems like crying, unwanted pregnancy and takes abortive drugs 2. During birth-hypoxia/anoxia to brain due to prolonged labor MR 3. After birth-after a traumatic experience MR 4 Classification of MR: 1. Mild/Moron IQ level: 50-69 Referred to as educable according to WHO Constitutes the largest segment about 85% Can reach up to grade 6

46 Susceptible to mental illness because of parents denies the truth so they force their child to continue studies 2. Moderate/Imbecile IQ level: 35-49 Referred to as trainable Constitutes about 10% of the entire population of MR Can reach up to grade 2-4 3. Severe/Idiots IQ level: 20-34 Constitutes about 3% Needs custodial/physical care 4. Profound IQ level: 19 and below Constitutes about 1% Needs constant aid and supervision Nursing Interventions for MR patients: 1. Assess the IQ level of the child by conducting IQ/Psychometric test 2. Analysis 3. Implementation: a. Emotional support to parents and child b. Never push the child, accept the stage where they are in and dont force to higher functioning because it may result to more frustrations retreating to fantastic world c. Facilitate optimal activity d. Mainstreaming of children with other regular children Nursing Diagnosis: 1. Altered family pattern/process 2. Risk for injury Autistic Disorder (AD): Also called Kanners Syndrome founded by Dr. Leo Kanner, a child psychiatrist A disturbance in social relatedness with cognitive and language deficit (may sariling mundo) May be due to lack of interpersonal skills (pakikipag kapwa tao) and disturbed social relation About 25-50% of AD are suffering from MR and 25% also have seizure disorder Diagnosis usually at 2-3 years old or 30 months when they already have playmates (BQ) Causes still unknown but multi-factorial: 1. Detached professional parent-parents are mechanical in providing care for children 2. Genetic vulnerability 3. Family adversity 4. Psychosocial adversity 5. Societal changes-poverty and child abuse

47 Mental Retardation 1. Affects both sexes 2. Low IQ 3. Multi-causal/multi-factorial Autistic Disorder 1. Seen among first born male 2. If without MR, above average 3. Unknown cause but with risk factors: a. Genetics b. High serotonin level c. Parents are usually high professional and care given to children is nonconveying of love 4. Gross abnormalities: a. Pica-eating non nutritive material b. Emotional outburst to minor stress like head banging c. Stereotype behavior like rocking d. Interest in inanimate bright spinning e. No eye contact f. Pronoun reversal where client addresses as you & other as I g. Echolalia h. Peculiar ways of expressing pain

4. Theres generalized delay in development but normal for stage where they are in: a. Chronological age is 18 but mental age is 8 years old b. Cognitive ability is up to grade 2 c. Responds emotionally like a normal 8 years old

Nursing Diagnosis: Family pattern disturbance

Nursing Interventions for Autistic Patients: 1. Assess 2. Analysis 3. Implementation: a. Safety is a nursing priority: protective care by setting limits b. All nursing personnel should be form & consistent c. Facilitate optimal ability whatever the patient can achieve only (BQ)- greatest nursing responsibility d. Need for love and belongingness e. Determine the underlying cause f. Reality orientation g. Family therapy h. Provide nutritional needs because refusal to eat indicates further regression i. Ignore temper tantrums j. Play with one child only Attention Deficit Hyperactivity Disorder (ADHD): A condition with the presence of inattention, hyperactivity and impulsivity in a child for more than 6 months: (BQ) 1. Inattention-the child cant complete an assigned task 2. Hyperactivity-the child takes 2-3 minutes for a child not to move

48 3. Impulsivity-the child hits/maltreats classmates Onset is before 7 years old Psychopathology: 1. Role of Nature (Genetics) a. Mild or subtle dysfunction of the frontal lobe responsible for motor regulation and concentration b. Perinatal insult c. Lead poisoning d. Hypersensitivity to food additives 2. Role of Nurture (Psychosocial) a. Parents who are alcoholic and suffering from mental disorders b. Child and sexual abuse c. Broken homes (unstable pattern) d. Family discord e. Urban dwellers-small space for the child to express energy & feelings Nursing Interventions for ADHD patients: 1. Assessment: assist the child to stop, look & listen before acting done by behavioral cognitive therapy-greatest nursing priority 2. Analysis: a. Risk for injury b. Altered parenting c. Family pattern disturbances 3. Implementation: a. Provide child training 1) Social Skills training through role playing & instructions by assisting the child in recognizing the impact of ones behavior to develop empathy on the child 2) Problem Solving Skill training because child misinterprets actions of others (Ex. Teach the child how to borrow things so that he wont hit others when they object his snatching of things from them) b. Provide parent training-they should be given new ways of understanding the illness and new ways of responding to the illness through: 1) Self Awareness Enhancement (SAE)-develop genuine feelings 2) Teach parents creative Stress Reduction Techniques (SRT) 3) Provide clear limits regarding unwanted behaviors 4) Positive reinforcement like point system or giving reward to the child 5) Mild punishment like time out, face the wall for 5 minutes 6) Allow child to have discussion of feelings Treatment Modalities: 1. CNS Stimulant a. Methylphenidate (Ritalin/Concerta): 1) a family of diexydrine 2) given immediately before, during or after meals because it is an appetite suppressant (BQ)

49 3) given 4-6 hours before retiring because of its side effect-insomnia (BQ) 4) Side Effects: insomnia, mood swing, lack of appetite & hypervigilance or over focused 5) Dose: 10-60 mg BID (8 am & 12 noon) b. Pemoline (Cylert): a form of amphetamine, slow acting, hepatotoxic & obsolete 2. Non stimulant medication: Stratera (Atomozotine)-very expensive 3. Selective Serotonin Reuptake Inhibitor (SSRI), third generation anti-depressants: child had chronic depression stress reduction like deep breathing, modified autogenic techniques 4. Neuroleptics: given on low dose for children who have psychosis March 04, 2006/1-5 Mrs. Lucy Espinosa, RN II. Cognitive Disorders all mental illness have organic pathology & with neurotransmitters involved are formerly called as Organic Brain Disorders which refer to disorders with known cause or Organic Brain Syndrome which are clusters of symptoms with unknown cause (BQ) these are disorders that affect the clients PORMA: P -Perception: presence of hallucination which is usually visual O -Orientation: disorientation to person, place & time R -Reasoning: problem in reasoning because of memory disturbance M -Memory: disturbance in memory causes anxiety on the part of the client A -Attention Memory-is the foundation of all this cognitive process 3 Main Types of Cognitive Disorder: 1. Amnestic Disorder with memory loss (most recent) caused by general medical condition, toxic agents or carbon monoxide poisoning Example: inability to learn new activity or information 2. Delirium-alteration in ones consciousness 3. Dementia characterized by gross cognitive abnormalities a progressive cognitive impairment which affects I AM JO: I -Insight: awareness of ones illness A -Abstract thinking or reasoning M -Memory J -Judgment: Theres an envelope on the floor. What will the client do? Examples: Normal person-Ill pick it up & return it to owner Antisocial-Ill open it & maybe theres money in it Paranoid-I wont open it & maybe theres an anthrax Dementia-Cant judge what to do with the envelope O -Orientation Differences between Delirium and Dementia (BQ): Delirium Dementia Only for a few hours to a month More than a month

50 With moments of lucidness & confusion Acute, temporary & reversible No fluctuation b/w lucidness & confusion Chronic, permanent but maybe reversible or irreversible: 1. Reversible-caused by inflammatory condition (encephalitis), infection or alcoholism 2. Irreversible: a. Dementia of Alzheimers Type-if detected early & treated with Aricept (Donepezil) that controls destruction of acetylcholine, neurotransmitter for memory b. Vascular or Multi-infarct Dementiafound on stroke victims Not good prognosis because mortality Gradual in onset & progressive in course happens within a year Symptoms of Delirium: Symptoms 1. Disorientation 4 As of Dementia (BQ): 2. Extreme anxiety & restlessness a. Amnesia-anterograde to retrograde 3. Confusion b. Aphasia-difficulty in naming persons & 4. Clouding of consciousness objects (left brain problem) 5. Visual hallucinations & delusions c. Agnosia-difficulty in recognizing 6. Undressing persons and objects 7. Playing with food d. Apraxia-difficulty in executing motor 8. Grabbing at others activities due to destruction of Ach Causes of Delirium: Cause: unknown 1.Prescriptive drugs-even within the 1. Predisposing Factors: therapeutic level will compromise the a. Aging: age related illness: Central Cholinergic System (CCS), a >Usual onset:60 y/o as early as 40 system for balance of acetylcholine >discovered by Alois Alzheimer, a (Ach) production German pathologist who studied the Example: Patient takes paracetamol, brain of a 50 y/o female then antacid then take steroid for >Findings: having allergy avoid poly pharmacy 1) Alzheimers tangles now called 2.Chemicals: alcohol neurofibrillary tangles that appears insecticide dense because of aging process pesticide 2) Senile plaques (ameloid deposits) 3. Head trauma: electrolyte imbalance may b. Neurobiological: create delirium effect 1) acetylcholine 4. General Medical Condition like: 2) Genetics-transmitted from parents Pneumonia, uremia and CHF to offspring Malaria falciparum 2. Precipitating Factors: a. Hypoxia- RBC common among pilots, stewardess & with asthma causing anemia where there is less O2 supply and ACH

51 b. Metabolic-DM & other metabolic dis. c. Toxic agents-aluminum salts and those who use aluminum foils d. Infections-meningitis e. Structural-common among boxers because of punch drunk syndrome f. Sensory-common in ICU clients because of frequent stimulation leads to ICU psychosis g. Non specific stressors-frequent stress cortisol destroys ACH Nursing Intervention for Delirious Clients: A. Assess B. Analysis (Nursing Diagnosis): 1. Risk for Injury 2. Anxiety 3. Disturbance in Sleeping Pattern Nursing Intervention for Demented Clients: A. Assessment: 1. Memory loss 2. Poor judgment & insight 4. Inability to think abstractly 5. Disoriented to time, place & person B. Analysis: 1. Risk for Injury 2. Alteration in Family/Thought Process 3. Sensory Perceptual Disturbances 4. Self Care Deficit C. Interventions: * Facilitate optimal ability of clientgreatest nursing priority 1. Safety-nursing priority a. well lighted rooms because of the symptom Sundown Syndrome (agnosia and visual hallucinations) which is worst in the evening b. non slippery floor > personality accentuation OC > personality change regression c. provide handrails or side rails 2. Short & concrete directions should be given-the easier to understand, the better 3. Family involvement by: a. Education as to expectations and symptoms, let the family know that patient has anterograde amnesia and dont give false hopes b. Management of guilt feelings by allowing family to express their

C. Interventions: *Maintain Life-greatest nursing priority or responsibility 1. Remove the cause-treat infection, withdraw from alcohol drinking & avoid polypharmacy 2. Manage symptoms judiciously, using right judgment, through nursing care and use environmental manipulation (keep room temperature at most appropriate level, draw curtains, dim lights & soft music induces sleep) 3. Provide emotional support and physical comfort 4. Administer anti-oxidants: Vitamin E, carrots & other fresh sources

52 feeling 4. Flexible activities: a. give unstructured activities because of their lability b. help them in grooming, feeding, exercise, interaction, small group activities In contrast with Schizophrenics where structured activities is advised because they are failure prone & fearful 5. Reality orientation: a. place a big wall clock with big #s b. place calendar with big letters & # c. put name on bed d. dont disarrange or touch patients things e. dont say the word remember because its non therapeutic 6. Reminiscence therapy a. Use of photo albums to facilitate life review therapy (BQ) that will enhance their memory & reduce loneliness 7. Encourage self care & teach activities of daily living (ADL) 8. Pet therapy because pets can give unconditional love 9. Consistent caregiver-frequent changing of caregiver adjustment produces anxiety to patient (BQ) Consistent environment-prevent over stimulation or under stimulation of environment not so noisy, crowded and quiet 9. Wandering due to disorientation, restlessness, boredom & need for exercise a. Safety b. Provide ID bracelet with alarm (which sounds at 100 meter distance) c. Chart with photo on file d. Alternative outlet for energy 10. Medications: a. Tacrine (Cognex) b. Donepezil (Aricept) c. Anti-oxidants: Vitamin E

53 d. Non-steroidal anti-inflammatory e. Metabolic Enhancers & Vasodilators: Hydergine f. Anti-depressants BQ: Youre new to clinical area and youre asked to administer medicines to a demented patient but was not sure of his identity. Whats your nursing action? c. ask co-worker to administer the medicines d. ask co-patient about the patient e. go to the chart and see the picture Answer: C Impairment in the Activities of Daily Living (ADL)based on the Stages of Alzheimer Level of Impairment Patient has difficulty with Mild Balancing checkbooks Preparing complex meals Managing a difficult medication schedule Moderate Simple food preparation, household clean up, yard work, some aspects of self care Severe Personal care, feeding, grooming & toiletry Profound Patient is oblivious to surroundings & totally dependent on care givers Terminal Patient is bed bound requiring constant care III. Mood Disorders Based on the Statistics of NCMH: 80% Schizophrenia 10% Substance Related with Psychosis 06% Mood Disorders (Diseases of the Rich) 04% Autistic Diseases Predominant Feature: Clients mood or emotions There are Two Extremes of Emotions: 1. Too little: client suffering from depression-despair and lethargy 2. Too much: client suffering from elation-vehement energy (manic) In some instances, clients thoughts and behaviors (inability to concentrate, ambivalence, indecisiveness, pessimism, self destructive thoughts and confusion) are affected due to mood In severe form of depression, the 1st symptom is psychomotor retardation=slowing down of speech, thought and activity. Likewise, decision making to commit suicide is hard to undertake because they dont have the psychic energy to do it. Hence, suicide is rare in severe depression because of psychomotor retardation. Suicide usually occurs when client shows signs of improvement (bright facial improvement or cheerful with no reason), the nurse should be on guard because client tends to commit suicide Depressed Elders Depressed Adolescents

54 1. That is it 2. No warning at all 3. lethal method 1. Ambivalent Cry for Help 2. With warning 3. lethal method

Two Types of Mood Disorders: A. Depressive Disorder-main symptom is depression only 2 Main types of Depressive Disorder: 1. Dysthymia (neurotic depression) for more than 2 years often than not the client experiences depression a diagnosis of chronicity and not the severity 2. Major Depression Depression is the predominant feeling of sadness or loneliness which covers the entire life of a person Types: a) Psychotic depression-with hallucinations & delusions b) Postpartum depression-occurs within 30 days postpartum (BQ) c) Seasonal Affective Disorders (SAD)-occurs during winter & fall common among European countries

Depression An abnormal, pathological reaction due to a loss: real, imagined or symbolic From an ambivalent relationship, theres always guilt feelings depression Prolonged Marked by self-blaming Usually endogenous

Grief Process A normal response to a normal or real loss From a harmonious relationship Short period: 6-12 weeks 3-6 months in USA 1 year for Filipinos Grief is resolved when client recalls (+) & (-) experiences with the loss without pain or anger Exogenous (its reactive coming from environment)

Psychopathology of Depression: 1. Role of Nature: in S erotonin (regulates sleep wake cycle & mood) oatmeal rich in Serotonin A drenalin D opamine N orepinephrine (also known as noradrenaline) 2. Role of Nurture: Anger is the universal symptom of distress Defense mechanism used: Introjection

55 Depressed individuals internalized hostilities turned inward to himself prone to commit suicide According to Payne, in depression the ego capitulates (surrenders) to a strong SE (punitive and rigid) while in mania, has a stronger ID

9 Criteria of Depression: Symptoms exist for more than 2 weeks that meet 4 or 5 of the criteria 1. Feel worthless, guilty, helpless and hopeless 2. Feel tired, weak and low in energy & motivation 3. Have trouble sleeping (insomnia) or too much sleeping (hypersomnia) In dysthymia, the problem is on onset of sleep; appetite, sex In psychotic depressed, the problem is on terminal insomnia 4. Loss of appetite or overeats In psychotic depressed, appetite, sex libido, weight 5. Have problems concentrating, remembering or making decisions 6. Think or talk about suicide 7. Cry more easily than usual 8. Have physical symptoms such as HA, stomachache or backaches) without organic origin 9. Feel restless and unable to sit still

Nursing Interventions: 1. Assess: 9 Criteria 2. Analysis: a. Risk for violence-directed both to self and others b. Chronic low self esteem c. Chronic isolation d. Ineffective coping e. Altered nutrition f. Sleep pattern disturbances 3. Implementation: a. Safety of Patient & Relatives (most importantly his loved ones)-a nursing priority because patients commit homicide first then suicide due to introjection b. Prevent suicide: S ingle -in USA=single, living alone & unemployed S upport system -none S uccess -depression S ex -Male: less attempt, successful suicide -Female: more attempt, successful suicide U nsuccessful attempts I dentification with the person who had suicide C hronic I llness D rugs: Hypotensive agents because it depletes NE, Ach & serotonin

56 Example: Reserpine and amphetamine A ge of person or AIDS: 1) Male adolescent-ambivalent; suicide is a cry for help, not decided yet 2) Elders-increasing & more successful because once they decided, its final; they dont express their intent; use high lethal method L ethality: or likelihood of suicide 1) Male: uses high lethal method; Example: hanging 2) Female: uses low lethal method; Example: slashing, taking poisons Hanging maybe prevented by: male wall must be waist up while in female wall must be up to shoulder 2 levels of Suicide Prevention in USA: 1) Level I-Undertaken when the client signs a non suicide contract (NSC), RN rounds every 15 minutes 2) Level II-Client refuses to sign NSC; one on one guarding; dont leave the patient alone In the Philippines, 1) Remove hazards 2) Make frequent irregular rounds because during patients lucid intervals they observe your time of rounds 3) Suicide is usually committed early in the morning; 8 out of 10 suicidal give warnings; commit suicide 7-9 months after the start of depression Kind firmness-the best attitude therapy. Provide a boring task like ask patient to sweep floor, ask patient to count seashells. If he makes a mistake, ask him to recount until he get bored & angry with you because of the boring job. Then congratulate patient when hes able to get angry because its a success that hes able to express feeling Remoralization-give simple praises & compliments after doing an activity, lower standards for them to encounter success because patients are demoralized Cognitive restructuring or reframing-I am now a survivor. I can do it. Because patients always blame themselves (I am the I to be blame), faulting & hopeless Avoid daytime napping

c.

d. e. f.

Treatment Modalities: 1. Electroconvulsive Therapy (ECT): a positive treatment alternative given to depressed patients so that he will be amenable to psychopharmacology. Therapeutic Effect: unknown According to other theories, ECT gives a feeling that patient died already and it releases guilt feelings patient is freed of sin already Voltage Used: as low as 90-110 volts Modified ECT: a. Patient is given Succinylcholine (Anectine), a muscle relaxant (BQ) After administration, nurse should have a prepared artificial respiration (O2) because the lung muscle may be paralyzed Given to manic and patient with grand mal seizures, it gives a calming effect

57 b. Give atropine S04 c. Anesthesia Side Effects: a. Temporary amnesia b. Confusion c. Disorientation d. Headache e. Weight gain Nursing Responsibility after ECT: Orient patient as to person, place & time by performing-Stoop down, make an eye contact, grasp hand & say Im Msyour nurse, its 11:00 am & youre in Pavilion II 2. Psychopharmacology: Anti-depressants has a therapeutic effect after 3-4 weeks so watch out for the possibility of suicide once mood changes after 4 weeks of treatment (BQ) a. Tricyclic anti-depressants (TCA) 2 Main types (also used in NCMH): 1) Imipramine HCL (Tofranil) 2) Dotheipin HCL (Prothiaden) Side Effects: Cardiac arrhythmiaMI Death Anti-cholinergic effects: nasal congestion, blurring of vision, constipation, hyponatremia, dry mouth Urinary retention (BQ) Edema Mania states because TCA acts on NE Insomnia because TCA acts more on NE BQ: The patient asks the nurse to allow him go out on pass in the hospital to see his ophthalmologist. What is the nursing action? Answer: Tell patient that blurring is a temporary effect of TCA b. Monoamine oxidase inhibitors (MAOI) Second generation drug that inhibits destruction of monoamines, a neurotransmitter Examples: 1) Tranylcypromine (Parnate) commonly used in USA parnate cheese syndrome; hard to administer because of dietary restrictions a) No to tyramine rich foods like aged cheese, parmesan & edam cheese because it develops hypertensive crisis manifested by occipital headache. Only fresh, cottage & white cheese are good for patients b) No to aged meat like ham, bacon & pizza c) No to over ripe fruits & vegetables d) No to caffeine containing food & beverages e) No to poorly refrigerated food f) No to decongestants & asthma tablets g) No to pickles & fermented food

58 2) Phenelzine (Nardil) c. Selective serotonin reuptake inhibitors (SSRI) Third generation drug that inhibits reabsorption of serotonin Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Seroxat) d. Selective serotonin norepinephrine reuptake inhibitors (SSNRI) Examples: Venlafaxine (Efexor or Effexor), Thioridazine HCL (Melleril)-are antipsychotic drug for anxiety, depression, tension, sleep disturbance & agitation SSRI & SSNRI are more on anticholinergic effect observe in atypical neuroleptics SSRI & SSNRI Side Effects: 1) Constipation- fluid intake 2) Temporary blurring of vision 3) Temporary nasal congestion-drink lots of water 4) Dry mouth-in USA, they give hard candies or bubble gum

B. Bipolar Disorder-alternate between mania and depression Types: 1. Bipolar I-with episode of mania, hypomania and depression; can reach the fullest arc of 2 pendulum parts: mania & depression; rapid cycling or sometimes it takes days 2. Bipolar II-with hypomania and depression; no mania because it cant reach the fullest arc; attenuated hypomania 3. Hypomania-mild form of mania; client is evaluative & keeps on comparing; never go into introspection; great spender; sexually promiscuous and result to substance abuse because of sleep pattern disturbances Signs and Symptoms of Mania: 1. Excess in everything a. Excess make up & adornment for female and growing of moustache & beard for male=mask or camouflage of depression First manifestation of bipolar male patients-mania First manifestation of bipolar female patients-depression b. Hyperkinesis=more elated more tired exhaustion sudden death which can be explained by the biological mechanism of mania: SAD Ne hyperkinetic (sobrang likot) electrolyte imbalance cardiac arrhythmia death c. Excessive sex with new acquaintances=engage in sexual intimacy with new acquiantances d. Inflated self esteem=mayabang

59 e. Excessive spending=great spender f. Impaired judgment Have distractibility because of too short attention span (BQ) Manic patients flatter you as soon as they meet you, hello guys but will leave you as soon as they meet another person They go into outburst of song & laughter Distractibility can be used therapeutically (BQ) because when patients are seen fighting, stop them and they will forget about the fight Staff splitting Manipulative & irritable Limit testing-manic patients try to play with your self esteem so nurse should do testing within 30 minutes Monopolizer Flight of ideas Delusions of grandeur

2.

3. 4. 5. 6. 7. 8.

Psychopathology of Mania: 1. Role of Nature (Biological basis): SADN Ne 2. Role of Nurture (Psychodynamic basis): Defense mechanism: Denial Laughing outside but crying inside: Reaction Formation Internalized hostilities (anger) turned outward environment violence Elation is a defense against underlying depression (denial) appears confident but basically over dependent or outgoing but actually self centered. When demands are frustrated hostility repressed depression According to Payne: mania=ID stronger while depression=SE Nursing Diagnosis: M ood elated A grandiose delusion N eed to sleep & eat I nappropriate C langing loud & vulgar -Risk for violence -Altered nutrition -Impaired verbal communication

Nursing Interventions: 1. Find an acceptable outlet for their excessive energy due to Ne BQ: What therapeutic outlet should a nurse use to manic patients? Answer: Let them join a square dance because there are directions to be followed during the dance 2. Remember that the environment affects their elation Simplify clients environment by reducing stimuli: a. white or cream curtains & avoid red b. wear pale colored clothes c. voice should be lowered & well modulated 3. Feed manic patients with finger foods which they can carry CHON and CHO to compensate for their energy consumption

60 Example: cheeseburger BQ: How to feed a manic patient? Answer: Serve food in the run 4. Use matter-of-fact attitude: consistent, firm & no demand because manic patients are manipulative if patient becomes assaultive, surround him in small circle to prevent assault to a single person or focus anger on one of you if patient is armed, ask him to drop it on the floor & not to hand it to you lesser # of person=lesser stimuli=lesser agitation Treatment Modalities: 1. Mood stabilizers: Lithium carbonate (Quilonium R in PI or Lithane in USA) L evel I ncontinence T hirst, thyroid H and & tremors I ncrease fluid U nsteady M ania, Morton salt Wait for 7-10 days for its therapeutic effect Patient must be given Haloperidol or Risperdal first while waiting for the effect because patient may die of exhaustion If patient is in lithium, no diuretics (BQ) should be given. It is given only if theres already toxicity Monitor Na intake of patient: Na= LiCO3 lithium toxicity (hyponatremia & hypokalemia) characterized by: L BM E xcessive thirst & voiding N ausea & vomiting A norexia C onvulsion Na= LiC03 no therapeutic level but dont Na intake Therapeutic level : Give 3-6 grams of salt & 3000 cc of water Acute Stage: give 1-1.5 mEq/L and 0.6-1.2 mEq/L for maintenance Toxic: 1.5-2.0 mEq/L 0.3 margin of safety 2. Anti-convulsants: also found to have mood stabilizing effect a. Carbamazepine (Tegretol) causes Steven-Johnsons disease b. Valproic acid (Depakene) 3. Beta blockers: Propanolol 4. Atypical neuroleptics: Olanzepine (Zyprexa)-newest & latest drugs found to have mood stabilizing effect

61 IV. Schizophrenia and other Psychosis termed as Sakropenia in NCMH; cancer of mental disorders most devastating & most severe of all mental illness because of wide variety of symptoms Definition: is characterized by a disturbance in thoughts, feelings, behavior and perception for more than 6 months: Thoughts-autism, looseness of association and delusion Feelings-ambivalence and affective disturbance Behavior-regression and withdrawal (going back to childhood) Perception-hallucinations usually auditory Classification: 1. Brief Psychotic Episode: psychotic symptoms for a few hours to 4 weeks (a month) 2. Schizophreniform: psychotic symptoms reach for 6 months 3. Schizophrenia: psychotic symptoms are more than 6 months BQ: Dante is sleepless for 4 days, doesnt eat and dress up for 2 weeks. 4 months PTC, he doesnt go to school anymore because he thinks that his classmates are talking at his back. What is his diagnosis? Answer: Schizophreniform disorder 4 As of Schizophrenia by Eugene Bleuler: 1. Autism-------------------2. Association is loose thoughts 3. Affective disturbance--4. Ambivalence------------- feelings 2 Prominent Defense Mechanisms used by Schizophrenics: 1. Regression-dancing like a kid, painting the wall with feces, bathes self with urine and trichotillomania (symptom of chronicity) 2. Withdrawal-not taking a bath, waxy flexibility Psychopathology: A. Role of Nature (Biological theories) 1. Biochemical-two big dopaminergic systems are responsible for the wide variety of positive symptoms of Schizophrenia: a. one dopaminergic system distribute dopamine to the brain b. the other distribute dopamine to the spinal cord 2. Neurostuctural-increased cerebral blood flow in the frontal lobe of the brain, enlarged ventricles, neuronal loss and brain atrophy (5% brain weight) attributes to the negative symptoms of Schizophrenia 3. Genetic-patients with schizophrenia seem to inherit a predisposition to the disorder B. Role of Nurture (Psychodynamic theories): seeds of mental illness are sown in childhood inadequate ego development, lack of nurturing attention in the earliest

62 years, role of family in the causation, strong association between schizophrenia and low socio-economic status 1. During the Oral phase-failure to establish trusting relationship with mother child cant invest emotional energy outside self develops primary narcissism if purely anxiety laden home (lots of fighting), child withdraw away from reality. 2. During the Phallic phase-failure to develop sexually resulting to confused sexual role and latent homosexuality (closet queen) C. Vulnerability-Stress Model: recognizes that both biological and psychodynamic predisposition to schizophrenia when coupled with stressful life events can precipitate a schizophrenic process 1. Depression related to schizophrenia-as the symptoms begin to subside, 25% of patients experience a post psychotic depression which is a natural part of schizophrenia that is masked during the acute phase of the illness and some drugs used to treat schizophrenia also produces depression 2. Relapses many patients will experience relapse and remission of symptoms throughout their illness patients most likely to suffer a relapse are those having frequent face to face contact with family who has high expressed emotion index, exposed to stressors and those not given antipsychotic medications 3. Substance abuse-is the most common co-morbid psychiatric condition associated with schizophrenia 4. Work-lack of work, inability to work and lack of a desire to work are all features of schizophrenia 5 Clinical Types of Schizophrenia: 1. Paranoid Most dangerous and hardest to convince that they are sick Essential Features: a. Presence of one or more delusions that are fixed, well organized & systematized persecutory leads to aggression a psychiatric emergency case or maybe grandiose brought by experiences of ridicule at home b. Frequent hallucinations that are usually auditory Incidence: a. Onset: 30 years and above; DSM IV=15-25; DSM IV-TR=10-25 years old b. Single or if married, separated c. Male d. With high IQ-gainly employed but dont stay in one job for a long time Symptoms: a. Extreme withdrawal-usually seen at the back of the door or wall, does environmental scanning before going in a room, crosses arms & stands sideways, no eye contact, highly suspicious because of Ne b. Unfounded jealousy-example: sewed the vagina of wife c. Highly critical & sarcastic-avoid competition Nursing Intervention for Risk of Violence: a. Assess b. Nursing Diagnosis:

63 1) Risk for violence 2) Altered thought process 3) Sensory perceptual alteration 4) Altered nutrition 5) Fluid volume deficit 6) Social Isolation c. Implementation: 1) Distance-client hates too much closeness (BQ); nearest distance 4 feet 2) Best attitude therapy: Passive friendliness; wait for the non verbal cues of the patient; all undertakings should be gradual (BQ) 3) Never whisper when talking, it should be within the hearing range of the patient; never touch them; never hold complicated instruments around them 4) Solitary activities like painting that will need close concentration to remove delusion-never let patient go into group activities & competitive activities 5) Remotivation Technique: to motivate patient to move again from their fantastic world back to reality so talk about nature, occupation, history or sports and never about family problems, politics or religion 6) Feeding-Let the patient to get first his own food tray inside the food cart according to Saunders (BQ) or can give sealed containers if available

2. Disorganized Formerly known as Hebephrenic (Goddess of Youth) More common in women Worst form of Schizophrenia Signs and Symptoms: a. Has disorganized thought: flat affect (apathy-manhid or bato), somatic delusions (ex. buntis ako, theres smoke or rat in my stomach) b. Has disorganized behavior: regressed infantile behavior (ex. holds vagina), silly behavior (eats vaginal secretion, paints feces on the wall or make feces into meatballs), silly smiles & giggles like a kid & witch 3. Catatonic 2 Phases of Catatonia: a. Catatonic stupor waxy flexibility-patient would experience physical discomfort than talk so nurse should prevent edema & cyanosis of lower extremities (BQ) catalepsy (motoric immobility)-pathologic form of withdrawal b. Catatonic excitement-theres impulsive behavior without external stimulus due to auditory hallucinations about their sexuality Nursing intervention: to prevent injury 4. Undifferentiated No prominent symptoms of paranoid, disorganized or catatonic Main symptoms are delusions & hallucinations

64 Delusions change or vary as compared to paranoid which is fixed or unchangeable 5. Residual No more positive symptoms (presence of unusual thoughts, perceptions & behaviors like hallucinations & delusions) dopamine More with negative symptoms (absence of what should be) dopamine a. Avolition-absence of a goal directed or voluntary activity b. Apathy-absence of feeling c. Anhedonia-absence of pleasure d. Alogia-absence of words e. Akinesia-absence of movement Nursing Interventions for all types of Schizophrenia except Paranoid: A. Assess-the symptoms are not due to cognitive disorders or drugs B. Analysis-same with paranoid type C. Interventions: 1. Attitude therapy: Active Friendliness (tender loving care) 2. Foster trusting and meaningful (one on one) relationship 3. Be honest, not intrusive and highly professional 4. Structured activity that are stimulating, stress free & provide support group 5. Bridge contact with reality

Guidelines in helping all kinds of Patients: 1. Accept the patient 2. Enhance their self esteem 3. Provide support 4. Protect them from embarrassment 5. Avoid failure & competition 6. Handle them realistically 7. Project environmental self control Treatment Modalities: 1. Use Psychotherapy a. Individual=nurse-patient relationship b. Group=small group meetings where personal problems are discussed 2. ECT-best for depressed patients 3. Activity Therapy 4. Social Therapy-milieu therapy 5. Psychopharmacotherapy: Anti-psychotics (BQ) or neuroleptics that are formerly known as major tranquilizers or ataractics a. Typical neuroleptic-cheaper but has more side effects dopaminergic activity; it completely blocks the pre-synapse of dopamine but create a hyperdopaminergic activity & also produce Hobonamic acid that gives metallic colored skin & a peculiar odor secreted in saliva, skin, urine & semen. 1) Chlorpromazine (Thorazine, Proma, Laractyl)

65 Sedating but less potent; given at 6 pm (usually an hour before sleeping to use it positively) Side Effects: a) Sedation is considered a SE but is used to help patient go back to a quality of life b) Postural or orthostatic hypotension is a major SE so there is risk for injury and to prevent this SE: Monitor BP before giving personal grooming Make sure floor is dry Let patient sit on bed first & dangle feet before standing up Let patient do all activities while still up so that he wont stand again when hes already lying on the bed c) Photosensitivity-patient should avoid direct contact or exposure to sunlight because they develop sunburn (BQ) d) Metallic colored skin e) Bleeding gums (agranulocytosis) f) Neuroleptic Malignant Syndrome (NMS)- a life threatening SE where patient develops uncontrollable fever even when given antipyretics, body rigidity, dyspnea, convulsions, VS death 2) Haloperidol (Haldol, Serenace) Potent but less sedating; given at 8 am & 1 pm Side Effects: same as a) to d) of chlorpromazine and Extrapyramidal Syndrome (EPS): a) Dystonia Appears on the first 24 hours characterized as robot like, oculogyric crisis (rolling of eyeball), protrusion of tongue, drooling of saliva due to difficulty & pain in swallowing, very tense muscle, opisthotonus Pain all over the body=pain of tongue (bumaligtad ang dila) blockage of airway death Nursing Responsibility: Give medication immediately as a doctor standing order to allay patients anxiety b) Akathisia-motor restlessness, continuous stomping of feet in one place (padyak ng padyak, parang may langgam sa paa) c) Parkinsonism-pill rolling movement of hands, mask-like face (appears constipated) d) Tardive dyskinesia-an irreversible SE even if medication is given described as an involuntary & repetitious movements of the muscle of the face, limbs & trunk such as: Involuntary mastication Involuntary lip smacking Involuntary rolling of eyes Involuntary muscle movement Involuntary protrusion of tongue (worm like protrusion)

66 BQ: Patient has a tardive dyskinesia, what should be your nursing action? Answer: Give medication & refer to MD Medications for EPS: a) Amantadine (Symmetrel) b) Biperiden (Akineton)-given in USA c) Diphenhydramine (Benadryl) d) Benzotropine (Cogentin) e) Artane-eradicated in hospital because commonly used by drug addicts in patients with parkinsonism because it makes you instantly drunk b. Atypical neuroleptic-novel, newer, expensive but less SE; have selective neuroleptic activity; can still give dopamine to some receptor sites & other selected receptor sites that are lacking with dopamine 1) Clozapine (Clozane in USA; Leponex in Philippines) Considered wonder drug in 90s Patients should be subjected to blood examination weekly for 18 weeks then monthly thereafter (BQ) Side Effects: Agranulocytosis (gum bleeding, sore throat & fever) 2) Risperidone (Risperdal) 3) Amisulpride (Solian) 4) Quetiapine (Seroquel)-good fo insomniacs 5) Ziprasidone (Zeldox)-from malady to melody 6) Olanzepine (Zyprexa) V. Substance Related Disorders 2 Main Types: 1. Substance related use disorder a. Substance abuse-ingesting substances causing family, societal, legal and occupational problems that may go to substance dependence b. Substance dependence (formerly known as addiction)-a maladaptive pattern of ingesting substances causing compulsions (psychological need), cravings (subjective desire), tolerance (gradual increase of the dose to get its desired resultBQ) and withdrawal (physical need)symptoms 2. Substance induced disorder a. Substance intoxication b. Substance withdrawal Alcohol Related Disorders: Blood alcohol level concentration: (+) Alcohol breath=0.06%-0.08% toxic screening for alcohol in USA (+) Alcohol breath=0.10%-0.15% toxic screening for alcohol in Philippines Lethal dose=0.45%, if BALC exceeds this dose, theres a tolerance Alcohol is the 3rd cause of death in USA Effects of Alcohol: CNS depressant (BQ) Initially, alcohol reaches the inhibitory center of the brain causing depression of inhibitory center uninhibited or heightened spirit (ataraxia) more alcohol

67 intake euphoria lowering of SE forces when it wears off shame & guilt because of guilt and wants to forget will go back to the alcohol resulting to vicious cycle of drinking Physical consequences of alcohol: 1. Hangover: 4-6 hours after heavy drinking caused by accumulation of acetaldehyde and HCL in the blood gastritis, palpitations, pounding headache, nausea & vomiting Mgt: Give patient black coffee and let him sleep in a quiet room because alcohol is absorbed & excreted slowly by the body 2. Black out (passing out): anterograde amnesia after heavy drinking (BQ) 3. Acute alcohol withdrawal: hangover, tactile hallucinations, uncontrollable marked tremors, seizure or rhum fits and no delirium the nurse should anticipate the occurrence of withdrawal symptoms by asking for the last time patient drink 4. Delirium due to alcohol According to Mosby, it occurs 48-72 hours Clouded consciousness, disorientation, paranoia, visual hallucinations and with delirium (confusion to place and time only) A fatal condition because patient may die of cerebral edema hence, it requires immediate hospitalization 5. Dementia of the Korsakoffs type: product of chronic alcoholism Nursing Interventions for Delirium due to Alcohol: 1. During the Acute Phase while patient is confined in the hospital Ask the patient, when was his last drink? Give Thiamine or vitamin B1 to prevent dementia (BQ), Magnesium SO4 to prevent convulsion, Vitamin C to detoxify, Valium for safe sedation with BP precaution Observe for shock and fever Place patient in mechanical restraints 2. Matter of Fact Attitude: best attitude therapy It means the use of prescribed attitude-firmly consistent, unified approach, objective and non judgmental Use confrontational strategy 3. Alcohol Free Environment BQ: What can be allowed in the room of an alcoholic? a. Rubbing alcohol b. Mouthwash c. Shaving lotion d. Shaving set Answer: D, electric and has no sharps 4. Detoxify clients through Aversive (to remove) Technique

68 A form of behavior modification technique BQ: Peping was ordered to have detoxification. What must the nurse do? a. Conceal the medication b. Explain the procedure c. Get the patients feeling regarding & before detoxifying Answer: C Give Disulfiram (Antabuse), an alcohol sensitizing substance which stabilizes the acetaldehyde and HCL acid BQ: What does it mean of patient has good understanding about antabuse? If in a party, what will you order? a. 30 cc brandy b. 30 cc red wine c. Glass of fruit juice Answer: C 5. Re-socialization Because alcoholics have very poor self esteem, they should join self help groups using group pressures as the therapist Alcoholic anonymous (AA)-for recovered alcoholics ALATEEN-for teenage children of recovered alcoholics ALANON-for families of recovered alcoholics because wives are codependents (enjoys being masochist) & enabler (covers up husbands actions) Defense mechanisms used by alcoholics: denial, rationalization and projection Nursing Diagnosis: Altered family process Ineffective individual coping Nursing Interventions: 1. Confrontational strategies-You have an alcohol breath again 2. Matter-of-Fact: point out consequences of behavior-I am sorry. The next time I smell you having alcohol breath, you wont be allowed to get out of the clinical area 3. Help client postpone gratification 4. Educate patient & relative 5. Provide support groups or self help groups like Narcotic Anonymous 6. Lifestyle changes 7. Therapeutic Community gives responsibilities Drugs: 1. Amphetamines-uppers; speed Examples: a. Methamphetamine HCL-shabu, sha, bato, ubas & siopao b. Phentermine resin (Ionamin)-appetite depressant c. Dexedrine (Dexis, Bencis)-given for ADHD d. Reactiven-taken by students who are reviewing e. Reductyl-relative of amphetamine produces acute psychotic-like symptoms that closely resemble schizophrenia, paranoid

69 experiences persecutory delusion which is also a predominant symptom of schizophrenia, paranoid withdrawal of amphetamine leads to crashing (withdrawal symptoms of painful, sad, very lonely to the point patient commits suicide in USA, rich clients use ice which is the more expensive kind of amphetamine and crack by poor clients Symptoms of Amphetamine Intoxication: T achycardia E vident weight loss P erspiration & chills P upillary dilatation P sychomotor agitation E levated blood pressure C onvulsion Symptoms of Amphetamine Withdrawal: F atigability I ncreased appetite-a rebound effect V ivid hallucination I nsomnia P sychomotor retardation & agitation

2. Cocaine-uppers Cocaine was discovered before the advent of anesthesia and coca cola was believed to contain cocaine Examples: f. Basulca-pure cocaine or coca paste which is sniffed or through IV g. Speedball-cocaine + heroin h. Hell-phencyclidine + cocaine i. Crack or Rock or Smoked cocaine an adulterated mixture of cocaine + water + baking soda produces a crackling sound at boiling point cheaper, potent & fast acting and easily available withdrawal symptom: crashing-difficult to handle because of the emotional pain experienced described as excruciating & agonizing leading to commit suicide or going back to cocaine use. the cardinal symptom of cocaine use: red excoriated nostril (BQ) because the drug is snorted or sniffed vasocongestion blood vessel breaks 3. Cannabis (Marijuana)-hallucinogen the Philippines is the #1 producer of marijuana

70 taken from an Indian hemp plant: Cannabis sativa 2 Types: a. Marijuana (damo)-dried leaves or the upper part of the plant is rolled into cigarette producing a sweet smelling smoke; not prohibited in Cambodia b. Hashish-leaves soft portion or upper part (very expensive) is pounded to produce a thick resin-like exudates=tetrahydrocannabinol (active ingredient of marijuana) BQ Effects: 1) Euphoria-mild effect 2) Hallucinations if taken in large amount 3) Perceptual distortions on time & space if moderate amount is taken: Time passes so slowly (faulty perception) Thinks distance is wide but in reality its close already Thinks height is still low though its high Perceives sound which are loud as soft Cardinal Symptoms: red eyes, cravings for junk food, dry mouth No dependence but causes compulsion

4. Hallucinogens Lysergic Acid Diethylamide (LSD)-a relative of ecstasy; morning glory seed Ecstasy Effect: a. Good trip-psychedelic & euphoric effect (very, very happy, more on feelings); sexually active, erection of penis for a week; produces tolerance b. Bad trip-patient goes into threatening hallucinations (too horrifying, they see monsters) 5. Inhalants Cardinal symptom: smell of a dead necrotic tissue (smell of halitosis) Vulnerable to respiratory diseases, nose is eroded with maggots (uod) Effect: feeling that they can fly, no thirst, no hunger pangs Used in very poor countries, rugby wrap in banana leaves, thinners (it cooks the lungs) & solvents 6. Sedative & hypnotic-downer Sedatives are given in small amount while hypnotics are given in large amount Barbiturate are given for a long period of time around 8 months & in large doses then taper gradually because sudden withdrawal causes respiratory depression, apnea, psychosis or sudden death In NCMH, epileptic patients are given Na dilantin (Phenytoin), an anticonvulsant, mix with Phenobarbital to prevent status epilepticus Carbamazepine (Tegretol) is commonly use nowadays for epilepsy, mania, trigeminal neuralgia, diabetic neuropathy BQ: What drug causes sudden death when stopped at once? Answer: Barbiturates

71

7. Opioid Derivatives-downer N arcotics: mixed with analgesics to counteract cancer pain; the raw material is used as cough suppressant; it acts also as anti-diarrheal C odeine: used as cough syrup M orphine & M ethadone: imported, expensive, synthetic and legal drug to lower withdrawal symptoms (BQ) H eroine & Hydromorphone Opioid Withdrawal Symptoms (According to occurrence): A nxiety: First stage C old-like or flu-like symptoms: Second stage-lacrimation, yawning & sneezing A bdominal cramps: LBM N ausea & vomiting 8. Phencyclidine (PCP) or Angel Dust Hogs because it is elephant tranquilizer PCP + alcohol family violence Effects: impulsiveness, unstableness 9. Caffeine: 250 mg (a cup) Brewed coffee-100 mg; Tea-40 mg; Chocolate:10-15 mg; Instant coffee-65 mg Intoxication: rumbling flow of thoughts, palpitation, frequent urination and eventually brain atrophy

VI. Anxiety and Other Related Disorders Definition: there is a high level of apprehension and development of behavioral pattern to avoid anxiety (BQ) Chief Predominant Symptom=Anxiety (fear of dying) + depression (prone to suicide) Behavioral Pattern=Rituals & Phobia Psychopathology of Anxiety: 1. Psychobiologic aspect of stress & anxiety: (Role of nature) a. GABA-an inhibitory neurotransmitter associated with relaxation response b. Serotonin c. Norepinephrine-is an excitatory neurotransmitter responsible for cardiovascular changes during stress & anxiety and prepares body for fight or flight response 2. Psychodynamic of Anxiety: (Role of nurture) a. According to Otto Rank: anxiety is due to birth trauma where intrauterine environment is the most favorable place to prevent anxiety; put baby in mothers chest after birth & breastfeeding to birth trauma

72 b. According to Sigmund Freud: anxiety is due to repressed ID repressed anger & unreleased sexual drive anxiety c. Defense mechanism: Repression & Symbolism Levels of Anxiety based on Keltners Definition: 1. Mild: +1 or + Theres total focus, attention, motivation, perceptual field No need for defense mechanism but only adaptive coping 2. Moderate: +2 or ++ Theres partial focus, selective inattention, physical pain, keeps on complaining Can be therapeutic with supervision & used palliative coping (watching TV) 3. Severe: +3 or +++ Theres scattered focus, mental block, psychological pain, decision making & problem solving are hard to do Uses defense mechanism like conversion & make use of maladaptive coping 4. Panic: +4 or ++++ Theres wild (homicide) & desperate (Suicide) behavior Dysfunctional coping is used BQ: During panic level, do the following except: a. Be alert b. Stay calm c. Encourage problem solving Answer: C

Normal Within the world of reality so there is resolution of crisis Restored homeostasis

Aware of reality

Anxiety With same amount of stress but resolution of crisis markedly prolonged to Can return to equilibrium Handled by psychiatrist as outpatient Mild symptoms Ignores reality Builds castle in the air

Borderline Resolution of crisis is outside of reality & within the reality of world Does not go back to normal equilibrium

Psychosis Reality disregarded (disorganized) Deteriorating Handled as inpatient Severe symptoms Denies reality, substitute a fantastic world Resides in the castle in the air

73 Defense mechanism: Displacement Undoing Obsessivecompulsive Psychotherapy Anxiolytics Pathological defenses: Projection Introjection ECT Neuroleptic

Subtypes of Anxiety Disorder: 1. Generalized Anxiety Disorder (GAD): Excessive generalized non specific fear, constant worry & apprehension occurring for more than 6 months There is feeling of impending doom, danger or catastrophe Symptoms: a. restlessness, feeling keyed up or on edge b. being easily fatigued c. difficulty concentrating, irritability d. sleep disturbance, muscle tension Nursing Interventions: a. Assist patient in developing adaptive coping responses-ultimate nurse goal b. Teach the client to: 1) Be kind to self & appreciate self 2) Be less critical of self 3) Maintain high self esteem 4) Share feelings when upset or restore self esteem when lowered 5) Identify physiological symptoms of anxiety 6) Manage stress with diet, exercise, rest, sleep & relaxation 7) Realize that some anxiety is part of living Types of Coping Adaptive Description Solves the problem that is causing the anxiety. The client is objective, rational and productive Normal Use Anxiety about the upcoming examination is reduced by studying effectively & passing the examination with a grade A Anxiety is temporarily reduced by jogging. Effective studying is then possible and a grade of a is still achievable

Palliative

Maladaptive

Temporarily decreases the anxiety but does not solve the problem and anxiety eventually returns. Temporary relief allows the client to return to problem solving Unsuccessful attempts to Anxiety is being ignored by decrease the anxiety going to a movie and then without attempting to solve handled by frantically

74 the problem the anxiety cramming for a few hours. remains A passing grade of C is obtained Is not successful in reducing Anxiety about the anxiety or solving the examination is ignored by problem. going out, drinking and then Even minimal functioning escaped by passing out. becomes difficult and new A grade of F resulted problems begin to develop

Dysfunctional

2. Phobic Disorder Irrational fear of a specific object, activity or event Anxiety detached from original source & attached to specific object Patient knows it is irrational & abnormal but if not entertained produces anxiety Types: a. Agoraphobia-fear of being in public or open spaces or situations where escape could be difficult or impossible; worst among the phobias because it results to house bound syndrome b. Social phobia-fear of being humiliated, scrutinized or embarrassed in public c. Simple phobia-fear of specific object or situation like fear of animals, flying or heights Example: School phobia-the most common among all phobias; fear is due to separation anxiety from leaving the mother; type of phobia wherein parents can be legally implicated (USA) bring the child to school immediately to avoid fixation (behavior therapy) d. Coitophobia-fear of coitus e. Misophobia-fear of dirt Defense Mechanism used: Displacement Treatment: Behavior Therapy a. Systematic desensitization (BQ)-gradual introduction of the feared object b. Flooding (Exposure/Implosive by D. Wolfe)-sudden introduction of the feared object c. Self exposure treatment 3. Panic Disorder Panic attacks: a. usually occur suddenly, unexpected & with no obvious precipitating factor b. accompanied by intense fear or discomfort c. lasting for hours after an attack d. it may be severe, frightening & incapacitating e. may occur in anticipation of or upon exposure to a trigger is an attack that lasts for an hour, reaching a peak in approximately 10 minutes accompanied by:

75 a. physiologic symptoms: racing heart, chest pain, dizziness & nausea, DOB, choking sensations, numbness & tingling sensations, trembling & diaphoresis b. feeling that one is having a heart attack c. feeling that one is going crazy d. fear of loss of control e. decreased perceptual ability f. decreased cognitive abilities Etiology: a. Genetically transmitted b. Induced by caffeine, carbon dioxide or Na lactate c. Biologic vulnerability-irregularities in synthesis & release of Ne, receptor hypersensitivity to serotonin or GABA Nursing Interventions: a. Stay with the patient during the attack b. Maintain calm demeanor c. Speak in short simple sentences d. Provide brown bag for hyperventilation e. Do not touch the patient during the attack 4. Post Traumatic Stress Disorder (PTSD) is re-experiencing a traumatic event through flashback, nightmares & depression occurring for more than 6 months Differentiated from: a. Normal Stress Reaction-last for a whole day then function is resolved b. Acute Stress Disorder (ASD)-resolves within 4 weeks or a month c. Adjustment Disorder-symptoms occur within 3 months but not more than 6 months after an identifiable event like separation, retirement, sudden marriage, child rearing demands; more severe than normal stress & grief process but less severe than ASD & PTSD Normal grief process can not adjust Adjustment Disorder can not adjust PTSD can not adjust Psychosis: Schizophrenia or Depression Symptoms: a. Exaggerated startle response b. Sleep disturbances c. Guilt d. Nightmares & flashbacks e. Anger with numbing of other emotions f. Patients often use drugs, alcohol or self medicate for distressful symptoms 5. Obsessive Compulsive Disorder (OCD) Obsessions are recurrent & persistent thoughts, ideas, impulses or images that are experienced as intrusive & senseless Compulsions are repetitive behaviors that are performed in a particular manner in response to an obsession & performed to prevent discomfort & neutralize anxiety

76 OCD patients recognize that the thoughts are products of their own minds & they know that they are ridiculous or morbid but cannot stop or control them therefore the thoughts become distressful & anxiety provoking OCD patients perform rituals which are coming from guilt laden conscience to relieve anxiety Defense Mechanism used: undoing Nursing Interventions: a. Allow patients to do their rituals b. Set limits if it is already affecting physical integrity c. Provide alternative that will entail perfections like folding linens d. Behavior therapy: also known as exposure treatment where OCD patients are exposed to feared stimuli & then resist the urge to perform rituals Nursing Interventions: A. Assess B. Analysis or Nursing Diagnosis: 1. Anxiety 2. Ineffective Coping C. Implementation: 1. Determine if it is really anxiety 2. Determine the level of anxiety 3. Determine the source of anxiety 4. Determine own anxiety (on the part of the nurse) 5. Provide an outlet like relaxation techniques, stress reduction techniques, deep breathing exercises, fun & humor 6. Show empathy like It must be difficult on your part 7. Provide a non-stimulating environment 8. Provide assertiveness technique due to low self esteem making him responsible for his actions & decisions 9. Anger Management

VII. Dissociative Disorders there is removal from conscious awareness of painful feelings, memories, thoughts or aspects of identity there is removal from consciousness of a highly traumatic event there is splitting off, walling off or alteration of ones consciousness the conscious, preconscious and unconscious must function as a unitary whole during a highly traumatic event there is splitting of conscious from preconscious & unconscious to have emotional stability & if splitting does not occur psychosis develops Etiology: 1. Trauma 2. Sexual & physical abuse in early childhood

77

Types: 1. Dissociative amnesia-theres loss of memory of important personal events that are traumatic or painful 2. Dissociative fugue sudden, unexpected travel away from home or work with a loss of memory about the past confusion about identity or assumption of partial or completely new identity is present takes one personality only Purpose of fugue: to carry out what the ego desires but what the SE prohibits meaning ignoring reality 3. Dissociative identity disorder formerly known as multiple or split personality because there is presence of two or more identifiable personalities that take control of the persons behavior loss of memory for important personal information change of personality is dramatic patients are confined because there are instances that the alter ego will commit suicide 3 faces of Eve:1) Eve-host; does not know the 2 alter 2) Eves alter 1-good eve (SE) 3) Eves alter 2-bad eve (ID) Treatment: do insight oriented through hypnotherapy causes staff splitting 4. Depersonalization experiences of feeling detached from or an outside observer of ones body or mental processes reality testing is intact (oriented to time, person or place)

VIII. Somatoform Disorders formerly known as psychosomatic disorders included in anxiety disorder are a group of disorders where patient unconsciously manifest bodily signs and symptoms without organic basis (or an adequate medical explanation can not be found) compared to malingering which is consciously manifesting physical complaints to achieve personal gain (BQ) commonly seen among patients with antisocial personality disorders 5 Specific Somatoform Disorders: 1. Somatization Disorder is characterized by frequent, recurrent, multiple physical complaints that may warrant medical treatment or even surgical intervention

78 defense mechanisms used: repression, displacement & denial patients do doctor shopping for 2 years (Doctor Shopper) onset is usually before 30 years old theres multiple areas of pain 2. Pain Disorder is characterized by symptoms of pain where theres only one localized area and site does not change 3. Hypochondriasis is characterized by somatic preoccupation, worry of having illness or fear of having serious illness based on misinterpretation of symptoms fear of getting illness (makukuha) fear of having the illness (meron na) Obsessive-compulsive disorder hypochondriasis defense mechanisms used: repression & regression patients are usually narcissistic nearest to psychosis 4. Conversion Disorder is characterized by one physical disability (BQ) which will be on the voluntary muscle or sensory function example: student has paralysis of the upper arm during examination 5. La Belle Indifference (BQ) is characterized by unconcerned over the physical disability & enjoys being sick because patient has primary (anxiety is relieved) and secondary gain (sympathy, attention & material rewards) Nursing Interventions: 1. Accept the patient in emotional pain 2. Anticipate needs so as not to feed on secondary gains 3. Be non judgmental because they are really suffering from physical distress Medications: 1. Antidepressants 2. Anxiolytics

IX. Psycho-physiological Disorders also known as psychosomatic disorder or psychological factor affecting medical condition are physical diseases in which emotional factors play a very important role Psycho-physiologic disorders Physical diseases Involuntary muscles (smooth muscle) Male expresses physiologically stresses Somatoform disorders Merely physical symptoms Voluntary muscles (those in contact with external world) psycho- Female expresses stresses symbolically

79 If emotional condition is not treated or resolved, it may lead to structural damage or life threatening event Defense Mechanisms: 1. Projection 2. Displacement 3. Psycho-physiologic regression No organic pathology or sometimes with a pathology but the somatoform signs and symptoms are inappropriate Defense Mechanisms: 1. Repression 2. Conversion 3. Displacement 4. Denial Nursing Interventions: Same with anxiety disorder plus the following 1. Reduced demands on client 2. Care for the total person both physical as well as emotional 3. Anger Management 4. Stress Management Technique 5. Teach client assertiveness training 6. Encourage expression of feeling X. Personality Disorders Personality is defined as the totality of emotional & behavioral traits that makes an individual unique becomes inflexible, maladaptive & rigid causes significant functional impairment or subjective distress personality disorders are disorders wherein the individual does not adjust to life instead exhibits behavioral problems are inflexibilities to various life situations clients show deeply ingrained & maladaptive patterns which start as early the time SE formation client dont mature, dont learn from their experiences and dont find their behaviors distressing to themselves because of others reactions or behaviors towards them feel distressful causing immense emotional pain and discomfort. Psychopathology: 1. Product of broken homes-resiliency; not capable of deep lasting relationship 2. Unstable or inconsistent family pattern (Father is lenient & mother is strict) 3. Family uses double blind communication: one message is sent with 2 meanings, verbal is different from the non verbal meaning 4. Low frustration tolerance Causes of Conduct Disorder (< 15 years old) Antisocial Disorder (> 15 years old) -------------------------------------------------------------------------------- Psychological Neurobiological Lower Socio-economic status 1. Chaotic Family dynamics 1. Genetics Media violence 2. Lack of parental empathy 2. Temperament Substance abuse and affection Disturbed parent-child 3. Faulty ego structure (SE) 3. Neurobiological relationship (rejection and 4. Learned behavior dysfunction chronic interaction)

80 -------------------------------------------------------------------------------- Behaviors associated with Conduct Disorder 1. Aggression to people & animals-cruelty & disrespect 2. Destruction of property-fire setting 3. Deceitfulness-stealing & lying 4. Serious violations of rules-running away from home & truancy Classification of Personality Disorders: Cluster A Cluster B Behaviors: Odd Behaviors: Dramatic Eccentric Emotional Erratic 1. Paranoid 1. Antisocial 2. Schizoid 2. Borderline 3. Schizotypal 3. Histrionic 4. Narcissistic Cluster A: Paranoid (Suspicious) Major Feature: Pervasive distrust and suspiciousness of others Schizoid (Asocial) Major Feature: Pervasive pattern of detachment from social relationships Indicated by 4 or more of Indicated by 4 or more of the following: the following: 1. Suspects without 1. Lacks desire, neither sufficient basis enjoys close relationships 2. Doubts trustworthiness or 2. Chooses to be alone loyalty 3. Lacks sexual experiences 3. Reluctant to confide and 4. Avoids activities fear that it will be used 5. Lacks close friends against him 6. Appears indifferent to praise or criticism 4. Interprets remarks as demeaning or threatening 5. Holds grudges 6. Reacts angrily when he perceives attacks on him 7. Recurrent suspicion as to fidelity or sexual partner Defense Mechanism: Projection Treatment: 7. Cold, detached or flat affect Cluster C Behaviors: Anxious Fearful 1. Avoidant 2. Dependent 3. Obsessive-compulsive

Schizotypal (Eccentric) Major Feature: Pervasive pattern of social & interpersonal deficits Indicated by 5 or more of the following: 1. Ideas of reference 2. Believes in superstitions, clairvoyance, telepathy or 6th sense 3. Unusual bodily illusions 4. Vague, circumstantial or metaphorical speech 5. Suspiciousness or paranoid ideation 6. Inappropriate or constricted affect 7. Odd, eccentric or peculiar behavior 8. Lacks close friends 9. Excessive social anxiety Treatment:

Defense Mechanism: Fantasy Treatment:

81 1. Individual Psychotherapy 1. Individual Psychotherapy 2. Behavior Therapy 2. Group Therapy 3. Pharmacotherapy: 3. Pharmacotherapy: a. Anti-anxiety agentsa. Anti-psychotic Diazepam (Valium) b. Anti-depressant b. Anti-psychoticc. Psychostimulant Thioridazine (Melleril) Pimozide (Orap) Nursing Interventions: 1. Foster trust by being non intrusive 2. Show empathy 3. Gently encourage participation in social activities Cluster B: Antisocial (Aggressive) Main Feature: Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years Indicated by 3 or more of the following: 1. Against societal norms 2. Deceitfulness 3. Impulsivity 4. Irritability and aggressiveness 5. Recklessness 6. Irresponsible in work and finances 7. Lack of remorse or guilt Borderline (Unstable) Main Feature: Pervasive pattern of instability of interpersonal relationships, self image, affect and marked impulsivity Indicated by 5 or more of the following: 1.Frantic efforts to avoid real or imagined abandonment 2.Unstable and intense interpersonal relationships 3. Identity disturbance 4. Impulsivity 5. Recurrent suicidal behavior, gestures, threats or selfmutilating 6. Rapid mood shifts and irritability 7. Chronic feelings of emptiness 8. Intense and uncontrollable anger 1. Psychotherapy 2. Pharmacotherapy: a. Anti-psychotic

Histrionic (Gregarious) Main Feature: Pervasive pattern of excessive emotionality and attention seeking Indicated by 5 or more of the following: 1. Uncomfortable in situations he is not the center of attraction 2. Inappropriate sexually seductive or provocative behavior 3. Displays rapidly shifting and shallow emotions 4. Uses physical appearance to draw attention to self 5. Speech is excessively impressionistic and lacking in detail 6. Dramatic and

Narcissistic (Egotistic) Main Feature: Pervasive pattern of grandiosity, need for admiration and lack of empathy Indicated by 5 or more of the following: 1. Grandiose self importance 2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or love 3. Believes that he is special 4. Requires excessive admiration 5. Sense of entitlement 6. Takes advantage of others 7. Lacks empathy 8. Envious of others 9. Arrogant, haughty behaviors or

82 exaggerated attitudes emotions 7. Easily influenced by others 8. Exaggerated intimacy with others Defense Defense Mechanism: Mechanism: Splitting-all good Repression and all bad (BQ) Dissociation Treatment: Treatment: Treatment: Treatment: 1. Self help groups 1.Psychotherapy 1. Psychoanalytic1. Pharmacotherapy: 2. Pharmacotherapy: 2. Behavior Therapy oriented a. Lithium Psychostimulant- 3. Pharmacotherapy: psychotherapy (Eskalith) Methylphenidate a. Antipsychotic 2. Pharmacotherapy: b. Antidepressant (Ritalin) b. Antidepressant a. Antidepressant (MAOIs) b. Anti-anxiety c. Benzodiazepine c. Antipsychotic Alprazolam (Xanax) d. Anticonvulsant Carbamazepine (Tegretol) Nursing Interventions: 1. Matter-of-Fact Approach: firmly consistent, setting limits, objective & non judgmental 2. Unified Team Approach: consistency among staff & accountability among clients 3. Encourage the use of foam bats 4. Journaling 9. Transient stress related paranoia or dissociative symptoms

Cluster C: Avoidant (Withdrawn) Major Feature: Pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation Indicated by 4 or more of the following: 1. Avoids interpersonal

Dependent (Submissive) Major Feature: Pervasive and excessive need to be taken care of leading to submissive and clinging behavior and fears of separation Indicated by 5 or more of the following: 1. Needs excessive amount

OCPD (Conforming) Major Feature: Pervasive pattern of preoccupation with orderliness, perfectionism, mental & interpersonal control Indicated by 4 or more of the following: 1. Preoccupied with details,

83 contact for fear of criticism, disapproval or rejection 2. Unwilling to get involved with people 3. Restrains intimate relationship for fear of being shamed or ridiculed 4. Fear of being criticized or rejected 5. Feelings of inadequacy 6. Feels inept, unappealing or inferior 7. Reluctant to engage in new activities of advice & reassurance from others to make decisions 2. Needs others to assume responsibility 3. Cant express disagreement with others for fear of loss of support or approval 4. Lacks self confidence 5. Volunteers to do things that are unpleasant to obtain support 6. Feels helpless when alone 7. Seeks another relationship urgently after another close relationship 8. Unrealistically ear of being left alone rules, lists, order, schedules or organization 2. Perfectionist or overly strict standards 3. Excessive devotion to work excluding leisure 4. Over conscientious, scrupulous and inflexible 5. Unable to discard worthless objects 6. Reluctant to delegate work to others 7. Money is hoarded for future 8. Rigidity & stubbornness

Treatment: 1. Group Therapy 2. Behavior Therapy: Assertiveness training 3. Pharmacotherapy: a. Anti-anxiety agents b. Antidepressants c. B-blockers-Atenolol (Tenormin)

Treatment: 1. Insight-oriented therapy 2. Behavior therapy: Assertiveness training 3. Family therapy 4. Group therapy 5. Pharmacotherapy: a. Imipramine (Tofranil) b. Benzodiazepines c. Serotonergic agents

Defense mechanism: Rationalization, undoing Isolation, intellectualization Treatment: 1. Free association 2. Non directive therapy 3. Pharmacotherapy: a. Clonazepam (Klonopin)-a benzodiazepine with anticonvulsant use b. Clomipramine (Anafranil) c. Serotonergic agent: Fluoxetine ( )

XI. Eating Disorders 2 Types of Eating Disorders: I. Anorexia Nervosa Definition: an eating disorder that is characterized by voluntary refusal to eat and maintaining body weight; there is no real anorexia and no loss of appetite but often suppress their hunger; a weight phobia and self imposed dieting Incidence: 1. Common among adolescent and young adult: 12-18 years old 2. 90-95% common among females 3. Mortality Rate: 15-20%

84 4. Prognosis: 21% die of malnutrition and 17-77% recover Psychopathology: 1. Cultural Theory: thinness is valued by society 2. History of being a model child: high achiever, source of family happiness, favorite of the family child conforms to the image but because parents control them, child becomes negative there is power struggle so child tends to control their body weight resulting to anorexia 3. Distorted body image: child sees self in the mirror as being fat Signs and Symptoms: 1. Weight loss of 15% or more of original body weight without apparent reason 2. History of high activity (athletic) & achievement in academics 3. Amenorrhea for 3 months 4. History of dieting 5. Hypothermia 6. Presence of lanugo Nursing Interventions: A. Assess: Signs and Symptoms B. Analysis: 1. Altered Nutrition: less than body requirements 2. Chronic low self esteem 3. Ineffective family and individual coping 4. Altered family processes C. Implementation: 1. Physical Aspect a. Measure I and O of client b. Weigh client 3x/week at the same time and check if client drinks water before being weighed c. Schedule client for a session with nutritionist d. Short term goal: steadily maintain an increase in weight of 2-3 lbs/week e. Long term goal: presence of menstruation (BQ)-indicates recovery from anorexia 2. Emotional Aspect a. Allow client to express their feelings b. Stay with client at least 1 -2 hours during and after feeding because they usually induce vomiting c. Never allow the client to leave the table during mealtime d. Remove table napkin or tissue paper around the client during meals e. Use matter-of-fact attitude because of their manipulative behavior II. Bulimia Nervosa Definition: an eating disorder that is characterized by recurrent binge and purge cycle 2x/week for 3 months Incidence: 1. Common among adolescents and early adults: 17-23 years old

85 2. 1-4.5% affects females; 0.4% affects men 3. Prognosis: good if identified early but tends to be episodic with remissions & relapses Diagnostic Criteria: 1. Recurrent episode of binge eating characterized as voracious 20x daily caloric intake in less than 2 hours and a sense of lack of control 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain 3. The binge eating & compensatory behaviors both occur on average at least 2x a week for 3 months Signs and Symptoms: 1. Binge on CHO ( serotonin level) done on a secret place 2. Associated with guilt when full and depression 3. Self induced vomiting producing wounds on throat & fingers, erosion of teeth enamel appearing like teeth of rats 4. Abuse of laxatives and purgatives Nursing Interventions: A. Assess B. Analysis: same with anorexia C. Implementation: 1. Establish a trusting relationship with the client 2. Praise simple accomplishment 3. Empathy Similarities between Anorexia and Bulimia: 1. Both experience fear of becoming fat and has distorted body image 2. Intense preoccupation with weight and dieting 3. Low self esteem Differences between Anorexia and Bulimia: Anorexia nervosa Bulimia nervosa Usually found in adolescents Common among college graduates Underweight Above average weight or slightly obese No insight and very hard to treat With insight Primary and Secondary Level of Prevention of eating Disorders: 1. Identify the individual at risk 2. Educate people about the potential risk of the disorder 3. Be alert of the most vulnerable time for onset of symptoms like life changes that involve separation from significant others Treatment of Eating Disorders: 1. Outpatient Therapy a. Individual therapy b. Family therapy to determine the underlying cause c. Group therapy

86 2. Inpatient Therapy a. Hospitalization to a medical unit b. Behavior Modification: token economy (reward system) and (+) reinforcement c. Cognitive Behavior Technique: 1) Psycho-education: tell client they can manage their own lives 2) Meal Planning: opportunity to plan their own meals 3) Introduction of avoided food 4) Self Monitoring 5) Stimulus Control: self hypnosis 3. Improve Family Interaction: improve relationships between parents and child XII. Sexual Disorders Psychopathology: 1. Biological imperative-brain decides whether a person is a man or woman 2. Cognitive switch-says an infant (1 years old) is neutral but the moment it goes into phallic development then child decides gender (boy or girl) 3. Social learning and labeling-learns behavior specifically during adolescence 4. Sexual expression depends upon the culture and the individual whether it is acceptable or not 5. Hormonal imbalance 6. Freudian Theory: during the phallic phase, heterosexual relationship with parents is important 7. Cultural Theory: depends on where the client is from Classification: 1. Gender Identity Disorder Gender identity: a persons psychological sense of maleness or femaleness Are disorders characterized by the confusion between the anatomical parts and psychological orientation Types: a. Transvestism (Cross dressing)-gratification by wearing the dresses of opposite sex; easier to treat; managed by Behavior Modification-thought stopping b. Transexualism-believes that he is trapped in a female body; hard to treat; managed by Aversion Therapy-ecstatic experience (pleasant effect of cross dressing) will be coupled with an unpleasant stimuli (ECT) 2. Paraphilias false sexual intimacy that becomes an abnormality only if it is the only means of gratification are disorders characterized by specialized sexual fantasies and intense sexual urges & practices sexual perversion or deviations 4 Criteria to call sexual act as perversion: a. If it is the sole means of gratification b. If the sexual act is being used for > 6 months c. If it causes to develop guilt or anxiety

87 d. If done to a non consenting person like children Forms of Sexual Deviations: a. Exhibitionism-exposure of ones genitals to stranger b. Fetishism-sexual focus is on objects c. Frotteurism-use of friction or rubbing d. Pedophilia-sexual arousal towards children 13 of age & younger e. Sexual masochism-receiving pain f. Sexual sadism-giving pain g. Voyeurism (peeping tom)-observing naked people or in sexual activity h. Telephone Scatologia-obscene phone calling i. Necrophilia-dead people or cadavers j. Partialism-focuses on one part of the body 1) Cunnilingus-licking the female genitals 2) Fellatio-licking the male genitals 3) Anilingulus-licking the anus k. Zoophilia (Bestiality)-animals l. Coprophilia-desire to defecate on a partner 1) Coprophagia-eat feces 2) Coprolalia-utterances of obscene words m. Klismaphilia-introducing enema into the anus n. Urophilia-desire to urinate on a partner o. Masturbation-direct stimulation of genitals with hand or fingers p. Hypoxyphilia-oxygen deprivation q. Soixante neuf-69 or 88 position r. Satyriasis-over sex male s. Nymphomania-over sex female t. Sodomy (Screw driver)-inserting penis into the male anus u. Buggery-inserting penis into the female anus

3. Sexual Dysfunctions Failure to initiate and complete a sexual cycle (excitement-plateau-orgasmresolution) Types: a. Sexual Desire Disorder 1) Hypoactive-absence of sexual fantasies & desire for sexual activity 2) Sexual Aversion-aversion to & avoidance of genital sexual contact with sexual partner b. Sexual Arousal Disorder 1) Female-failure to attain excitement

88 2) Male-failure to attain erection c. Orgasm Disorder 1) Anorgasmia-absence of female orgasm 2) Male orgasmic disorder-failure to achieve ejaculation 3) Premature Ejaculation-failure of the penis to gain voluntary control d. Sexual Pain Disorder 1)Dyspareunia-pain during sexual intercourse 2)Vaginismus-continuous contractions of the vaginal wall Nursing Interventions: a. Accept the person in great emotional pain b. Self awareness c. Never let your own sexual values affect the sexual orientation of your clientdont be moralistic & dont impose your own standard Nursing Responsibilities: a. Concrete & comprehensive knowledge of the sexual function & dysfunction b. Having skills in communication techniques c. Being comfortable with their own sexual values & expressions d. Being willing & able to explore & separate personal values & attitudes from those of clients e. Becoming proficient in using the nursing process to assess, diagnose, intervene & evaluate care to promote optimal sexual health f. Prevent any sexual activity

PHARMACOTHERAPY I. Treatment modality focus on Physical Therapy A. Electroconvulsive Therapy (ECT) 1. Definition: induction of a brief & artificial convulsion by passing an electrical current through electrode applied to one or both temples 2. Indications: a. Major Depressive illness that has not responded to antidepressant medication or in-patients unable to take medication b. Bipolar disorder in which the patient has not responded to medication

89 c. Acutely suicidal patients who have not received medication long enough to achieve a therapeutic effect d. For elders with history of hypertension & cardiac illness 3. Administration: a. Medications: Atropine Sulfate-reducing secretions by blocking vagal stimulation Succinylcholine (Anectine)-a muscle relaxant that reduce grand mal seizures Anesthesia with short acting barbiturate b. Procedure: Make patient lie with back resting on a pillow to promote hyperextension of the spine preventing fracture of the vertebrae or dislocation Let patient bite mouth gag Apply electrode jelly on the temple to ensure complete contact 2 assistants support shoulder & wrist joints and another one to support the knee Terminal plugs are inserted into electrodes using 90-110 volts in a split of second (.5 to 2 seconds) Applied uni-temporal, bi-temporal or frontal for 3 consecutive days/week from 6 to 12 treatments Patient goes into grand mal seizure When convulsion subsides & breathing is resumed, turn the patient on his side to prevent swallowing of saliva 4. Nursing Considerations: a. Before ECT Medical history, complete physical, neurological & laboratory examination Obtain informed consent NPO after midnight Check for dentures b. After ECT Provide comfort Remain with the client until alert Orient patient as to time, place & person Document all treatments 5. Side Effects: a. Headache b. Weight gain c. Hypertension d. Temporary loss of memory for 3 to 6 months B. Anti-Psychotic Drugs (Neuroleptics or Major Tranquilizers): Patients are given ECT & drugs so that patient will be amenable to other forms of therapy

90 Used to treat severe mental illness such as Schizophrenia, Manic Depression and Paranoia It blocks dopamine receptors Desired Effects: sedation, emotional quieting, psychomotor slowing & alleviating of major symptoms of Schizophrenia Major Categories of Side Effects: 1. Anticholinergic 2. Antiadrenergic 3. Agranulocytosis 4. Extrapyramidal Symptoms (EPS) 5. Neuroleptic Malignant Syndrome (NMS) Other Side Effects: 1. Jaundice 2. Amenorrhea 3. Galactorhea 4. Photosensitivity 5. Impaired Ejaculation 6. Can trigger diabetes & heart disease Classification based on Potency (Keltner): High Potency: Butyrophenone: Haloperidol Less sedating (Haldol, Serenace) More EPS Thioxanthene: Flupentixol (Fluanxol,Prolixin, Permitil) Thiothixene (Navane) Piperazine: Trifluoperazine (Stelazine) Fluphenazine (Prolixin) Moderate Potency Dibenzoxazepine: Loxapine (Loxitane) Dihydroindolone: Molindone (Moban) Piperazine: Perphenazine (Trilafon) Low Potency Aliphatic: Anti-cholinergic SE: dry mouth, blurred Chlorpromazine vision, photophobia, mydriasis, nasal (Thorazine, Proma, Laractyl, Psynor) congestion, urinary retention Promazine (Promazine, Sparine) Anti-adrenergic SE: hypotension Chlorprothixene (Taractan) Tachycardia Piperidine: Mesoridazine (Serentil) Thioridazine (Mellaril) Typical Anti-psychotic: Cheaper 1. Chlorpromazine (Thorazine, Proma, Laractyl)-sedating effect 2. Haloperidol (Haldol, Serenace)-highly potent Side Effects: a. Postural hypotension-Chlorpromazine b. Extrapyramidal Symptoms: 1st 24 hours will observe the following 1) Dystonia-rigidity in muscles that control posture, gait or ocular movement occurring 1-2 days a) Opisthotonus

91 b) Difficulty talking c) Difficulty swallowing d) Drooling of saliva e) Oculogyric crisis 2) Akathisia-motor restlessness (stomping feet) occurring 1-6 weeks 3) Parkinsonism-pin rolling movement, mask-like face occurring 1-4 weeks 4) Tardive dyskinesia-late appearing involves the muscles of mouth & face a) Blinking of eye b) Protrusion of tongue c) Lip smacking d) Grinding of teeth c. Photosensitivity d. Agranulocytosis-fever, sore throat & gum bleeding e. Neuroleptic Malignant Syndrome-uncontrollable fever, rigidity & tremors Atypical Anti-psychotic: Newer drug, less side effect but expensive 1. Clozapine (Leponex)-given for 18 weeks Side Effects: a. High incidence of life threatening agranulocytosis therefore monitor laboratory weekly for 18 months, monthly thereafter b. High rate of seizure c. Relative lack of EPS 2. Risperidone (Risperdal) 3. Olanzepine (Zyprexa) 4. Amisulpride (Solian) 5. Quetiapine (Seroquel) 6. Ziprasidone (Zeldox) II. Anxiolytic 1. Benzodiazepines: Diazepam (Anxionil, Trazepam & Valium) Clorazepate (Tranxene) Bromazepam (Lexotan) Alprazolam (Xanor) 2. Hydroxyzine diHCL: Iterax Side Effects: a. Habituation b. Drowsiness c. Never give coffee because antagonistic d. Alcohol has potentiating effect III. Antidepressant Allows 2-3 weeks for therapeutic effects to kick in Be careful during this time as symptoms have not yet resolved A. Tricyclic antidepressant: blocks neurotransmitter re-uptake of serotonin, norepinephrine & dopamine Welcome Effects: Sedation Improved appetite Side Effects: 1. Anticholinergic effects

92 2. Orthostatic hypotension 3. Trigger cardiac arrhythmia 4. May increase energy for suicide 5. Blocks alpha 1 adrenergic receptors on peripheral blood vessels causing edema Examples: 1. Old: Imipramine HCL (Tofranil)- High anti-cholinergic & sedative effect First line of drugs for Panic Disorder Amitriptyline (Elavil)Most cardiotoxic & orthostatic hypotension High anti-cholinergic & sedative effect 2. New: Dothiepin HCL (Prothiaden) B. MAO Inhibitor: Blocks monoamine oxidase, an enzyme involved in inactivation of norepinephrine, serotonin & dopamine end results increased neurotransmitters 1. Tranylcypromine (Parmate) 2. Phenelzine (Nardil) Difficult to administer because client has to change diet: 1. Avoid tyramine rich food: aged cheese (can give white & cheddar cheese) 2. Do not give banana, cold & asthma tablets, beans, red wine, refrigerated food & caffeine If the not allowed food are given, it can cause hypertensive crisis Serotonin Syndrome: potentially lethal consequence of combining serotonin-enhancing psychotropic drugs such as: 1. SSRI + MAOI 2. MAOI + L-tryptophan 3. Clomipramine + MAOI Signs & Symptoms of Serotonin Syndrome: 1. Hyperreflexia 2. Hyperthermia 3. Myoclonus 4. NMS

C. Selective Serotonin Re-uptake Inhibitor (SSRI) Less cardiac side effects, anti-cholinergic & sedating effects Side Effects: 1. GIT symptoms: nausea, vomiting & diarrhea 2. Headache & dizziness 3. Decreased libido Types: 1. Fluoxetine (Prozac) 2. Paroxetine (Paxil, Seroxat)-16x more potent than Prozac

93 3. Sertraline (Zoloft)-5x more potent than Prozac D. Selective Serotonin Norepinephrine Re-uptake Inhibitor (SSNRI) Few if any anti-cholinergic, antihistaminic or adrenergic effects It has a lower potential for drug interaction than other antidepressants & does not exaggerate the effects of alcohol Example: Venlafaxine (Efexor) IV. Anti-Manic (increased norepinephrine) Peak Effect: 7-10 days so while trying to achieve the peak level, give neuroleptics (Thorazine or Haldol) A. Lithium Carbonate (Lithane, Quilonium R) Narrow therapeutic index (0.6 to 1.2 Meq/L); toxic dose (1.5 to 2 Meq/L) Hyponatremia: increases lithium Hypernatremia: decreases lithium Give 3-6 grams of NaCl & 3 L of water Side Effects: Dry mouth, nausea & diarrhea (common) Polyuria & polydipsia occurs in 70% of cases Major Toxicity: 1. Giddiness 2. Tinnitus 3. Blurred Vision 4. Convulsion Signs & Symptoms: 1. LBM 2. Anorexia 3. Convulsion 4. Excessive Thirst 5. Nausea & Vomiting Do not give with antacids Do not give NSAIDs & Diuretics causes lithium toxicity but if theres toxicity, give mannitol B. Valproic Acid (Depakene) C. Carbamazepine (Tegretol): drug interaction with antibiotics, calcium channel blocker & ACE inhibitor