Review in Psychiatric Nursing

PSYCHOLOGICAL THEORIES

 FREUD’S PSYCHOANALYSIS
 Personality
 Id
 Ego
 Superego
 Psychosexual Stages of Development
 Oral (0-18 mos)
 Anal (18mos.-3yrs)
 Phallic (3-6yrs.)
 Latency (6-12yrs)
 Genital (12-
 Defense Mechanisms

Defense Mechanisms- techniques used by the ego to keep threatening and unacceptable material out of
consciousness therefore reducing anxiety. Defense mechanisms are workings of the unconscious mind.

A number of phenomena are used to aid in the maintenance of repression. These are termed Ego Defense
Mechanisms (the terms “Mental Mechanisms” and “Defense Mechanisms” are essentially synonymous
with this). The primary functions of these mechanisms are:
1. to minimize anxiety
2. to protect the ego
3. to maintain repression

Mechanism Definition Example

Compensation Covering up of weaknesses by A boy who cannot participate in sports studies hard and gets goo
placing emphasis on a more grades.
comfortable area
A physically unattractive adolescent becomes an expert dancer.

A youth with residual muscle damage from poliomyelitis becom

an athlete.
Conversion Unconscious expression of A student develops headache before taking a exam.
intrapsychic conflicts symbolically
through physical symptoms. A man's arm becomes paralyzed after impulses to strike another.

Denial Unconscious to admit an A man who has had a heart attack refuses to acknowledge illness an
unacceptable behavior or idea to follow prescribed therapy.

a person having an extramarital affair gives no thought to th

possibility of pregnancy.

persons living near a volcano disregard the dangers involved.

a disabled person plans to return to former activities witho

planning a realistic program of rehabilitation.

Displacement Discharging pent-up feelings to a
less threatening object.
Dissociation Unconscious separation of painful
feelings from an unacceptable idea,
situation, or object.
A man who is angry at his boss comes home and yells at his wife.
A rape victim tells that she felt as if she were outside of her bod
watching what was happening.
 Some dissociation is helpful in
keeping one portion of one's life
from interfering with another (e.g.,
not bringing problems home from
the office). However, dissociation is
responsible for some symptoms of
mental illness; it occurs in "hysteria"
(certain somatoform and dissociative
disorders) and schizophrenia, The
dissociation of hysteria involves a
large segment of the consciousness
while that in schizophrenia is of
numerous small portions. The
apparent splitting of affect from
content often noted in schizophrenia
is usually spoken of as dissociation
of affect, though isolation might be a
better term.

Fantasy Gratifying frustrated desires by A man who fails to get a part in the play, imagines himself chose
imaginary achievements. for the lead role.

Identification Imitating the behavior of someone A teenager dresses like that of her idolized movie star.
feared or respected.

Intellectualization Using only logical explanations A wife tells her husband that a dented car is better than a wrecke
without feeling or an affective car.
component.

The individual deals with emotional

conflict or internal or external
stressors by the excessive use of
abstract thinking or the making of
generalizations to control or
minimize disturbing feelings.

Introjection Unconsciously incorporating other A young girl scolds her brother just like her mother would.
people’s norms and values as if they
were your own.

Projection Blaming someone else for one’s A husband forgets to pay the bill and blames his wife for n
difficulties. reminding him.

Rationalization Justification of behavior though A student fails an exam and says that the teacher did not clarify th
faulty logic. material sufficiently.

Reaction formation Acting oppositely to what the person A woman who dislikes her sister sends her gifts every holiday.
truly feels.

Regression Return to an earlier, more A 6 year old begins to wet his pants following the birth of his bab
comfortable level of functioning. sister.
Repression Involuntary and unconscious
forgetting of painful ideas, feelings
and events.
Restitution Attempting to restore unconscious
guilt feelings.
Sublimation Channeling instinctual drives into
acceptable activities.
Substitution Replacement of unacceptable objects
or need with one that is more
acceptable.
Suppression Conscious exclusion of anxiety
producing feelings or ideas from
awareness.
Symbolization An external object is made to
symbolize an internal feeling or idea.
Undoing Doing something to counteract or
relieve guilt feelings.
THERAPEUTIC COMMUNICATION
Technique Definition
Using Silence Gives person time to think and
say more.
Accepting Receiving information in a non-
judgmental manner. Does not
necessarily indicate agreement.
Giving recognition Shows awareness of change or
efforts. Does not imply right or
wrong.
Offering self Making self available and
showing interest, concern and
desire to understand.
Giving broad openings Clarifies that the lead is to be
taken by the client
Offering general leads Using neutral expressions to
encourage the client to continue
talking.
Placing the events in Asking for relationships among
time or sequence events.
Making observations Commenting on what is seen or
heard to encourage discussion of
feelings and thoughts. Helpful
with withdrawn patients.
A accident victim becomes amnesic about the details of the acciden
but was aware at that time.
A nurse who regrets not caring for her mother when she was dyin
because of anger chooses to work with terminal patients.
A man with excessive sexual drives becomes a successful nud
painter.
A woman who wants to marry a man exactly like her dead fath
marries someone who looks a little bit like him.
A woman says she is not ready to talk about her condition.
A young woman gives flowers and chocolates to his girlfriend.
A mother spanks her child and brings home a gift for him the ne
day.
Example
Yes.
Uh hmm
I follow what you say
I’m with you
Good morning, Mr. Santos
I noticed you shaved this morning.
You’ve combed your hair
I’ll sit with you for a while.
I would like to spend some time with you.
Where would you like to begin?
What are you thinking about?
What would you like to discuss?
Go on.
And then.
Tell me about it.
What lead up to…?
What happened before?
When did this happen?
You seem restless.
I noticed you’re biting of lips.
You appear tense when you…
Encouraging Asking for client’s views of their What is happening to you right now?
descriptions of situation. What does the voice seem to be saying?
perceptions
Voicing doubt Expressing uncertainty about the That doesn’t sound like it.
reality of client’s perceptions Isn’t that unusual?
and conclusions, used when the
nurse wants to explore other
explanations.

Presenting reality Offering a view of what is real
and not, without arguing with
the client.
Encouraging Asking for similarities and
comparison differences among feelings,
behavior and events.
I know the voices are real to you, but I
don’t hear them.
You are not in heaven, you are in the
hospital.
Has this ever happened to you before?
Is this the way u felt when..?

Restating Repeating the main idea Pt: I can’t sleep. I stay awake all night.
expressed Nurse: You have difficulty sleeping?

Reflecting Directing feelings and ideas Patient: do you think I should?

back to the client.
Focusing Concentrating on a topic until its
meaning is clear.
Exploring Looking at certain ideas more
fully. However, if the patient
chooses not to elaborate, the
nurse should not pry.
Giving information Providing information that will
help clients make better choices.
Seeking clarification Clarifying vague
communications, help clients
clarify own thoughts.
Verbalizing the implied Rephrasing or putting into
concrete terms what the client
implies to highlight an
underlying message.
Nurse: Do you think you should?
Patient: My brother spends all the money
and still has the nerve to ask for more
Nurse: This makes you angry?
Explain more about…
This point seems worth looking at more
closely.
Tell me more about…
Can you describe it more fully?
I am…
My purpose on being here is…
This medication is for…
The rules and regulations of this ward are…
What do you mean by…?
What is the main point of what you just
said?
I’m not sure I follow you.
Patient: There is nothing to do at home.
Nurse: It sounds you might be bored at
home.
Patient: I can’t talk to you or to anyone. It’s
only a waste of time.
Nurse: Do you feel no one understands?

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

Technique Definition Example

Reassuring Closes off the communication Don’t worry.
by giving information that is not You’ll feel better tomorrow.
based on facts and truth. Everything will be alright.
Giving approval Encourages the client to That is good.
continue doing something for
the sake of the nurse’s approval
rather than for own learning.

Rejection This is a communication barrier Talk to the doctor about this.

since the patient may avoid
expressing his or her own
thoughts / feelings to avoid the
risk of rejection.

Disapproving Denies the client’s thoughts and That is not good.

feelings by implying that the I’d rather you wouldn’t.
nurse has the right to judge the
client and the client has to
please the nurse.

Agreeing Provides no opportunity for the That’s right.

patient to change their views. I agree.

Disagreeing Challenging the patient to I disagree with that.

defend his/her thoughts and
feelings which serves as a
hindrance in the communication
process.

Advising Fosters dependency and inhibits I think you should…

the problem-solving process.

Probing Communication barriers that Tell me about…

may make the patient feel Let’s talk about your family and relatives.
needed and valued only for the
information they can give.

Testing Implies that the nurse feels that Do you know what this drug is for?
the patient needs help.

Defending Gives the impression that the Dr. Santos is a very good doctor.
client has no right to express The hospital staff is very competent to take
own opinions and feelings. care of you.

Requesting an “Why” questions require Why did you?

explanation analysis of the problem which
increases anxiety. Patient may
respond defensively.

Minimizing feelings This technique fails to explore Patient: I wish I were dead.
the feelings of the patient. Nurse: Everyone gets down once in a while.

Making stereotypical Blocks off the communication It’s for your own good.
comments process since the patient is
encouraged to have empty
responses.

Changing the subject Fails to address the message of Let’s discuss that later.
 the patient. The nurse maybe Let’s leave that and talk about…
threatened by an anxiety
provoking topic thus the
perceived need to change the
subject.

Using denial Closes off the communication Patient: I’m nothing

by failing to identify the feelings Nurse: Of course you’re something,
and thoughts of the patient. everybody’s something.

 ERICKSON’S PSYCHOSOCIALTHEORY

Age Stage Activity Strength/ Factor SO

0-1 y/o Trust vs. mistrust infant takes in food Realistic hope Mother
(feeding)
2-3y/o Autonomy vs. sense of control over Conflict (toilet
shame and doubt interpersonal training)
relationships and self-
control
4-5 y/o Initiative vs. guilt ability to move freely, Purpose
acquiring language (independence)
skills, curiosity,
imagination and
ambition or setting
goals.
6-12 y/o Industry vs. child strives hard to Competence (school)
inferiority read and write, pursue
his hobbies and be the
best among the rest.
13-18 y/o Identity vs. role They try-out new roles Fidelity (peers)
confusion and beliefs during their
search of a sense of ego
identity
19-25y/o Intimacy vs. ability and willingness Love
isolation to share a mutual trust
26-40 y/o Generativity vs. procreation of children, Care (parents)
stagnation production of work and
creation of new ideas
that impacts a great
number of people
41-above Ego-integrity vs. intimate relationships Wisdom (reflection)
y/o despair established and caring
for others. They feel
whole and coherent

ADULT MANIFESTATIONS OF ERICKSON’S STAGES OF DEVELOPMENT

 Life stage Adult behaviors reflecting mastery Adult behaviors reflecting developmental problems
Trust vs. mistrust  Realistic trust of self and others  Suspiciousness/testing others
(0-18 mos.)  Confidence in others  Fear of criticism and affection
 Optimism and hope  Dissatisfaction and hostility
 Shares openly with others  Projection of blame and feelings
 Relates to others effectively  Withdrawal from others
Or
 Overly trusting of others
 Naïve and gullible
 Shares too quickly and easily
Autonomy vs.  Self control and willpower  Self doubt/self conscious
Shame and doubt  Realistic self concept and self-  Dependence on others for approval
(18 mos.- 3 yrs.) esteem  Feeling of being exposed/ attacked
 Pride and a sense of goodwill  Sense of being out of control of the self and one’s life
 Simple cooperativeness  Obsessive compulsive behaviors
 Generosity tempered by withholding Or
 Delayed gratification when  Excessive independence or defiance, grandiosity
necessary  Denial of problems
 Unwillingness to ask for help
 Impulsiveness
 Recklessness regarding safety for self and others
Initiative vs. Guilt  An adequate conscience  Excessive guilt/embarrassment
(3-5 yrs)  Initiative balance with restraint  Passivity and apathy
 Appropriate social behaviors  Avoidance of activities/pleasures
 Curiosity and exploration  Rumination and self pity
 Healthy competitiveness  Assuming a role as victim/self-punishment
 Sense of direction  Reluctance to show emotions
 Original and purposeful activities  Underachievement of potentials
Or
 Lack of follow-up on plans
 Little sense of guilt for actions
 Excessive expressions of emotion
 Labile emotions
 Excessive competitiveness/showing off
Industry vs.  Sense of competence  Feeling of unworthiness and inadequacy
inferiority (6-12  Completion of projects  Poor work history (quitting, being fired, lack o
yrs.)  Pleasure in efforts and effectiveness promotions, absenteeism, lack of productivity)
 Ability to cooperate and  Inadequate problem solving skills
compromise  Manipulation of others/ violation of others’ rights
 Identification with admired others  Lack of friends of the same sex
 Joy of involvement in the world and Or
with others  Overly high achieving/ perfectionists
 Balance of work and play  Reluctance to try new things for fear of failing
 Feeling unable to gain love of affection unless total
successful
 Being a workaholic
Identity vs. role  Confident of self  Feelings of confusion, indecision and alienation
confusion (12-18  Emotionally stable  Vacillation between dependence or independence
yrs)  Commitment to career planning and  Superficial, short-term relationships with another person
realistic long-term goals Or
 Sense of having a place in society  Dramatic overconfidence
 Establishing an intimate relationship  Acting out behaviors (including alcohol and drug abuse)
  Fidelity to friends
 Development of personal values
 Testing out adults
Intimacy vs.  Ability to give and receive love
isolation (18-25 or  Commitment and mutuality with
30 years) others
 Collaboration in work and affiliation
 Sacrificing for others
 Responsible sexual behaviors
Generativity vs.  Productive, constructive, creative
stagnation (30-65 activity
years)  Personal and professional growth
 Parental and societal responsibilities
Integrity vs. despair  Feelings of self-acceptance
(65 yrs. to death)  Sense of dignity, worth, and
importance
 Adaptation to life according to
limitations
 Valuing one’s life
 Sharing of wisdom
 Exploration of philosophy of life
and death
 PIAGET’S COGNITIVE DEVELOPMENTAL THEORY
 Sensorimotor Stage (0-2) senses
 Preoperational thought stage (2-7)
 Preconceptual-learning to think in mental images (2-4)
 Intuitive- egocentrism (4-7)
 Concrete operational stage (8-12) - more logical and has concepts of morality, numbers and spatial
relationships
 Formal operational (12- ) - adult logic and reason
RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT
 Provide support, treat patients with respect and dignity
 Uplift patient’s self-esteem, don’t patronize
 Do not place patients in situations wherein they will feel inadequate or embarrassed
 Flamboyant display of sex role behaviors
 Persistent aloneness/isolation
 Emotional distance in all relationships
 Prejudices against others
 Lack of established vocation; many career changes
 Seeking of intimacy through casual sexual encounters
Or
 Possessiveness and jealousy
 Dependency on parents and/or partner
 Abusiveness towards loved ones
 Inability to try new things socially or vocational
(staying in routine/ mundane job/activities
 Self-centeredness/ self-indulgence
 Exaggerated concern for appearance and possessions
 Lack of interest in the welfare of others
 Lack of civic or professional activities/responsibilities
 Loss of interest in marriage and/or extramarital affairs
Or
 Too many professional or community activities to th
detriment of the family or self
 Sense of helplessness, hopelessness, worthlessnes
uselessness, and/or meaninglessness
 Withdrawal and loneliness
 Regression
 Focusing on past mistakes, failures and dissatisfactions
 Feeling too old to start over
 Suicidal ideas or apathy
 Inability to occupy self with satisfying activities (hobbie
volunteer work, social events)
Or
 Inability to reduce activities
 Overtaxing strength and abilities
 Feeling indispensable
 Denial of death as inevitable
 Treat patients as individuals
 Provide reality testing
 Handle hostility therapeutically
 Provide psychopharmacologic treatment

BASIC PRINCIPLES IN DEVELOPING THERAPEUTIC NURSE-PATIENT RELATIONSHIP

 Do not reinforce or argue a patients hallucinations or delusions

 Orient patient to time, person and place
 Do not touch patients without warning them
 Avoid whispering or laughing when patients are unable to hear all of the conversations
 Reinforce positive behaviors
 Avoid competitive activities with some patients
 Do not embarrass patients
 For withdrawn patients, start with one-to-one interactions
 Allow and encourage verbalization of feelings
 Be calm when talking to patients
 Accept patients as they are but do not accept all behaviors
 Keep promises
 Be consistent
 Be honest

CHARACTERISTICS OF A MENTALLY HEALTHY PERSON

1. A mentally healthy person is free from internal conflicts. He is not at war with himself.
2. He is well adjusted. He is able to get along well with others. He is able to form effective
relationships. He is able to accept criticisms and is not upset easily.
3. He searches for an identity.
4. He has a strong sense of self-esteem.
5. He knows himself, his needs, problems and goals (self-actualization).
6. He has good control over his behavior.
7. He is productive.
8. He faces problems and tries to solve them intelligently.

CHARACTERISTICS OF MENTAL ILLNESS

1. When a person’s behavior is causing distress and suffering to the individual and/or others around
him
2. Abnormal changes in one’s thinking, feeling, memory, perceptions and judgment, resulting in
changes in talk and behavior.
3. Abnormal behavior causes disturbance in the person’s day-to-day activities, job and interpersonal
relationships.

Neurosis
 Frequently talks about his symptoms
 Does not lose contact with reality
 Personality is intact
 Continue to function socially and at work
 Hospitalization is usually not required
Psychosis
 Denies that there is something wrong with
him
 Loses contact with reality
 Personality is often disorganized and
deteriorates.
 Cannot act normally in society and may
harm self and others.
 Often requires hospitalization

PREVENTION OF MENTAL ILLNESS

PRIMARY PREVENTION- involves the promotion of general mental health and protection against the
occurrence of specific diseases. Primary prevention aims to prevent the onset of a disease or a disorder,
thereby reducing the incidence (number of of new cases occurring in a specific period in time).
 Elimination of etiological agents
 Reducing risk factors
 Enhancing host resistance or interfering with disease transmission
 Reducing stress factors
 Counseling
o Student’s counseling
o Marriage counseling
o Sex counseling
o Genetic counseling
 Special centers
o Child guidance centers
o Crisis intervention center
o Geriatric center
 Mental health education

SECONDARY PREVENTION- early identification and effective treatment of an illness or disorder, with
the goal of reducing the prevalence (total number of existing cases in a year) is the aim of secondary
prevention.
 Population screening
 Crisis intervention services
 Mental health education

TERTIARY PREVENTION- aims to reduce the prevalence of residual defect or disability due to illness
or disorder. It involves rehabilitation after defect and disability have been fixed. Community reintegration
is also part of tertiary prevention.

CRISIS
 Refers to the state of the reacting individual who finds himself in a hazardous situation in which
the habitual problem solving activities are not adequate and do not lead to rapidly to the previously
achieved balance state.

CRISIS INTERVENTION- means of entering into the life situation of an individual, family or group to
alleviate the impact of a crisis including stress in order to help mobilize the resources of those directly
affected, as well as those who are in the significant “social orbit.”

CONCEPT OF LOSS

GRIEF- is the process of coping with a loss.

STAGES OF DEATH AND DYING (KUBLER-ROSS)

 Denial and isolation
 Anger
 Bargaining
 Depression
 Acceptance

STAGES OF GRIEF
 Shock and disbelief
 Developing awareness
 Restitution and resolution of the loss
COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE

 Toddler (1-3 yo)

o No specific concept of death and thinks only in terms of the living.
o Reacts more to pain and discomfort of illness and immobilization.
o Experience separation anxiety a great deal

Nursing interventions:
Focus on parents
 Assist parent to deal with their feelings
 Encourage parents’ participation in child’s care

 Preschooler (3-5 yo)

o Death is a kind of sleep. It is a form of punishment
o Life and death can change place with one another

Nursing interventions
 Utilize play for expressing thoughts and feelings
 Explain what is death that it is final and not sleep
 Permit a choice of attending the funeral

 School Age (5-12)

o Death is personified
o Child fears mutilation and punishment
o Anxiety is alleviated by nightmares and superstition
o Death is perceived as a final process

Approaches:
 Accept regressive or protest behavior
 Encourage verbalization of feelings

 Adolescent (12-16)
 Mature understanding of death
 May have strong emotions about death, silent, withdrawn, angry
 Worry about physical changes

Approaches:
 Support maturational crisis
 Encourage verbalization of feelings
 Respect need for privacy and personal expression for anger , sadness or fear.

 Adult
 Death is disruption of the life cycle
 Death is viewed on terms of its effect on significant others.

 Older adult
 Emphasis is on religious beliefs for comfort. A time of reflection, rest and peace

SCHIZOPHRENIA

A group of mental disorders that feature withdrawal, affective problems and interrupted thought processes.

BLEULER’S FOUR A’S OF SCHIZOPHRENIA

 Affective Disturbances: inappropriate, blunted or flattened affect
 Autism: Preoccupation with the self without concern for external reality
 Associative looseness: The stringing together of unrelated topics
 Ambivalence: simultaneous opposite feelings

Subtypes:

Paranoid Type
 Dominant: hallucinations and delusions
 No disorganized speech, disorganized behavior, catatonia, or inappropriate affect present.
 Preoccupied with 1 or more systematized delusions or with frequent auditory hallucinations
related to a single theme.

Disorganized type
 Dominant: disorganized speech and disorganized behavior and inappropriate affect.
 Delusions and hallucinations, if present, are not prominent or fragmented.
 Associated features including grimacing, mannerisms and other oddities of behavior.
 Incoherence
 Looseness of associations
 Grossly disorganized behavior
 Flat or grossly inappropriate affect

Catatonic
 Motor immobility (waxy flexibility or stupor)
 Excessive purposeless motor activity (agitation)
 Extreme negativism or mutism
 Peculiar voluntary movements
o Posturing
o Stereotyped movements
o Prominent mannerisms
o Prominent grimaces
 Echolalia and echopraxia

Residual
o No longer has active phase symptoms (e.g. delusions, hallucinations, or disorganized speech and
behaviors)
o However, persistence of some symptoms is noted, e.g.
o Marked social isolation or withdrawal
o Marked impairment in role function (wage earner, student or home maker)
o Markedly eccentric behavior or odd beliefs
o Marked impairment in personal hygiene
o Marked lack of initiative, interest , or energy
o Blunted or inappropriate affect

Undifferentiated type
o Has active phase symptoms (does have hallucinations, delusions, and bizarre behaviors).
Prominent delusions, hallucinations, incoherence or grossly disorganized behavior.
o No clinical presentation dominates e.g.
o Paranoid
o Disorganized
o catatonic

POSITIVE SYMPTOMS OF SCHIZOPHRENIA

 Hallucinations
 Delusions

TYPES OF DELUSIONS
1. Persecutory- suspicious of people and believes that others are trying to harm him, trying to kill
and poison him.
2. Grandiosity- suddenly the person starts to harbour a false belief that he is extraordinarily
powerful, wealthy and a very important person. He believes that he can achieve anything and
everything, and feels that all the world is under him.
3. Jealousy or infidelity- false belief that his spouse is unfaithful and is having extramarital affairs.
4. Control ( Passivity Phenomenon)- false belief that his thoughts , actions and feelings are all not
his own but are being controlled by some external agencies.
5. Nihilistic- false belief that the world is going to end or his body parts are missing.
6. Ideas of reference- the person has false idea that people around him talk about him and make fun
of him.

 Abnormal thought form

 Bizarre behavior
 Develops over a short time

Pathoanatomy:
 Hyperdopaminergic process
 No structural changes

NEGATIVE SYMPTOMS
 Alogia (poverty of speech)
 Affective flattening
 Anhedonia (lack of pleasure)
 Attentional impairment
 Avolition (poor motivation)
 Asocial behavior
 Anergia (lack of energy)

Pathoanatomy:
 Nondopaminergic process
 Structural changes
 Increased ventricular brain ratio
 Decreased cerebral blood flow

SCHIZOPHRENIC PROGNOSIS

Good Poor
 Later Onset  Younger Onset
 Obvious precipitating factors  No precipitating factors
 Acute Onset  Insiduous Onset
 Good premorbid social, sexual and work  Premorbid social and sexual and work
history history
 Affective symptoms (esp. depression)  Withdrawn, autistic behavior
 Paranoid or catatonic features
 Undifferentiated or disorganized features
 Married  Single, divorced or widowed
 Family history of mood disorders
 Good support systems
 Undulating course
 Positive symptoms
 Family history of schizophrenia
 Poor support systems
 Chronic course
 Negative symptoms
 Neurological signs and symptoms
 History of perinatal trauma
 No remission in 3 years
 Many relapses

Etiology:

 BIOLOGICAL
 Biochemical theories
 Dopamine hypothesis
 Excessive dopaminergic activity in cortical areas are responsible for the acute positive symptoms of
schizophrenia. This maybe due to increase in the synthesis of dopamine, increase release or turnover of
dopamine, or increase in number of dopamine receptors

 NEUROSTRUCTURAL THEORIES
 Negative symptoms are due to pathoanatomy: increased ventricular brain ratio, brain atrophy, and
decreased cerebral blood flow

 GENETIC THEORIES

 VIRAL INFECTIONS AND FETAL INSULTS

PSYCHODYNAMIC THEORIES

 DEVELOPMENTAL THEORY
 Freudian
 Poor ego boundaries
 Fragile ego
 Inadequate ego development
 Love-hate relationships
 Arrested psychosexual development
 Erikson and Sullivan
 Absence of warm, nurturing attention during the early childhood years
 Blocks the expression of those same affective responses during the later years
 Disordered social interactions, avoid social interaction due to painful childhood experiences

 FAMILY THEORIES
 Lack of loving and nurturing primary caregiver
 Inconsistent family behaviors
 Faulty communication patterns

 VULNERABLE STRESS MODEL

 Both biological and psychodynamic predisposition to schizophrenia, when coupled with stressful
life events can precipitate a schizophrenic process

DISRUPTIVE PATIENTS
 Set limits on disruptive behavior
 Decrease environmental stimuli
 Frequently observe escalating patients in order to intervene.
 Modify the environment to minimize objects that can be used as weapons
 Be careful in stating what the staff will do if a patient acts out; however follow through once a
violation occurs
 When using restraints, provide for safety by evaluating the patient’s status of hydration, nutrition,
elimination, and circulation.

WITHDRAWN PATIENTS
 Arrange nonthreatening activities that involve these patients in “doing something”.
 Arrange furniture in a semicircle or around a table so that patients are forced to sit with someone.
Interactions are permitted in this situation, but should not be demanded. Sit in silence with patients
who are not ready to respond. Some will move the chair away despite the nurses’ efforts
 Help patients to participate in decision making as appropriate.
 Provide patients with opportunities for non-threatening socialization with the nurse on a one-to-one
basis.
 Reinforce appropriate grooming and hygiene (assist first if needed)
 Provide remotivation and resocialization group experiences. Often students work with occupational or
recreational therapists to provide these experiences.
 Provide psychosocial rehabilitation.

SUSPICIOUS PATIENTS
 Be matter-of-fact when interacting with these patients.
 Staff members should not laugh or whisper around patients unless the patients can hear what is
said. The nurse should clarify any misconceptions that patients have.
 Do not touch suspicious patients without warning. Avoid close physical contact.
 Patients who fear being poisoned should be allowed to open a can of food and serve themselves.
Obviously, this maybe difficult top arrange in some hospital settings.
 Maintain eye contact.
 Do not “slip” medications into juices or food without talking to patients. Catching the nurse in the act
of doing this will reinforce their suspicious.

PATIENTS WITH IMPAIRED COMMUNICATION

 Provide opportunities for patients to make simple decisions.
 Be patient and do not pressure patients to make sense.
 Do not place patients in group activities that would frustrate them, damage their self-esteem, or overtax
their availability.
 Provide opportunities for purposeful psychomotor activity.

PATIENTS WITH DISORDERED PERCEPTIONS

 Attempt to provide distracting activities.
 Discourage situations in which patients talk to others about their perceptions.
 Monitor television selections. If you cannot sensor programs, be available to explain, discuss, and
clarify following programs
 Monitor for command hallucinations that may increase the potential for patients to become dangerous.
 Have staff members available in the dayroom so that patients can talk to real people or real events
 Paging systems may reinforce perceptual problems and should be eliminated if possible.

DISORGANIZED PATIENTS
 Remove disorganized patients to a less stimulating environment.
 Provide a calm environment; the staff should appear calm.
 Provide safe and relatively simple activities for these patients.
 Provide information boards with schedules and refer to them often so patients can begin to use this
as an orienting function
 Help protect each patient’s self esteem by intervening if a patient does something that is
embarrassing.
 Assist with grooming and hygiene.
PATIENTS WITH ALTERED LEVELS OF ANXIETY

HYPERACTIVITY
 Allow patients to stand for a few minutes during group meetings.
 Provide a safe environment and a place where patients can pace without inordinately bothering other
patients
 Encourage participation in activities or games that do not require fine motor skills or intense
concentration.

IMMOBILITY
 Provide nursing care for catatonic or immobile patients in order to minimize
 circulatory problems and loss of muscle tone.
 Provide adequate diet, exercise, and rest.
 Maintain bowel and bladder function, and intervene before problems arise.
 Observe patients to prevent victimization (verbal or physical) by others.

OTHER PSYCHOTIC DISORDERS

DELUSIONAL DISORDER

Difference between delusional disorder and schizophrenia

 Delusions have a basis in reality
 The patients have never met the criteria for schizophrenia
 Behavior is relatively normal except in relation to their delusions.
 If mood episodes have occurred concurrently with delusions, their total duration has been
relatively brief.
 Symptoms are due to directly to a substance or to a medical condition.

BRIEF PSYCHOTIC DISORDER

 Psychotic disturbance that last less than one month and are not related to a mood disorder, a
general medical condition, or a substance-induced disorder.
 Delusions
 Hallucinations
 Disorganized speech
 Catatonic behavior

SCHIZOPHRENIFORM
 Typical signs of schizophrenia and at least one month but no longer that six months.

SCHIZOAFFECTIVE
 Schizophrenic symptoms are dominant but are accompanied by major depressive or manic
symptoms

MOOD DISORDERS

MAJOR DEPRESSION
 Chronic Fatigue
 Psychomotor retardation or pronounced reduced mental and physical activity
 Psychomotor agitation or pronounced agitated mental and physical activity
 Sleep disturbances
 Disturbance in appetite
 GI complaints
 Impaired libido
 Apathy
 Sadness
 Hopelessness
 Helplessness/ ruminations of inadequacy
 Thoughts of Death
 Spontaneous crying without apparent cause
 Dependency
 Passiveness
 Anhedonia
 Lack of interest in self care
 Deep sense or feeling of sadness
 Anxiety
 Unconscious anger or hostility directed inward
 Guilt feelings
 Indecisiveness
 Lack of self-confidence

Objective signs of depression:

 Alterations in activity
 Psychomotor agitation
 Unable to sit still
 Pacing and engaging in hand wringing
 Pulling or rubbing the hair, skin, clothing or other objects
 Psychomotor retardation
 Slowing of speech
 Decreased frequency of speech
 Increased pauses before answering
 Soft or monotonous speech (dysprosody)
 Muteness
 General slowing of body movements
 Change in sleeping patterns
 Change in eating behaviors
 Negligence of personal hygiene
 Altered socialization
 Easily distracted
 Underachievement leading to lack of productivity on the job
 Withdrawn

Subjective Signs:
 Alterations in affect
 Overall affective sense is one of low self-esteem
 Guilt
 Alterations in cognition
 Ambivalence and indecision
 Inability to concentrate
 Confusion
 Loss of interest and motivation
 Pessimism, self blame, self depreciation
 Self destructive thoughts and thoughts of death and dying
 Alterations of a physical nature
 Complaints of abdominal pain, anorexia, chest pain, dizziness, fatigue, headache
 Preoccupation with the body
 (+) panic attacks
 Alterations of perceptions
 (+) delusions (somatic and nihilistic)
  (+) hallucinations

Etiology:
 Biological theories
 Due to a chemical imbalance or deficiency of certain neurotransmitters in the brain. These
neurotransmitters are norepinephrine, serotonin and dopamine
 Psychodynamic Theories
 Debilitating Early life experiences
 Intrapsychic conflict
 Reactions to life events

PSYCHOTHERAPEUTIC NURSE-PATIENT RELATIONSHIP

 Accept them as they are. Help them focus on the positive.
 Keep self help strategies simple
 Be honest to develop trust.
 Be sincere and empathic
 Point out even small accomplishments and strengths to a depressed patient
 Reward patients who try to be independent
 Should not embarrass patient
 Never reinforce hallucinations, delusions or irrational beliefs
 Recognize anger. Encourage verbalizations
 Spend time with the withdrawn patient
 Provide opportunities for independent decision making without any pressure

PATIENTS WITH LOW SELF-ESTEEM

 Encourage to participate in individual and group activities to experience accomplishments and
receive positive feedback.
 Provide assertiveness training.
 Help patients avoid embarrassment through socially unacceptable behaviors and appearance.

WITHDRAWN PATIENTS
 Keep brief but frequent contacts.
 Include these patients in group activities

ANOREXIC PATIENTS
 Encourage to eat and spoon feed them if necessary
 Allow patients to choose their food
 Provide small frequent feedings and record intake.
 Monitor and record bowel elimination. Since constipation is a side effect of anti-depressant, include
high fiber foods in the patient’s diet.
 Allow patients to eat food from their home if he prefers it.

PATIENTS WITH SLEEP DISTURBANCES

 Depressed patients want to sleep but suffer insomnia. They may be seen lying in their beds most
of the time but this does not necessarily mean that they are sleeping or resting.
 For patients taking TCA, combining the daily dose in just one single dose at bedtime will decrease
daytime sleepiness.
 Discouraging patients to have day naps would help in their wanting to sleep at night.
 Depressed patients who prefers to sleep most of the time should not be given daytime access to
their rooms. Activities could be substituted for daytime napping.

PATIENTS WITH POTENTIAL FOR SELF-INJURY AND SUICIDE

 Self-injury- act of deliberate harm to one’s own body
 Suicide- intentional, deliberate acts of ending one’s life that are a result of considerable thought and
planning

Suicide clusters
 Mild intent- reflects action of the person who has thought of suicide and maybe trying to solve a
problem situation through suicide threat or gesture.
 Has intense need for attention and recognition
 Done to manipulate or blackmail another
 Moderate intent
 Serious to end life but ambivalent
 Lethal intent
 Fully expected to die
 Method and timing are meant to be fatal

Assessment of suicidal behavior

 Direct warning
 Depressed behavior
 Frequent talks about death, wanting to be dead, appears to be in deep thought
 Changes in social behavior
 Social withdrawal, suddenly feels very happy after being depressed, collects potentially dangerous
items, gives away personal things

Assessment of suicidal behavior

 Making final plans
 Suicide history
 Use of drugs and alcohol
 Commanding hallucinations

Signs and symptoms

Physiological changes
 Disturbance in sleep pattern
 Fatigue
 Anorexia with accompanying weight loss
 Constipation or diarrhea
 Shift in mood during the day
 Somatic complaints
 Psychomotor retardation
 Agitation and restlessness

Behavioral
 Loss of motivation
 Lack of interest
 Social withdrawal
 Flat, sad affect
 Decreased interest in sex
 Suicidal talks and acts
 Gives away personal things

Mental changes
 Negative self concept
 Negative expectations of the future
 Impaired concentration
 Exaggerated view of problems
 Suicidal ideations and thoughts of death
Care strategies
 Be available to the patients, have someone to stay with them. Provide structure and assistance
 Take the patient seriously
 Provide one-one supervision
 Restrict to the ward
 Supervise eating, toileting, smoking, sleeping
 Make rounds at irregular times
 Assess and evaluate for changes
 Help patient to evaluate strengths and other ways to cope such as seeking interpersonal support or other
anxiety reducing activities
 Provide a safe environment in which the patient is protected and cared for until the impulses are
controlled
 Maintain a safe unit
 Remove potentially harmful objects and supervise use of razors, mirrors, pointed objects, lotions, drugs,
chemicals…
 Use seclusion but ensure that patient is within sight and seconds away
 Encourage the patient to verbalize feelings and plans
 Obtain a “NO SUICIDE” contract

BIPOLAR DISORDERS
 Psychomotor overexcitability or excitement
 Insomnia with fatigue
 Euphoria or elated mood
 Distractability
 Pressured speech
 Flight of ideas
 Manipulative or demanding behavior
 Destructive or combative behavior
 Delusions of grandeur
 Impaired judgment

Continuum of symptoms associated with Mania

Mild (“high”)
 Transient feeling of elation; a high feeling
 Feelings of well-being, confidence
 Minor alterations in habit and activity patterns
Moderate (Hypomania)
 Clear sense of euphoria
 Talkativeness, pressured speech
 Flight of ideas
 Grandiosity, excessive spending
 Hypersexuality
 Impulsivity
 recklessness

Severe( “mania”/ euphoria)

 Hyperactivity
 Talkativeness
 Flight of ideas
 Inflated self esteem
 Decreased need for sleep
 Distractability
 Excessive buying, sexual indiscretions

Objective behaviors
 Disturbances of speech
 Altered Social, interpersonal and occupational relationships
 Manipulation of self esteem of others
 Ability to find vulnerability in others
 Ability to shift responsibility
 Limit testing
 Alienation of family
 Alteration in activity and appearance
Hyperactive and agitated
Pacing
Flamboyant gestures
Colorful dresses
Lack of sleep and poor nutrition

Subjective behaviors:
 Alterations in affect
 Alterations of perception

Etiology:
 Psychodynamic theories
 Family dynamics
 Mania as a defense

 Biological theories
 Imbalance between cholinergic and noradrenergic systems. Depression-increased cholinergic
activities; mania- increased noradrenergic activity.

Psychotherapeutic management:
 Safety
 Clear, concise directions and comments
 Limit setting
 Reinforcement of reality
 Provide a homogenous group , if possible

MANIPULATIVE PATIENT
 Manipulation refers to a coping strategy that a person employs to get one’s needs met without regard for
others
 To cope with unmet needs for trust, security and control

Typical behaviors
 Assuming instant intimacy
 Using flattery
 Claiming Entitlement
 Splitting
 Categorizes providers as ‘good’ or ‘bad’ based on whether the staff has done what the patient wants
 Ignites power struggles

Care strategies
 Limit setting
 Establish boundaries
 Put restrictions on problematic behaviors
 Communicate constantly
 Introduce shift nurses to illustrate shift-shift teamwork
 Acknowledge grievances without defensiveness
 Use clear, direct, specific approach when setting limits
 Enforce limits consistently
 Use clear, direct, specific approach when setting limits
 Enforce limits consistently
 Let the patient know that you are available and won’t abandon them
 Firm kindness approach

Sexually provocative behavior

 This behavior can be overt or covert and influenced by age, gender, and cultural mores
 Employed by patients who needs to prove his worth
 Represents and unconscious bid for friendliness, warmth, attention to feelings of loneliness, alienation,
or social isolation.
 Effort to compensate
 Impaired body image or functioning
 Regression

Sexually provocative behaviors

 Flirting
 Excessive use of flattery
 Touching in sexually suggestive manner
 Commenting on staff’s behaviors or body parts
 Making sexist remarks
 Discussing sexual prowess

Sexually provocative behavior care strategies

 Clarify one’s role as a nurse. Set boundaries
 Redirect personal questioning
 Document interactions and behaviors
 Develop a consistent approach
 Evaluate pre-existing problems that may affect behavior
 Set limits on behaviors
 Give positive reinforcements when appropriate

Violent and agitated behavior

 Agitation- anxiety associated with severe motor restlessness

 Potential violence- a growing tension and less ability to control it
 Actual violence- an act of aggression towards others, to self or objects in the environment

VIOLENT AND AGITATED BEHAVIOR

Behavioral cues
 Verbal- raising voice, shouting, speaking profanities, threatens, suspicious, makes demands.
 Non-verbal- excessive psychomotor activity, pacing about, fist clenching, intensified facial
expression, threatening stances, violent gestures

Care strategies
 Check for any history of violence
 Observe current behavior
 Observe physical distance in approaching the patient
 Ensure space on both sides
 Assume an oblique position instead of direct approach
 Avoid aggressive posture
 Utilize active listening
 Utilize restraints or limit setting
 Assess patients need for seclusion or physical restraints
PHYSICAL RESTRAINT AND SECLUSION

Indications:
 Prevent imminent harm to the patient or other person
 Prevent serious disruption of the treatment program or serious damage to the physical environment
 To provide control to psychotic symptoms that are severe and causing serious psychological pain
 Decrease stimulation a patient receives.

Important policies to consider:

 Restraints and seclusions must be ordered by the physician
 Informed consent
 Policies should be explained to the relatives
 Explain to the patient the purpose of the restraint and the seclusion
 Ensure a safe environment
 Teamwork is essential
 Patient should not be abandoned. Must be monitored and evaluated regularly
 Nobody except the staff shall remove the restraints

Care strategies:
 Initial action and objective is to talk down the patient and guide away from the extraneous stimulus
 Give prn medication if ordered and set a contract
 Form a four-man restraining team
 Choose a restraint leader and designate the role of each member of the team
 Present to the patient a “show of force” by gathering sufficient personnel.
 Designate a seclusion marshal who would clear the are of other patients and any physical obstruction
 State clearly the purpose and rationale of the procedure
 Ensure correct team positioning
 Ensure that when restraining the patient, care must be observed to avoid injury by holding on the
patient’s joints
 Assume an oblique position in approaching the patient
 Approach the patient calmly and promptly
 Use proper body mechanics and maintain physical contact at all times. Use cross chest carry while other
members hold the extremities
 Restrain the patient on 4 extremities using a double knot type, with a fingerbreadth allowance so as not
to impede blood circulation. Ensure proper body position is maintained
 Isolate the patient with the head away from the door
 Give tranquilizers or sedatives prescribed by the physician
 Debrief family with regards to restraining and isolation. Ensure that the patient’s need for elimination,
food intake, comfort and safety are met
 Assess if the patient’s behavior is under control and no longer possess a threat to self or others

SEXUAL DISORDERS

SEXUAL DYSFUNCTION
 Characterized by the inhibition of sexual appetite or psychophysiological changes that
compromise the sexual response cycle

THE SEXUAL RESPONSE CYCLE

1. Desire phase
2. Excitement phase
3. Orgasm phase
4. Resolution phase

Types:
 Sexual desire disorder
 Have little or have no sexual desire or an aversion to sexual contact
 Sexual arousal disorders
Cannot attain the physiologic requirements for sexual intercourse
e.g.
Women-lubrication
Men- erection
 Orgasm disorder
Inability to achieve orgasm
 Sexual pain disorder
Suffer genital pain (dyspareunia) before, during and after intercourse
Vaginismus

PARAPHILIAS
 Sexual instinct is expressed in ways that are socially prohibited or unacceptable and are
biologically undesirable.

Types:
1. Pedophilia- victim: <13 y/o; pedophile: >_ 16 y/o or at least 5 years older
2. Incest
3. Exhibotionism
4. Fetishism- inanimate objects
5. Frotteurism- rubbing one’s genitals against an unconsenting individuals thighs or buttocks
6. Sexual masochism
a. hypoxyphilia-strangulation/oxygen deprivation
7. Sexual sadism
8. Voyeurism

ANXIETY-
ANXIETY- feeling of apprehension due to anticipation of danger

2 causes:
 Threats of psychological integrity or well being
 i.e. guilt, threats to self esteem, love and belongingness
 Threats to physical integrity
 i.e. illness, unmet needs, safety

Selye’s GAS
 Stages:
 Alarm-
Alarm- adrenaline is released when threat is recognized
 Resistance-
Resistance- fight or flight
 Exhaustion-
Exhaustion- relaxation or death

Stage Physical Changes Psychosocial changes

Alarm reaction  Release of adrenaline=vasoconstriction; inc.  Increased level of alertness
BP, inc. HR, and force of cardiac contraction  Increased level of anxiety
 Increased hormone levels  Task/defense oriented behavior
 Enlargement of adrenal cortex
 Marked loss of body weight
 Irritation of gastric mucosa
 Shrinkage of thymus, spleen and lymph
nodes
Stage of resistance  Hormone levels readjust  Increased/intensified use of coping mechanism
 Reduction in activity and size of adrenal  Tendency to rely on defense oriented behavior
cortex
 Lymph nodes return to normal size
 Weight returns to normal
Stage of  Decreased immune response  Defense oriented behaviors
Exhaustion  Depletion of adrenal glands and hormone  Disorganization of thinking
production  Disorganization of personality
 Weight loss  Sensory stimuli maybe perceived with
 Enlargement of lymph nodes and appearance of illusion
dysfunction of lymphatic system  Reality contact maybe reduced with
 Cardiac failure, renal failure or death may appearance of delusion or hallucinations.
occur

Levels of Anxiety
 Mild
Perception is more alert than usual
 Moderate
 Narrowed perception
 Difficulty focusing
 Selective inattention
 Mild physical complaints such as stomachache
 Severe
 Very narrowed perception
 Unable to focus on problem solving
 Increased physical discomfort

 Panic
 Unable to see the whole situation or reality
 Distortion of perception

Level Effects upon the ability to observe Effects upon the ability on what is
happening
Mild Person is alerted, sees, hears, and grasps  Increased awareness and alertness
more than previously  Attention is possible
 Level, that can motivate leaning  Skill in seeing relations can be used.
and can produce growth and creativity
in the individual.
 Associated with the tension of
everyday life.
Moderate Person’s perceptual field is narrowed. Selected inattention, i.e. individuals fails to
Sees, hears, grasps less but can attend to notice what goes on in situations peripheral
more if asked to do so. to the immediate focus but can notice if
attention is pointed there by another
observer.
Severe Perceptual filed is greatly reduced. Dissociating tendencies operate to panic i.e.
HEARING IS NOT POSSIBLE the person does not notice what goes on in a
He tends to focus on a specific detail and situation ( specifically communication with
all his behavior aimed at getting relief. reference to the self). And there is inability
to do so even when attention is pointed to
this direction by another observer.
Panic Involves disorganization of the Person becomes immobilized (emotional
personality. paralysis)
Loss of control Increase motor activity
Unable to do things even with direction Decrease ability to relate to others.
Distorted perceptions
Loss of rational thought

ANXIETY DISORDERS
 PHOBIC DISORDERS
Irrational, excessive fear of a condition or object
Degree of fear expressed is obviously unusual and out of proportion to the attending circumstances
 e.g.
 Claustrophobia (close space)
 Agoraphobia (open space)
 Acrophobia(heights)
 Hydrophobia (water)
 Xenophobia (strangers)
 Arachnophobia (spiders)
 Zoophobia (animals)
 Allurophobia (cats)
 Chromophobia (colors)
 Mysophobia (dirt)
 Bacillophobia (germs)

Etiology
 Psychoanalytic view
 Individual experiences severe diffused anxiety which is only incompletely resolved by repression and
so there is displacement of the anxiety to an external focus which the individual then tries to avoid

Treatment for phobic disorders

1. Drug treatment- anxiolytics
2. Behavior Therapy
a. Systematic Desensitization
b. Flooding- sudden exposure of the patient to the phobic situation until he is no more fearful.
c. Implosion- flooding carried out in imagination.
3. Accept patients and their fears with a non-critical attitude
4. Provide and involve in activities that do not produce anxiety but will increase involvement rather
than avoidance
5. Help patients with physical safety and comfort needs
6. Help the patient to recognize that their behavior is a method of coping with needs
7. Assertiveness training and goal setting

OBSESSIVE COMPULSIVE DISORDER

Definition:
 Obsession- persistent thought that wont go away thru logical effort
 Compulsion- uncontrollable impulse to repeatedly perform an act

Etiology:
 Genetic predisposition
 Decreased serotonin

Symptoms:
 Ritualistic behavior
 Constant doubting if he\she has performed the activity

Nursing Care:
 Allow the patient to perform the ritual to decrease the anxiety and energy level
 Provide structured activities to decrease the ritual to a degree that is comfortable to the patient

Note: The individual recognizes the unreasonableness and absurdity of the obsessions and compulsions but
is unable to control it.
POST-TRAUMATIC STRESS DISORDER
 Developed usually after experiencing a traumatic event

Symptoms:
 Events are traumatic to anyone and are unusual life events
 Sleep disturbances: Insomnia due to nightmares
 Patient may appear to re-experience the event while awake
 Psychic numbness: unable to move in life; stuck in the experience of the past

Management:
 Psychotherapy
 Group therapy
 Anxiolytics

Nursing Care:
 Be nonjudgmental and honest; offer empathy and support; acknowledge any unfairness or
injustices to the trauma
 Assure patient that what they are feeling are typical reactions to serious trauma
 Help patient to recognize the connections between the trauma experience and their current
feelings, behaviors and problems.
 Help patients to evaluate past behaviors in the context of the trauma, not in the context of current
values and standards
 Encourage safe verbalizations of feelings, especially anger.
 Encourage adaptive coping strategies and techniques
 Encourage patients to establish or reestablish relationships

CHRONIC ANXIETY DISORDER OR GENERALIZED ANXIETY DISORDER

 Anxiety is directly felt and expressed
 Difficulty in controlling the anxiety
 Often admitted to the hospital

Symptoms:
 Excessive worry and anxiety
 Difficulty in controlling the worry
 Anxiety and worry are evident in:
 Restlessness
 Fatigue and irritability
 Decreased ability to concentrate
 Muscle tension
 Disturbed sleep

Nursing Care:
 Provide a calm and quiet environment
 Ask the patient to identify what and how they feel to increase awareness of what is happening to
them
 Encourage to describe and discuss their feelings with you to increase awareness of the connection
between feelings and behaviors
 Help patients to identify possible causes of their feelings
 Listen carefully for patients’ expressions of helplessness and hopelessness; assess for suicidality
 Plan and involve patients in activities such as going for walks and playing recreational games
 Discuss with patients their present and previous coping mechanisms
 Discuss with patients the meaning of problems and conflicts to appraise stressors, explore their
personal values, and define the scope and seriousness of their problems
 Use supportive confrontation and teaching.
 Assist patients with exploring alternative solutions and behaviors
 Encourage patients to test new adaptive coping behaviors through role playing or implementation.
 Teach patients relaxation exercises
 Promote use of hobbies and recreational activities.

SOMATOFORM DISORDERS
 Have physical symptoms with no known organic or physiological cause
 Defense mechanisms used
 Repression
 Denial
 Displacement

HYPOCHONDRIASIS
 Thought disorder
 Characterized by persistent, severe, morbid preoccupation with one’s physical and emotional health and
accompanied by various somatic complaints without demonstrated organic cause
 Individual is aware and exaggerates the intensity and importance of sensations that most others
disregard.

SICK BEHAVIOR extra love, attention and sympathy

Primary gain Secondary gain

Characteristics:
 No pathology
 Doctor shopping
 Symptoms are under unconscious control

CONVERSION DISORDER
 Repression
 Conversion

Characteristics:
 Physical disability without pathology
 Motor
 Paralysis
 paresthesia
 Sensory
 Hysterical Blindness
 Mutism/deafness
 Labelle indifference-
indifference- indifference with his/her condition

Treatment:
 Psychotherapy
 Hypnosis

Management:
 Acknowledge complaints
 Divert attention
 Keep the patient busy
 Discourage secondary gains
 Encourage independence
MENTAL RETARDATION
 Below average general intellectual functioning originating during the development period and
associated with impairment in adaptive behavior.

Levels IQ range
 Mild Mental retardation 50-69
 Moderate Mental retardation 35-49
 Severe mental retardation 20-34
 Profound mental retardation below 20

Normal Milestones
 3 months- holding neck erect
 6 months- sitting with support
 9 months-1 year- walking
 11/2 years- speaking few words or phrases

AUTISM
 Withdrawal of the child into the self and into a fantasy world of his own creation. Course is chronic.

Symptoms:
 Failure to form interpersonal relationships
 Impairment in communication
 Bizarre responses to the environment
 Extreme fascination for objects that move (e.g. fans, trains)
 Fluctuating mood sudden crying or laughing
 Self mutilating behaviors

ATTENTION DEFICIT HYPERACTIVITY DISORDER

 A disorder occurring in childhood characterized by poor attention span, overactivity and impulsiveness.
The child responds to multiple stimuli at the same time.

Symptoms:
 Easily distracted; not able to sit or do one thing for some time. Disorganized behavior
 Sustaining attention is very difficult. Hence is disruptive and overactive in the classroom.
 The child often has excessive gross motor activity (e.g. excessive running-climbing, difficulty in
sitting for long, restlessness)

CONDUCT DISORDERS
 Disorders where the child’s behavor is against social norms and values. The behaviors are repetitive
and persistent. They violate rules. Their conduct is worse than ordinary mischief.

Common Problems:
 Truancy ( not attending school, spending time somewhere else)
 Lying, stealing, substance abuse, breaking things, setting fire, often running away from home,
gambling poor peer group relations, fights with others, thefts outside home.
 Does not accept responsibility and learn from past experiences and go on repeating the same
mischief again and again. They often get caught by the police.

COGNITIVE DISORDERS

DELIRIA
 Characterized by a change in cognition and a disturbance of consciousness, which manifests as a
reduced ability to focus, sustain or shift attention. Delirium tends to develop over a short period of time
and tends to fluctuate during the course of the day.

Symptoms:
 Reduced awareness of and attentiveness to the environment
 Reduced stare of consciousness
 Disorganized thinking
 Rambling, irrelevant or incoherent speech,
 Memory impairment
 Disturbances in sleep
 Disturbances in psychomotor activity and sensory misperceptions
 Disorientation

Nursing Interventions:
 Manipulation of the environment to provide familiarity and to decrease the fear of a strange place
is also beneficial

DEMENTIA
 Characterized by the development of multiple cognitive deficits manifested by both memory
impairment and at least one of the cognitive disturbances of aphasia, apraxia, agnosia or disturbances in
planning. The course is gradual in onset with an unabated decline. Prognosis is usually poor.

Symptoms:
 Cardinal symptoms: problems with orientation, judgement, attention, intellect and memory.
 Alterations in memory ( short and long term, alterations in reasoning, language and personality)
 Alterations in abstract thinking
 Decreased capacity for generalization, differentiation, concept formation, and logical reasoning
 Alterations in judgment
 Alterations in perceptions
 (+) visual and auditory hallucinations
 (+) delusions arising out of a reaction to a cognitive deficit
 (+) illusions

ALZHEIMER’S DISEASE
 Age related, progressive disorder of the CNS, characterized by chronic cognitive dysfunction
 Four A’s of Alzheimer’s disease
 Amnesia
 Agnosia
 Aphasia
 Apraxia

Delirium Dementia
 Acute onset  Insidious onset
 Presence of disorientaion, anxiety, poor  Disturbed memory, personality
attention deterioration
 Clouding of consciousness or drowsiness  Clear consciousness
 Perceptual abnormalities are common  Global impairment of cerebral function
(hallucinations and illusions)  Progressive course
 Fluctuating course  Mostly irreversible
 Reversible

Nursing Management:
 Daily routine
 Stress
 Safety
 Wandering

PERSONALITY DISORDERS
 This involves lifelong, inflexible, and dysfunctional patterns of relating and behaving. These
dysfunctional patterns and behaviors usually cause distress to others. However, they do not find their
behaviors distressing to others.

Classification of Personality Disorders

1. Withdrawn (odd and eccentric)
a. Schizotypal
b. Schizoid
c. Paranoid
2. Dependent (anxious and fearful)
a. Avoidant
b. Dependent
3. Inhibited
a. Obsessive Compulsive
4. Anti-social (dramatic, emotional, flamboyant and erratic)
a. Histrionic
b. Borderline
c. Narcissistic

Characteristics of Personality Disorders

1. It is not a mental illness
2. It is a maladaptive behavior
3. It is the possession of abnormal personality traits
4. It is a long lasting, most of the time, lifelong problem
5. It causes significant impairment in social occupational functioning
6. It produces distress to the individual and to others.

PARANOID PERSONALITY DISORDER

 Suspicious
 Doubt trustworthiness of others
 Fear of confiding in others
 Fear personal information will be used against him
 Interpret remarks as demeaning or threatening
 Hold grudges toward others
 Becomes angry and threatening when they perceive to be attacked by others

Intervention: centered on building trust

SCHIZOID PERSONALITY DISORDER

 Lacks desire for close relationships or friends
 Chooses to be alone
 Lack of sexual experiences
 Avoids activities
 Appears cold and detached

Interventions: building trust followed by identification and appropriate verbal expression

SCHIZOTYPAL PERSONALITY DISORDER
 Ideas of reference
 Magical thinking or odd beliefs
 Unusual perceptual experiences, including bodily illusions
 Peculiar thinking
 Vague, stereotypical, overelaborate speech
 Suspiciousness
 Blunted or inappropriate affect
 Eccentric appearance or behavior
 Few close relationships
 Uncomfortable in social situations

Interventions: Improving Interpersonal relationships, social skills., and appropriate behaviors

ANTI-SOCIAL PERSONALITY DISORDER

 Violates rights of others
 Engages in illegal activities
 Aggressive behavior
 Lack of guilt or remorse
 Irresponsible in work and with finances
 Impulsiveness
 Recklessness
 Manipulative

Interventions: Consistency and firmness in confronting behaviors and enforcing rules and policies.

Nursing Care of Antisocial Personality Disorders:

LONG TERM: helping person to accept responsibility for and consequences of his actions.
SHORT TERM: minimize manipulation and acting out.
 Encourage the patient to talk about his behavior, its limits and consequences.
 Discuss how manipulative behavior prevents him from establishing a close relationship.
 Help the client identify more adaptive strategies.
 Provide positive reinforcement for non-manipulative behavior because thay cannot be corrected by
punishment.
 Assist him to understand his positive qualities.
 Develop trust and rapport.
 Provide group situations for the patient.

BORDERLINE PERSONALITY DISORDER- DISORDER- maybe due to neglect, over involvement or abusive
family. Defense mechanism: splitting (viewing things as all good or all bad)
 Frantic avoidance of abandonment; real or imagined
 Unstable and intense interpersonal relationships
 Identity disturbances
 Impulsivity
 Self-mutilating behavior
 Rapid mood shifts
 Chronic feelings of emptiness
 Problems with anger
 Transient dissociative and paranoid symptoms

Interventions: Use of empathy. Recognize the reality of the patient’s pain, should offer support and should
empower and work with the patient to understand control and change dysfunctional behaviors. Provide safe
environment.
 NARCISSISTIC PERSONALITY DISORDER
 Grandiose self importance
 Fantasies of unlimited power, success or brilliance
 Believes he or she is special
 Needs to be admired
 Sense of entitlement
 Takes advantage of others for own benefit
 Lacks empathy
 Envious of others or others are envious of him
 Arrogant

Interventions: supportive confrontation on what the patient sways and what exists. Limit setting and
consistency to decrease manipulation and entitlement behaviors.

HISTRIONIC PERSONALITY DISORDER-DISORDER- dramatizes all events and draws attention to self
 Overly dramatic
 Draws attention to self
 Extroverted and thrives on being the center of attraction
 Uses somatic complaints to avoid responsibility and support dependency
 Dissociation

Interventions: Positive reinforcement in the form of attention, recognition or praise are given for
unselfish or other-centered behaviors.

DEPENDENT PERSONALITY DISORDER

 Unable to make daily decisions without much advice and reassurance
 Needs others to be responsible for important areas of life.
 Seldom disagrees with others because of fear of loss of support or approval
 Problems with initiating with projects or doing things on his own because of little self confidence
 Performs unpleasant tasks to obtain support from others
 Anxious or helpless when alone because of fear of being unable to care for self
 Urgently seeks another relationship for support and care after a close relationship ends
 Preoccupied with fear of being alone to care for self

Interventions: increase responsibility for self in day to day living; assertiveness training

AVOIDANT PERSONALITY DISORDER

 Avoids occupations involving interpersonal contact due to fears of disapproval or rejection
 Uninvolved with others unless certain of being liked
 Fears intimate relationships due to fear of shame or ridicule
 Preoccupied with being criticized or rejected in social situations
 Inhibited and feels inadequate in new interpersonal situations
 Believes self to be socially inept, unappealing and inferior to others
 Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed

OBSESSIVE COMPULSIVE PERSONALITY DISORDER

 Preoccupied with details, lists, rules, organization
 Perfectionism that interferes with task completion
 Too busy working to have friends or leisure activities
 Overconscientious and inflexible
 Unable to discard worthless or worn-out objects
 Others must do things his or her way in work or task related activity
 Reluctant to spend and hoards money
 Rigid and stubborn
CHEMICAL DEPENDENCE

DRUG ABUSE

Reasons for taking drugs:

 Search for euphoria
 Relief from psychological pain of diverse origins
 Wanting to feel better than they do
 To avoid withdrawal symptoms

Factors involved in drug abuse:

1. The drug is seen as a reinforcer
2. Tolerance
3. Physical dependence
4. The abuser
 The personality, degree of stability and attitude of the individual
5. The environment
 Stress
 Isolation
 Peer group influence
6. The motivating factors
 Initiation by company
 Curiosity
 Pleasure
 Acceptance by the group

DEPRESSANTS

ALCOHOL
 Physiological effects
Disinhibition, impaired judgment and fuzzy thinking
 Sedation and toxicity
Delirium Tremens-
Tremens- CNS irritability; the body not only invents sensory inputs but also has extreme
motor agitation; hallucinations may occur; seizures (grand mal) may also be present.

Nursing issues:
 Overdose
 Disulfiram (Antabuse)- intake of disulfiram with alcohol creates an ill feeling in the person
( sweating, flushing of the face and neck, throbbing headache, nausea and vomiting, palpitation,
dyspnea, tremors and weakness
 Interactions
 Fetal alcohol Syndrome-
Syndrome- microencephaly, cleft palate, altered palmar creases, cardiac defects,
anomalous genitalia, mental retardation, and depressed sucking reflex

Withdrawal and Detoxification

 Withdrawal:
 tremulousness
 nervousness
 anxiety
 anorexia, n/v
 insomnia and other sleep disturbances
 rapid pulse, increase blood pressure
 profuse perspiration
 diarrhea
 fever
 unsteady gait
 difficulty concentrating
 exaggerated startle reflex
 craving for alcohol and other drugs
Physical complications of alcoholism:

Gastrointestinal
 Dyspepsia
 Vomiting
 Acute or chronic gastritis
 Peptic ulcer
 Cancer
Liver
 Fatty degeneration of the liver
 Alcoholic Hepatitis
 Cirrhosis
Pancreas
 Acute and chronic pancreatitis
Cardiovascular
 Alcoholic cardiomyopathy
 High risk for myocardial infarction
Blood
 Folic acid deficiency anemia
 Decreased WBC production
Muscle
 Peripheral muscle weakness
 Muscle wasting
Skin
 Spider angiomas
 Acne
Nutrition
 Protein malnutrition
 Vitamin Deficiency disorders like pellagra and beriberi
Joints
 Gout due to increased uric acid level
Reproductive system
 Sexual dysfunction in males
 Failure of ovulation in females
Pregnancy
 Fetal Alcohol syndrome- fetal abnormalities like mental retardation and growth deficiency
Nervous System
 Alcoholic peripheral neuropathy
 Wernicke’s-Korsakoff syndrome
 Rum fits during withdrawal
Psychiatric Complications
 Pathologic intoxication
 Withdrawal phenomenon
 Alcoholic Hallucinosis- vivid hallucinations developing shortly after cessation or reduction of
alcohol use.
 Alcoholic psychosis- paranoia in chronic alcohol use
 Morbid jealousy
 Alcohol amnestic disorder- impairment in long term and short term memory with disorientation
and confabulation
 Alcoholic dementia- due to prolonged use and maybe rendered irreversible

Management of alcoholism
 Assessment of the patient
 o His drinking pattern
o Work spot
o Family
o Environment
 Physical methods
o Detoxification
o Disulfiram Therapy
 Psychological methods
o Counseling
o Individual and group psychotherapy
o Marital/family therapy
o Behavioral modification (Aversion therapy)
o Relapse prevention therapy
 Rehabilitation
 Alcoholic anonymous

Detoxification
 Administration of minor tranquilizers to control anxiety, insomnia, agitation and tremors
 Assess fluid and electrolyte imbalance
 Reestablish proper nutrition by giving high protein diet (if no liver damage).
 Supplementation- vitamin C to acidify urine to increase excretion of alcohol; B complex for liver
damage.
 Provide calm, safe environment
 Control nausea and vomiting
 Administer anticonvulsant (for seizures or rumfit)

Care of alcoholics in the acute stage of withdrawal

 Provide calm, quiet environment. Well-lighted rooms reduce fears and illusions
 Safety. Observe for signs of DT
 Side rails up
 Physical restraint if highly disturbed or hyperactive
 Keep potentially dangerous items out of patients access to prevent self harm
 Monitor VS every 15 minutes
 Frequently reorient patient to reality and surroundings
3 element of detoxification:
 secure environment
 sedation
 supplements

BARBITURATES

INHALANTS

OPIOIDS AND NARCOTICS

STIMULANTS

COCAINE

PhysiologicEffects:
 Euphoria
 Increased mentalalertness
 Increased strength
 Anorexia
 Increased sexual stimulation
 Increased motor activity
 Tachycardia
 Increased blood pressure
 Deeper respirations
 Dilated pupils
 Nasal septum perforation

AMPHETAMINES

Physiologic Effects:
 Wakefulness
 Alertness
 Heightened concentration, energy
 Improved mood to euphoria
 Insomnia and amnesia
 Amphetamine induced psychosis

HALLUCINOGENS
Natural hallucinogens
 Mescaline
 Psilocybin
 Marijuana

Synthetic Hallucinogens
 LSD
 PCP

Psychotherapeutic Management:
 Help patient understand positive motivators that will help in establishing new goals and direction
for his life
 Trusting relationship; firm inimplementing rules
 Expressing empathy and providing a safe environment
 Group treatment
 Assertion training
 Lifestyle issues
 ersonalresponsibilityConscience development
Milieu Management:
 Drug free environment
 Suicide prevention
 Thwarting inappropriate sexual behaviors
 Active, meaningful schedules

EATING DISORDERS

ANOREXIA NERVOSA

Symptoms:
 Refusal to maintain body weight over a minimum normal weight for age and height
 Intense fear of gaining weight or becoming fat, even though underweight
 Disturbance in the way in which one’s bodyweight, shape or size is experienced
 In females, absence of menses of at least 3 consecutive cycles

Objectives of Care:
 Increasing self esteem
 Increasing body weight to at least90% of average weight for age and height
 Reestablishing good eating behavior

Nursing Interventions:
 Monitor daily caloric intake
 Observe signs of purging
 Monitor activity level
 Weigh daily
 Provide accurate information on nutrition and discuss realistic and healthy diet
 Regularly monitor electrolyte status
 Convey warmth and sincerity
 Listen empathically
 Be honest
 Set limits
 Assist in identifying at least three positive characteristics
 Involve patient in care
 Teach patient about their illness
 Avoid long silences
 Behavior modification: reward increase in weight with meaningful privileges
 Identify patient’s non weight related interests to reduce anxiety and refocus attention.

BULIMIA NERVOSA

Symptoms:
 Recurrent episodes of binge eating
 Feeling of lack of control over eating behaviors during the eating binges
 Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self
induced vomiting
 Binge eating and inappropriate eating behaviors
 Persistent over concern with body shape and weight

Management:
 Trust
 Help patient identify feelings associated with binge-purge behaviors
 Accept patient as worthwhile human beings because they are often ashamed of their behavior
 Encourage patient to discuss positive qualities about themselves
 Teach about bulimia nervosa
 Encourage to explore interpersonal relationships
 Encourage patients to adhere to meal and snack schedules
 Encourage the patient to approach the staff if she feels like binging or purging
 Encourage to attend group sessions
 Encourage family therapy
 Encourage participation in art, recreation and occupational therapy
 Encourage the patient to describe their body image at different ages of their lives.

ABUSE

Definition:
 To take unfair or undue advantage of; to use or treat as to injure, hurt or damage.
 Misuse of power by one to inflict pain and injury to another who is less powerful.
 Abuse may involve omission or commission
 Sexuality abusive behavior- refers to some act as fondling of the genital area, oral-genital contact
or penetration of a bodily orifice.
 No consent of the victim.

General considerations:
 No population or socioeconomic group is immune to neglect or abuse.
 The less powerful a person is- the less likely she is to acknowledge abuse openly or seek
assistance of others.
 Lack of power or control over their own lives leads to distrust.
 Nurse should be comfortable with abuse and victimization behavior before they can become
therapeutic.

Categories of abuse:
 Spouse
 Rape
 Child physical abuse and neglect
 Child sexual abuse