Exam 1 Outlines

Chapter 2: Historical Perspective ​VIV

● Mental health and mental illness has a basis in the cultural beliefs of the society in which a behavior is taking place
○ Some cultures are more liberal so there is a large range of behaviors that are acceptables; other cultures have little
tolerance for certain behaviors

HISTORICAL OVERVIEW OF PSYCHIATRIC CARE

● Primitive beliefs regarding mental disturbances took several views; these beliefs evolved with increasing knowledge about
mental illness and changes in cultural, religious, and sociopolitical attitudes.
○ Hippocrates 400 B.C. HUMORS
■ Began a movement away from the belief in the supernatural
■ Associated insanity and mental illness with an disequilibrium in the interaction of the four body fluids 
→ blood, black bile, yellow bile, and phlegm AKA humors
■ Treated with vomiting and diarrhea with potent cathartic drugs
○ Middle Ages 500 A.D. - 1500 (Europe)
■ Associated mental illness with witchcraft and the supernatural
■ Mentally ill people were sent out to sea on  sailboats → expression came from this “ship of fools” 
○ Middle Ages 500 A.D. - 1500 (Middle Eastern)
■ Began to think that those who are ill actually are ill and special units were made within general 
hospitals, also residential institutions → these can be considered the first asylums 
○ Colonial Americans → mentally ill taken care of by the community or incarcerated (if no fam/other)
■ 18th century: First hospital for mentally ill by Benjamin Rush (AKA the father of american psychiatry)
● Initiated humanistic care for the mentally ill (kindness, exercise, socialization, blood letting,
purging, restraints, and extreme temperatures)
■ 19th century: State asylums by Dorothea Dix, believed mental illness was curable and hospital should
provide humanistic therapeutic care
● Mentally ill population grew → institutions became overcrowded, understaffed, and 
conditions deteriorated
■ 1873: Psychiatric nursing (\^-^/) by Linda Richards (AKA first american psychiatric nurse)
● Established numerous psychiatric hospitals and the first school of psychiatric nursing (1882)
○ Psychiatric schools focused on custodial care for mentally ill not the study of psych
concepts
■ 1955: psychiatric nursing becomes a requirement for all nursing schools
● Increased need for psych nurses bec WWII, the government passed the national mental health act
of 1946 ($$ for edu in psych related stuff and social workers)
○ Graduate level education in psych nursing established
○ Antipsych meds introduced

MENTAL HEALTH
● There are many attempts to define mental health, concepts include various aspects of individuals functioning
○ Ex: Maslow’s hierarchy of needs FIG 2-1 pg 15

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 ○ Ex: Jahoda and her list of 6 indicators of mental health
■ 1. A Positive Attitude Towards Self
● Objective view of self; knows and accepts strengths and limitations
● Sense of personal identity and a security within environment
■ 2. Growth, Development, and the Ability to Achieve Self-Actualization
● Individuals achieves tasks associated with levels of development (Erikson ch 3) and gains
motivation for advancements to highest potential
■ 3. Integration
● Focus on maintenance in various life processes → ability to adapt to environment and 
development of a philosophy of life to manage anxiety and stress 
■ 4. Autonomy
● Individual's ability to be independent/self directing
● Makes choices and accepts responsibility for outcomes
■ 5. Perception of Reality
● Accurate reality perception (no disorientation & ability for empathy) is a positive indicator of
mental health
■ 6. Environmental Mastery
● Individual has achieved a satisfactory role within a group, society, or environment
● Able to love and accept the love of others
● Able to strategize, make decisions, change, adjust, and adapt
○ Ex: Black and Anderson's definition of mental health
■ A state of being that is relative rather than absolute
■ Successful mental functions: productive activities, fulfilling relationships with ppl, ability to adapt/change/
and coping.
○ Ex: Robinson’s definition of mental health
■ A dynamic state → thought, feeling, behavior is age-appropriate and congruent with local/cultural 
norms 
○ Book:
■ “Mental HEALTH is viewed as the ​successful ​adaptation to stressors from the internal/external
environment, evidence by thoughts, feelings, and behaviors that are age ​appropriate ​and congruent
with local/cultural norms”

MENTAL ILLNESS

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 ● Universal concept of mental illness is difficult to define bec cultural factors but 2 elements associated with perception
regardless of cultural origin (according to Horwitz):
○ 1​. ​Incomprehensibility- ​ inability of the general population to understand the motivation behind the behavior
■ “Observers attribute labels of mental illness when the rules, conventions, and understandings they use to
interpret behavior fail…”
○ 2. Cultural relativity​- rules, conventions, and understandings are conceived within an individual's unique culture
■ “Normal” and “abnormal” behavior is defined by cultural/societal norms
■ Horwitz cultural aspects of mental illness BOX 2-1 pg 16
● 1. Community members initially recognize deviated behavior rather than psych professionals
● 2. Relatives/close ppl less likely to label mentally ill; they try to “normalize” the behavior by
trying to find an explanation
● 3. Psychiatrist sees person with mental illness most often when there is no more denying the
illness by family/cultural norms
● 4. Lowest social class usually more mental illness symptoms, tend to tolerate more deviant
behaviors and less likely to label mental ill (label applied by psych)
● 5. Higher social class greater recognition of mental illness behaviors; likely to self/family label;
psych assistance sought near first signs
● 6. Highly educated greater recognition of mental illness behavior. More relevant is the ​amount and
type​ of education (lawyers, social workers, artist, teachers, nurses) more likely seek psych
assistance than business executives, computer specialist, accountants, and engineers
● 7. Jewish more likely seek assistance than catholics or protestants
● 8. Women more likely to recognize symptoms and seek assistance than men
● 9. The greater the cultural distance from the ​mainstream​ culture the greater negative response by
society to mental illness
● “Mental ILLNESS is viewed as the ​maladaptive ​responses to stressors from the internal/external environment,
evidence by thoughts, feelings, and behaviors that are age ​incongruent ​ with local/cultural norms, and that interfere
with the individual's social, occupational, and/or physical functioning”

PSYCHOLOGICAL ADAPTATION TO STRESS

● All individuals exhibit some characteristics associated with both mental health and mental illness at any given point in time
○ An individual's response to stressful situations is influenced by their perception of the event and predisposing factors
(heredity, temperament, learned response patterns, developmental maturity, coping strategies, support systems)
○ Anxiety and grief are two major primary psychological response patterns to stress
■ Anxiety- ​a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and
helplessness
■ Grief- ​is a subjective state of emotional, physical, and social responses to the loss of a valued entity
- ​ANXIETY
● Anxiety- a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness
● It is such a common feeling almost considered universal; arises from chaos, confusion, fears of the unknown/ambiguity.
● Anxiety becomes problematic when it interferes with the ability to meet basic needs
● Peplau described 4 levels of anxiety (​*​TABLE 2-1 lEVELS OF ANXIETY pg 18*​)
○ 1. Mild Anxiety
■ seldom a problem; associated with tension experienced in the response to events of day to day living
■ Prepares you for action; sharpens the senses, ↑ motivation, ↑ productivity, ↑ perceptual field → 
heightened awareness of environment
■ Learning is enhanced; able to function at optimal level
○ 2. Moderate Anxiety
■ Perceptual field diminishes; less alert to events, ↓ attention span, ↓ ability to concentrate, ↑ muscular 
tension and restlessness 
■ Assistance with problem solving necessary
○ 3. Severe Anxiety

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 ■ Perceptual field greatly diminished; concentration centers wither on one particular detail or many 
extraneous details; Attention span is limited → difficult with even the simplest tasks 
■ Physical symptoms (headaches, palpitations, insomnia)
■ Emotional symptoms (confusion, dread, horror)
○ 4. Panic Anxiety (most intense)
■ Unable to focus on even one detail in the environment; misperceptions are common and a loss of 
contact with reality may occur → hallucinations or delusions 
■ Behavior → wild and desperate actions or extreme withdrawal; Communication → becomes ineffective 
■ **feeling of terror, convinced that they have a life threatening illness/fear that they are going crazy/losing
control
■ Prolonged anxiety can lead to physical and emotional exhaustion which can be life threatening

● Behavioral Adaptation Responses to Anxiety

○ Mild Anxiety → COPING BEHAVIORS ​to satisfy their needs for comfort

■ sleeping/yawning
■ eating/drinking
■ Physical exercise
■ Day-dreaming
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 ■ Smoking
■ Laughing
■ Crying
■ Cursing
■ Pacing
■ Nail biting
■ Foot swinging/finger tapping/fidgeting
■ Talking to someone … etc
○ Mild-to-Moderate Anxiety → EGO DEFENSE MECHANISMS (15)
■ Ego governs problem solving and rational thinking → some mechanisms are adaptive others can 
become maladaptive (interfere with ability to deal with reality or occupation performance)
■ TABLE 2-2 EGO DEFENSE MECHANISMS pg 19

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 ○ Moderate-to-Severe Anxiety → PSYCHOPHYSIOLOGICAL RESPONSES 
■ If unresolved over an extended period of time → physiological disorders (​doesn't say wtf thatmeans)​
■ May exacerbate symptoms of , delay recovery from, or interfere with treatment of other medical conditions
● Other conditions include… Cardiovascular, gastrointestinal, neoplastic, neurological, and
pulmonary conditions
○ Severe Anxiety → PSYCHONEUROTIC RESPONSES 
■ Extended periods of repressed severe anxiety → result in psychoneurotic patterns of behaving 
(neurosis/psychosis)
● Neurosis (AKA psychosis?)​ is excessive anxiety expressed directly or altered through defense
mechanisms, with symptoms such as obsession, compulsion, phobia, or sexual dysfunction
● Common characteristics​ of ppl with neurosis:
○ They are aware of their distress and that their behaviors are maladaptive
○ They are unaware of any possible psychological causes of distress
○ They feel helpless to change their situation
○ They have no loss of contact with reality
● Examples of psychoneurotic ​responses ​in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5):
○ 1. Anxiety disorders- disorders with characteristic feature of symptoms of anxiety and
avoidance behaviors (phobias, panic disorder, generalized anxiety, separation anxiety)
○ 2. Somatic symptom disorders- disorders with characteristic feature of physical
symptoms with no known cause
○ 3. Dissociative disorders- disorders with characteristic feature of disruption of
consciousness, memory, identity, or perception of the environment (dissociative amnesia,
identity, and/or depersonalization-derealization)
○ Panic Anxiety → PSYCHOTIC RESPONSES 
■ An extreme level of anxiety; may lose contact with reality
■ Psychosis ​is defined as “a severe mental disorder characterized by gross impairment in reality testing,
typically manifested by delusions, hallucinations, disorganized speech, or disorganized or catatonic
behavior”
■ Common characteristics​ of ppl with psychoses:
● They exhibit minimal distress (emotional tone is flat, bland, or inappropriate)
● They are unaware that their behavior is maladaptive and of any psychological problems
● They are exhibiting a flight from reality into a less stressful world or into one in which they are
attempting to adapt.
■ Examples of psychotic ​responses​:
● Schizophrenic- ​a brain disorder in which people interpret reality abnormally.
● Schizoaffective- ​a condition in which a person experiences a combination of schizophrenia
symptoms such as hallucinations or delusions — and mood disorder symptoms, such as mania or
depression
● Delusional disorders
- GRIEF
● Grief- is a subjective state of emotional, physical, and social responses to the loss of a valued entity
○ A loss is anything that is identified/perceived as such by the individual; it can be real (death of a loved one), may be
perceived (loss of femininity after mastectomy), failure (​can also be perceived as a loss)​ , ANY situation that creates
change for the individual (​can be identified as a loss)​ , anticipated  → all/any can trigger grief response 
○ Mourning- ​a period with characteristic emotions and behaviors of grief
■ *the absence of mourning is considered maladaptive*
● Stages of Grief (​‘normal” mourning​)
○ *May not experience all of these stages, or in this order, may fluctuate and overlap between stages*
○ Stage 1: Denial- ​stage of shock and disbelief
■ Ex: “no, it can't be true!”
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 ■ The reality of the loss is not acknowledged
■ It is a protective mechanism to allow the individual to cope at the moment
○ Stage 2: Anger
■ Ex: “why me?!” “it's not fair”
■ Envy and resentment towards individuals not affected by the loss; Anger can be directed at self, others,
even God
■ May be preoccupied with an idealized image of the lost entity
○ Stage 3: Bargaining
■ Ex: “If God helps me through this, I promise…”
■ Sometimes the promise is associated with feelings of guilt for not having performed satisfactorily,
appropriately, or sufficiently.
○ Stage 4: Depression
■ The full impact of the loss is experienced; intense sadness/depression
■ Quiet desperation and disengagement from all association with the lost entity.
■ *different than ​pathological ​depression (in which the individual becomes fixed in an earlier stage of the
grief process)
○ Stage 5: Acceptance
■ Brings a feeling of peace regarding the loss that has occurred
■ Focus is on the reality of the loss and its meaning for the individual affected by it
● Anticipatory Grief
○ When a loss is anticipated, individuals often begin the work of grieving before the actual loss occurs
○ Most re-experience the grieving once loss occurs but may have a ​shorter ​and less intense process of mourning
○ Can be problematic because the person disengages emotionally from the dying person, who may then experience
feelings of rejection by loved ones at a time when this psychological support is so necessary
● Resolution
○ Grief can last weeks to years, must be processed at individuals own pace; usually lasts a year
○ Length of grief may be prolonged by various factors: ambivalence (love-hate) relationship, guilt (bec promotes
anger towards self), the number of recent losses (may not have completed grieving for a previous loss- especially the
elderly!) can lead to ​bereavement overload
○ Resolution reached when the individual can look back on the relationship (of dead person) and accepts the pleasures
and disappointments (positives and negatives); preoccupation with the lost entity is replaced with energy and desire
to pursue new stuff
● Maladaptive Responses
○ Occur when an individual is not able to progress through the stages of grieving to achieve resolution; usually
become fixed on denial or anger
○ Can be considered ​pathological​ if grieving is prolonged, delayed or inhibited, or distorted
■ Prolonged response characterized by an intense preoccupation with the ​memories ​of the lost entity for ​many
years
● associated with stages of denial or anger, disorganization of functioning and intense emotional
pain
■ Delayed or inhibited response characterized by the individual becoming fixated in the ​denial ​stage
● Emotional pain from the loss is not experienced, but anxiety disorders, sleeping disorders, or
eating disorders may be evident
● Individual may remain in denial for years until grief response is triggered by a reminder of the loss
or even another unrelated loss
■ Disoriented response is characterized by the individual becoming fixated in the ​anger ​stage
● Normal behaviors associated with grieving are exaggerated (helplessness, hopelessness, sadness,
anger, etc)
● Turns anger inwards on self → overwhelming despair and is unable to function in normal 
activities of daily living, 

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 Chapter 3: Personality Disorders ​VIV

● Personality-​ The combination of character, behavioral, temperamental, emotional, and mental traits that are unique to each
specific individual.
○ “the characteristic way in which a person thinks,​ ​feels, and behaves; the ingrained pattern of behavior that each
person evolves, both consciously and unconsciously…”
● Nurses must have a basic knowledge of human personality development to understand maladaptive behavioral responses
commonly seen in psychiatric clients
● Developmental theories identify behaviors associated with various stages (age group) through which individuals pass → 
specify what is appropriate or inappropriate
○ Stages can overlap
○ Ideally, an individual successfully fulfills all the tasks associated with one stage before moving on to the next stage
but IRL hardly happens
■ One reason is ​temperament- ​the inborn personality characteristics that influence an individual’s manner of
reacting to the environment, and ultimately his or her developmental progression
■ The ​environment ​may also influence one’s developmental pattern
● Ex: Individuals who are reared in a dysfunctional family system often have retarded ego
development
○ When an individual becomes fixed in a lower level of development psychopathology may become evident

PSYCHOANALYTIC THEORY
● Sigmund Freud AKA father of psychiatry, first to identify development by stages
○ First 5 years MOST important → develop character 

- STRUCTURE OF PERSONALITY
● Freud organized the structure of personality into three components: id, ego, and superego
● Id​- the locus of instinctual drives—the “pleasure principle”
○ Present at birth → infants instinctual drive to satisfy needs to survive
○ Id driven behaviors are impulsive and may be irrational
● Ego- ​AKA rational self - the “reality principle”
○ Develops between 4-6 months
○ The ego experiences the external world, adapts to it, and responds to it.
○ A primary function of the ego is one of mediator; maintains harmony among the external world, the id, and the
superego
● Superego- ​the “perfection principle”
○ Develops between 3-6 years
○ Values and morals are derived out of a system of rewards and punishments
○ The superego is composed of two major components: the ​ego-ideal ​and the ​conscience.
■ When a child is rewarded for “good” behavior, the self-esteem is enhanced, and the behavior becomes part
of the ​ego-ideal​; that is, it is internalized as part of his or her value system
■ The ​conscience​ is formed when the child is punished for “bad” behavior.
■ When moral and ethical principles or internalized ideals and values are disregarded, the conscience
generates a feeling of guilt
○ The superego is important because it assists the ego in the control of id impulses BUT when the superego becomes
rigid and punitive, problems with low self-confidence and low self-esteem arise.

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- TOPOGRAPHY OF THE MIND
● Freud classified all mental contents and operations into three categories: conscious, preconscious, and unconscious.
● Conscious
○ Includes all memories that remain within an individual’s awareness
■ Ex: phone #, birthdays, significant others, etc
○ It is the smallest of the three categories.
○ The conscious mind is under the control of the ego, the rational and logical structure of the personality
● Pre-conscious
○ Includes all memories that may have been forgotten or are not in present awareness but can be readily recalled into
consciousness.
■ Ex: telephone number or addresses once known
○ The preconscious enhances awareness by suppressing unpleasant or nonessential memories from consciousness
○ It is under the control of the superego, which helps to suppress unacceptable thoughts and behaviors
● Unconscious
○ Includes all memories that one is unable to bring to conscious awareness
○ It is the largest of the three topographical levels
○ Unconscious material consists of unpleasant or nonessential memories that have been repressed and can be retrieved
only through therapy, hypnosis, and with certain substances that alter awareness and have the capacity to restructure
repressed memories.
○ Unconscious material may also emerge in dreams and in seemingly incomprehensible behavior.

- DYNAMICS OF THE PERSONALITY

● Freud believed that psychic energy is the force or impetus required for mental functioning AKA ​LIBIDO
○ Originating in the id; instinctual drive to fulfill basic physiological needs such as hunger, thirst, and sex
○ As the child matures, psychic energy is diverted from the id to form the ego and then from the ego to form the 
superego → ego has the largest share in the end 
● If disbalance of libido we get ​cathexis and anticathexis
○ Cathexis is when the id invests energy into an object in an attempt to achieve gratification → impulsive 
behaviors 
■ Ex: an individual who instinctively turns to alcohol to relieve stress.
○ Anticathexis is the use of psychic energy by the ego and the superego to control id impulses, but the superego 
would exert control → self deprecating behavior 
■ Ex: an individual does not drink “If I drink my family will be hurt and angry. I’m such a weak person”
○ Ego has defense mechanisms to prevent imbalance
■ Excessive ego → self-absorbed behaviors 

- ​FREUD'S STAGES OF PERSONALITY DEVELOPMENT ​ (​ Freud is a freak obsessed with libido)

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 ● Freud described formation of the personality through five stages of ​psychosexual ​development with emphasis on the first 5
years of life
● Oral stage: birth to 18 months
○ Behavior directed by the id, with the goal of immediate gratification of needs
○ Focus of energy is the mouth → suckling, chewing, biting 
○ Infant cannot differentiate self from mother which causes feelings of anxiety and insecurity
○ At 4-6 month ego develops infant can differentiate which gives a sense of security and trust by the fulfilment of
needs
● Anal stage: 18 months to 3 years
○ Goal to gain independence and control
○ Focus on the excretory function → potty training
■ If strict potty training can result in
● 1. Child retains feces → as adults stubbornness, stinginess, and miserliness
● 2. Child expels poop in an unacceptable manner → as adults malevolence, cruelty to others, 
destructiveness, disorganization
■ Permissive and accepting potty training → as adults extroverted, productive, and altruistic 
● Phallic stage: 3 to 6 years
○ Focus of energy in the genital area → discovering differences between genders (heightened interest in 
sexuality)
○ Oedipus complex ​(males) and ​electra complex ​(females) may develop; when a child unconsciously wants to
eliminate the parent of the same gender in order to replace them
○ Guilt feelings emerge once the superego is developed; the child develops a strong identification with the parent of
the same gender and internalizes that parent’s attitudes, beliefs, and value system.
● Latency stage: 6 to 12 years
○ Focus changes from egocentrism to interest in group activities, learning, and socialization
○ Preference from same gender relationships, even reject members of opposite gender
● Genital stage: 13 to 20 years
○ Focus is on relationship with members of opposite gender to find a mate due to the maturation of the genital 
organ → a reawakening of the libidinal drive 
○ Sexual maturity develops from self-gratification of behaviors deemed acceptable by societal norms.
○ Interpersonal relationships are based on pleasure derived from the interaction rather than from the self-serving
implications of childhood associations

- RELEVANCE OF PSYCHOANALYTIC THEORY TO NURSING PRACTICE

● Knowledge of the structure of personality helps in the mental health care setting
○ Can recognize behaviors associated with id, ego, superego
○ Can assess developmental levels
○ Can understand ego defense mechanisms to determine if they are maladaptive behaviors, make a plan of care, or
help patients accept themselves

INTRAPERSONAL THEORY

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 ● Harry Stack​ ​Sullivan (1953) believed that individual behavior and personality development are the direct result of
interpersonal relationships (​social interaction)​
● Major concepts:
○ Anxiety- ​a feeling of emotional discomfort toward the relief or prevention of which ​all ​behavior is aimed
■ Chief disruptive force and the main factor in the development of serious difficulties in living
■ Arises from inability to satisfy needs or inability to achieve security
○ Satisfaction of needs-​ is the fulfillment of all requirements associated with an individual’s physicochemical
environment (ex: oxygen, food, water, warmth, rest etc.)
■ If any of these absent it produces discomfort
○ Intrapersonal security-​ is the feeling associated with relief from anxiety. When all needs have been met, one
experiences a sense of total well-being
○ Self-system-​ a collection of experiences, or security measures, adopted by the individual to protect against anxiety;
based on early life experiences
■ The “good me”- the part of the personality that develops in response to positive feedback from the 
primary caregiver  → keeps doing these behaviors 
● Ex: feeling of pleasure and gratification
■ The “bad me”- the part of the personality that develops in response to negative feedback from the 
primary caregiver  → avoids these by changing behavior 
● Ex: anxiety, discomfort, and distress
■ The “not me”- the part of the personality that develops in response to situations that produce intense 
anxiety in the child.  → denies feelings of anxiety in effort to relieve anxiety, become a “not me” 
sensation 
Can have SERIOUS implications for mental disorders in adult life
● Ex: feelings or horror, awe, dread, and loathing
- SULLIVAN’S STAGES OF PERSONALITY DEVELOPMENT
● Infancy: birth to 18 months
○ The major developmental task for the child is the gratification of needs
○ Activity associated with the mouth, such as crying, nursing, and thumb sucking
● Childhood: 18 months to 6 years
○ Learns that interference with fulfillment of personal wishes and desires may result in delayed gratification, which
they learn to accept this bec. it results in parental approval, a more lasting type of reward
○ Tools include the mouth, the anus, language, experimentation, manipulation, and identification.
● Juvenile: 6 to 9 years
○ Major task of the juvenile stage is formation of satisfactory relationships within peer groups; accomplished through
the use of competition, cooperation, and compromise
● Pre-adolescence: 9 to 12 years
○ Focus on developing relationships with persons of the same gender
○ The ability to collaborate with and show love and affection for another person begins at this stage.
● Early adolescence: 12 to 14 year
○ Struggling with developing a sense of identity that is separate and independent from parents
○ Major task is formation of satisfactory relationships with members of the opposite gender →  the emergence of 
lust in response to biological changes is a major force
● Late adolescence: 14 to 21 years
○ Characterized by tasks associated with the attempt to achieve interdependence within the society and the 
formation of a lasting & intimate relationship with a selected member of the opposite gender → the genital 
organs are the major developmental focus 

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- ​RELEVANCE OF INTERPERSONAL THEORY TO NURSING PRACTICE
● Relationship development is a major psychiatric nursing intervention; Nurses develop therapeutic relationships with clients in
an effort to help them generalize this ability to interact successfully with others.
● Knowledge about the behaviors associated with all levels of anxiety and methods for alleviating anxiety helps nurses to assist
clients achieve interpersonal security and a sense of well-being.

THEORY OF PSYCHOSOCIAL DEVELOPMENT

● Erik Erikson (1963) studied the influence of social processes on the development of the personality.
● Described eight stages during which individuals struggle with developmental “crises” Specific tasks associated with each
stage must be completed for resolution of the crisis and for emotional growth occur
- ​ERICKSON’S STAGES OF PERSONAL DEVELOPMENT
● Trust vs Mistrust: birth to 18 months
○ Major developmental tasks is to develop a basic trust in mother figure and generalize it to others
■ Achievement results in self-confidence, optimism, faith in the gratification of needs and desires, and 
hope for the future → Learns trust when needs are consistently met 
■ Non- Achievement results in emotional dissatisfaction​ ​with the self and others, suspiciousness, and 
difficulty with relationships  → when the primary caregivers fail to respond to the infant’s distress 
signal promptly and consistently
● Autonomy vs Shame and Doubt: 18 months to 3 years
○ Major developmental task is to gain some self-control and independence within the environment
■ Achievement results in a sense of self control and the ability to delay gratification, and a feeling of 
self-confidence  → Autonomy  achieved when parents encourage and provide opportunities for 
independent activities
■ Non- Achievement results in a lack of self-confidence, a lack of pride, a sense of being controlled by 
others, and a rage against the self  → when primary caregivers restrict independent behaviors 
(physically and verbally) or set the child up for failure with unrealistic expectations
● Initiative vs Guilt: 3 to 6 years
○ Major developmental task is to develop a sense of purpose and the ability to initiate and direct one’s own
activities.
■ Achievement results in the ability to exercise restraint and self-control of inappropriate social 
behaviors. Assertiveness and dependability increase, and enjoys learning and personal achievement. 
The conscience develops, by controlling the impulsive behaviors  → Initiative is achieved when 
creativity is encouraged and performance is recognized and positively reinforced
■ Non- Achievement results in feelings of inadequacy and a sense of defeat. Guilt is experienced to the 
point of accepting liability in situations for which one is not responsible. May view themselves as evil 
or deserving of punishment  → parents continuously expect higher level of achievement than possible
● Industry vs Inferiority: 6 to 12 years
○ Major developmental task is to achieve a sense of self-confidence by learning, competing, performing
successfully, and receiving recognition from significant others, peers, and acquaintances.
■ Achievements results in a sense of satisfaction and pleasure in interaction with others. Masters reliable 
work habits and develops attitudes of trustworthiness; conscientious, pride in achievement, enjoys play 

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 but desires balance →  Industry is achieved when encouragement is given to activities and 
responsibilities in the school, community, within the home, and recognition is given for 
accomplishments.
■ Non- achievement results in difficulty in relationships because of feelings of personal inadequacy; 
cannt cooperate or compromise with others, nor problem solve or complete tasks successfully. May 
become either passive or overly aggressive; If this occurs, they may manipulate others to satisfy his or 
her own needs or desires; may become a workaholic with unrealistic expectations for personal 
achievement. → when parents set unrealistic expectations for the child, when discipline is harsh and 
tends to impair self-esteem, and when accomplishments are consistently met with negative feedback
● Identity vs Role confusion : 12 to 20 years
○ Major developmental task is to integrate the tasks mastered in the previous stages into a secure sense of self
■ Achievement results in a sense of confidence, emotional stability, and a view of the self as a unique 
individual. Commitments are made to a value system, to the choice of a career, and to relationships → 
Identity is achieved when adolescents are allowed independence by making decisions that influence 
their lives. Parents should offer support when needed but should gradually relinquish control in effort 
to encourage the development of independence 
■ Non- Achievement results in a sense of self consciousness, doubt, and confusion about one’s role in 
life. Personal values or goals for one’s life are absent. Long-term commitments to relationships with 
others are nonexistent. A lack of self-confidence is often expressed by delinquent and rebellious 
behavior → 
● When independence is discouraged and the adolescent is nurtured in the dependent position, when
discipline within the home has been overly harsh, inconsistent, or absent, when there has been
parental rejection or frequent shifting of parental figures
● Intimacy vs Isolation: 20 to 30 years
○ Major developmental task is to form an intense, lasting relationship or a commitment to another person, a
cause, an institution, or a creative effort
■ Achievement results in the capacity for mutual love, respect, and the ability to commit. The intimacy 
goes beyond sexual contact, it is personal sacrifices made for one another → Intimacy is achieved when 
an individual has developed the capacity for giving of oneself to another. This is learned when one has 
been the recipient of this type of giving 
■ Non- Achievement results in withdrawal, social isolation, and aloneness. Unable to form lasting, 
intimate relationships, often seeking intimacy through numerous superficial sexual contacts. No career 
is established; may have a history of occupational changes (or may fear change and thus remain in an 
undesirable job situation) → when love in the home has been deprived or distorted through the 
younger years. One fails to achieve the ability to give of the self without having been the recipient 
early on from primary caregivers.
● Generativity vs Stagnation or Self-absorption: 30 to 65 years
○ Major developmental task is to achieve the life goals established for oneself while also considering the welfare
of future generations.
■ Achievement results in a sense of gratification from personal and professional achievements and from 
meaningful contributions to others. The individual is active in the service of and to society → achieved 
when the individual expresses satisfaction with this stage in life and demonstrates responsibility for 
leaving the world a better place in which to live
■ Non- Achievement results in lack of concern for the welfare of others and total preoccupation with 
the self. Become withdrawn, isolated, and highly self-indulgent, with no capacity for giving to others. 
→ when earlier developmental tasks are not fulfilled and the individual does not achieve the degree of 
maturity required to derive gratification by giving to others 
● Ego integrity vs Despair: 65 to death
○ Major developmental task is to review one’s life and derive meaning from both positive and negative events,
while achieving a positive sense of self.
■ Achievement results in a sense of self worth and self-acceptance as one reviews life goals, accepting 
that some were achieved and some were not. Derive a sense of dignity from his or her life experiences 
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 and does not fear death, rather view it as another stage of development → Ego integrity is achieved 
when individuals have successfully completed the developmental tasks of the other stages and have 
little ​desire to make major changes in how their lives have progressed.
■ Non- Achievement results in a sense of self-contempt and disgust with how life has progressed. The 
individual would like to start over and have a second chance at life. Feel worthless and helpless to 
change. Anger, depression, and loneliness are evident. May focus on past failures or perceived failures. 
Impending death is feared or denied, or ideas of suicide may prevail → when earlier tasks are not 
fulfilled: self-confidence, a concern for others, and a strong sense of self-identity were never achieved.

-RELEVANCE OF PSYCHOSOCIAL DEVELOPMENT THEORY TO NURSING PRACTICE

● Relevant to nursing practice in that it incorporates socio-cultural concepts into the development of personality
● Erikson provides a systematic, stepwise approach and outlines specific tasks that should be completed during each stage.
○ Can be used quite readily in psychiatric/mental health nursing.
○ Many individuals with mental health problems are still struggling to achieve tasks from a number of developmental
stages.
● Nurse can plan care to assist these individuals to fulfill these tasks and move on to a higher developmental level

THEORY OF OBJECT RELATIONS

● Margaret Mahler formulated a theory that describes the separation individuation process of the infant from the maternal
figure (primary caregiver).
- MAHLER’S DEVELOPMENTAL THEORY
● Phase I: the autistic phase (birth - 1 month)
○ AKA “normal autism”
○ The infant exists in a half-sleep/half-waking state and does not perceive the existence of other people or an external
environment.
○ The fulfillment of basic needs for survival and comfort is the focus and is merely accepted as it occurs.
● Phase II: the symbiotic phase (1 - 5 months)
○ Symbiosis is a type of “psychic fusion” of mother and child.
■ The child views him/herself as an extension of the mother, but with a developing awareness that it is she
who fulfills the child’s every need.
○ The absence of or rejection by the maternal figure at this phase can lead to symbiotic psychosis
● Phase III: the separation-individuation (5 - 36 months AKA ​3 years)​
○ AKA “psychological birth” of the child
○ Separation ​is defined as the physical and psychological attainment of a sense of personal distinction from the
mothering figure.
○ Individuation ​with a strengthening of the ego and an acceptance of a sense of “self,” with independent ego
boundaries.

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 ■ Subphase 1: differentiation (5 - 10 months)
● Child’s physical movements away from the mothering figure →  primary recognition of 
separateness commences
■ Subphase 2: Practicing (10 - 16 months)
● Now able to move away from, and return to, the mother; the child experiences feelings of
exhilaration from increased independence and sense of omnipotence
■ Subphase 3: Rapprochement (16 - 24 months)
● Rapprochement, is extremely critical to the child’s healthy ego development
● The child is even more aware of their separateness from the mother, while fearlessness and 
omnipotence diminishes → child wants to be close to mother again but not full symbiotic 
stage 
○ Wants mother to be available to provide “emotional refueling” on demand
● Mother's response to the child is important:
○ If the mothering figure is available →  the child develops a sense of security in the 
knowledge that they are loved and will not be abandoned
○ If emotional needs are inconsistently met or if the mother rewards clinging, 
dependent behaviors and withholds nurturing when the child demonstrates 
independence → feelings of rage and fear of abandonment develop and often persist 
into adulthood.
■ Subphase 4: consolidation (24 - 36 months)
● Individuality and sense of separateness of self are established
● The child has the ability to integrate both “good” and “bad”
● A degree of object constancy is established; mom is separate and there when love needed

- RELEVANCE OF OBJECT RELATIONS THEORY TO NURSING PRACTICE

● Helps the nurse assess the client’s level of​ ​individuation from primary caregivers.
○ The emotional problems of individuals can be traced to lack of fulfillment of the tasks of separation/individuation
■ Ex: include problems related to dependency and excessive anxiety
■ Ex: an individual with borderline personality disorders is thought to be fixed in the rapprochement ph.

COGNITIVE DEVELOPMENT THEORY

● Jean Piaget AKA the father of child psychology
● Worked on cognitive development theory in children based on the premise that human intelligence is an extension of
biological adaptation, or one’s ability to adapt psychologically to the environment.
● Believed that human intelligence progresses through a series of stages (based on age) demonstrating at each successive stage
a higher level of logical organization than at the previous stages.
- PIAGET’S STAGES OF COGNITIVE DEVELOPMENT
● Stage 1: sensorimotor (birth - 2 years)
○ At the beginning of life, a child is concerned only with satisfying basic needs and comforts
○ The self is not differentiated from the external environment
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 ■ Differentiation occurs with increasing mobility and awareness
■ Knowledge is gained about the ability to manipulate objects and experiences t
○ Object permanence​—the notion that an object will continue to exist when it is no longer present to the senses
■ Ex: the toy still exists even if you cant see it/it is covered
● Stage 2: preoperational (2 - 6 years)
○ Preoperational thought​ is characterized by egocentrism (when a personal experiences are thought to be universal)
and the child is unable to accept the differing viewpoints of other
○ Language development progresses and the ability to attribute special meaning to symbolic gestures.
○ Reality is often given to inanimate objects
○ Object permanence culminates in the ability to conjure up mental representations of objects or people​.
● Stage 3: concrete operations (6 - 12 years)
○ The ability to apply logic to thinking begins in this stage; however, “​concreteness​” still predominates.
○ An understanding of reversibility and spatiality is developed
■ Ex: recognizes that changing the shape of objects does not necessarily change the amount, weight, volume,
or the ability of the object to return to its original form.
○ The ability to classify objects by any of their several characteristics
■ Ex: can classify all poodles as dogs but recognizes that all dogs are not poodles.
○ The concept of a lawful self is developed at this stage; becomes more socialized and rule conscious.
● Stage 4: formal operations (12 - 15+ years)
○ Able to think and reason in abstract terms; can make and test hypotheses using logical and orderly problem solving
○ Current situations and reflections of the future are idealized, and a degree of egocentrism returns during this stage.
■ May be some difficulty reconciling idealistic hopes with more rational prospects but ​Formal operations
allow individuals to distinguish between the ideal and the real
○ Most individuals achieve ​cognitive maturity​, the capability to perform all mental operations needed for adulthood,
in middle to late adolescence.

- RELEVANCE OF COGNITIVE DEVELOPMENT THEORY TO NURSING PRACTICE

● Nurses who assist with cognitive therapy must have knowledge of how cognition develops in order to help clients identify the
distorted thought patterns and make the changes required for improvement in affective functioning
○ In cognitive therapy, the individual is taught to control thought distortions that are considered to be a factor in the
development and maintenance of mood disorders.
○ Therapy focuses on changing “automatic thoughts” that occur spontaneously and contribute to the distorted effect
● In the cognitive model, depression is characterized by a triad of negative distortions related to expectations of the
environment, self, and future.
○ In this model, depression is viewed as a distortion in cognitive development, the self is unrealistically devalued, and
the future is perceived as hopeless.

THEORY OF MORAL DEVELOPMENT

● Lawrence Kohlberg’s (1976) stages of moral development are not closely tied to specific age groups
○ Research was conducted with males ranging in age from 10 to 28 years

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 ● Kohlberg believed that each stage is necessary and basic to the next stage and that all individuals must go through the stages
sequentially​ (IN ORDER)
- KHOLBERG’S STAGES OF MORAL DEVELOPMENT
● Level 1: preconventional level (4 - 10 years)
○ Stage 1: punishment and obedience orientation
■ The individual is responsive to cultural guidelines of good/bad and right/wrong, but in terms of the
consequences
■ Fear of punishment is incentive for conformity
● Ex: I’ll do it, because if I don’t I can’t watch TV for a week
○ Stage 2: instrumental relativist orientation
■ Behaviors are guided by egocentrism and concern for self; but occasionally the needs of others are
considered
■ Decisions are based on personal benefit
● Ex: I’ll do it if I get something in return
● Level 2: conventional level (10 - 13 years and into adulthood)
○ Stage 3: interpersonal concordance orientation
■ Behavior is guided by the expectations of others
■ Approval and acceptance within a group is incentive to conform
● Ex: I’ll do it because you asked me to. . . because it will help you. . . because it will please you
○ Stage 4: law and order orientation
■ There is a personal respect for authority
■ Rules and laws are required and override personal principles and group mores →  all individual/groups 
are subject to the same code of order, and no one shall be exempt 
● Ex: I’ll do it because it is the law
● Level 3: postconventional level (from adolescence and onwards)
○ Stage 5: social contract legalistic orientation
■ Have developed a system of values and principles that determine​ for them​ what is right or wrong; behaviors
are guided by this value system, provided they do not violate the human rights of others
■ Believe all individuals are entitled to certain inherent human rights, and they live according to universal
laws and principles. However, laws are subject to scrutiny and change as needs within society evolve and
change
● Ex: I’ll do it because it is the moral and legal thing to do, even though it is not my personal choice
○ Stage 6: universal ethical principle orientation
■ Behavior is directed by internalized principles of honor, justice, and respect for human dignity
■ Laws are abstract and unwritten, such as the “Golden Rule,” “equality of human rights,” and “justice 
for all.” → when one fails to meet these the consequence is intense guilt. 
● The allegiance to these principles is so strong that the individual will stand by them even knowing
that negative consequences will result
● Ex: I’ll do it because I believe it is the right thing to do, even though it is illegal and I will be
imprisoned for doing it

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- RELEVANCE OF MORAL DEVELOPMENT THEORY TO NURSING PRACTICE
● Moral development affects critical thinking about how individuals ought to behave and treat others
● Moral behavior reflects the way a person interprets basic respect for other persons, such as the respect for human life,
freedom, justice, or confidentiality
● Psychiatric nurses must be able to assess the level of moral development of their clients in order to help them advance toward
a higher level of developmental maturity

A NURSING MODEL- PEPLAU

● Psychological tasks (4) are developmental lessons that must be learned on the way to achieving maturity of the personality
○ tasks are related to the demands made on nurses in their relations with clients
■ The nurse-patient relationship is seen as an opportunity for nurses to help patients to complete the
unfinished psychological tasks
- PEPLAU’S STAGES OF PERSONALITY DEVELOPMENT
● Learning to count on others
○ Nurses and clients come together as strangers and bring “raw materials,” (biological components, personality
characteristics (temperament), individual intellectual capacity, and specific cultural or environmental influences)
■ Peplau calls these “raw materials” → an infant comes into this world with these raw materials
■ The newborn is capable of experiencing comfort and discomfort → learns to communicate feelings to 
fulfill needs by the mothering figure who provides love and care unconditionally → BUT fulfillment 
of needs is inhibited when goals of the mothering figure become the focus, and love and care are 
contingent on meeting the needs of the caregiver rather than the infant 
■ Clients with unmet dependency needs regress during illness and others regress because of physical
disabilities associated with their illness
○ Peplau believed that nurses provide unconditional care, they help these clients progress toward more mature levels
of functioning take on the role of “surrogate mother,” in which the nurse fulfills needs for the client with the intent
of helping him or her grow, mature, and become more independent
● Learning to delay satisfaction
○ During toddler-hood or first step in the development of interdependent social relations
○ Comparable to the anal stage of development → ​potty training
○ If an individual fails to complete this task, consequences can occur:
■ Exploitation and manipulation of others to satisfy their own desires because they are unable to do so
independently
■ Suspiciousness and envy of others; directing hostility toward others in an effort to enhance their own
self-image
■ Hoarding and withholding possessions from others; miserliness
■ Inordinate neatness and punctuality
■ Inability to relate to others through sharing of feelings, ideas, or experiences
■ Ability to vary the personality characteristics to those required to satisfy personal desires at any given time

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 ○ When nurses observe these types of behaviors in clients, it is important to encourage full expression and to convey
unconditional acceptance.
■ When the client learns to feel safe and unconditionally accepted, they are more likely to let go of the
oppositional behavior and advance in the developmental progression.
● Identifying oneself
○ A child learns to structure self-concept by observing how others interact with him/her
○ Roles and behaviors are established out of the child’s perception of the expectations of others
■ Ex: When children perceive that adults want them to say immature/ infants, they perceive themselves as
helpless and dependent
■ Ex: When the perceived expectation is that the child must behave in a manner beyond his or her
maturational level, the child is deprived of the fulfillment of emotional and growth needs at the lower levels
of development
○ It is important for the nurse to recognize cues that communicate how the client feels about themselves and about the
presenting medical problem
○ Nurses must also be aware of the predisposing factors that they bring to the relationship → like their attitudes 
and beliefs about certain issues which can negative effect on the client, interfere with the therapeutic 
relationship and  with the client’s ability for growth and development
■ Ex: a nurse who has strong beliefs against abortion may treat a client who has just undergone an abortion
with disapproval and disrespect
○ Nurses must have knowledge and appreciation of their own concept of self in order to develop the flexibility
required to accept all clients as they are, unconditionally.
● Developing skills in participation
○ Comparable to Sullivan’s juvenile stage → Develops the capacity to compromise, compete, and cooperate with 
others (basic skills for collaborations)
○ Consensual validation- ​Children begin to view themselves through the eyes of their peers
■ Preadolescents take on a more realistic view of the world and a feeling of their place in it
■ The capacity to love others (besides mom) develops at this time and is expressed in relation to one’s
self-acceptance
○ Failure to develop appropriate skills results in:
■ An individual’s difficulty with participation in confronting the recurring problems of life
○ It is not the responsibility of the nurse to teach solutions to problems, but rather to help clients improve their
problem-solving skills so that they may achieve their own resolution
■ By developing the skills of competition, compromise, cooperation, consensual validation, and love of self
and others
■ By helping patients to identify the problem, define a goal, and take the responsibility for performing the
actions necessary to reach that goal

- RELEVANCE OF PEPLAU’S MODEL TO NURSING PRACTICE

● Peplau’s model provides nurses with a framework to interact with clients, many of whom are fixed in an earlier level of
development
○ The role the nurses assume assists clients to progress
○ Nurses serve to facilitate learning of that which has not been learned in earlier experiences

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21
 Chapter 4: Psychobiology ​AMY

● Neuroscientific revolution=study of the organic basis for psychiatric illness

● Biology, psychology and sociology are interacting systems
● The Nervous System: An Anatomical Review
○ The Brain
■ Three major divisions, subdivided into six major parts

● Forebrain
○ Cerebrum
■ Right and left hemisphere and largest part of human brain
■ Two hemispheres connected by a deep groove which has 200 million neurons
(nerve cells) called the ​corpus callosum
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 ● Information processed through corpus callosum so that each
hemisphere is aware of the activity of the other
■ Surface of cerebrum consists of gray matter and called the ​cerebral cortex
● Neuron cell bodies look gray
● Thought to be actual thinking structures of brain
■ Another pair of masses of gray matter called ​basal ganglia​ is found deep within
the cerebral hemispheres
● Responsible for certain subconscious aspects of voluntary movement,
such as swinging the arms when walking, gesturing while speaking,
and regulating muscle tone
■ Cerebral cortex identified by numerous folds called ​gyri​ and deep grooves
between the folds called ​sulci
● Extensive folding extends the surface area of the cerebral cortex and
permits the presence of millions more neurons than would be possible
without it
■ Each hemisphere of cerebral cortex divided into frontal lobe, parietal lobe,
temporal lobe and occipital lobe

■ The Frontal Lobes

● Voluntary body movement controlled by impulses through these lobes
○ Right frontal lobe controls motor activity on left side and vice
versa
● Movements that permit speaking from left lobe usually
● May also play a role in emotional experience, as evidenced by changes
in mood and character after damage to this area
○ Alterations include fear, aggressiveness, depression, rage,
euphoria, irritability and apathy and are related to a frontal
lobe connection to the limbic system
● May also be involved in thinking and perceptual interpretation of
information
■ The Parietal Lobes
● Somatosensory input occurs here
○ Touch, pain and pressure, taste, temperature, perception of
joint and body position, and visceral sensations

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 ● Also contain association fibers linked to the primary sensory areas
through which interpretation of sensory-perceptual information is made
● Language interpretation associated with left hemisphere of parietal lobe
■ The Temporal Lobes
● Upper anterior temporal lobe concerned with auditory functions, while
lower part is dedicated to short-term memory
● Sense of smell has connection to temporal lobes, as the impulses
carried by the olfactory nerves end in this area
● Play a role in expression of emotions through an interconnection with
the limbic system
● Involved with language interpretation with the left parietal lobe
■ The Occipital Lobes
● Primary area of visual reception and interpretation
● Visual perception gives individuals the ability to judge spatial
relationships such as distance and to see in 3D is processed in this area
● Language interpretation influenced by occipital lobes through an
association with the visual experience

○ Diencephalon
■ Connects the cerebrum with lower structures of the brain
■ Major structures include thalamus, hypothalamus and limbic system
● Thalamus
○ Integrates all sensory input (except smell) on its way to the
cortex
■ Helps cerebral cortex interpret whole picture rapidly,
rather than experiencing each sensation individually
○ Involved in temporarily blocking minor sensations, so that an
individual can concentrate on one important event when
necessary
■ When studying, may be unaware of ticking clock
next to you because of thalamus blocking these
incoming sensations

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● Hypothalamus
○ Located just below the thalamus and just above the pituitary
gland and has many functions
○ 1) Regulation of the Pituitary Gland
■ Has two lobes, posterior and anterior lobe
■ Posterior lobe​: actually just extended tissue from
hypothalamic. Stores ​antidiuretic hormone
(maintaining blood pressure through regulation of
water retention), and ​oxytocin​ (hormone responsible
for stimulation of the uterus during labor and the
release of milk from mammary glands)
■ Hypothalamus detects body’s needs for these
hormones and sends nerve impulses to the posterior
pituitary for their release
■ Anterior lobe​: consists of glandular tissue that
produces a number of hormones; these are regulated
by “releasing factors” from the hypothalamus; when
these hormones are required, the releasing factors
stimulate the release of hormone from the anterior
pituitary and the hormone in turn stimulates its target
organ to carry out specific function
○ 2) Direct Neural Control over the Actions of the Autonomic
Nervous System
■ Hypothalamus regulates appropriate visceral
responses during various emotional states
○ 3) Regulation of Appetite
■ Appetite is regulated through response to blood
nutrient levels
○ 4) Regulation of Temperature
■ Hypothalamus senses internal temperature changes in
the blood that flows through the brain. It receives
information through sensory input from the skin
about external temperature changes. Hypothalamus
then uses information to promote certain types of
responses (sweating or shivering) that help to
maintain temperature in normal range
● Limbic system
○ Consists of portions of the cerebrum and the diencephalon
○ Major components include the medially places corticol and
subcorticol structures and the fiber tracts connecting them
with one another and with the hypothalamus
○ System composed of amygdala, mammillary body, olfactory
tract, hypothalamus, cingulate gyrus, septum pellucidum,
thalamus, hippocampus, and fornix
■ Has been called the “emotional brain” and is
associated with feelings of fear and anxiety anger,
rage, and aggression; love, joy and hope, and with
sexuality and social behavior

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 ● Midbrain
○ Mesencephalon
■ Structures of major importance include nuclei and fiber tracts
■ Extends from pons to the hypothalamus and is responsible for integration of
various reflexes, including visual reflexes (automatically turning away from a
dangerous object when it comes into view), auditory reflexes (automatically
turning toward a sound that is heard) and righting reflexes (automatically
keeping the head upright and maintaining balance)
● Hindbrain
○ Pons
■ This is a bulbous structure that lies between the midbrain and the medulla
■ Composed of large bundles of fibers and forms a major connection between the
cerebellum and the brainstem
■ Also contains central connections of cranial nerves V through Viii and centers
for respiration and skeletal muscle tone
○ Medulla
■ This is the connecting structure between the spinal cord and the pons and all of
the ascending and descending fiber tracts pass through it
■ Vital centers are contained in the medulla, and it is responsible for regulation of
heart rate, blood pressure, and respiration
■ Reflex centers are here too for swallowing, sneezing, coughing and vomiting
■ Contains nuclei for cranial nerves IX through XII
■ Medulla, pons and midbrain form the brainstem
○ Cerebellum
■ Separated from the brainstem by the fourth ventricle but has connections to the
brainstem through bundles of fiber tracts
■ Situated just below the occipital lobes of the cerebrum
■ Function of cerebellum concerned with involuntary movement, like muscular
tone and coordination and the maintenance of posture and equilibrium
○ Nerve Tissue
● Tissue of CNS consists of nerve cells called neurons that generate and transmit electrochemical
impulses
● A neuron has a cell body, an axon, and dendrites

26
○ Cell body contains nucleus and is essential for the continued life of the neuron
○ Dendrites are processes that transmits impulses toward the cell body
○ The axon transmits impulses away from the cell body
○ Axon and dendrites are covered by layers of cells called neuroglia that form a “sheath” of
myelin
■ Myelin is a phospholipid that provides insulation against short-circuiting of the
neurons during their electrical activity and increases the velocity of the impulse
■ White matter of brain called this because myelin makes it look white
■ Gray matter has no myelin

○ Three classes of neurons

■ Afferent (sensory)
● Carry impulses from receptors in the internal and external periphery to
the CNS, where they are then interpreted into various sensations
■ Efferent (motor)
● Carry impulses from the CNS to effectors in the periphery such as
muscles (respond by contracting) and glands (respond by secreting)
■ Interneurons
● Exist entirely within CNS and 99% of all nerve cells belong in this
group
● May carry only sensory or motor impulses or they may serve as
integrators in the pathways between afferent and efferent neurons
● Account in large part for thinking, feelings, learning, language, and
memory
● Directional pathways can be seen below

27
■ Synapses
● Information is transmitted through the body from one neuron to another
○ Some messages can take a few neurons while others may require thousands
○ Neurons don’t actually touch each other
○ Junction between two neurons is called a synapse
○ The small space between the axon terminals of one neuron and the cell body or dendrites
of another is called the ​synaptic cleft
○ Neurons conducting impulses toward the synapse are called ​presynaptic neurons​ and
those conducting impulses away are called​ postsynaptic neurons
○ Neurotransmitters are stored in the axon terminals of the presynaptic neuron
○ An electrical impulse through the neuron causes the release of the neurotransmitter into
the synaptic cleft
○ Neurotransmitter diffuses across the synaptic cleft and combines with receptor sites that
are situated on the cell membrane of the postsynaptic neuron
○ Result is the determination of whether or not another electrical impulse is generated
■ If one generated, result is called an ​excitatory response​ and the electrical
impulse moves on to the next synapse, where same process occurs
■ If one is not generated, the result is called an ​inhibitory response​ and synaptic
transmission is terminated
○ Cell body or dendrite of the postsynaptic neuron also contains a chemical inactivator that
is specific to the neurotransmitter that has been released by the presynaptic neuron
○ When synaptic transmission has been completed, chemical inactivator quickly inactivates
neurotransmitter to prevent unwanted, continuous impulses, until a new impulse from the
presynaptic neuron releases more neurotransmitter
○ This can be seen below

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○ Autonomic Nervous System
■ ANS is actually considered part of the peripheral nervous system
■ Regulation is integrated by the hypothalamus, however, and therefore the emotions exert a great deal of
influence over its functioning
● For this reason the ANS has been implicated in the etiology of a number of psychophysiological
disorders
■ ANS has two divisions
● Sympathetic
○ Dominant in stressful situations and prepares the body for fight or flight
○ Neuronal cell bodies of the sympathetic division originate in the thoracolumbar region of
the spine
○ Their axons extend to the chains of sympathetic ganglia where they synapse with other
neurons that subsequently innervate the visceral effectors
○ This results in an increase in heart rate and respirations and a decrease in digestive
secretions and peristalsis
○ Blood is shunted to the vital organs and to skeletal muscles to ensure adequate
oxygenation
● Parasympathetic
○ Neuronal cell bodies of parasympathetic division originate in the brainstem and the sacral
segments of the spinal cord, and extend to the parasympathetic ganglia where the synapse
takes place either very close to or actually in the visceral organ being innervated
○ A localized response is possible
○ This system dominates when an individual is in a relaxed, nonstressful condition
○ Heart and respirations are maintained at a normal rate and secretions and peristalsis
increase for normal digestion
○ Elimination functions are promoted

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○ Neurotransmitters
● Neurotransmitters (NTs) are chemicals that convey information across synaptic clefts to
neighboring target cells
○ Stored in small vesicles in the axon terminals of neurons
○ When action potential, or electrical impulse, reaches this point, the neurotransmitters are
released from the vesicles
○ They cross the synaptic cleft and bind with receptor sites on the cell body or dendrites of
the adjacent neuron to allow the impulse to continue its course or to prevent the impulse
from continuing
○ After neurotransmitter has performed its function, it either returns to the vesicles to be
stored and used again or it is inactivated and dissolved by enzymes
■ Reuptake: being stored and reused
■ Cholinergics
● Acetylcholine
○ First chemical to be identified and proven as a NT
○ Major effector chemical in the ANS, producing activity at all sympathetic and
parasympathetic presynaptic nerve terminals and all parasympathetic postsynaptic nerve
terminals
○ Highly significant in neurotransmission that occurs at the junctions of nerve and muscles
○ Acetylcholinesterase is the enzyme that destroys ACh or inhibits its activity
○ In the CNS, ACh neurons innervate the cerebral cortex, hippocampus, and limbic
structures

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 ■ Pathways especially dense through the area of the basal ganglia in the brain
○ Functions
■ Sleep
■ Arousal
■ Pain perception
■ Modulation and coordination of movement
■ Memory acquisition and retention
■ May have some role in certain disorders of motor behavior and memory, like
Parkinson’s, Huntington’s disease and Alzheimer’s
■ Monoamines
● Norepinephrine
○ NE is the NT that produces activity at the sympathetic postsynaptic nerve terminals in the
ANS resulting in the “fight or flight” responses in the effector organs
○ In the CNS, NE pathways originate in the pons and medulla and innervate the thalamus,
dorsal hypothalamus, limbic system, hippocampus, cerebellum, and cerebral cortex
○ When NE is not returned for storage in the vesicles of the axon terminals, it’s
metabolized and inactivated by the enzymes monoamine oxidase (MAO) and
catechol-O-methyl-transferase (COMT)
○ Functions
■ Regulation of mood
■ Cognition
■ Perception
■ Locomotion
■ Cardiovascular functioning
■ Sleep and arousal
■ Also implicated in certain mood disorders like depression and mania, anxiety
states, and schizophrenia
● Dopamine
○ Dopamine pathways arise from the midbrain and hypothalamus and terminate in the
frontal cortex, limbic system, basal ganglia, and thalamus
○ Dopamine neurons in the hypothalamus innervate the posterior pituitary and those from
the posterior hypothalamus project to the spinal cord
○ Inactivating enzymes are MAO and COMT (same as ACh)
○ Functions
■ Regulation of movements and coordination
■ Emotions
■ Voluntary decision making ability
■ Inhibits release of prolactin (influences pituitary)
○ Increased levels of dopamine associated with mania and schizophrenia
● Serotonin
○ Pathways originate from cell bodies located in the pons and medulla and project to areas
including the hypothalamus, thalamus, limbic system, cerebral cortex, cerebellum, and
spinal cord
○ Serotonin not returned to be stored in the axon terminal vesicles is catabolized by MAO
○ Functions
■ Sleep and arousal
■ Libido
■ Appetite
■ Mood
■ Aggression
■ Pain perception

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 ○Serotoninergic system has been implicated in etiology of certain psychopathological
conditions including anxiety states, mood disorders, and schizophrenia
● Histamine
○ Histamine mediates in allergic and inflammatory reactions
○ In CNS, information on what it does is new and limited
○ Highest concentrations found within various regions of the hypothalamus
○ Histaminic neurons in posterior hypothalamus are associated with sustaining wakefulness
○ MAO catabolizes histamine
○ May play a role in depressive illness
■ Amino Acids
● Inhibitory Amino Acids
○ Gamma-Aminobutyric Acid (GABA)
■ Widespread distribution in CNS, with high concentrations in hypothalamus,
hippocampus, cortex, cerebellum, and basal ganglia of brain, in the gray matter
of the dorsal horn of the spinal cord, and in the retina
■ Most associated with short inhibitory interneurons, although some long axon
pathways within the brain also have been identified
■ Catabolized by enzyme GABA transaminase
■ These inhibitory NTs prevent postsynaptic excitation, interrupting the
progression of the electrical impulse at the synaptic junction
● Enhancing the GABA system is mechanism for benzodiazepines
■ Alterations in GABA system have been implicated in etiology of anxiety
disorders, movement disorders (Huntington’s) and forms of epilepsy
○ Glycine
■ Highest concentrations in the CNS are found in the spinal cord and brainstem
■ Little known about enzymatic metabolism of glycine
■ Appears to be NT of recurrent inhibition of motor neurons within the spinal
cord, and is possibly involved in the regulation of spinal and brainstem reflexes
■ It has been implicated in pathogenesis of certain types of spastic disorders and in
“glycine encephalopathy”, known to occur with toxic accumulation of the NT in
the brain and cerebrospinal fluid
● Excitatory Amino Acids
○ Glutamate and Aspartate
■ Appear to be primary excitatory NTs in the pyramidal cells of the cortex, the
cerebellum, and the primary sensory afferent systems
● Also found in the hippocampus, thalamus, hypothalamus, and spinal
cord
■ Inactivated by uptake into the tissues and through assimilation in various
metabolic pathways
■ Function in the relay of sensory information and in the regulation of various
motor and spinal reflexes
■ Alterations in systems has been implicated in etiology of certain
neurodegenerative disorders, like Huntington’s, temporal lobe epilepsy, and
spinal cerebellar degeneration
■ Implicated that increased levels of glutamate in anxiety and depressive disorders
and decreased levels in schizophrenia
■ Neuropeptides
○ Classified by area of the body in which they are located or by their pharmacological or
functional properties
○ Often coexist with the classic NTs within a neuron
● Opioid Peptides
○ Include endorphins and enkephalins
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 ○ Found in various concentrations in the hypothalamus, thalamus, limbic structures,
midbrain, and brainstem
○ Enkephalins also found in GI tract
○ Thought to have a role in pain modulation, with their natural morphine-like properties
○ Released in response to painful stimuli, and may be responsible for producing the
analgesic effect following acupuncture
○ These alter the release of dopamine and affect the spontaneous activity of the
dopaminergic neurons
■ Some implications in schizophrenia
● Substance P
○ First neuropeptide to be discovered
○ Present in high concentrations in the hypothalamus, limbic structures, midbrain, and
brainstem, and is also found in the thalamus, basal ganglia, and spinal cord
○ Found to be highly concentrated in sensory fibers, and thought to play a role in sensory
transmission, and particularly in regulation of pain
○ Substance P abnormalities associated with Huntington’s, Alzheimer’s and mood
disorders
● Somatostatin
○ Also called growth hormone inhibiting hormone
○ Found in cerebral cortex, hippocampus, thalamus, basal ganglia, brainstem, and spinal
cord, and has multiple effects on the CNS
○ As NT, somatostatin exerts both stimulatory and inhibitory effects
○ Depending on part of brain, it can stimulate dopamine, serotonin, norepinephrine, and
acetylcholine, and inhibit norepinephrine, histamine, and glutamate
○ Acts as a neuromodulator for serotonin in the hypothalamus, thereby regulating its
release (determining whether it is stimulated or inhibited)
○ It’s possible that somatostatin may serve this function for other NTs as well
○ High concentrations have been reported in brain specimens of clients with Huntington’s,
and low concentrations with Alzheimer’s

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34
● Neuroendocrinology
■ Under direction of hypothalamus which has direct control over pituitary gland
● Pituitary gland size of pea, but is sometimes called the master gland

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○ Pituitary Gland
■ The Posterior Pituitary (Neurohypophysis)
● Hypothalamus has direct control over posterior pituitary through efferent neural pathways
● Two hormones found in posterior pituitary
○ Vasopressin (antidiuretic hormone)
○ Oxytocin
○ Both produced by hypothalamus and stored in posterior pituitary
○ Release mediated by neural impulses from hypothalamus
● Antidiuretic Hormone
○ Main function to conserve body water and maintain normal blood pressure
○ Release of ADH stimulated by pain, emotional stress, dehydration, increased plasma
concentration, and decreases in blood volume
○ Alteration in the secretion may be a factor in the polydipsia observed in about 10-15% of
hospitalized psych patients
○ Other factors correlated with this behavior include adverse effects of psychotropic meds
○ May also play role in learning and memory, in alteration of the pain response, and in the
modification of sleep patterns
● Oxytocin
○ Stimulates contraction of the uterus at the end of pregnancy and stimulates release of
milk from mammary glands
○ Also released in response to stress and during sexual arousal
○ Role in behavioral functioning unclear
■ Possible that oxytocin may act in certain situations to stimulate the release of
adrenocorticotropic hormone (ACTH), playing an overall role in hormonal
response to stress
■ The Anterior Pituitary (Adenohypophysis)
● Hypothalamus produces releasing hormones that pass through capillaries and veins of the
hypophyseal portal system to capillaries in the anterior pituitary, where they stimulate secretion of
specialized hormones
● Most hormones regulated by negative feedback mechanism

● Growth Hormone
○ Aka somatotropin
○ Stimulated by growth hormone releasing hormone (GHRH) from the hypothalamus
■ Stimulated in response to hypoglycemia and to stressful situations
○ Its release is inhibited by growth hormone inhibiting hormone (GHIH), or somatostatin,
also from the hypothalamus

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 ■ Release of GHIH stimulated in response to periods of hyperglycemia
○ Responsible for growth in children
○ Also responsible for continued protein synthesis throughout life
○ During fasting, stimulates the release of fat from the adipose tissue to be used for
increased energy
○ GH has direct effect on protein, carbs, and lipid metabolism which results in increased
serum glucose and free fatty acids to be used for increased energy
○ Possible correlation between abnormal secretion of GH and anorexia nervosa
● Thyroid-Stimulating Hormone
○ Thyrotropin-releasing hormone (TRH) from hypothalamus stimulates the release of
thyroid stimulating hormone (TSH), or thyrotropin, from anterior pituitary
○ TSH stimulates thyroid gland to secrete triiodothyronine (T3) and thyroxine (T4)
■ Integral to the metabolism of food and regulation of temperature
○ Correlation between thyroid dysfunction and altered behavioral functioning studied
■ Early literature associated hyperthyroidism with irritability, insomnia, anxiety,
restlessness, weight loss, and emotional liability, and with some progressing to
delirium or psychosis
○ Symptoms of fatigue, decreased libido, memory impairment, depression, suicidal
ideations associated with chronic hypothyroidism
○ Various forms of thyroid dysfunction correlated with mood disorders, anxiety, eating
disorders, schizophrenia and neurocognitive disorders
● Adrenocorticotropic Hormone
○ Corticotropin releasing hormone (CRH) from hypothalamus stimulates release of ACTH
from the anterior pituitary
○ ACTH stimulates adrenal cortex to secrete cortisol
■ Cortisol not well understood, but seems to be secreted in stressful situations
■ Disorders of adrenal cortex can lead to hyposecretion or hypersecretion
○ Addison’s disease is result of hyposecretion of hormones from adrenal cortex
■ Behavioral symptoms of hyposecretion
● Mood changes with apathy, social withdrawal, impaired sleep,
decreased concentration, fatigue
○ Cushing’s disease is hypersecretion of cortisol
■ Behavioral symptoms of hypersecretion
● Depression, mania, psychosis, suicidal ideation
● Cognitive impairments also commonly observed
● Prolactin
○ Serum prolactin levels regulated by prolactin releasing hormone (PRH) and prolactin
inhibiting hormone (PIH) form hypothalamus
○ Prolactin stimulates milk production by mammary glands in presence of high levels of
estrogen and progesterone during pregnancy
○ Behavioral symptoms of hypersecretion
■ Depression, decreased libido, stress intolerance, anxiety, increased irritability
● Gonadotropic Hormones
○ Called this because they produce an effect on the gonads-ovaries and testes
○ Includes Follicle stimulating hormone (FSH) and luteinizing hormone (LH)
■ Released from anterior pituitary and this is stimulated by gonadotropin releasing
hormone (GnRH) from hypothalamus
○ In women
■ FSH initiates maturation of ovarian follicles into the ova and stimulates their
secretion of estrogen
■ LH responsible for ovulation and the secretion of progesterone from corpus
luteum
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 ○ In men
■ FSH initiates sperm production in testes
■ LH increases secretion of testosterone by interstitial cells of testes
○ Gonadotropins regulated by negative feedback of gonadal hormones at hypothalamic or
pituitary level
○ Limited evidence to correlate gonadotropins to behavioral functioning, but some
observations made to warrant hypothetical consideration
■ Studies indicated decreased levels of testosterone, LH and FSH in depressed
men
■ Increased sexual behavior and aggressiveness have been linked to elevated
testosterone levels in both men and women
■ Decreased plasma levels of LH and FSH commonly occur in patients with
anorexia nervosa
■ Supplemental estrogen therapy has resulted in improved mentation and mood in
some depressed women
● Melanocyte-Stimulating Hormone
○ MSH from hypothalamus stimulates pineal gland to secrete melatonin
○ Release of melatonin appears to depend on onset of darkness and is suppressed by light
○ Studies indicate that environmental light can affect neuronal activity and influence
circadian rhythms
○ Correlation between abnormal secretion of melatonin and symptoms of depression has
led to the implication of melatonin in the etiology of seasonal affective disorder (SAD),
where individuals become depressed only during the fall and winter months when amount
of daylight decreases
○ Circadian Rhythms
● Human biological rhythms largely determined by genetic coding, with input from external
environments influencing cyclic effects
● Circadian rhythms follow a near 24-hour cycle and may influence a variety of regulatory functions
○ Sleep-wakefulness cycle
○ Body temperature regulation
○ Patterns of activity like eating and drinking
○ Hormone secretion
● 24 hour rhythms affected to large degree by cycles of lightness and darkness
○ Occurs because of “pacemaker” in brain that sends messages to other systems in the body
and maintains 24 hour rhythm
■ Endogenous pacemaker appears to be the suprachiasmatic nuclei of
hypothalamus
■ Nuclei receive projections of light through retina and in turn stimulate electrical
impulses to various other systems in body, mediating release of NTs or
hormones that regulate bodily functioning
● May last as long as a year
○ Circannual rhythms are particularly relevant to certain medications, such as cyclosporine,
that appears to be more effective at some times than others during the period of about a
year
● One study shows that administration of chemo during appropriate circadian phase can significantly
increase efficacy and decrease toxic effects of certain cytotoxic agents
■ The Role of Circadian Rhythms in Psychopathology
● Circadian rhythms may play a role in psychopathology
● Many hormones have been implicated in behavioral functioning so it is reasonable to believe that
peak secretion times could be influential in predicting certain behaviors
○ Association with depression with increased secretion of melatonin during darkness hours

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 ○ External manipulation of light-dark cycle and removal of external time cues often have
beneficial effects on mood disorders
● Premenstrual cycle symptoms linked to disruptions in biological rhythms
○ Premenstrual dysphoric disorder (PMDD) symptoms strongly resemble those with
depression
○ Hormonal changes in etiology
■ Progesterone-estrogen imbalance
■ Increase in prolactin and mineralocorticoids
■ High levels of prostaglandins
■ Decrease in endogenous opiates
■ Changes in metabolism of biogenic amines (serotonin, dopamine,
norepinephrine, acetylcholine)
■ Variations in secretion of glucocorticoids or melatonin
● Sleep disturbances common in depression and PMDD
● Body functions affected by 24 hour biological rhythms below

○ Sleep
● Sleep wakefulness cycle genetically determined and established after birth
● Without cues, cycle still develops about a 25 hour periodicity, which is close to the 24 hours
normal circadian rhythm
● Sleep measured by types of brain waves during various stages of sleep activity
● Dreaming episodes
○ Characterized by rapid eye movement (REM)
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 ● Stage 0: Alpha Rhythm
○ Characterized by relaxed, waking state with eyes closed
○ Alpha brain rhythm has a frequency of 8-12 cycles per second
● Stage 1: Beta Rhythm
○ Characterized the “transition” into sleep, or period of dozing
○ Thoughts wander, drifting in and out of sleep
○ Beta brain wave rhythm has frequency of 18-25 cycles per second
● Stage 2: Theta Rhythm
○ Characterizes the manner in which about half of sleep time is spent
○ Eye movement and muscular activity are minimal
○ Theta brain wave rhythm has frequency of 4-7 cycles per second
● Stage 3: Delta Rhythm
○ Period of deep and restful sleep
○ Muscles relaxed, HR and BP fall, breathing slows
○ No eye movement
○ Delta brain wave rhythm has frequency of 1.5-3 cycles per second
● Stage 4: Delta Rhythm
○ Deepest sleep
○ People who suffer from insomnia or other sleep disorders often don’t experience this
stage
○ Eye movement and muscular activity minimal
○ Delta waves predominant
● REM Sleep: Beta Rhythm
○ Dream cycle during REM
○ Eyes dart around under closed eyelids more rapidly than when awake
○ Brain wave pattern is similar to stage 1
○ HR and respirations increase; BP can increase or decrease
○ Muscles hypotonic
● Stages 2-REM repeat themselves
● More likely to experience longer periods of stages 3 and 4 early in cycle while longer periods of
REM sleep occur later in cycle
○ REM sleep about 4-5 times during night
● Amount of REM sleep and deep sleep decreases with age, while time spent in drowsy wakefulness
and dozing increases
■ Neurochemical Influences
● Many neurochemicals shows to influence sleep-wakefulness cycle
○ Several studies revealed info about serotonin and sleep inducing quality
○ L-tryptophan, amino acid precursor to serotonin, used for many years as effective
sedative-hypnotic to induce sleep in individuals with sleep onset disorder
○ Serotonin and norepinephrine appear to be most active during non REM sleep
○ Acetylcholine activated during REM sleep
○ GABA unclear with sleep facilitation
■ Sedative effects of drugs that enhance GABA transmission, like
benzodiazepines, suggest that GABA plays role in regulation of sleep and
arousal
○ Some studies suggest ACh induces and prolongs REM sleep
■ Histamine appears to have inhibitory effect
○ Neuroendocrine mechanisms seem to be more closely tied to circadian rhythms than do
sleep-wakefulness cycle
■ Exception: growth hormone secretion exhibits increases during early sleep
period and associated with slow-wave sleep
● Genetics
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○ Behaviors involve multiple genes
○ Genotype: total set of genes present in an individual at the time of conception, and coded in DNA
○ Phenotype: characteristics of physical manifestations that identify a particular genotype
■ Eye color, height, blood type, language, hair type, method of communication
■ Genetic or acquired, or a combo of both
○ Many psych disorders probably from genetics and environmental influences
○ Several risk factors
■ Familial: compares percentages of family members with the illness to those in the general population or
within a control group of unrelated individuals
■ Estimate prevalence of psychopathology among relatives, and make predictions about predisposition to an
illness based on familial risk factors
■ Schizophrenia, bipolar, major depressive, anorexia, panic, somatic symptom, antisocial personality,
alcoholism all disorders that have familial tendencies
○ Studies that are purely genetic search for specific gene responsible
■ Many studies exist in which mutation of a specific gene or change in number or structure of a chromosome
has been associated with etiology
● Huntington’s, CF, phenylketonuria, Duchenne’s muscular dystrophy, Down syndrome
○ Risk factors for early onset Alzheimer’s disease linked to mutations on chromosomes 21, 14 and 1
○ Other studies linked a gene in a region of chromosome 19 that produces apolipoprotein E (ApoE) with late onset
Alzheimer's
○ Other studies conducted to estimate existence and degree of genetic and environmental contributions to etiology of
certain psychiatric disorders
■ Twin studies
● Examine frequency of a disorder in monozygotic (identical genetically) and dizygotic (fraternal)
twins
● Twins called ​concordant​ when both members suffer from same disorder
○ Concordance in monozygotic twins stronger for genetic involvement evidence than in
dizygotic twins
● Suggested a twin genetic link in alcoholism, schizophrenia, major depressive disorder, bipolar
disorder, anorexia nervosa, panic disorder, and obsessive-compulsive disorder
■ Adoption studies
● Comparisons are made of the influences of genetics versus environment on the development of a
psychiatric disorder
○ Knowles describes four types of adoption studies
■ Adopted children whose biological parents had psychiatric disorder but whose
adoptive parents did not
■ Adopted children whose adoptive parents had psychiatric disorders but whose
biological parents did not
■ Adoptive and biological relatives of adopted children who developed a
psychiatric disorder
■ Monozygotic twins reared apart by different adoptive parents
● Disorders in which adoption studies suggest possible genetic link
○ Alcoholism, schizophrenia, major depression, bipolar disorder,
attention-deficit/hyperactivity disorder, antisocial personality disorder

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42
● Psychoimmunology
○ Normal Immune Response
● Cells responsible for ​nonspecific​ immune reactions include
○ Neutrophils
○ Monocytes
○ Macrophages
■ Work to destroy invasive organism and initiate and facilitate damaged tissue
■ Specific​ immune mechanisms take over if nonspecific doesn’t work
● Specific immune mechanisms
○ Divided into two major types
■ Cellular response
● Controlling elements are T lymphocytes (T cells)
● When antigen invades, T cells, particularly the CD4 T lymphocytes
(aka helper T cells) become sensitized to and specific for foreign
antigen; divide many times and produce antigen-specific CD4 T cells
with other functions
○ Killer T Cell: destroys viruses that reproduce inside other cells
by puncturing the cell membrane of the host cell and allowing
the contents of the cell, including viruses, to spill out into
bloodstream where they can be engulfed by macrophages
○ Suppressor T cell: serves to stop the immune response once
foreign antigen has been destroyed
■ Humoral response
● Controlling elements are B lymphocytes (B Cells)
● Activated when antigen specific CD4 T cells communicate with B cells
in spleen and lymph nodes
○ B cells in turn produce antibodies specific to foreign antigen
○ Antibodies attach themselves to foreign antigens so that they
can't invade body cells
○ Invader cells destroyed without being able to multiple
■ Implications of the Immune System in Psychiatric Illness
● Biological response to stress
○ Hypothesized that individuals become more susceptible to physical illness following
exposure to stressful stimuli or life event
○ Response thought to be due to effect of increased glucocorticoid release from adrenal
cortex following stimulation from hypothalamic-pituitary-adrenal axis during stress

43
 ■ Results in suppression in lymphocyte proliferation and function
● Studies show nerve endings exist in tissues of immune system
○ CNS has connections in bone marrow and thymus (immune cells produced here) and in
spleen and lymph nodes (where immune cells stored)
● GH, released in response to certain stressors, can enhance immune functioning, whereas
testosterone inhibits it
● Increased production of epinephrine and norepinephrine occurs from stress and can decrease
immunity
● Serotonin demonstrates both enhancing and inhibitory effects
● Studies correlate a decrease in lymphocyte functioning with periods of grief, bereavement, and
depression, associating degree of altered immunity with severity of depression
● Studies attempt to correlate the onset of schizophrenia to immune system abnormalities
○ Still unclear
● Psychopharmacology
■ Pivotal point in mid 20th century
● Phenothiazine class of antipsychotics introduced in US
○ Help to function effectively
○ Historical Perspectives
■ Psychotropic Medication: medication that affects psychic function, behavior, or experience
■ We used to fear those with mental illness
■ In 18th century, “moral reform” happened
● Had hospitals concerned with patients needs
○ Only custodial care though: food and shelter but no hope of change for future
○ Likelihood to return to families diminished
■ Early 20th century
● Advent of somatic therapies
○ Insulin shock therapy, wet sheet packs, ice baths, ect, psychosurgery
● Before 1950, sedatives and amphetamines were only significant psychotropic meds available
● Now we use antipsychotics, antidepressants, anti anxiety meds
○ Knowing how drugs work help with etiology of disorder
● Psychotropic meds don’t “cure”, but used as adjunct to individual or group psychotherapy
○ Psychotropic meds relieve physical and behavioral symptoms
■ Don’t resolve emotional problems
○ Role of the Nurse
■ Ethical and Legal Implications
● Understand ethical and legal implications associated with administration of psychotropic meds
■ Assessment
● Baseline assessment conducted before a client is placed on regimen
● Assessment example on page 70
■ Medication Administration and Evaluation
■ Client Education
○ How do Psychotropics Work?
■ Most meds have effects at the neuronal synapse, producing changes in NT release and receptors to which
they bind
● Its hypothesized that most antidepressants work by blocking the reuptake of NTs, specifically,
serotonin and norepinephrine
○ Reuptake is process of NT inactivation by which the NT is reabsorbed into the
presynaptic neuron from which it had been released
○ Blocking the reuptake process allows more of the NT to be available for neuronal
transmission
○ Could also result in undesirable side effects
● Some antidepressants also block receptor sites that are unrelated to their mechanisms of action
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 ○ Alpha-adrenergic, histaminergic, muscarinic cholinergic receptors
○ Blocking these receptors also associated with certain side effects
● Antipsychotic meds block dopamine receptors
○ Some affect muscarinic cholinergic, histaminergic and alpha-adrenergic receptors
● The atypical antipsychotics block a specific serotonin receptor
● Benzodiazepines facilitate transmission of inhibitory NT GABA
● Psychostimulants work by increasing norepinephrine, serotonin, and dopamine release
● Exact mechanisms of actions are unknown
● Therapeutic effects of some meds like antidepressants and antipsychotics may take weeks
● Long term neuropharmacological reactions to increased norepinephrine and serotonin levels relate
more to their mechanisms of actions
○ Recent research says that therapeutic effects are related to the nervous system’s
adaptation to increased levels of NTs
○ Adaptive changes result from homeostatic mechanism that relates to cell and maintains
equilibrium

45
● Implications for Nursing
○ To ensure smooth transition from psychosocial focus to one of biopsychosocial emphasis, must have clear
understanding of the following
46
■ Neuroanatomy and neurophysiology
■ Neuronal processes
■ Neuroendocrinology
■ Circadian rhythms
■ Genetic influences
■ Psychoimmunology
■ Psychopharmacology
■ Diagnostic technology

47
 Chapter 5: Legal and Ethical Issues in Psychiatric/Mental Health Nursing ​VIV

● Nurses constantly make difficult decisions regarding good and evil or life and death; especially with mental illness patients,
nurses are held to the highest level of legal and ethical accountability in their professional practice
● Nursing competency and client care accountability are compromised when the nurse has inadequate knowledge about the
laws that regulate the practice of nursing
○ Knowledge will enhance the quality of care the nurse provides in his or her psychiatric/mental health nursing
practice and will also protect the nurse within the parameters of legal accountability

ETHICAL CONSIDERATIONS
● Theoretical perspectives
○ An ethical theory is a moral principle or a set of moral principles that can be used in assessing what is morally right
or morally wrong; they provide guidelines for ethical decision making.
○ Utilitarianism- “the greatest-happiness principle.”
■ Actions are right if they promote happiness and are wrong if they make you unhappy
■ Action is taken based on the end results that produced the most good AKA happiness
○ Kantianism
■ Named for philosopher Immanuel Kant; Directly opposed to utilitarianism
■ AKA deontology- from the Greek word deon, which means “that which is binding; duty”
■ It is not the consequences or end results that make an action right or wrong; rather it is the principal or
motivation on which the action is based that is the morally decisive factor
● Ex: I make this choice because it is morally right and my duty to do so
○ Christian ethics
■ Ethical decision making is focused on the way of life and teachings of Jesus Christ; all decisions about right
and wrong should be centered in love for God & the golden rule
■ Importance of virtues such as love, forgiveness, and honesty
■ Golden rule: “Do unto others as you would have them do unto you.”
○ Natural law theory
■ based on the writings of St. Thomas Aquinas; decisions about right versus wrong are self-evident and
determined by human nature
■ as rational human beings, we inherently know the difference between good and evil (believed to be
knowledge that is given to man from God), and this knowledge directs our decision making
○ Ethical egoism
■ What is right and good is what is best for the individual making the decision
■ An individual’s actions are determined by what is to their advantage even it is not good for anyone else
involved
● Ethical dilemmas
○ An ethical dilemma is a situation that requires an individual to make a choice between two equally unfavorable
alternatives/no clear reason to choose one action over another
■ The individual making the choice experiences conscious conflict
■ Often taking no action is considered an action taken
● Ethical principles- ​fundamental guidelines that influence decision making
○ Autonomy
■ Arises from the Kantian duty of respect for persons as rational agents
■ Emphasizes the status of persons as autonomous moral agents whose right to determine their destinies
should always be respected
● BUT it presumes that individuals are always capable of making independent choices for
themselves and it is NOT always true (individuals in comas, mentally ill, etc.)
● As healthcare workers we must ensure that respect for an individual's autonomy is not disregarded

48
 ○ Beneficence
■ Beneficence refers to one’s duty to benefit or promote the good of others
● Health-care workers who act in their clients’ interests are beneficent, provided their actions really
do serve the client’s best interest
○ Autonomy of an individual may be overridden when the patient has been deemed harmful
to self or others
■ Peplau recognized client ​advocacy ​as an essential role for the psychiatric nurse (advocacy means acting in
another’s behalf—being a supporter or defender)
● Ex: educating the patients fam. To make the right decision
○ Nonmaleficence
■ Nonmaleficence is the requirement that health-care providers do no harm to their clients, either
intentionally or unintentionally
● philosophers suggest that this principle is more important than beneficence; it is more important to
avoid doing harm than it is to do good
● Ex: psych patient refuses to take meds, as a nurse you still need to make sure they stay safe (no
harm of themselves or others) while experiencing psych symptoms
○ Justice AKA “fairness”
■ AKA ​distributive justice;​ it's the right of individuals to be treated equally regardless of race, sex, marital
status, medical diagnosis, social standing, economic level, or religious belief
● Duty to treat all individuals equally and fairly including all resources within the society should be
distributed evenly regardless of race… ​same shit as above
○ Veracity
■ Veracity refers to one’s duty to always be truthful; health-care provider must tell the truth and not
intentionally deceive or mislead clients
■ There are some times where veracity must be limited, such as when the truth would knowingly produce
harm or interfere with the recovery process; however, patients have the right to know about their diagnosis,
treatment, and​ ​prognosis
● A model for making ethical decisions
○ 1. Assessment:
■ Gather objective and subjective data about the situation
■ Consider both personal and others values involved
○ 2. Problem identification:
■ Identify the conflict between the alternative actions
○ 3. Planning:
■ Explore the benefits and consequences of each alternative
■ Consider principles of ethical theories
■ Select an alternative
○ 4. Implementation:
■ Act on the decision made and communicate the decision to others
○ 5. Evaluation (​of outcomes​)
■ If acceptable continue implementation
■ If unacceptable restart at step 3
● Ethical issues in psychiatric/mental health nursing
○ The right to refuse medication
■ The AHA’s Patient’s Bill of Rights states: “The patient has the right to refuse treatment to the extent
permitted by law, and to be informed of the medical consequences of his action.
● “Extent permitted by law” includes the 1st (right of speech), 5th (due process), 8th (freedom from
cruelty and unusual punishment), and 14th (due process) amendments
● “Medical consequences” include involuntary commitment, legal competency hearing, or client
discharge from the hospital.
■ In psychiatric health limitations exist (Weiss-Faffie and Purtell) force medication has 3 criteria:
● 1. Patient exhibits behavior that is dangerous to self or others
49
 ● 2. Physicians must have a reasonable chance of providing help to the patient
● 3. Patient must be judged incompetent to evaluate the benefits of the treatment in question
○ The right to the least restrictive treatment alternative
■ Health-care personnel must attempt to provide treatment in a manner that least restricts the freedom of
patients
● Treatment and symptoms vary
■ The problem arises in selecting the least restrictive means among involuntary chemical intervention,
seclusion, and mechanical restraints

LEGAL CONSIDERATIONS
● The Patient Self-determination Act, as part of the Omnibus Budget Reconciliation Act of 1990:
○ requires healthcare facilities to provide clear written information for every patient concerning his/her legal rights to
make healthcare decisions, including the right to accept or refuse treatment
■ BOX 5-3 pg 84 (106 ebook)​: list of the rights of patients affirmed by this law
● Nurse practice acts
○ The legal parameters of professional and practical nursing are defined within each state by the state’s nurse practice
act, including:
■ Definition of important terms (definition of nursing and various types of nurses recognized)
■ Education and other training requirements for licensure and reciprocity statement
■ Descriptions of the scope of practice for the various levels of nursing (APN, RN, LPN)
■ Conditions in which nurses license may be suspended or revoked, and instructions for appeal
■ General authority and powers of the state board of nursing
○ Most nurse practice acts are general in their terminology and do not provide specific guidelines for practice
■ Nurses must understand the scope of practice that is protected by their license, and should seek assistance
from legal counsel if they are unsure about the proper interpretation of a nurse practice act
● Types of law- ​identified by source/origin
○ Statutory law-​ law that has been enacted by a legislative body, such as a county or city council, state legislature, or
the U.S. Congress
■ Ex: the nurse practice acts
○ Common law- ​derived from decisions made in previous cases
■ Common law in the US is developed on a state basis of specific subjects may differ from state to state
■ Ex: how deal with a nurse's refusal to provide care for a specific patient
● Classification ​within ​statutory and common law
○ Civil law-​ protects the private and property rights of individuals and businesses. 2 types:
■ Torts-​ a violation of a civil law in which an individual has been wronged
● One party asserts that wrongful conduct on the part of the other has caused harm, and seeks
compensation for harm suffered
● May be intentional or unintentional
○ Ex: unintentional- negligence or malpractice
○ Ex: intentional- procedure without consent
■ Contracts
● one party asserts that the other party, in failing to fulfill an obligation, has breached the contract,
and either compensation or performance of the obligation is sought as remedy
○ Criminal law
■ Provides protection from conduct deemed injurious to the public welfare
■ Provides punishment for those who break the law → prison, parole, loss of privilege, a fine, or a 
combination 
● Legal issues in psychiatric/mental health nursing
○ Confidentiality and right to privacy
■ The Fourth, Fifth, and Fourteenth Amendments to the U.S. Constitution protect an individual’s privacy
● The only individuals who have the right to access to a patient's medical information are those
involved in their medical care
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 ■ HIPPA 1996- Health Insurance Portability and Accountability Act
● Under this law, individuals have the rights to access their medical records, to have corrections
made to their medical records, and to decide with whom their medical information may be shared
● The actual document belongs to the facility or therapist, but the information belongs to the client
○ Federal privacy rule applies to information that is called ​protected health information
(PHI) w​ hich applies to most healthcare providers
■ PHI: individually identifiable health information indicators that (1) identifies the
individual or (2) with respect to which there is a reasonable basis to believe the
information can be used to identify the individua​l
● Pertinent medical information may be released without consent in a life-threatening situation. If so
the following must be recorded:
○ The date of disclosure, person to whom information was disclosed, reason for disclosure,
reason written consent could not be obtained, and the specific information disclosed
● Privileged communication-​ differ from state to state; grant certain professionals privileges under
which they may refuse to reveal information about, and communications with, patients
● In certain instances nurses may be called on to testify in cases in which the medical record is used
as evidence. In most states, the right to privacy of these records is exempted in civil or criminal
proceedings. DOCUMENTATION IS IMPORTANT!
■ Exception: a duty to warn (protection of a third part)
● There are exceptions to the laws of privacy and confidentiality:
● Tarasoff VS Regents of the University of California
○ Mr. P student at cali-U fell in love with Ms. Tarasoff, but she didn't like him. He got 
angry and began stalking her. Mr. P went to a psychiatrist, which he told that he was 
going to kill Ms. T when she got back from south america/vacation that summer. 
Psych dr. dx: suffering from acute and severe paranoid schizophrenia. Campus police 
arrested him but then released him due to him appearing rational and promising to 
stay away from Ms. T. but this nigga cray cray sooo she came back from vaca. and he 
resumed to stalk her and eventually stabbing her to death! Neither Ms. T nor her 
family were given a warning that Mr. P had these intentions → court: pych dr said 
that telling ppl would breach confidentiality but court said hey you gotta break that 
rule sometimes in order to protect a third party 
○ Court made guidelines for therapists to follow in determining their obligation to take
protective measures
■ 1. Assessment of a threat of violence by a client toward another individual
■ 2. Identification of the intended victim
■ 3. Ability to intervene in a feasible, meaningful way to protect the intended
victim
● Implications for nursing:
○ All psychiatric nurses have a responsibility to protect a third party who is being
threatened by the client. If a client confides in the nurse the potential for harm to an
intended victim, it is the duty of the nurse to report this information to the psychiatrist or
to other team members
■ This is not a breach of confidentiality and the nurse may be considered negligent
for failure to do so
■ All members of the treatment team must be made aware of the potential danger
that the client poses to self or others
■ Detailed written documentation of the situation is essential
○ Informed consent- ​the preservation and protection of individual autonomy in determining what will and will not
happen to the person’s body; individual's right to accept/reject treatment
■ Info about the procedure must be given with adequate time to consider pros/con, alternatives, why the tx,
possible outcomes/risks/side effects, outcome if no tx.
■ Consent may be challenges under the following and may be obtained from a legal guardian:
51
 ● 1. When a client is mentally incompetent to make a decision and treatment is necessary to preserve
life or avoid serious harm
● 2. When refusing treatment endangers the life or health of another
● 3. During an emergency, in which a client is in no condition to exercise judgment
● 4. When the client is a child (consent is obtained from parent or surrogate)
● 5. In the case of therapeutic privilege: Information about a treatment may be withheld if the
physician can show that full disclosure would
○ a. hinder or complicate necessary treatment
○ b. cause severe psychological harm, or
○ c. be so upsetting as to render a rational decision by the client impossible
■ A guardian always has the right to withdraw consent after it has been given. When this occurs, the
physician should be informed & the client should also be informed about the consequences of refusing
treatment
● If treatment has already been initiated, the physician should terminate treatment in a way least
likely to cause injury to the client and inform the client of guardian of the risks associated with
interrupted treatment
■ Nurses should ensure that the following three major elements of informed consent have been addressed:
● 1. ​Knowledge​: The client has received adequate information on which to base his or her decision.
● 2. ​Competency​: The individual’s cognition is not impaired to an extent that would interfere with
decision making or, if so, that the individual has a legal representative.
● 3.​ Free will:​ The individual has given consent voluntarily without pressure or coercion from
others.
○ Restraints and seclusion
■ The Patient Self-determination Act of 1991 includes a set of patient rights; one is an individual’s right to
freedom from restraint or seclusion except in an emergency situation.
■ The use of seclusion and restraint as a therapeutic intervention for psychiatric patients has been
controversial and many efforts have been made to minimize or eliminate its use, because there have been
injuries and deaths associated with it
● Restraints ​generally refers to any manual method or medication used to restrict a person’s
freedom of movement​ ​of an individual whose behavior is out of control and poses an immediate
risk to the physical safety and psychological well-being of the individual and others
○ Restraints are never to be used as punishment or convenience for the staff
○ Other methods such as “talk down” (verbal intervention) and chemical restraints
(tranquilizers) should be tried first
● Seclusion ​is a type of physical restraint where the patient is confined alone in a room from which
they are unable to leave. The room is usually minimally furnished to promote the client’s comfort
and safety
■ Standards regarding seclusion and restraints
● 1. Seclusion or restraint should be discontinued as soon as possible
● 2. Orders should be renewed every 4 hrs for adults (18+), every 2 hours for children (17-9), every
hour for children (<9) (unless state law is different), max renewed for 24 consecutive hours
● 3. An in-person evaluation must be conducted within 1 hr of implementation. RN s and physicians
assistants may do this assessment but must consult with the physician
● 4. Patients in restraints or secluded must be continuously monitored (in person or through video
or audio)
● 5. Staff involved must be trained to monitor the physical and psychological well-being of the
patient including respiratory, circulatory, skin integrity, and VS
■ False imprisonment​ is the deliberate and unauthorized confinement of a person within fixed limits by the
use of verbal or physical means
● Commitment issues
○ Voluntary admissions
■ Approximately ⅔ of people voluntarily admitted
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 ■ To be admitted voluntarily, an individual makes direct application to the institution for services and may
stay as long as treatment is deemed necessary, they may sign out at any time UNLESS they are considered
harmful to self or others
○ Involuntary commitment- ​involuntary admission ?
■ The Fourteenth Amendment provides citizens protection against loss of liberty and ensures due process
rights; including protection from unlawful searches and seizures without probable cause
■ Involuntary commitments must follow this criteria:
● 1. In an emergency situation (for the client who is dangerous to self or others)
● 2. For observation and treatment of mentally ill persons
● 3. When an individual is unable to take care of basic personal needs (the “gravely disabled”)
■ 1. Emergency commitments
● When an individual manifests behavior that is clearly and imminently dangerous to self or others
● Usually instigated by relatives or friends of the individual, police officers, the court, or health-care
professionals
● Emergency commitments are time limited and a court hearing for the individual is scheduled; The
court may decide that the client may be discharged or if necessary and if voluntary admission is
refused by the client an additional period of involuntary commitment may be ordered
■ 2. The mentally ill person in need of treatment
● Most states have established definitions of what constitutes “mentally ill” Some examples:
○ Individuals unable to make informed decisions concerning treatment
○ Individuals likely to cause harm to self or others
○ Individuals unable to fulfill basic personal needs necessary for health and safety
■ Involuntary outpatient commitment (IOC)
● Is a court ordered mechanism used on a person with mental illness to submit to treatment on an
outpatient basis. A number of eligibility criteria:
○ Hx of repeated involuntary hospitalization
○ Likelihood that w/o treatment the individual will deteriorate to the point of requiring
inpatient commitment
○ Presence of severe and persistent mental illness and limited awareness of the illness or
need for treatment or risk of homelessness/incarceration/violence/suicide
○ The existence of individualized tx plan likely to be effective and a provider of tx
● The need for this kind of legislation arose after it was recognized that patients with ​schizophrenia
who did not meet criteria for involuntary hospital treatment were dangerous to themselves or
others
■ 3. The gravely disabled client
● “Gravely disabled” is an individual with a mental illness is in danger of serious physical harm
from inability to provide for basic needs such as food, clothing, shelter, medical care, and personal
safety
○ A guardian, conservator, or committee will be appointed by the court to ensure the
management of the person
● Nursing liability
○ Malpractice and negligence (​used interchangeably​)
■ Negligence- ​The failure to exercise the standard of care that a reasonably prudent person would have
exercised in a similar situation; any conduct that falls below the legal standard established to protect others
against unreasonable risk of harm, except for conduct that is intentionally, wantonly, or willfully
disregardful of others’ rights.
■ Malpractice- ​a specialized form of negligence applicable only to professionals: An instance of negligence
or incompetence on the part of a professional. To succeed in a malpractice claim, a plaintiff must also prove
proximate cause and damages.
■ In the absence of any state statutes, common law is the basis for injuries caused by acts of malpractice and
negligence
■ Elements of a nursing malpractice lawsuit:
53
 ● 1. A duty to the patient existed based on the recognized standard of care
● 2. A breach of duty occurred, meaning that the care given was not consistent with the recognized
standard of care
● 3. The client was injured
● 4. The injury was directly caused by the breach of a standard of care
○ Types of lawsuits that occur in psychiatric nursing
■ Most malpractice suits against nurses are civil actions; that is they are considered breach of conduct actions
on the part of the professional, for which compensation is being sought.
● A nurse may be charged with ​breach of confidentiality​ for revealing aspects about a client’s case,
or even for revealing that an individual has been hospitalized, if that person ​can show that the
information revealed resulted in harm
○ Defamation of character​- when shared information is detrimental to the client’s
reputation; communication that is malicious and false
■ Libel- ​when the information is in writing
■ Slander- ​oral defamation
● Invasion of privacy-​ a charge that may result when a client is searched without probable cause
○ Many institutions conduct body searches on clients with mental illness as a routine
intervention
○ Assault- ​an act that results in a person’s genuine fear and apprehension that they will be
touched without consent
○ Battery-​ the unconsented touching of another person; these charges can result when a
treatment is administered against a client's wishes and outside an emergency situation
○ Harm or injury need not have occurred for these charges to be legitimate
○ Avoiding liability
■ The following proactive nursing actions in an effort to avoid nursing malpractice:
● 1. Responding to the patient
● 2. Educating the patient
● 3. Complying with the standard of care
● 4. Supervising care
● 5. Adhering to the nursing process
● 6. Documenting carefully
● 7. Following up by evaluating the care that was given

54
 Chapter 7: Relationship Development/ Nurse- Client Relationship- K

· The nurse-client relationship is the foundation on which psychiatric nursing is established. It is a relationship in which both
participants must recognize each other as unique and important to human beings. It is also a relationship in which mutual learning
occurs.
· ​Therapeutic Relationship​- an interaction between two people (usually a caregiver and a care receiver) in which input from both
participants contributes to a climate of healing, growth promotion, and/or illness prevention.

Role of a Psychiatric Nurse

· ​Peplau​ identified several subroles within the role of the nurse:
1. The Stranger​: A nurse is at first a stranger to the client. The client is also a stranger to the nurse.
This principle implies: (1) accepting the patient as he is; (2) treating the patient as an emotionally able stranger and relating to
him on this basis until evidence shows him to be otherwise.

2. The Resource Person​: According to Peplau, “a resource person provides specific answers to questions usually formulated
with relation to a larger problem.” In the role of resource person, the nurse explains, in language that the client can understand,
information related to the client’s health care.

3. The Teacher:​ In this subrole the nurse identifies learning needs and provides information required by the client or family to
improve the health situation.

4. The Leader:​ Autocratic leadership promotes overvaluation of the nurse and clients’ substitution of the nurse’s goals for their
own. Laissez-faire leaders convey a lack of personal interest in the client.

5. The Surrogate​: Outside of their awareness, clients often perceive nurses as symbols of other individuals. They may view the
nurse as a mother figure, a sibling, a former teacher, or another nurse who has provided care in the past. This occurs when a client is
placed in a situation that generates feelings similar to ones he or she has experienced previously.
Peplau explained that the nurseclient relationship progresses along a continuum. When a client is acutely ill, he or she may incur the
role of infant or child, while the nurse is perceived as the mother surrogate.

6.​ ​The Technical Expert: ​The nurse understands various professional devices and possesses the clinical skills necessary to perform
the interventions that are in the best interest of the client.
7.​ ​The Counselor: ​The nurse uses “interpersonal techniques” to assist clients to learn to adapt to difficulties or changes in life
experiences.
Peplau believed that the emphasis in psychiatric nursing is on the counseling subrole.

· Peplau suggested that it is essential for the staff nurse working in psychiatry to have a general knowledge of basic counseling
techniques.
· A therapeutic or “helping” relationship is established through use of these interpersonal techniques and is based on a sound
knowledge of theories of personality development and human behavior.
· Sullivan (1953) believed that emotional problems stem from difficulties with interpersonal relationships. Interpersonal theorists,
such as Peplau and Sullivan, emphasize the importance of relationship development in the provision of emotional care

Dynamics of a Therapeutic Nurse-Client Relationship

· Travelbee, who expanded on Peplau’s theory of interpersonal relations in nursing, has stated that it is only when each individual
in the interaction perceives the other as a unique human being that a relationship is possible.
o​ “Human-to-human relationship,” which she describes as a “mutually significant experience.”
· Therapeutic relationships are goal oriented. Ideally, the nurse and client decide together what the goal of the relationship will be.
Most often the goal is directed at learning and growth promotion, in an effort to bring about some type of change in the client’s life.

55
Therapeutic Use of Self
· ​Therapeutic use of self-​ the instrument for delivery of care; the ability to use one’s personality consciously and in full awareness
in an attempt to establish relatedness and to structure nursing intervention (Travelbee).
· Use of the self requires self-awareness and self-understanding
· The nurse must understand that the ability and extent to which one can effectively help others in time of need is strongly
influenced by this internal value system—a combination of intellect and emotions.

​ aining Self-Awareness
G
· Self-awareness requires that an individual recognize and accept what he or she values and learn to accept the uniqueness and
differences in others.
· An individual’s value system is established very early in life and has its foundations in the value system held by the primary
caregivers. It is culturally oriented; it may change many times over the course of a lifetime; and it consists of beliefs, attitudes, and
values
· Values clarification is one process by which an individual may gain self-awareness.

1. Beliefs-​ an idea that one holds to be true, and it can take any of several forms
Rational beliefs- ideas for which objective evidence exists to substantiate their truth.
Ex: Alcoholism is a disease
Irrational beliefs- ideas that an individual holds as true despite the existence of objective contradictory evidence. Delusions can be a
form of irrational beliefs
Ex. Once an alcoholic has been through detox and rehab, he or she can drink socially if desired
Faith (sometimes called “blind beliefs”)- an ideal that an individual holds as true for which no objective evidence exists
Ex. Belief in a higher power can help an alcoholic stop drinking
Stereotype- a socially shared belief that describes a concept in an oversimplified or undifferentiated matter
Ex. All alcoholics are skid-row bums.

2. Attitudes​- a frame of reference around which an individual organizes knowledge about his or her world, has an emotional
component, can be prejudgment and may be selective and biased.
Attitudes fulfill the need to find meaning in life and to provide clarity and consistency for the individual.
3. Values-​ abstract standards, positive or negative, that represent an individual's ideal mode of conduct and ideal goals.
Ex of ideal modes of conduct: seeking truth and beauty; being clean and orderly; behaving with sincerity, justice,
reason, compassion, humility, respect, honor, and loyalty.
Ex of ideal goals: security, happiness, freedom, equality, ecstasy, fame, and power.
Values differ from attitudes and beliefs in that they are action oriented or action producing
Only when the belief is acted on does it become a value.
Values may be viewed as a kind of core concept or basic standards that determine one’s attitudes and beliefs, and
ultimately, one’s behavior.
TABLE 7–1 The Process of Values Clarification LEVEL OF OPERATIONS CATEGORY CRITERIA
EXPLANATION

Levels of Operation Category Criteria Explanation

Cognitive Choosing 1. Freely “This value is mine. No

2. From alternatives one forced me to choose
3. After careful it. I understand and
consideration of the accept the consequences
consequences of holding this value.”

56
 Emotional Prizing 4. Satisfied; pleased with “I am proud that I hold
the choice this value, and I am
5. Making public willing to tell others
affirmation of the choice, about it.”
if necessary

Behavioral Acting 6. Taking action to The value is reflected in

demonstrate the value the individual’s behavior
behaviorally for as long as he or she
7. Demonstrating this holds it.
pattern of behavior
consistently and
repeatedly Choosing
Prizing Acting
**Raths, Harmin, and Simon (1978) identified a seven-step process of valuing that can be used to help clarify personal values. This
process is presented in Table 7-1. The process can be used by applying these seven steps to an attitude or belief that one holds. ​When
an attitude or belief has met each of the seven criteria, it can be considered a value.

The Johari Window

· The Johari Window is a representation of the self and a tool that can be used to increase self-awareness
· The self arises out of self-appraisal and the appraisal of others and represents each individual’s unique pattern of values,
attitudes, beliefs, behaviors, emotions, and needs
· Self-awareness is the recognition of these aspects and understanding about their impact on the self and others

Known to Self Unknown to Self

Known to Others The open or public self The unknowing self

Unknown to Others The private self The unknown self

1. The open or public self:​ The upper left quadrant of the window represents the part of the self that is public; that is, aspects of
the self about which both the individual and others are aware.
Ex​. Susan, a nurse who is the adult child of an alcoholic, has strong feelings about helping alcoholics to achieve sobriety. She
volunteers her time to be a support person on call to help recovering alcoholics. She is aware of her feelings and her desire to help
others. Members of the Alcoholics Anonymous group in which she volunteers her time are also aware of Susan’s feelings and they
feel comfortable calling her when they need help refraining from drinking.

2. The Unknowing self​: The upper right quadrant of the window represents the part of the self that is known to others but
remains hidden from the awareness of the individual.
Ex​. When Susan takes care of patients in detox, she does so without emotion, tending to the technical aspects of the task in a
way that the clients perceive as cold and judgmental. She is unaware that she comes across to the clients in this way

3. The Private self:​ The lower left quadrant of the window represents the part of the self that is known to the individual, but
which the individual deliberately and consciously conceals from others.
Ex​. Susan would prefer not to take care of the clients in detox because doing so provokes painful memories from her
childhood. However, because she does not want the other staff members to know about these feelings, she volunteers to take care of
the detox clients whenever they are assigned to her unit.

4. The Unknown self:​ The lower right quadrant of the window represents the part of the self that is unknown to both the
individual and to others.

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 Ex​. Susan felt very powerless as a child growing up with an alcoholic father. She seldom knew in what condition she would
find her father or what his behavior would be. She learned over the years to find small ways to maintain control over her life situation,
and left home as soon as she graduated from high school. The need to stay in control has always been very important to Susan, and she
is unaware that working with recovering alcoholics helps to fulfill this need in her. The people she is helping are also unaware that
Susan is satisfying an unfulfilled personal need as she provides them with assistance

· The goal of increasing self-awareness by using the Johari Window is to increase the size of the quadrant that represents the open
or public self. The individual who is open to self and others has the ability to be spontaneous and to share emotions and experiences
with others. This individual also has a greater understanding of personal behavior and of others’ responses to him or her.

Conditions Essential to Development of a Therapeutic Relationship

1. Rapport-​ a primary task in establishing a relationship; implies special feelings on the part of both the client and the nurse
based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude; may be accomplished by
discussing non-health-related topics.

2. Trust- t​ o trust another, one must feel confidence in that person’s presence, reliability, integrity, veracity, and sincere desire to
provide assistance when requested; Trust cannot be presumed; it must be earned; Trustworthiness is demonstrated through nursing
interventions that convey a sense of warmth and caring to the client.

o​ Many psychiatric clients experience concrete thinking, which focuses their thought processes on specifics rather than generalities,
and immediate issues rather than eventual outcomes.
o​ Ex. of nursing interventions that build trust are on pg. 127**

3. Respect-​ to show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior.
o​ The psychologist ​Carl Rogers​ called this unconditional positive regard
o​ Many psychiatric clients have very little self-respect because, as a result of their behavior, they have been rejected by others in the
past. Recognition that they are being accepted and respected as unique individuals on an unconditional basis can serve to elevate
feelings of self-worth and self-respect
o​ ​Ex.​ of nursing intervention to show respect are on pg. 127**

4. Genuineness​- the concept of genuineness refers to the nurse’s ability to be open, honest, and “real” in interactions with the
client. To be “real” is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be
apparent in the therapeutic relationship
o​ When one is genuine, there is ​congruence​ between what is felt and what is being expressed
o​ May call for a degree of ​self-disclosure​- expressing feelings, sharing personal experiences, etc. Care must be taken when using
self-disclosure to avoid role reversal.
§ Self-disclosure reveals “humanness,” creating a role for the client to model in similar situations

5. Empathy​- is the ability to see beyond outward behavior and to understand the situation from the client’s point of view; with
empathy, the nurse can accurately perceive and comprehend the meaning and relevance of the client’s thoughts and feelings.

o​ With ​empathy​ the nurse “accurately perceives or understands” what the client is feeling and encourages the client to explore these
feelings; while understanding the client’s thoughts and feelings, the nurse is able to maintain sufficient objectivity to allow the client
to achieve problem resolution with minimal assistance.

o​ With ​sympathy​ the nurse actually “shares” what the client is feeling, and experiences a need to alleviate distress; the nurse actually
feels what the client is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on
helping the client resolve the problem at hand.

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o​ Accurate empathetic perceptions on the part of the nurse assist the client to identify feelings that may have been suppressed or
denied.
o​ Positive emotions are generated as the client realizes that he or she is truly understood by another.
o​ As the feelings surface and are explored, the client learns aspects about self of which he or she may have been unaware.
Phases of a Therapeutic Nurse-Client Relationship
Psychiatric nurses use interpersonal relationship development as the primary intervention with clients in various psychiatric/mental
health settings.

TABLE 7–2 Phases of Relationship Development and Major Nursing Goals

PHASE GOALS
1. Pre-interaction Explore self-perceptions
2. Orientation (introductory) Establish trust
Formulate contract for intervention
3. Working Promote client change
4. Termination Evaluate goal attainment
Ensure therapeutic closure

Tasks of the relationship have been categorized into four phases:

1. The Pre Interaction Phase​: preparation for the first encounter with the client
● Obtaining available information about the client
● Initial assessment has begun
● Initial information allows the nurse to become aware of personal responses to knowledge about the client
● Examining one’s feelings, fears, and anxieties about working with a particular client

2. The Orientation (Introductory) Phase​: the nurse and the client become acquainted
● Creating an environment for the establishment of rapport and trust
● Establishing a contract for intervention that details the expectations and responsibilities of both nurse and client
● Gathering assessment information to build a strong client database
● Identifying the client’s strengths and limitations
● Formulating nursing diagnoses
● Setting goals that are mutually agreeable to the nurse and client
● Developing a plan of action that is realistic for meeting the established goals
● Exploring feelings of both the client and nurse in terms of the introductory phase

3. The Working Phase:​ the therapeutic work of the relationship is accomplished during this phase
● Maintaining the trust and rapport that was established during the orientation phase
● Promoting the client’s insight and perception of reality
● Problem-solving using the model presented earlier in this chapter
● Continuously evaluating progress toward goal attainment

Transference & Countertransference in the working phase:

● Transference-​ ​occurs when the client unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person
from his or her past
○ Triggered by something about the nurse’s appearance or personality characteristics that reminds the client of the
person
○ Transference can interfere with the therapeutic interaction when the feelings being expressed include anger and
hostility.
○ Anger toward the nurse can be manifested by uncooperativeness and resistance to the therapy.
○ Transference can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse;
the nurse is overvalued and the client forms unrealistic expectations of the nurse.

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 ○ When the nurse is unable to fulfill those expectations or meet the excessive dependency needs, the client becomes
angry and hostile

● Countertransference-​ refers to the nurse’s behavioral and emotional response to the client
○ These responses may be related to unresolved feelings toward significant others from the nurse’s past, or they may
be generated in response to transference feelings on the part of the client
○ Types of behaviors that cause countertransference:
■ The nurse over identifies with the client’s feelings, as they remind him or her of problems from the nurse’s
past or present.
■ The nurse and client develop a social or personal relationship
The nurse may be completely unaware or only minimally aware of the countertransference as it is occurring

4. ​The Termination Phase- m​ ain task involves bringing a therapeutic conclusion to the relationship
· Termination occurs when:
1. Progress has been made toward attainment of mutually set goals.
2. A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and client.
3. Feelings about termination of the relationship are recognized and explored. Both the nurse and client may experience feelings
of sadness and loss. The nurse should share his or her feelings with the client. Through these interactions, the client learns that it is
acceptable to have these kinds of feelings at a time of separation. With this knowledge, the client experiences growth during the
process of termination

Boundaries in the Nurse-Client Relationship

1. Material boundaries​- these are physical property that can be seen, such as fences that border land.
2. Social boundaries​- these are established within a culture and define how individuals are expected to behave in social
situations.
3. Personal boundaries-​ these are boundaries that individuals define for themselves. They include ​physical distance boundaries​,
or just how close individuals will allow others to invade their physical space; and ​emotional boundaries​, or how much individuals
choose to disclose of their most private and intimate selves to others.
4. Professional boundaries-​ these boundaries limit and outline expectations for appropriate professional relationships with
clients. They separate therapeutic behavior from any other behavior that, well intentioned or not, could lessen the benefit of care to
clients.
a. Self-disclosure- self-disclosure on the part of the nurse may be appropriate when it is judged that the information may
therapeutically benefit the client.
b. Gift-giving- individuals who are receiving care often feel indebted toward health-care providers. And, indeed, gift-giving
may be part of the therapeutic process for people who receive care
c. Touch- nursing by its very nature involves touching clients. Touching is required to perform the many therapeutic procedures
involved in the physical care of clients. Caring touch is the touching of clients when there is no physical need.
i. Caring touch often provides comfort or encouragement and, when it is used appropriately,
it can have a therapeutic effect on the client. However, certain vulnerable clients may misinterpret the meaning of touch.
d. Friendship or romantic association- when a nurse is acquainted with a client, the relationship must move from one of a
personal nature to professional. If the nurse is unable to accomplish this separation, he or she should withdraw from the nurse-client
relationship.

· Warning signs exist that indicate that professional boundaries of the nurse-client relationship may be in jeopardy
1. Favoring one client’s care over that of another
2. Keeping secrets with a client
3. Changing dress style for working with a particular client
4. Swapping client assignments to care for a particular client
5. Giving special attention or treatment to one client over others
6. Spending free time with a client
7. Frequently thinking about the client when away from work
8. Sharing personal information or work concerns with the client
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9. Receiving of gifts or continued contact/communication with the client after discharge
Chapter 8: Therapeutic Communication-K

● Hays and Larson describe the role of the nurse as providing the client with the opportunity to accomplish the following:
○ Identify and explore problems in relating to others
○ Discover healthy ways of meeting emotional needs
○ Experience a satisfying interpersonal relationship
● The therapeutic or nontherapeutic value of verbal/nonverbal communication techniques used with the client are the “tools” of
psychosocial intervention

What is Communication?
● Communication-​ an interactive process of transmitting information between two or more entities
● Interpersonal communication-​ a transaction between the sender and the receiver
● In the transactional model of communication, both participants simultaneously perceive each other, listen to each other, and
are mutually involved in creating meaning in a relationship

The Impact of Preexisting Conditions

● In all interpersonal transactions, both the sender and receiver bring certain preexisting conditions to the exchange that
influence both the intended message and the way in which it is interpreted.
○ Values, Attitudes & Beliefs
■ Learned ways of thinking; children generalize their values, attitudes, and beliefs based off of their parents
■ Prejudice is expressed verbally through negative stereotyping
■ Values are expressed symbolically in nature
● Example. Someone who values freedom will display an American flag on their property
○ Culture or Religion
■ Cultural mores, norms, ideas, and customs provide the basis for our way of thinking
■ Cultural values are learned and are different from society to society
■ Religious symbolic gestures include wearing a cross around the neck or hanging a crucifix on the wall
○ Social Status
■ Studies of nonverbal indicators of social status or power have suggested that high-status persons are
associated with gestures that communicate their higher power position.
● Example. They use less eye contact, more relaxed posture, louder voice pitch
○ Gender
■ Influences the manner in which people communicate
■ Gender signals-​ masculine or feminine; provide a basis for distinguishing between members of each gender
○ Age or Developmental Level
■ Age influences communication and is most evident in adolescence
● Example. Slang, acronyms
■ Developmental influences on communication may relate to physiological alterations.
● Example. American Sign language
○ Environment in Which the Transaction Takes Place
■ Territoriality-​ the innate tendency to own space; individuals lay claim to areas around them as their own
● This influences communication when an interaction takes place in the territory “owned” by one or
the other
● Interpersonal communication can be more successful if the interaction takes place in a “neutral”
territory
■ Density-​ refers to the number of people within a given environmental space
● Example. High density situations correlate with aggressive behaviors
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 ■Distance​- the means by which various cultures use space to communicate.
● Hall​ identified four kinds of spatial interaction
○ Intimate distance​- the closest distance that individuals will allow between themselves and
others; 0-18 inches
○ Personal distance​- reserved for interactions that are personal in nature, such as close
conversations with friends or colleagues; 18-40 inches
○ Social distance-​ conversations with strangers or acquaintances, such as at a cocktail party
or in a public building; 4-12 feet away
○ Public distance-​ this distance is considered public space, and communicants are free to
move about in it during the interaction; exceeds 12 feet
Nonverbal Communication
● 70-80% of all effective communication is nonverbal
○ Physical Appearance and Dress
■ Nonverbal stimuli that influence interpersonal responses and, under some conditions, they are the primary
determinants of such responses.
● Examples. Formal or casual dress, hair long or short, tattoos, masks, cosmetics, jewelry,
eyeglasses, badges
○ Body Movement and Posture
■ The way in which an individual positions his or her body communicates messages regarding self-esteem,
gender identity, status, and interpersonal warmth or coldness
■ Reece and Whitman identified response behaviors that were used to designate individuals as either “warm”
or “cold” persons.
● Warm gestures- shift of posture towards the other person, smile, eye contact, hands remain still
● Cold gestures- slumped posture, indirect eye contact, drumming fingers on the desk, no smile
○ Touch
■ Can elicit both negative and positive reactions, depending on the people involved and the circumstances of
the interaction; a very basic and primitive form of communication, and the appropriateness of its use is
culturally determined.
■ Functional Professional- i​ mpersonal and businesslike. It is used to accomplish a task.
● Example. A tailor measuring a customer for a suit or a physician examining a client.
■ Social Polite- ​impersonal, but it conveys an affirmation or acceptance of the other person.
● Example. A handshake
■ Friendship Warmth-​ indicates a strong liking for the other person, a feeling that he or she is a friend.
● Example. Laying one’s hand on the shoulder of another
■ Love Intimacy- c​ onveys an emotional attachment or attraction for another person.
● Example. Engaging in a strong, mutual embrace
■ Sexual Arousal-​ an expression of physical attraction only.
● Example. Touching another in the genital region
■ Contact cultures(France, Latin America, Italy) v. Noncontact cultures(Germany, US, Canada)
○ Facial Expressions
■ Primarily reveal an individual’s emotional states
■ Serve to complement and qualify other communication behaviors, and at times even take the place of verbal
messages
○ Eye Behavior
■ Eye contact indicates that the communication channel is open, and it is often the initiating factor in verbal
interaction between two people.
■ Eye behavior is regulated by social rules- dictate where, when, for how long, and at whom we can look
■ Eye contact rarely lasts longer than 3 seconds before one or both viewers experience a powerful urge to
glance away; breaking eye contact lowers stress levels.
○ Vocal Cues or Paralanguage
■ Paralanguage-​ the gestural component of the spoken word; consists of pitch, tone, and loudness of spoken
messages; the rate of speaking; expressively placed pauses; and emphasis assigned to certain words
■ Vocal emphasis can alter interpretation of the message
■ Verbal cue​s- play a major role in determining responses in human communication situations; How a
message is verbalized can be as important as what is verbalized.
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Therapeutic Communication Techniques
● Therapeutic Communication​- caregiver verbal and nonverbal techniques that focus on the care receiver’s needs and advance
the promotion of healing and change. Therapeutic communication encourages exploration of feelings and fosters
understanding of behavioral motivation. It is nonjudgmental, discourages defensiveness, and promotes trust
● Hays and Larson identified a number of techniques to assist the nurse in interacting more therapeutically with clients.
● Techniques start on pg. 140**
Nontherapeutic Communication Techniques
● Hays and Larson identified several approaches that are considered to be barriers to open communication between the nurse
and client.
● Techniques start on pg. 142**
Active Listening
● To listen actively is to be attentive to what the client is saying, both verbally and nonverbally.
● Nurse communicates acceptance and respect for the client, and trust is enhanced
○ S​- Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the
client has to say.
○ O-​ Observe an open posture. Posture is considered “open” when arms and legs remain uncrossed. This suggests
that the nurse is “open” to what the client has to say. With a “closed” position, the nurse can convey a somewhat
defensive stance, possibly invoking a similar response in the client.
○ L-​ Lean forward toward the client. This conveys to the client that you are involved in the interaction, interested in what
is being said, and making a sincere effort to be attentive
○ E-​ Establish eye contact. Eye contact, intermittently directed, is another behavior that conveys the nurse’s
involvement and willingness to listen to what the client has to say. The absence of eye contact or the constant shifting
of eye contact elsewhere in the environment gives the message that the nurse is not really interested in what is being
said.
○ R​- Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed
and comfortable with the client. Restlessness and fidgetiness communicate a lack of interest and may convey a
feeling of discomfort that is likely to be transferred to the client
Process Recordings
● Written reports of verbal interactions with clients.
● They are verbatim (to the extent that this is possible) accounts, written by the nurse or student as a tool for improving
interpersonal communication techniques.
● Includes the verbal and nonverbal communication of both nurse and client.
● The exercise provides a means for the nurse to analyze both the content and the pattern of the interaction.

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Feedback
● Method of communication for helping the client consider a modification of behavior.
● Gives information to the client about how they are perceived by others
● Should be presented in a manner that discourages defensiveness on the part of the client
● Feedback Criteria
○ Feedback is descriptive rather than evaluative and focuses on the behavior rather than on the client
○ Avoiding evaluative language reduces the need for the client to react defensively
○ Feedback should be specific rather than general
○ Feedback should be directed toward behavior that the client has the capacity to modify. To provide feedback about a
characteristic or situation that the client cannot change only provokes frustration.
○ Feedback should impart information rather than offer advice. Giving advice fosters dependence and may convey the
message to the client that he or she is not capable of making decisions and solving problems independently. It is the
client's right and privilege to be as self-sufficient as possible.
○ Feedback should be well timed. Feedback is most useful when given at the earliest appropriate opportunity
following the specific behavior.

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 Chapter 9: Nursing Process-K
The Nursing Process
● The nursing process consists of six steps and uses a problem-solving approach that has come to be accepted as nursing’s
scientific methodology; goal directed, with the objective being delivery of quality client care; dynamic, ongoing process that
continues for as long as the nurse and client interactions are directed toward the client’s physical and behavioral responses
● (Re) Assessment- Diagnosis- Outcome Identification- Planning- Implementation- Evaluation

● Assessment- ​A systematic, dynamic process by which the registered nurse, through interaction with the patient, family,
groups, communities, populations, and health-care providers, collects and analyzes data. Assessment may include the
following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental,
economic, and lifestyle
○ Information is gathered from which to establish a database for determining the best possible care for the client
■ Info is collected from interviews, observations, consultations, clients records, and physical assessments

● Nursing Diagnosis- ​clinical judgments about individual, family, or community experiences/responses to actual or potential
health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability
○ Data gathered during the assessment are analyzed

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 ○ Diagnoses and potential problem statements are formulated and prioritized
○ Diagnoses are congruent with available and accepted classification systems
● Outcomes Identification- ​end results that are measurable, desirable, and observable, and translate into observable behaviors
○ Derived from the diagnosis
○ They must be measurable and include a time estimate for attainment.
○ They must be realistic for the client’s capabilities, and are most effective when formulated cooperatively by the
interdisciplinary team members, the client, and significant others
○ The ​Nursing Outcomes Classification (NOC)​ is a comprehensive, standardized classification of patient/client
outcomes developed to evaluate the effects of nursing interventions
■ Each of the NOC outcomes has a label name, a definition, a list of indicators to evaluate client status in
relation to the outcome, and a five-point Likert scale to measure client statu
● Planning
○ For each diagnosis identified, the most appropriate interventions, based on current psychiatric/mental health nursing
practice and research, are selected.
○ Client education, referrals, and priorities for delivery of nursing care are included
○ Nursing Interventions Classification (NIC)​ is a comprehensive, standardized language describing treatments that
nurses perform in all settings and in all specialties
■ Each NIC intervention has a definition and a detailed set of activities that describe what a nurse does to
implement the intervention
● Implementation
○ Interventions selected during the planning stage are executed, taking into consideration the nurse’s level of practice,
education, and certification
○ Documentation occurs at this step

● Evaluation​- the process of determining the progress toward attainment of expected outcomes, including the effectiveness of
care
○ Nurse measures the success of the interventions in meeting the outcome criteria
○ The diagnoses, outcomes, and plan of care are reviewed and revised as needed

Why Nursing Diagnosis?

● The ANA defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems”
● The major purpose of NANDA-I is to “to develop, refine and promote terminology that accurately reflects nurses’ clinical
judgments

Nursing Case Management

● The concept of case management evolved with the advent of diagnosis-related groups (DRGs) and shorter hospital stays
● Clients are assigned a manager who negotiates with multiple providers to obtain diverse services
● This type of health-care delivery process serves to decrease fragmentation of care while striving to contain cost of services
● Case management in the acute care setting strives to organize client care through an episode of illness so that specific clinical
and financial outcomes are achieved within an allotted time frame.
● Managed care​ refers to a strategy employed by purchasers of health services who make determinations about various types of
services in order to maintain quality and control costs
○ Managed care may exist in virtually any setting in which medical providership is a part of the service; that is, in any
setting in which an organization (whether private or government-based) is responsible for payment of health-care
services for a group of people
■ Example. health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
● Types of clients who benefit from case management
○ The frail elderly
○ Individuals with developmental disabilities
○ Individuals with physical disabilities
○ Individuals with mental disabilities

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 ○ Individuals with long-term medically complex problems that require multifaceted, costly care
○ Individuals who are severely compromised by an acute episode of illness or an acute exacerbation of a severe and
persistent illness
● The ​case manager​ is responsible for negotiating with multiple health-care providers to obtain a variety of services for the
client

Critical Pathways of Care

● Critical pathways of care (CPCs) may be used as the tools for provision of care in a case management system.
● A ​critical pathway​ is a type of abbreviated plan of care that provides outcome-based guidelines for goal achievement within a
designated length of stay
● CPCs are intended to be used by the entire interdisciplinary team
● The nurse is responsible for ensuring that each of the assignments is being carried out

Concept Mapping
● Concept mapping​ is a diagrammatic teaching and learning strategy that allows students and faculty to visualize
interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments

Documentation of the Nursing Process

● Problem-Oriented Recording
○ Follows the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format.
i. S = Subjective data: Information gathered from what the client, family, or other source has said or reported.
ii. O = Objective data: Information gathered through direct observation by the person performing the
assessment; may include a physiological measurement such as blood pressure or a behavioral response such
as affect.
iii. A = Assessment: The nurse’s interpretation of the subjective and objective data.
iv. P = Plan: The actions or treatments to be carried out (may be omitted in daily charting if the plan is clearly
explained in the written nursing care plan and no changes are expected).
v. I = Intervention: Those nursing actions that were actually carried out.
vi. E = Evaluation of the problem following nursing intervention (some nursing interventions cannot be
evaluated immediately, so this section may be optional).
● Focus Charting
○ Focus Charting differs from POR in that the main perspective has been changed from “problem” to “focus,” and a
data, action, and response (DAR) format has replaced SOAPIE

○ Lampe​ suggested that a focus for documentation can be any of the following
i. Nursing Diagnosis
ii. Current client concern or behavior
iii. Significant change in the client status or behavior
iv. Significant event in the client’s therapy
v. **Focus ​cannot​ be a medical diagnosis

vi. D = Data: Information that supports the stated focus or describes pertinent observations about the client
vii. A = Action: Immediate or future nursing actions that address the focus, and evaluation of the present care
plan along with any changes required
viii. R = Response: Description of client’s responses to any part of the medical or nursing care
● The (A) PIE Method
○ A problem-oriented system, PIE charting uses accompanying flow sheets that are individualized by each institution
○ A = Assessment: A complete client assessment is conducted at the beginning of each shift. Results are documented
under this section in the progress notes. Some institutions elect instead to use a daily client assessment sheet

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 designed to meet specific needs of the unit. Explanation of any deviation from the norm is included in the progress
notes
○ P = Problem: A problem list, or list of nursing diagnoses, is an important part of the APIE method of charting. The
name or number of the problem being addressed is documented in this section.
○ I = Intervention: Nursing actions are performed, directed at resolution of the problem
○ E = Evaluation: Outcomes of the implemented interventions are documented, including an evaluation of client
responses to determine the effectiveness of nursing interventions and the presence or absence of progress toward
resolution of a problem.
● Electronic Documentation
○ EHRs have been shown to improve both the quality of client care and the efficiency of the health-care system
○ The IOM identified a set of eight core functions that EHR systems should perform in the delivery of safer, higher
quality, and more efficient health care
i. Health Information and Data​. EHRs would provide more rapid access to important patient information
thereby improving care providers’ ability to make sound clinical decisions in a timely manner.
ii. Results Management​. Computerized results of all types can be accessed more easily by the provider at the
time and place they are needed.
iii. Order Entry/Order Management​. Computer-based order entries improve workflow processes by
eliminating lost orders and ambiguities caused by illegible handwriting, generating related orders
automatically, monitoring for duplicate orders, and improving the speed with which orders are executed.
iv. Decision Support​. Computerized decision support systems enhance clinical performance for many aspects
of health care.
v. Electronic Communication and Connectivity​. Improved communication among care associates, such as
medicine, nursing, laboratory, pharmacy, and radiology, can enhance client safety and quality of care.
vi. Patient Support.​ Computer-based interactive client education, self-testing, and self-monitoring have been
shown to improve control of chronic illnesses
vii. Administrative Processes.​ Electronic scheduling systems increase the efficiency of healthcare
organizations and provide more timely service to patients.
viii. Reporting and Population Health Management.​ Health-care organizations are required to report
health-care data to government and private sectors for patient safety and public health.

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 Chapter 16: Managing Aggression Behavior
Mara

Anger becomes a problem when it is not expressed and when it is expressed aggressively, but it is a normal human emotion that can
provide an individual with a positive force to solve problems

ANGER AND AGGRESSION, DEFINED

● Anger​: an emotional state that varies in intensity from mild irritation to intense fury and rage. It is accompanied by
physiological and biological chances, such as increases in HR, BP, and levels of the hormones epinephrine and
norepinephrine.
● Anger and aggression are significantly different
● The expression of anger is learned
● The expression of anger can come under personal control
● Anger creates a state or preparedness by arousing the sympathetic nervous system. The activation of this system results in
increased HR and BP, increased secretion of epinephrine and increased levels of serum glucose
● When anger goes unresolved, this physiological arousal can be the predisposing factor to a number of health problems .
● Aggression​: a behavior intended to threaten or injure the victim’s security or self-esteem. It means “to go against,” “to
assault,” or “to attack.” It is a response that aims at inflicting pain or injury on objects or persons. Whether the damage is
caused by words, fists, or weapons the behavior is virtually always designed to punish. It is frequently accompanied by
bitterness, meanness, and ridicule. An aggressive person is often vengeful.
● Aggression is a almost always a negative function or destructive use of anger.

PREDISPOSING FACTORS TO ANGER AND AGGRESSION

Modeling
● One of the strongest forms of learning
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 ● How parents or significant others express anger becomes the child's method of anger expression
● Whether role modeling is positive or negative depends on the behavior of the models
● The American Academy of Pediatrics has suggested that monitoring what children view and regulation of violence in the
media re necessary to prevent this type of violent modeling.

Operant Conditioning
● Operant conditioning occurs when a specific behavior is reinforced.
● I.e. Positive reinforcement: when a child wants something and has been told “no” by a parent, they might have a temper
tantrum. If, when the temper tantrum begins, the parent lets the child have what is wanted, the anger has been positively
reinforced (or rewarded).
● I.e. Negative reinforcement: a mother asks her child to pick up her toys and the child becomes angry and has a temper
tantrum, If, when the temper tantrum begins, the mother things “Oh it's not worth all this!” and picks up the toys herself; the
anger has been negatively reinforced the child was rewarded by not having to pick up her toys)

Neurophysiological Disorders
● Some research has implicated epilepsy of temporal and frontal lobe origin in episodic aggression and violent behavior (these
patients usually respond to anticonvulsant meds)
● Tumors in the brain, particularly in the areas of the limbic system and the temporal lobes; trauma to the brain, resulting in
cerebral changes; and diseases, such as encephalitis, have all been implicated in the predisposition to aggression and violent
behavior.

Biochemical Factors
● Violent behaviors may be associated with hormonal dysfunction caused by Cushing’s disease or hyperthyroidism
● Some research indicates that various neurotransmitters may play a role in the facilitation and inhibition of aggressive
impulses.

Socioeconomic Factors
● High rates of violence exist within the subculture of poverty in the US. This has been attributed to lack of resources, breakup
of families, alienation, discrimination and frustration.

Environmental Factors
● Physical crowding may be related to violence through increased contact and decreased defensible space.
● A relationship between heat and aggression also has been indicated
● A number of studies have found a strong link between use of alcohol and violent behavior.
● Other substances, including cocaine, amphetamines, hallucinogens, and anabolic steroids, have also been associated with
violent behaviors.

THE NURSING PROCESS

● Anger Management​: The use of various techniques and strategies to control responses to anger-provoking situations. The
goal of anger management is to reduce both the emotional feelings and the physiological arousal that anger engenders.

Assessment
● Best intervention is prevention
● Anger
○ Can be associated with a number of typical behaviors, including (but not limited to):
■ Frowning, facial expression
■ Clenched fists
■ Low-pitched verbalizations forced through clenched teeth
■ Yelling and shouting
■ Intense eye contact or avoidance of eye contact
■ Easily offended

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 ■ Defensive response to criticism
■ Passive-aggressive behaviors
■ Emotional overcontrol with flushing of the face
■ Intense discomfort continuous state of tension
○ Anger has been IDed as a stage in the grieving process. Individuals who become fixed in this stage may become
depressed
○ Because of the negative connotation to the word anger, some clients will not acknowledge that what they are feeling
is anger. These individuals need assistance to recognize their true feelings and to understand that anger is acceptable.
● Aggression
○ Behaviors can be classified as mild, moderate, severe, or extreme
○ Aggression has the following characteristics
■ Pacing, restlessness
■ Tense facial expressions and body language
■ Verbal or physical threats
■ Loud voice, shouting, use of obscenities, argumentative
■ Threats of homicide or suicide
■ Increase in agitation, with overreaction to environmental stimuli
■ Panic anxiety, leading to misinterpretation of environment
■ Disturbed thought processes; suspiciousness
■ Angry mood, often disproportionate to the situation
○ In contrast to anger, aggression is almost always goal directed and has the aim of harm to a specific person or object
○ Intent ​is a requisite in the definition of aggression. It refers to behavior that is intended to inflict harm or destruction.
● Assessing Risk Factors
○ The individual who becomes violent usually feels an underlying helplessness.
○ Three factors have been IDed as important considerations in assessing for potential violence include the following:
■ Past History of violence
■ Client diagnosis
■ Current behavior
○ Past hx of violence is widely recognized as a major risk factor for violence in a treatment setting
○ Diagnoses that have a strong association with violent behavior are schizophrenia, major depression, bipolar disorder,
and substance use disorders
○ Neurocognitive disorders and antisocial, borderline, and intermittent explosive personality disorders have also been
associated with a risk for violent behavior.
○ Prodromal Syndrome​: is characterized by anxiety and tension, verbal abuse and profanity, and increasing
hyperactivity.
■ Behaviors associated w/ this prodromal stage include rigid posture; clenched fists and jaws; grim, defiant
affect; talking in a rapid, raised voice; arguing and demanding; using profanity and threatening
verbalizations; agitation and pacing; and pounding and slamming
■ Most assaultive behavior is preceded by a period of increasing hyperactivity
○ Broset Violence Checklist is a quick, simple, and reliable checklist that can be used as a risk assessment for potential
violence (63% accurate).

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Care Plan for the Individual who Expresses Anger Inappropriately (pp. 265-270)

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 Chapter 20: Complimentary Treatment and ECT AMY

Electroconvulsive therapy (ECT) is controversial, but has been used continuously for more than 50 years
● Electroconvulsive Therapy, Defined
○ ECT: the induction of a grand mal (generalized) seizure through the application of electrical current to the brain
○ Stimulus applied through electrodes that are placed bilaterally in the frontotemporal region or unilaterally on the
same side as the dominant hand
■ Controversy over placement exists
○ Another point of controversy is the amount of electrical stimulus applied
■ Dose based on client’s seizure threshold, which is highly variable among individuals
○ Duration of seizure should be at least 15-25 seconds
○ Movements are minimal because muscle relaxant administered before
○ Tonic phase
■ 10-15 seconds
■ Identified by a rigid plantar extension of the feet
○ Clonic phase
■ Characterized by rhythmic movements of the muscles that decrease in frequency and finally disappear
○ Most patient require an average of 6-12 treatments, but can go up to 20 treatments
■ Every other day treatments, three times per week
● Historical Perspectives
○ First ECT treatment in April 1938 by Ugo Cerletti and Lucio Bini in Rome
○ Other somatic therapies tried before this though
■ Insulin coma therapy
● Introduced by German psychiatrist Manfred Sakel in 1933
● Used for schizophrenia
● Insulin injection treatments induced a hypoglycemic coma which Sakel claimed was effective in
alleviating schizophrenic symptoms
○ Vigorous medical and nursing interventions required during coma
○ Some fatalities occurred when clients failed to respond to efforts to stop the coma
● Has been discontinued
■ Pharmacoconvulsive therapy
● Introduced in Budapest in 1934 by Ladislas Meduna
● Induced convulsions with intramuscular injections of camphor in oil for schizophrenics
○ Treatment based on clinical observations and his theory that there was a biological
antagonism between schizophrenia and epilepsy
○ By inducing seizures, he hoped to reduce schizophrenia symptoms
● Discovered that camphor was unreliable so he began using pentylenetetrazol (Metrazol)
○ Some symptoms were reduced
○ Was most widely used for producing seizures in psychotic patients until ECT came in
1938
● Brief resurgence of pharmacoconvulsive therapy in 1950’s when flurothyl (Indoklon), potent
inhalant convulsant, was introduced for those who were unwilling to consent to ECT
● No longer used
○ ECT accepted from 1940-1960, followed by 20 year period where it was objectionable
○ Second acceptance wave in 1980 and has been increasing
■ Non Acceptability in 1960 coincided with intro of tricyclic and MAOI antidepressant drugs, and ended with
realization that replacement of ECT did not materialize

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 ○ Typical ECT client white, female, middle aged and from middle to upper income background
○ Many public hospitals don’t offer service
● Indications
○ Major Depression
■ Shown to be effective
■ Particularly in clients who also experience psychotic symptoms and those with psychomotor retardation
and neurovegetative changes such as disturbances in sleep, appetite, and energy
■ Symptoms associated with major depressive disorder, major depressive disorder with psychotic or
melancholic symptoms and bipolar disorder depression
■ ECT not often used as treatment of choice for depressive disorders, but is considered after trial of therapy
with antidepressant meds has been ineffective
○ Mania
■ ECT indicated in acute manic episodes of bipolar disorder
■ Rarely used presently because it is superceded by antipsychotic drugs and/or lithium, but ECT has been
shown to be effective when medications don’t work
○ Schizophrenia
■ ECT can induce remission in some clients with acute schizophrenia, particularly if accompanied by
catatonic or affective (depression or mania) symptomatology
■ ECT not valuable with chronic schizophrenic illness
○ Other Conditions
■ Tried with clients with neuroses, obsessive-compulsive disorders, and personality disorders
■ Little evidence exists to support the treatment with these conditions
● Contraindications
○ Only absolute contraindication is increased intracranial pressure (from brain tumor, recent cardiovascular accident,
or other cerebrovascular lesion)
■ ECT associated with physiological rise in cerebrospinal fluid pressure during treatment which results in
increased intracranial pressure that could lead to brainstem herniation
○ Various other conditions that can be high risk are largely cardiovascular in nature
■ Myocardial infarction or cerebrovascular accident within preceding 3-6 months
■ Aortic or cerebral aneurysm
■ Severe underlying hypertension
■ Congestive heart failure
■ Clients with cardiovascular problems are at risk
● Initial vagal response results in sinus bradycardia and drop in BP
● Followed immediately by tachycardia and hypertensive response
■ Severe osteoporosis
■ Acute and chronic pulmonary disorders
■ High risk or complicated pregnancy
● Mechanism of Action
○ Exact mechanism unknown
○ Several theories exist, but biochemical theory has most credibility
■ Biochemical theory
● Electric stimulation results in significant increases in the circulating levels of several
neurotransmitters like serotonin, norepinephrine, and dopamine which are the same biogenic
amines affected by antidepressant drugs
● Additional evidence shows that ECT may also result in increases of glutamate and
gamma-aminobutyric acid
○ One study revealed that therapeutic response may be related to the modulation of white matter microstructure in
pathways connecting frontal and limbic areas, which are altered in major depression
● Side Effects
○ Most common side effects are temporary memory loss and confusion
■ Some say these represent irreversible brain damage
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 ■ Black and Andreasen
● ECT disrupts new memories that have not been stored in long term memory. ECT can cause
anterograde and retrograde amnesia that is most dense around treatment time. Anterograde clears
out quickly, but retrograde can extend back to months before treatment. Memory loss could be
from ECT or ongoing depressive symptoms
○ Controversy between unilateral or bilateral ECT
■ Studies show unilateral placement decreases amount of memory disturbance, but often requires a higher
stimulus dose or greater number of treatments
● Risks Associated with Electroconvulsive Therapy
○ Mortality
■ Mortality rate from ECT is 2 per 100,000 treatments
■ Major cause is from cardiovascular complications (acute myocardial infarction or cerebrovascular accident)
usually in individuals with previous compromised cardiovascular status
■ Assess and manage prior to treatment
○ Permanent Memory Loss
■ Some clients report retrograde amnesia extending back to months before treatment-gaps in specific
personal memories
■ Sackheim reported on longitudinal study of clinical and cognitive outcomes in patients with major
depression treated with ECT
● Evaluated shortly after ECT and 6 months later
● Cognitive deficits at 6 month interval were directly related to type of electrode placement and
electrical waveform used
○ Bilateral electrodes resulted in more severe and persistent retrograde amnesia than
unilateral placement
● Extent of amnesia directly related to number of ECT treatments received
● Stimulation produced by sine wave (continuous) current resulted in greater short and long term
deficits than those produced by short pulse wave (intermittent) current
■ Black and Andreasen
● Suggest all clients receiving ECT be informed of possibility for some permanent memory loss
○ Brain Damage
■ Critics say ECT always results in brain damage
● Evidence based largely on animal studied in which subjects receive excessive electrical dosages
and the seizures were unmodified by muscle paralysis and oxygenation
■ No evidence to substantiate that ECT produces any permanent changes in brain structure or functioning
● The Role of the Nurse in Electroconvulsive Therapy
○ Nurses teach and prep for ECT; they provide support before, during and after ECT to client and family; assist
medical professionals who conduct therapy
○ Assessment
■ Complete physical exam
● Cardiovascular
● Pulmonary status
● Lab blood and urine
● Skeletal history
● Xray assessment
● mood
■ Consent
○ Diagnosis/Outcome Identification
■ Select appropriate nursing diagnosis
■ Nursing diagnoses found on table 20-1 on page 314
○ Planning/Implementation
■ ECT usually performed in morning
■ NPO for 6-8 hours
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 ■ Team is usually psychiatrist, anesthesiologist, two or more nurses
■ Interventions
● Consent
● Recent lab reports available
● Vital signs, raise side rails
● Pretreatment medication
○ Usual order is atropine sulfate or glycopyrrolate (Robinul) IM
○ These decrease secretions and counteract effects of vagal stimulation (bradycardia)
■ Client is supine
● IV short acting anesthesia usually methohexital and propofol
● Muscle relaxant usually succinylcholine chloride IV
■ Client is oxygenated
■ Maybe BP cuff on lower leg
■ airway/bite block
○ Evaluation
■ List on page 315

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 Chapter 32: Personality Disorders ​AMY

● Personality​: The totality of emotional and behavioral characteristics that are particular to a specific person and that remain
somewhat stable and predictable over time (From Greek persona, means the “real” person)
○ Personality traits: characteristics with which an individual is born or develops early in life; influence the way in
which person perceives and relates to environment and are quite stable over time
○ Personality disorders occur when traits become rigid and inflexible & contribute to maladaptive patterns of behavior
or impairment in functioning.
■ All people exhibit some behaviors of disorders at some point, but only when there is significant functional
impairment occurs is it considered a disorder
○ Personality development occurs in response to multiple biological and psychological influences (ex: hereditary,
temperament, experiential learning, social interaction)
■ Many say it occurs in orderly, stepwise fashion, but the stages overlap as maturation occurs at different
rates
● Sullivan, Erikson, Mahler

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 ○ Individuals with personality disorders not often treated in acute care, but many patients with other psychiatric and
medical diagnoses manifest symptoms of personality disorders
■ Nurses in psych settings will likely see borderline and antisocial personality characteristics
● Borderline personality disorder: unstable, hospitalization required because of multiple attempts of
self injury
● Antisocial personality disorder: enter psych unit as result of judicially ordered evaluation
○ Historical Aspects
■ Hippocrates: all disease stemmed from an excess or imbalance among four bodily humors (yellow bile,
black bile, blood, phlegm)
● Four personality styles result from excesses in the four humors
○ Irritable and hostile choleric (yellow bile)
○ Pessimistic melancholic (black bile)
○ Overly optimistic and extraverted sanguine (blood)
○ Apathetic phlegmatic (phlegm)
● Personality disorders first recognized by medical profession to have own special concern in 1801
when they recognized that individuals can behave irrationally even when powers of intellect are
intact
○ Termed moral insanity
● DSM-5 has ten specific types of personality disorders
● APA has proposed complex diagnostic system to identify impairments in personality functioning
specifically related to the dimensions of ​self​ and ​interpersonal relations​ and to personality ​trait
domains and​ ​facets
● Current diagnostic system classifies personality disorders into three clusters
○ Cluster A: behaviors described as odd or eccentric
■ Paranoid personality disorder
■ Schizoid personality disorder
■ Schizotypal personality disorder
○ Cluster B: behaviors described as dramatic, emotional or erratic
■ Antisocial personality disorder
■ Borderline personality disorder
■ Histrionic personality disorder
■ Narcissistic personality disorder
○ Cluster C: behaviors described as anxious or fearful
■ Avoidant personality disorder
■ Dependent personality disorder
■ Obsessive-compulsive personality disorder
○ Types of Personality Disorders
■ Paranoid personality disorder
■ Schizoid personality disorder
■ Schizotypal personality disorder
■ Antisocial personality disorder
■ Borderline personality disorder
■ Histrionic personality disorder
■ Narcissistic personality disorder
■ Avoidant personality disorder
■ Dependent personality disorder
■ Obsessive-compulsive personality disorder

1. Paranoid Personality Disorder

● Definition and Epidemiological Statistics
○ “Pervasive, persistent, and inappropriate mistrust of others. They are suspicious of others’ motives and assume that
others intent to exploit, harm, or deceive them”
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 ○ Prevalence of 1-4% of population; often only diagnosed when individual seeks treatment for a mood or anxiety
disorder
○ More commonly diagnosed in men
● Clinical Picture
○ Constantly on guard, hypervigilant, ready for any real or imagined threat; appear tense and irritable; have developed
a hard exterior and become immune or insensitive to the feelings of others; avoid interaction with other people,
unless forced to relinquish some of own power; feel that others are there to take advantage of them
○ Extremely over sensitive and tend to misinterpret even little cues within the environment, magnifying and distorting
them into thoughts of trickery and deception; they trust no one so constantly testing the honesty of others; they have
an intimidating manner that provokes exasperation and anger in almost everyone they come in contact with
○ They maintain self-esteem by attributing their shortcomings to others; don’t accept responsibility for their own
behaviors and feelings and project responsibility onto others; envious and hostile toward others who are successful
and believe they are unsuccessful because they are treated unfairly; extremely vulnerable and constantly on
defensive; real or imagined threats can release hostility and anger fueled by past animosities; they desire reprisal and
vindication so a possible loss of control can result in aggression and violence (outbursts usually brief and external
control soon regained, behavior is rationalized, and defense reconstructed)

● Predisposing Factors
○ Possible hereditary link
○ Higher incidence among relatives clients with schizophrenia
○ Psychosocially, they may have been subjected to parental antagonism and harassment; serve as scapegoats for
displaced parental aggression (no hope of affection and approval)
■ Learn to perceive world as harsh and unkind
■ “Chip on the shoulder” attitude
■ Learn to attack first because of humiliation and betrayal

2. Schizoid Personality Disorder

● Definition and Epidemiological Statistics
○ Characterized primarily by profound defect in ability to form personal relationships or to respond to others in a
meaningful way
○ Display lifelong pattern of social withdrawal; discomfort with human interaction is noticeable
○ Prevalence in general population is estimated to be between 3-7.5%
■ Many are never observed in clinical setting
■ Gender ratio unknown, but diagnosed more in men
● Clinical Picture
○ Appear cold, aloof, indifferent to others
○ Prefer to work in isolation and are unsociable; little need or desire for emotional ties
○ Able to invest enormous affective energy in intellectual pursuits
○ In presence of others they are shy, anxious or uneasy; inappropriately serious about everything and have difficulty
acting in a lighthearted manner
○ Behavior and conversation show little to no spontaneity

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 ○ Usually unable to experience pleasure; affect bland and constricted

● Predisposing Factors
○ Role of hereditary unclear, but introversion appears to be a highly inheritable characteristic
○ Psychosocially, schizoid personality disorder probably influenced by early interactional patterns that the person
found to be cold and unsatisfying
■ Childhoods often described as bleak, cold, notably lacking empathy and nurturing
● Child with this parenting may get schizoid personality disorder if the child possesses a
temperamental disposition that is shy, anxious, and introverted

3. Schizotypal Personality Disorders

● Definition and Epidemiological Statistics
○ Once were “latent schizophrenics”
○ Behavior is odd and eccentric, but does not decompensate to level of schizophrenia; this is more graver form of the
less severe schizoid personality pattern
○ Schizotypal personality disorder has a prevalence of 1-2%
● Clinical Picture
○ Aloof and isolated and behave in bland and apathetic manner
○ Magical thinking, ideas of reference, illusions, depersonalization
■ Ex: superstitiousness, belief in clairvoyance, telepathy or 6th sense, “others can feel my feelings”
○ Speech can be bizarre and people often cannot orient their thoughts logically and become lost in personal
irrelevancies and in tangential asides that seem vague, digressive, and not pertinent to the topic at hand (further
alienates them from others)
○ Under stress, people decompensate and demonstrate psychotic symptoms: delusional thoughts, hallucinations,
bizarre behavior, usually brief in duration though; often talk or gesture to themselves (“living in their own world”);
affect bland or inappropriate (laugh at own problems or sad situations)

● Predisposing Factors

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 ○ More common among first degree biological relatives of people with schizophrenia than among the general
population
■ Considered a part of the genetic spectrum of schizophrenia
○ Other biogenic factors that may contribute: anatomical deficits or neurochemical dysfunctions resulting in
diminished activation, minimal pleasure-pain sensibilities, impaired cognitive functions
■ Support close link between schizotypal pd and schizophrenia
○ Early family dynamics may be characterized by indifference, impassivity, or formality, leading to pattern of
discomfort with personal affection and closeness
■ Early on, affective deficits made them unattractive and unrewarding social companions
■ Likely shunned, overlooked, rejected, humiliated by others leading to feelings of low self-esteem and
marked distrust of interpersonal relations
■ They fail at coping so begin to withdraw and reduce contact with individuals and situations that evoked
sadness and humiliation
■ Inner world more rewarding than reality

4. Antisocial Personality Disorder

● Definition and Epidemiological Statistics
○ Antisocial personality disorder is a pattern of socially irresponsible, exploitative, and guiltless behavior that reflects
a general disregard for the rights of others
■ Individuals exploit and manipulate others for personal gain and are unconcerned with obeying the law
■ Difficulty sustaining consistent employment and in developing stable relationships.
○ Prevalence in the US estimates 2-4% in men and about 1% in women
○ More common among lower socioeconomic classes, particularly among highly mobile inhabitants of impoverished
urban areas
○ This disorder is identified as ​dissocial personality disorder​ in the ICD-10
○ Was categorized as a sociopathic or psychopathic reaction that was symptomatic of several underlying personality
disorders
○ Seldom seen in clinical settings, encountered more in prisons, jails or rehab centers
● Clinical Picture
○ A pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights
of others
■ Exploit others for personal gain
■ Unconcerned with obeying the law
○ Difficulty sustaining consistent employment and in developing stable relationships
○ Appear cold and callous, intimidating others with brusque and belligerent manner
○ Can be argumentative and at times cruel and malicious; lack warmth and compassion and are suspicious of the
qualities in others
○ Low tolerance for frustration, act impetuously and are unable to delay gratification; restless and easily bored; take
lots of chances and seek thrill
○ Act cheerful, gracious and charming when things go their way; furious and vindictive when it’s not their way
■ First they demean and dominate
■ Show contempt for the weak and underprivileged
○ See themselves as victims, using projection as primary ego defense mechanism
■ Don’t accept responsibility for behavior
○ Only trust themselves
○ One of the most distinctive characteristics is they ignore conventional authority and rules

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 ● Predisposing Factors
○ Biological Influences
■ More common among first degree biological relatives of those with the disorder
■ Twin studies implicated role of genetics
■ Higher number of relatives with disorder or alcoholism for patients with disorder
■ Children more likely to have disorder if parents have disorder, even if separated at birth
■ Characteristics associated with temperament may be significant
● Temper tantrums from infancy and become furious when waiting for bottles or diaper changes
● Develop bullying attitude as they mature and are undaunted by punishment and unmanageable
● Daring and foolhardy in willingness to chance physical harm, unaffected by pain
■ Predisposing factors may be ADHD and conduct disorder
■ No basic pathological process has been identified
■ Bienenfeld
● Serotonin dysregulation in septohippocampal system
● Abnormalities in prefrontal brain systems and reduced autonomic activity
○ Family Dynamics
■ Frequently arises from chaotic home environment
■ Parental deprivation during first 5 years of life appear to be a critical predisposing factor in development of
antisocial personality disorder
● Separation from parental delinquency appears to be more highly correlated with disorder than
parental loss from other causes
● Presence or intermittent appearance of inconsistent impulsive parents, not the loss of a consistent
parents, is environmentally​ most​ damaging
■ Studies show that severe physical abuse in childhood is common
● Abuse provides model for behavior
● Abuse results in injury to child’s central nervous system, impairing function
● Abuse endangers rage in child, which is displaced onto others
■ The following can influence the predisposition to the disorder:
● Absence of parental discipline
● Extreme poverty
● Removal from home
● Growing up without parents of both genders
● Erratic and inconsistent methods of discipline
● Being “rescued” each time they are in trouble
● Maternal deprivation
● Clinical Pearl**Do not attempt to coax or convince the client to do the “right thing”. Do not use the words “you should or
shouldn’t…” , instead, use the words “you will be expected to…”

5. Borderline Personality Disorder

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● Definition and Epidemiological Statistics
○ Characterized by a pattern of intense and chaotic relationships, with affective instability and fluctuation attitudes
toward other people
■ Impulsive, directly and indirectly self-destructive, lack a clear sense of identity
○ Prevalence estimated at 1-2%
■ More common in women than men, with female ratios to men at 4:1
○ Identified as ​emotionally unstable personality disorder​ in the ICD-10
● Clinical Picture
○ These clients are borderline between neuroses or psychoses
○ Other titles include ambulatory schizophrenia, pseudoneurotic schizophrenia, emotionally unstable personality
○ Always seem to be in state of crisis; affect is one of extreme intensity and behavior reflects frequent changeability
○ Often exhibit a single dominant tone like depression, which may give way periodically to anxious agitation or anger
outbursts
○ Chronic Depression
■ Very common (many were diagnosed with depression first)
■ Occurs in response to feelings of abandonment by mother
■ Underlying depression is sense of rage that is sporadically turned inward on self and externally on
environment
■ Seldom do they know true source of feelings
○ Inability to be alone
■ Because of chronic fear of abandonment, they have little tolerance for being alone
■ Prefer frantic search for companionship, no matter how unsatisfactory, so being alone
● Patterns of Interaction
○ Clinging and Distancing
■ Clinging: exhibit helpless, dependent, even childlike behaviors; over idealize a single individual with
whom they want to spend all of their time with, express a frequent need to talk, they seek constant
reassurance
● May act out or self-mutilate when then cannot be with chosen person
■ Distancing: hostility, anger, devaluation of others, arises from a feeling of discomfort with closeness
● Also occurs in response to separation, confrontations, or attempts to limit certain behaviors
● Manifested by discrediting or undermining their strengths and personal significance
○ Splitting
■ This is a primitive ego defense mechanism that is common
■ Arises from lack of achievement of object constancy and is manifested by an inability to integrate and
accept both positive and negative feelings
● People and life situations are either all good or all bad
○ Manipulation
■ In efforts to prevent separation, they become master manipulators
■ Any behavior is acceptable to achieve the desired result which is relief from separation anxiety
● Playing one person against another is common to rid of abandonment fears
○ Self-Destructive Behaviors
■ Repetitive, self-mutilative behaviors are classic manifestations
■ Can be fatal, but most commonly they are manipulative gestures designed to elicit a rescue response
■ Suicide attempts common and usually result from feelings of abandonment (always have safety plan so
they will be found)
■ Cutting, scratching, burning also examples
■ One hypothesis for pain suggests they may have higher levels of endorphins in body which increases their
pain threshold
■ Another theory relates to the personal identity disturbance
● Since many injury behaviors take place when individual is in state of depersonalization or
derealization, he or she does not initially feel the pain
● Continue to hurt themselves until they feel pain to counteract the unreality feelings
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 ● Pain may validate their existence
○ Impulsivity
■ Poor impulse control based on primary process functioning
● Substance abuse, gambling, promiscuity, reckless driving, binging and purging

● Predisposing Factors
○ Biological Influences
■ Biochemical
● Possible serotonergic defect
■ Genetic
○ Psychosocial Influences
■ Childhood Trauma
● Families had chaotic environments-trauma, neglect, separation, secual and physical abuse, serious
parental psychopatholigy like substance abuse of antisocial personality disorder
● 70% of patients report history or sexual or physical abuse
● PTSD linked too
○ Developmental Factors
■ Theory of Object Relations (Mahler): infant passes through six phases from birth to 36 months which is
when the sense of separateness from parent is finally established
● Phase 1 (Birth to 1 month), Autistic Phase
○ Baby spends most time in half-waking and half-sleeping state
○ Main goal is fulfillment of needs for survival and comfort
● Phase 2 (1-5 months), Symbiotic Phase
○ Psychic fusion of mother and child
○ Child views self as extension of parent, but there’s a developing awareness of external
sources of needs fulfillment
● Phase 3 (5-10 months), Differentiation Phase
○ Child begins to recognize that there is a separateness between self and parent
● Phase 4 (10-16 months), Practicing Phase
○ Characterized by increased locomotor functioning and ability to explore the environment
independently
○ Sense of separateness is increased
● Phase 5 (16-24 months), Rapprochement Phase
○ Awareness of separateness is acute and is frightening to the child, who wants to regain
some lost closeness but not return to symbiosis
○ Child wants mother for emotional refueling and maintaining feelings of security
● Phase 6 (24-36 months), On the way to object constancy phase
○ Child completes individuation process and learns to relate to objects in effective, constant
manner

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 ○ Sense of separateness is established, child is able to internalize a sustained image of the
loved object or person when out of sight
○ Separation anxiety resolved
■ Individual becomes fixed in rapprochement phase in borderline personality disorder
● Child shows increasing separation and autonomy
● Mother feels threatened by child’s increasing independence
● The mother withdraws the emotional support or refueling that is so vitally needed during this
phase and instead rewards clinging, dependent behaviors and punishes independent behaviors
● The child begins to satisfy the mother's needs and suffers from internal conflict and experiences
fear of abandonment
● Internalized rage manifests itself as depression in the adult
● Clinical Pearl** Recognize when the client is playing one staff member against another. Remember that splitting is the
primary defense mechanism of these individuals, and the impressions they have of others as either “good” or “bad” are a
manifestation of the defense. Do not listen as the client tries to degrade other staff members. Suggest that the client discuss
the problem directly with the staff person involved

6. Histrionic Personality Disorder

● Definition and Epidemiological Statistics
○ Characterized by colorful, dramatic, extroverted behavior in excitable, emotional people
○ Difficulty maintaining long lasting relationships, but require constant affirmation of approval and acceptance from
others
○ Prevalence thought to be 2-3% and more common in women than men
● Clinical Picture
○ Self-dramatizing, attention seeking, overly gregarious, seductive
○ Use manipulative and exhibitionistic behaviors in their demands to be the center of attention
○ Demonstrate (in mild pathological form) what our society tends to foster and admire in its members: well liked,
successful, popular, extroverted, attractive and sociable
■ Beneath surface is driven quality-all consuming need for approval and a desperate striving to be
conspicuous and to evoke affection or attract attention
■ Failing at this results in feelings of dejection and anxiety
○ Highly distractible and flighty by nature
○ Difficulty paying attention to detail
○ Can portray themselves as carefree and sophisticated on one hand and inhibited and naive on other
○ Highly suggestible, impressionable, and easily influenced by others, and strongly dependent
○ Interpersonal relationships are fleeting and superficial; lacks ability to provide another with genuinely sustained
affection (failed through life to develop the richness of inner feelings)
○ Somatic complaints can be common, and fleeting episodes of psychosis may occur during stress

● Predisposing Factors
○ Neurobiological correlates have been proposed
■ Characteristics of enhanced sensitivity and reactivity to environmental stimuli to heightened noradrenergic
activity in the individual
■ Impulsivity may be associated with decreased serotonergic activity

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 ○ Heredity may be a factor because disorder is apparently more common among first degree biological relatives of
people with disorder than general population
■ It’s suggested that behavioral characteristics of histrionic personality disorder may be associated with a
biogenetically determined temperament; histrionic personality disorder arises out of an “extreme variation
of temperamental disposition”
○ Psychosocially, learning experiences may contribute to development disorder
■ Child may have learned that positive reinforcement was contingent on ability to perform parentally
approved and admired behaviors
■ Likely that child rarely received either positive or negative feedback
■ Parental acceptance and approval came inconsistently and only when behaviors met parental expectations
■ “Children experience frustration in getting attention and exaggerate behaviors basic to their gender
stereotype to secure compliments and affection; enter adolescence with a thirst for attention and love”

7. Narcissistic Personality Disorder

● Definition and Epidemiological Statistics
○ Exaggerated sense of self-worth
○ Lack empathy, hypersensitive to the evaluation of others
○ Believe they have inalienable right to receive special consideration and that their desire is sufficient justification for
possessing whatever they seek
○ Concept of narcissism has roots in 19th century; viewed by early psychoanalysts as normal phase of psychosexual
development
○ Prevalence is estimated to be about 6% and diagnosed more in men than women
● Clinical Picture
○ Appear to lack humility, being overly self-centered and exploiting others to fulfill own desires
○ Often don’t conceive of their behavior as being inappropriate or objectionable
○ Believe they are entitled to special rights and privileges; “superior”
○ Although grounded in grandiose distortions of reality, their mood is usually optimistic, relaxed, cheerful and
carefree
■ Can easily change though, because of their fragile self-esteem
■ If they don’t meet self-expectations, don’t receive the positive feedback they expect, or draw criticism from
others, they can respond with rage, shame, humiliation, or dejection
■ May turn inward and fantasize rationalizations that convince them of their stature and perfection
○ They exploit others for self-gratification and results in impaired interpersonal relationships
○ In selecting a mate, they frequently choose a person who provides them with praise and positive feedback and who
doesn’t ask for much in return

● Predisposing Factors
○ Several psychodynamic theories exist regarding the predisposition of narcissistic personality disorder
■ Skodol and Gunderson

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 ● As children, these individuals had their fears, failures, or dependency needs responded to with
criticism, disdain, or neglect; they grow up with contempt for these behaviors in themselves and
others and are unable to view others as sources of comfort and support
● Project an image of invulnerability and self-sufficiency that conceals their true sense of emptiness
and contributes to their inability to feel deeply
■ Martinez-Lewi
● Parents of individuals with this disorder were often narcissistic themselves
● Parents were demanding, perfectionistic and critical and placed unrealistic expectations on the
child
● Children model parents behavior, giving way to adult narcissist
● May have been physical or emotional abuse of neglect
■ Narcissism may develop from environment in which parents attempt to live their lives vicariously through
children
● Expect child to achieve things the parents did not, possess those things that the parents did not
possess, and have a better and easier life
● Parents don’t subject child to requirements and restrictions that parents had growing up, so child
grows up believing that he/she is above that which is required for everyone else
■ Bosson and Prewitt-Freilino
● “Parents pamper and indulge children so children think every wish is a command, receive without
giving in return, that they deserve prominence without effort. Children learn to associate self with
positive affect and develop extremely favorable implicit self-representations. The world is not as
accepting and causes parental overindulgence, leading to failure, humiliation and weakness in the
child.
8. Avoidant Personality Disorder
● Definition and Epidemiological Statistics
○ Extremely sensitive to rejection and this can lead to a very socially withdrawn life
■ May be strong desire for companionship, but extreme shyness and fear or rejection creates a need for
unusually strong assurances of unconditional acceptance
○ Prevalence is about 2.4% and equal in men and women
● Clinical Picture
○ Awkward and uncomfortable in social situations
■ Seen as timid, withdrawn or cold and strange
■ Those close to them know about sensitivities, touchiness, evasiveness and mistrustful qualities
○ Speech is slow and constrained, with frequent hesitations, fragmentary thought sequences, occasional confused and
irrelevant digression
○ Lonely and express feelings of being unwanted
○ View others as critical, betraying and humiliating
○ They desire close friends, but avoid them because of rejection
○ Depression, anxiety and anger at oneself for failing to develop social relations are common

● Predisposing Factors
○ No clear cause
○ Contributing factors most likely combo of biological, genetic, and psychosocial influences

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 ○ Infants with hyperirritability, crankiness, tension and withdrawal behaviors may possess a temperamental
disposition toward avoidant pattern
○ Primary psychosocial predisposing influence is parental rejection and censure (reinforced by peers)
■ Reared in families in which they are belittled, abandoned, criticized, so that natural optimism is
extinguished and replaced with feelings of low self-worth and social alienation
■ Learn to be suspicious and to view the world as hostile and dangerous

9. Dependent Personality Disorder

● Definition and Epidemiological Statistics
○ “A pattern of relying excessively on others for emotional support”
■ Evident in tendency to allow others to make decisions, to feel helpless when alone, to act submissively, to
subordinate needs to others, to tolerate mistreatment by others, to demean oneself to gain acceptance, and
to fail to function adequately in situations that require assertive or dominant behavior
○ Relatively common and more common in women than men; more common in youngest children of a family
● Clinical Picture
○ Notable lack of self-confidence that is often apparent in their posture, voice, mannerisms
○ Typically passive and acquiescent to the desires of others
○ Overly generous and thoughtful and underplay their own attractiveness and achievements
○ Appear to others to “see the world through rose-colored glasses”, but alone they feel pessimistic, discouraged, and
dejected
■ Others don’t know about suffering, they suffer in silence
○ Assume passive and submissive role in relationships
■ Willing to let others make important decisions
■ Feel fearful and vulnerable because they lack confidence to care for themselves when relationships end
■ May hastily and indiscriminately attempt to establish another relationship with someone they feel can care
and nurture them
○ Avoid positions of responsibility and become anxious when forced into them
○ Feelings of low self-worth and easily hurt by criticism and disapproval
○ Will do almost anything (even if unpleasant or demeaning) for acceptance of others

● Predisposing Factors
○ Infant can be genetically predisposed
■ Twin studies measuring submissiveness have shown higher correlation between identical twins than
fraternal twins
○ Psychosocially, dependency fostered in infancy when stimulation and nurturance are experienced exclusively from
one source
■ Infant becomes attached to one source to the exclusion of all others
■ If exclusive attachment continues as child grows, then dependency is nurtured
○ Problems can arise when parents become overprotective and discourage independent behaviors
■ Parents that make new experiences too easy for the child encourage their child to give up efforts at
achieving autonomy
■ Child fears losing love and acceptance if they try independent behaviors
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10. Obsessive-Compulsive Personality Disorder
● Definition and Epidemiological Statistics
○ Very serious and formal and have difficulty expressing emotions
○ Overly disciplines, perfectionistic, and preoccupied with rules
○ Inflexible about way things must be done and have a devotion to productivity to the exclusion of personal pleasure
○ Intense fear of making mistakes leads to difficulty with decision making
○ Relatively common and occurs more often in men; most common in oldest children
● Clinical Picture
○ Inflexible and lack spontaneity; meticulous and work diligently and patiently as tasks that require accuracy and
discipline
○ Especially concerned with matters of organization and efficiency, tend to be rigid and unbending about rules and
procedures
○ Socially, they are polite and formal
○ “Rank conscious”, a characteristic that is reflected in their contrasting behaviors with “superiors” as opposed to
“inferiors”
○ Tend to be very solicitous to and ingratiating with authority figures
■ Very autocratic and condemnatory, appearing pompous and self-righteous, to subordinates
○ They have the “bureaucratic personality”, or company man
■ See themselves as conscientious, loyal, dependable, and responsible, and are contemptuous of people
whose behavior they consider frivolous and impulsive
■ Emotional behavior is considered immature and irresponsible
○ On surface, they appear calm and controlled, but underneath is ambivalence, conflict and hostility
■ Commonly use defense mechanism of reaction formation
● Don’t dare to expose true feelings of defiance and anger, so they withhold these feelings so
strongly that the opposite feelings come forth
■ Defenses of isolation, intellectualization, rationalization and undoing are commonly evident also

● Predisposing Factors
○ Psychoanalytical view, the parenting style in this disorder is overcontrol
■ Parents expect children to live up to their imposed standards of conduct and condemn them if they do not
■ Praise much less frequent than punishment for undesirable behaviors
■ Individuals learn what they must not do to avoid punishment rather than what they can do

Application of the Nursing Process

● Borderline Personality Disorder (Background Assessment Data)
○ Put earlier in types of disorders
● Diagnosis/Outcome Identification
○ Table 32-2 on page 683 has nursing diagnoses and behaviors listed for each
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 ○ Outcome criteria (the client:)
■ Has not harmed self
■ Seeks out staff when desire for self-mutilation is strong
■ Is able to identify true source of anger
■ Expresses anger appropriately
■ Relates to more than one staff member
■ Completes activities of daily living independently
■ Does not manipulate one staff member against the other in order to fulfill own desires
● Planning/Implementation
○ Risk for Self-Mutilation/Risk for self-directed or other directed violence
○ Complicated Grieving
○ Impaired Social Interaction
● Concept Care Mapping
○ Figure 32-1 on page 687
● Evaluation
● Antisocial Personality Disorder (Background Assessment Data)
○ Put earlier in types of disorders
● Diagnosis/Outcome Identification
○ Nursing diagnoses in table 32-4 on page 691
● Planning/Implementation
○ Risk for other-directed violence
○ Defensive coping
● Concept Care Mapping
● Evaluation

Treatment Modalities
● Most clinicians believe it is best to strive for lessening the inflexibility of the maladaptive traits and reducing their
interference with everyday functioning and meaningful relationships
● Selection of intervention is generally based on the area of greatest dysfunction, like cognition, affect, behavior or
interpersonal relations
● Interpersonal Psychotherapy
○ Brief and time-limited, or it may involve long term exploratory psychotherapy
○ May be appropriate because personality disorders largely reflect problems in interpersonal style
○ Long term
■ Attempts to understand and modify maladjusted behaviors, cognition, and affects of clients with personality
disorders that dominate personal lives and relationships
■ Core element of treatment is establishment of an empathic therapist-client relationship..therapist is role
model for client
○ Suggested for client with paranoid, schizoid, schizotypal, borderline, dependent, narcissistic, and
obsessive-compulsive disorders
● Psychoanalytical Psychotherapy
○ Treatment of choice with histrionic personality disorder
○ Focuses on unconscious motivation for seeking total satisfaction from others and for being unable to commit oneself
to a stable, meaningful relationship
● Milieu or Group Therapy
○ Especially appropriate for antisocial disorder, for those who respond more adaptively to support and feedback from
peers
■ Feedback from peers is more effective than in one to one interactions with a therapist
○ Group therapy (emphasize the development of social skills) can be helpful in overcoming social anxiety and
developing interpersonal trust and rapport in clients with avoidant personality disorder
● Cognitive/Behavioral Therapy
○ Behavioral strategies offer reinforcement for positive change
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 ○ Social skills training and assertiveness training teach alternative ways to deal with frustration
○ Cognitive strategies help the client recognize and correct inaccurate internal mental schemata
○ Useful for obsessive-compulsive, antisocial and avoidant disorders
● Dialectical Behavior Therapy
○ Type of psychotherapy developed by Marsha Linehan as a treatment for chronic self-injurious and parasuicidal
behavior of clients with borderline personality disorder
■ A complex, eclectic treatment that combines concepts of cognitive, behavioral and interpersonal therapies
with eastern mindfulness practices
○ 5 functions of DBT
■ 1) to enhance behavioral capabilities
■ 2) to improve motivation to change
■ 3) to ensure that new capabilities generalize to the natural environment
■ 4) to structure the treatment environment such that client and therapist capabilities are supported and
effective behaviors are reinforced
■ 5) to enhance therapist capabilities and motivation to treat clients effectively
○ 4 primary modes of treatment in DBT
■ 1) Group skills training
● Clients are taught skills considered relevant to the particular problems experienced by people with
borderline disorder, such as core mindfulness skills, interpersonal effectiveness skills, emotion
modulation skills, distress tolerance skills
■ 2) Individual psychotherapy
● Weekly sessions in which dysfunctional behavioral patterns, personal motivation, and skills
strengthening are addressed
■ 3) Telephone contact
● Therapist is available to the client by telephone, usually on a 24 hour per day basis, but the
therapist can set limits
● “Gives the patient help and support in applying the skills that she is learning to her real life
situation between sessions and to help her find ways of avoiding self-injury”
■ 4) Therapist consultation/ team meeting
● Therapists meet regularly to review their work with their clients. These meetings are focused
specifically on providing support for each other, keeping the therapists motivated, and providing
effective treatment to their clients
○ In controlled studies, DBT has been shown to diminish self-destructive behaviors in clients with borderline
personality disorder.
○ DBT has shows to decrease the dropout rate from treatment and the number of hospitalizations
○ Improvement has been shown in reducing anger and in global and social adjustment scores
○ DBT is now used with substance use disorders, eating disorders, schizophrenia, and PTSD
● Psychopharmacology
○ Drugs have no effect in direct treatment of the disorder itself, but some symptomatic relief can be achieved
○ Antipsychotics are helpful in treatment of psychotic decompensations experienced by clients with paranoid,
schizotypal, and borderline disorders
○ Variety of pharm interventions used with borderline disorder
■ SSRIs and MAOIs have been successful in decreasing impulsivity and self-destructive acts in these clients
■ MAOIs not commonly used because of concerns about violations of dietary restrictions and higher risk of
fatality with overdose
■ SSRIs and atypical antipsychotic combo has been successful in treating dysphoria, mood instability, and
impulsivity in clients with borderline disorder
■ Antipsychotics have resulted in improvements in illusions, ideas of reference, paranoid thinking, anxiety
and hostility
■ Lithium carbonate and propranolol (Inderal) may be useful for the violent episodes of those with antisocial
disorder

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 ■For avoidant personality disorder, anxiolytics can be helpful when previously avoided behavior is being
attempted
■ Antidepressants like sertraline (Zoloft) and paroxetine (Paxil) may be useful is panic disorder develops
● *** READ IMPLICATIONS OF RESEARCH FOR EVIDENCE-BASED PRACTICE (p. 689-690)
● *** READ IMPLICATIONS OF RESEARCH FOR EVIDENCE-BASED PRACTICE (p. 696)

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